Trauma: Chest

Question 1

What is the second biggest cause of trauma mortality?

Answer 1

Chest trauma, accounting for 25% of all fatal trauma

Traumatic Brain Injury (TBI) is the leading cause.

Question 2

What percentage of chest trauma cases require surgery?

Answer 2

Approximately 15%

This indicates the severity of certain chest injuries.

Question 3

What are some causes of immediate death in chest trauma?

Answer 3

Aortic rupture, cardiac injury, tracheal destruction

These injuries can lead to rapid mortality.

Question 4

In New Zealand and Australia, what type of chest trauma is most common?

Answer 4

Blunt chest trauma

This contrasts with other regions where penetrating trauma may be more prevalent.

Question 5

What are the main pathophysiological problems associated with chest trauma?

Answer 5

A & B problems: Impairment of ventilation and gas exchange at alveolar level; C problems: Impairment of circulation and cardiac function due to tamponade

These impairments affect the overall respiratory and circulatory systems.

Question 6

What should be done for unstable patients with chest trauma?

Answer 6

Insert bilateral chest tubes

This helps to relieve pressure and restore ventilation.

Question 7

For stable patients with chest trauma, what is the next step after a chest X-ray?

Answer 7

Consider chest tube placement

This is contingent on the findings from the CXR.

Question 8

What imaging may be required to further investigate chest trauma?

Answer 8

CT scan

Question 9

Fill in the blank: Approximately 15% of chest trauma cases require _______.

Answer 9

surgery

This highlights the need for surgical intervention in severe cases.

Question 10

True or False: Most chest trauma cases in NZ/Aus are due to penetrating injuries.

Answer 10

False

Most cases are blunt trauma.

Question 11

What is an open pneumothorax?

Answer 11

A type of pneumothorax where air enters the pleural space through a wound

Open pneumothorax is seen in less than 1% of all civilian major thoracic injuries and is usually associated with close range shotgun blasts or high velocity missiles.

Question 12

How can air movement be detected in an open pneumothorax?

Answer 12

Air movement through the wound can sometimes be heard

This is an important clinical sign during examination.

Question 13

What is the recommended method to seal a wound in open pneumothorax?

Answer 13

Seal the wound with an occlusive dressing

A three-sided occlusive dressing acts like a one-way valve.

Question 14

What procedure may be necessary due to the risk of tension pneumothorax?

Answer 14

Tube thoracostomy

Tension pneumothorax can occur if air continues to enter the pleural space.

Question 15

What is the primary method for reconstructing devitalized tissue in open pneumothorax?

Answer 15

Reconstruction primarily with myocutaneous flaps

This is part of the management of extensive thoracic injuries.

Question 16

What is tension pneumothorax?

Answer 16

A common threat to life caused by trapped air in the pleural space

It is easily treatable with needle thoracocentesis, finger thoracostomy, or chest tube insertion.

Question 17

What percentage of penetrating chest trauma results in a simple ‘closed’ pneumothorax?

Answer 17

20%

This indicates the prevalence of closed pneumothorax in penetrating chest injuries.

Question 18

What are the percentages of haemothorax and haemopneumothorax in penetrating chest trauma?

Answer 18

• Haemothorax: 30%
• Haemopneumothorax: 40-50%

These are significant complications following penetrating chest trauma.

Question 19

What are the signs of a massive haemothorax?

Answer 19

Shock, ventilatory embarrassment, and mediastinal shift

These symptoms indicate severe blood loss and respiratory compromise.

Question 20

What is the definition of massive haemothorax?

Answer 20

Initial blood loss of >1.5L or ongoing blood loss of 200mls for 2-4hrs

This definition is retrospective and assessed after chest tube insertion.

Question 21

What is often the first procedure performed in cases of suspected massive haemothorax?

Answer 21

Tube thoracostomy

This is due to the degree of respiratory compromise, which may necessitate immediate intervention.

Question 22

What percentage of patients with massive haemothorax have injury to a systemic vessel?

Answer 22

85%

Commonly involved vessels include intercostal or internal mammary arteries.

Question 23

What percentage of penetrating injuries to the tracheobronchial tree occurs in major thoracic trauma?

Answer 23

<2%

Such injuries are rare but can have severe consequences.

Question 24

What are the clinical presentations of tracheobronchial injuries?

Answer 24

• Massive haemoptysis
• Airway obstruction
• Mediastinal air
• Subcutaneous emphysema
• Persistent air leak after chest tube placement

These symptoms indicate significant injury to the tracheobronchial tree.

Question 25

What is the initial management for significant air-leak in tracheobronchial injuries?

Answer 25

Advance ET tube past the site of injury and inflate cuff ## Footnote This can help control the airway and manage the leak.

Question 26

What surgical approach is used for proximal tracheobronchial injuries?

Answer 26

Posterolateral thoracotomy ## Footnote This allows for exploration and potential repair with monofilament suture.

Question 27

What may be required for some proximal tracheobronchial injuries?

Answer 27

Segmentectomy or lobectomy ## Footnote This is necessary in cases where the injury is extensive and cannot be repaired.

Question 28

What is the nature of penetrating trauma to the thoracic oesophagus?

Answer 28

Rare ## Footnote Cervical injury is more common and typically identified during neck exploration.

Question 29

How is cervical oesophageal injury usually detected?

Answer 29

Due to dysphagia ## Footnote Dysphagia, or difficulty swallowing, is a key symptom leading to the discovery of cervical injuries.

Question 30

What is the prognosis of late presentation with posterior mediastinitis?

Answer 30

Grave situation with high mortality ## Footnote Late diagnosis significantly increases the risk of mortality.

Question 31

What is the recommended treatment if oesophageal injury is diagnosed during initial neck exploration?

Answer 31

2 layer closure with PDS ## Footnote PDS refers to polydioxanone, a type of suture material.

Question 32

What should be done if thoracic oesophageal injury is diagnosed within 6 hours?

Answer 32

Attempt repair ## Footnote Early intervention is critical for better outcomes.

Question 33

What is the operative decision for oesophageal injury if diagnosed between 6-24 hours?

Answer 33

Repair vs drainage and nutritional support ## Footnote The decision depends on the patient's condition and the extent of the injury.

Question 34

What happens if an oesophageal injury is diagnosed after 24 hours?

Answer 34

Primary repair will fail; open drainage, antibiotics, nutritional support, consider diversion ## Footnote Delay in treatment increases the likelihood of complications.

Question 35

What is a common cause of pulmonary contusion?

Answer 35

Direct chest trauma, high velocity missiles, shotgun blast ## Footnote These are typical scenarios leading to pulmonary contusion.

Question 36

What physiological issues arise from pulmonary contusion?

Answer 36

Ventilation-perfusion mismatch and shunts ## Footnote These injuries can worsen over time, leading to increased complications.

Question 37

What is the typical treatment for pulmonary contusion?

Answer 37

Cardiovascular and tailored ventilatory support, usually in ICU ## Footnote Intensive care is often required to manage these patients effectively.

Question 38

What defines flail chest?

Answer 38

Multiple adjacent ribs fractured in multiple places allowing part of the chest wall to move independently ## Footnote This condition results in paradoxical movement of the chest wall.

Question 39

What was the traditional treatment for flail chest?

Answer 39

Internal splinting – positive pressure ventilation ## Footnote This method aims to stabilize the chest wall during breathing.

Question 40

What is gaining traction as a treatment for rib fractures in young patients?

Answer 40

Open reduction and fixation of rib fracture ## Footnote This approach may reduce ventilator time and risk of pneumonia.

Question 41

What potential benefits does open reduction and fixation of rib fractures provide?

Answer 41

Reducing time on ventilator and risk of ventilator-associated pneumonia ## Footnote Early stabilization can lead to improved recovery outcomes.

Question 42

What is air embolism?

Answer 42

An uncommon condition where air enters the vascular system

Question 43

What percentage of air embolism cases occur with penetrating injuries?

Answer 43

65%

Question 44

What are some causes of air embolism?

Answer 44

* Trauma * Fistula between bronchus and pulmonary vein * Open cardiac injury * Iatrogenic causes * Air via IVL or disconnected CVL * Head and neck surgery * Cardiac surgery

Question 45

What is venous air embolism?

Answer 45

Air enters venous vessels, goes to the right ventricle, and into the lungs, causing occlusion and impaired gas exchange

Question 46

What are the consequences of venous air embolism?

Answer 46

* Impaired gas exchange * Pulmonary edema * Increased airway resistance * Increased right ventricular pressure * Circulatory collapse

Question 47

What is arterial air embolism?

Answer 47

Air enters directly into the heart or vessels due to trauma, surgery, or barotrauma and causes systemic emboli

Question 48

What areas are most sensitive to ischemia from arterial air embolism?

Answer 48

* Brain * Heart

Question 49

What are the potential outcomes of arterial air embolism?

Answer 49

* Stroke * Myocardial infarction (MI)

Question 50

How does positive pressure ventilation affect air embolism?

Answer 50

It can force air into the pulmonary vein

Question 51

What are signs of air embolism presentation?

Answer 51

* Sudden lateralizing neurological signs * Sudden cardiovascular collapse * Froth on arterial blood gas

Question 52

What is the initial management step for air embolism in the emergency department?

Answer 52

Perform thoracotomy if air is seen in coronary vessels

Question 53

What should be done to the hilum of the offending lung during management?

Answer 53

Clamp the hilum

Question 54

What should be done to a laceration in the lung during management?

Answer 54

Oversew the laceration

Question 55

What should be vented during the management of air embolism?

Answer 55

Left atrium and left ventricle

Question 56

What is cardiac injury more commonly associated with?

Answer 56

Penetrating trauma ## Footnote Cardiac injuries are seen in 5% of thoracic trauma cases.

Question 57

What are the common presentations of cardiac injury?

Answer 57

Decreased cardiac output, increased central venous pressure, decreased BP, decreased heart sounds ## Footnote E-FAST often demonstrates pericardial fluid.

Question 58

What is the immediate treatment for all cardiac injuries?

Answer 58

Thoracotomy ## Footnote Ideally performed in the operating room.

Question 59

Where should the pericardium be opened during thoracotomy?

Answer 59

1cm anterior to the phrenic nerve crossing ## Footnote It is crucial to identify the phrenic nerve to avoid injury.

Question 60

What are two methods for emergency control of bleeding in ED thoracotomy?

Answer 60

Foley catheter balloon, skin stapler ## Footnote These methods can be used during the initial management of cardiac injuries.

Question 61

What sutures are commonly used to repair cardiac injuries?

Answer 61

3/0 or 4/0 prolene on SH needle +/- Teflon pledgets ## Footnote Teflon pledgets are usually used if there is surrounding contusion to bolster closure.

Question 62

What should be avoided when repairing cardiac injuries?

Answer 62

Oversewing coronary arteries ## Footnote This can lead to myocardial infarction (MI).

Question 63

What is ED Thoracotomy?

Answer 63

Thoracotomy performed outside operating theatre as a desperate measure ## Footnote It is done to try to save patients in extremis.

Question 64

What are the objectives of ED thoracotomy?

Answer 64

Control of bleeding, release cardiac tamponade, control intrathoracic bleeding, control air-embolism or bronchopleural fistula, permit open cardiac massage, allow temporary occlusion of descending aorta ## Footnote These objectives aim to stabilize the patient.

Question 65

What are the indications for performing an ED thoracotomy?

Answer 65

Witnessed cardiac arrest with high likelihood of isolated intrathoracic injury, severe post-injury hypotension (<60mmHg) ## Footnote Conditions may include cardiac tamponade, air embolism, thoracic hemorrhage.

Question 66

What are the contraindications for performing ED thoracotomy?

Answer 66

CPR in the absence of endotracheal intubation >5min, CPR >10min regardless of intubation, blunt trauma with no signs of life at scene ## Footnote Only pulseless electrical activity in ED is also a contraindication.

Question 67

What is the procedure for left anterolateral thoracotomy?

Answer 67

Incise pericardium to relieve tamponade, repair cardiac wounds, stop pulmonary hemorrhage ## Footnote Finger occlusion or local oversewing may be used during repair.

Question 68

What is the purpose of aortic cross-clamping during thoracotomy?

Answer 68

Controls subdiaphragmatic hemorrhage and diverts blood above diaphragm ## Footnote This is done by incising pleura adjacent and dissecting esophagus from aorta.

Question 69

What is the purpose of the underwater seal chest drain?

Answer 69

To allow drainage of pleural fluid while preventing air from entering the pleural space ## Footnote It maintains a negative pressure environment to facilitate fluid removal.

Question 70

What are the two systems of underwater seal chest drains?

Answer 70

1-bottle system and 3-bottle system ## Footnote Each system has different configurations for managing pleural drainage.

Question 71

What is the function of bottle A in the 3-bottle system?

Answer 71

Fluid trap or collection bottle ## Footnote It can be independently emptied and allows accurate record of drainage amount.

Question 72

What is the role of bottle B in the 3-bottle system?

Answer 72

Underwater seal drain ## Footnote It maintains a predetermined level to allow for drainage of pleural fluid.

Question 73

What does continuous bubbling in bottle B indicate?

Answer 73

Bronchopleural fistula ## Footnote This occurs when there is an abnormal connection between the bronchial tubes and the pleural space.

Question 74

What is bottle C in the 3-bottle system used for?

Answer 74

Manometer or pressure-regulating bottle ## Footnote It allows suction to be attached and should bubble continuously.

Question 75

How is the maximum negative pressure generated by suction determined?

Answer 75

By the distance (in cm) the vent tube is below the water line ## Footnote This distance can be adjusted to achieve desired suction levels.

Question 76

In the 1-bottle system, where is the chest drain connected?

Answer 76

To a tube approximately 3 cm under water in the underwater-seal bottle ## Footnote This creates a seal that allows for drainage while preventing air entry.

Question 77

What happens when pleural pressure exceeds +3 cm water in the 1-bottle system?

Answer 77

It forces air or fluid from the pleural space into the bottle ## Footnote This is essential for maintaining proper fluid levels in the pleural cavity.

Question 78

What is a disadvantage of the 1-bottle system?

Answer 78

Increased pressure required to force contents into the bottle as liquid accumulates ## Footnote This can impede the clearance of pleural collections.

Question 79

What is the relationship between hydrostatic pressure and the height of the fluid column?

Answer 79

Hydrostatic pressure is proportional to the height of the fluid column ## Footnote This principle helps maintain the underwater seal in the chest drain.