Management of Surgical Emergencies Part 1 : Critical Care Chest Trauma Trauma causes of Breathlessness and Emergency Management Copyright UKCS #284661815

Learning Outcomes Primary Survey “B” - Breathing with ventilatory support Life threatening breathing problems & Specific injuries Features, signs and treatment What we plan to cover in this session. Run through this quickly

Primary Assessment (Survey) Rapidly identify immediate life threatening and reversible injuries Airway, Breathing, Circulation, Disability Treat problems as they are identified Systematic Repeatable Worth reminding the participants of this important point

Primary Assessment: Expose (remember the back) Look, feel, percussion, auscultation (remember the back if possible) Treat life threatening problems Reassess following intervention Vital Signs, oximetry and CXR (if available) Step-by-step guide to a simple routine for checking the Breathing and Ventilation in the Primary Survey. You could demonstrate it on one of the participants as you talk?

Penetrating chest injury Primary Assessment: Life-threatening injuries: Penetrating chest injury -v- Blunt chest injury Airway Obstruction Tension Pneumothorax Open Pneumothorax Massive Haemothorax Flail Chest Cardiac Tamponade ATOMiC

Primary Assessment: Potentially life-threatening injuries to look out for: Penetrating chest injury: Tension pneumothorax Massive haemothorax Cardiac tamponade Open pneumothorax SIGNS MANAGEMENT Allow about 1 minute each for the participants to list these 3 injuries, plus their clinical presentations.

Diagnosis? Tension Pneumothorax History of penetrating trauma, PPV or chronic airway disease Common signs Air hunger (tachycardia, tachypnoea, agitation, cyanosis – Sats<92%, SBP<90, RR <10) Late / rare signs Hyper-resonance , hypotension, neck veins, deviated trachea

Tension pneumothorax Clinical diagnosis X-ray not necessary Management – Immediate Needle Decompression How, where Intercostal drain

Needle decompression

Needle decompression

Large haemothorax Supine Erect

Haemothorax Up to 40% blunt injuries Up to 90% penetrating injuries Multiple sites Potential to bleed up to 50% of circulating volume into each hemithorax Massive Haemothorax = 1000-1500mL or 250ml/ hour over next 3-4 hours 400mL – blunting of costophrenic angle

More than one pathology!

Chest Drain insertion

Open Pneumothorax Definition Pathophysiology? Wound diameter? Treatment?

Primary Assessment: Specific, potentially life-threatening injuries to look out for: (b) Blunt chest injury - Flail chest (90% associated with pulmonary contusions) - Ruptured aorta - Ruptured diaphragm Again, only a minute each to list these and brief discussion about pathophysiology

Multiple rib #s with flail segment

Flail chest

Wide mediastinum due to ruptured aorta

Wide mediastinum due to ruptured aorta

Ruptured left diaphragm

Act to fix what you find: Oxygen (if available) Needle decompression & secure Chest drain v non-tube thoracostomy ?Thoracotomy: Indications in haemothorax? Penetrating injury NB: Getting a CXR and calling the surgeons are non-therapeutic manoeuvres Emphasise that the participants must act to save a life, and consider the timing of CXR and calling for help (call early, but act before help arrives)

Questions?

Summary: How to assess ‘B’ in primary survey Specific injuries to look for and how to recognise them Indications for chest drain Timing of the CXR Potential dangers of # ribs… Remember to look at patients back Go through these quickly: less than a minute each Copyright UKCS #284661815