1. Chest trauma

2. 30 yo male M:Driver in 80 kph head on collision Restrained I:Chest wall & sternal pain, leg injuries S:140/80 110bpm sats 90% T:15 mg IV morphine, Oxygen Arrives in ED moaning, disorientated, splint on leg, hard collar on neck High flow oxygen

3. Chest trauma The key to effective trauma management is to minimize the time to definitive management so the initial management should be focused and abbreviated List significant differential diagnosis in chest trauma Inspection; Retractions Symmetrical chest wall expansion Wounds, flail segments Palpation; Chest wall tenderness crepitus Subcutaneous emphysema Position trachea Auscultation Very difficult in ED room; low sensitivity but good specificity Determine absence / asymmetry of breath sounds JVP (difficult to ascertain in neck collars and low in low volume states Absence of pain, tenderness and auscultatory abnormalities in the patient with normal mental status has a NPV near 100%

4. Chest trauma Soon after arrival 100/70, PR 130, sats 92% on oxygen mask, skin dusky What would you do and what are you looking for?

6. Chest trauma Pneumothorax how reliable is the clinical examination? how reliable is the trauma CXR? how is a tension pneumothorax treated? what do we do with occult PTx on CT? how do we treat stab wound to the chest?

7. Chest trauma Pneumothorax - simple - open - tension Cause - Sudden increase in intra thoracic pressure - Rib fractures lacerate the lung - Deceleration injury tears the lung - Blunt force disrupts the alveoli Examination universal finding - chest pain. Respiratory distress common (50-7% - tachycardia, ipsilateral decreased air entry inconsistent(<25%)- low sats, tracheal dev, hypotension rare (10%) - cyanosis, hyperresonance, drowsy - ipsilateral; hyper-expansion, hypo-motility Tracheal deviation is inconsistent and poorly predictive In the ventilated patient; rapid onset drop in saturations and blood press

8. Chest trauma CXR supine misses 30 - 50%  the supine AP CXR is much less sensitive (75%)than the erect CXR  Air accumulates in the anteromedial recess  abnormal hyperlucency in lower chest/upper abdomen as air collects in the anterior costo-phrenic abscess  Sub-pulmonary air collection or hyperlucency  Deep sulcus sign; abnormally deep and lucent costophrenic angle. Ant PTx  Unusually well defined mediastinal structures because of postero-medial air  Depression of hemi-diaphragm U/S (more sensitive than CXR >90%)

9. ultrasound

16. Chest trauma Tension pneumothorax Any patient you clinically suspect of having tension PTx and in distress, is hypoxic or hypotensive decompress urgently without radiologic confirmation (sats < 92% on O2, syst < 90, RR < 10, drowsy, cardiac arrest) mortality is 4 fold in intubated patients if thoracotomy is delayed waiting for CXR Needle thoracotomy 14# cannula in 2/3 ICS MCL. however, up to ⅓ patients have a thicker chest wall than cannula length can use 4/5 ICS MAL if chest wall too thick follow by insertion of a chest tube Wait for CXR confirmation in stable patients (with PTx)  Confirms diagnosis and may prevent unnecessary thoracostomy  May reveal diaphragmatic rupture which would make thoracostomy dangerous

17. what would happen if we inserted a L sided chest tube?

18. tension pneumothorax

22. Chest trauma Occult pneumothorax; diagnosed by CT in 2 – 8 % 20% will require tube thoracostomy When do we treat occult pneumothorax? guidelines for thoracostomy 1. > 5×80mm 2. associated rib fractures 3. requiring future positive pressure ventilation 4. multiple injuries, haemorrhagic shock, brain injury What do you do if you elect to do nothing? repeat CXR in 6 and 24 hours

25. stabbing Most are clinically stable on arrival 15% require operative management ‘normal CXR’ require repeat in 6 hrs Injury to ‘cardiac box’ = clavicle-costal margin between midclavicular lines  Less than 25% make it to hospital; of which  41% present haemodynamically stable  CXR; 59% widened mediastinum 27% haemothorax  CT; replacing angiogram, shows trajectory 10-30% involve the abdomen; when wound is below 4 th nipple

26. Chest trauma 58 yo male motorbike rider hit by truck from behind Complaining of chest pain, no LOC 120 bpm, 140/90, RR 28, sats 94% on 8L O2

29. Chest trauma Haemothorax clinical Decreased chest expansion, decreased breath sounds (dull to percussion) CXR (sens 50%, spec 90%) moderate size: >400-500 mls blood to detect on supine CXR diffuse non-segmental opacification through which lung markings can be seen, large size >1500mls ground glass appearance on CXR haemodynamic compromise from blood loss and mediastinal shift U/S ( sens 90%, spec 95%) tube thoracostomy lung re-expansion will tamponade bleed place ICC posteriorly unless there is a pneumothorax as well 10-15% require thoracotomy thoracotomy if stable and bleeds>200mls/hr or >1500ml in total if unstable and bleeds>100mls/hr or > 100ml in total no improvement in haemothorax will require a second ICC antibiotics prob not required if adequate drainage of haemothorax and sterile technique used

31. Chest trauma – rib# Compression or shearing of the lung parenchyma leads to localized disruption of the alveolar capillary membrane and lung interstitium. Blood leaking out into the interstitium 50% rib fractures undetectable radiologically Rib fractures cause severe pain, delayed morbidity and mortality that leads to pneumonia Chest wall injury; ⅓ have pulmonary complications 30% pneumonia ↑rib#s → ↑mortality esp>3-4 ribs (13% mortality) age; > 65yo mortality (8 vs 61%)(Bulger) each additional rib# increases mortalityby 19% elderly patients with rib fractures should be admitted concurrent ≥ 2 extra-thoracic injuries ↑↑ mortality Blunt chest injury treatment;  pain control (epidural analgesia better outcome, esp if > 4 rib# and > 65yo)  chest physio  mobilisation  Unnecessary IV fluid administration should be meticulously avoided

32. Rib # 1 st and 2 nd rib# may indicate severe neurovasc injuries most common in ejected MVA victims Lower rib#s may indicate -abdo injuries diaphragmatic injuries Admit ≥ 3 rib#s, underlying resp disease, complications (pneumo, heamo, pul contusion), pain not controlled (must be able to deep breathe and cough), unable to cope at home, elderly Sternal fractures; ECG troponin; not routinely required unless haemo unstable

33. 1. Deep sulcus 2. Widened mediastinum, obscured aortic knuckle, opacified aorto-pul window 3. R side Contusion 4. L Haemothorax 5. 7 – 10 R rib#

34. Chest trauma 52 yo male Hit by car travelling at 70 kph Brief LOC, chest pain 120 bpm, 100/70, sats 90% You are the doctor completing the primary survey

38. Chest trauma Flail chest  most severe form of blunt chest trauma; mortality 10-20%  Poor outcome is due to the underlying pulmonary contusion  Causes long term chest wall pain and exertional dyspnoea  Advances in knowledge and ICU techniques over the last 3 decades have not impacted on mortality  Management Unnecessary IVF infusion should be avoided Obligatory mechanical ventilation should be avoided (Trinkle) (intubate to improve gas exchange and not for mechanical correction) Optimal analgesia (epidural) Chest physio CPAP works (Tanaka, Gunduz) Surgical fixation worked in old studies not comparing new techniques

39. Cardiac echo

40. Blunt Cardiac Injury Sustained from rapid deceleration with direct blow to the chest Suspect with mechanism or poor cardiovascular response to their injury Difficult diagnosis  Chest pain or SOB  Chest wall tenderness, flail, crepitus  Sinus tachy, arrhythmia, pump failure No single or combination of test reliably diagnoses it Normal ECG in stable patient with blunt chest trauma essentially rules out significant risk of blunt myocardial injury Cardiac echo for unexplained hypotension, ECG changes or pump failure Troponin has no important clinical value in diagnosis of BCI

42. Blunt aortic injury Mainly MVA, pedestrian, falls, impact from any direction Second most common cause of death in blunt injuries; 85% die pre-hospital CXR can be used as a initial screening tool (98% NPV if normal)  Widened mediastinum most common trigger for additional workup to exclude BAI  supine 10cm, PA 8cm and mediastinal/chest ratio 0.38 (at level or aortic arch)  Other signs; obscured or indistinct aortic knob depression L main bronchus deviation NGT opacification aorto-pul window displaced L parasternal stripe fracture 1 st rib, apical cap  CXR may be normal in 25% Screen with CTA; 100% NPV Angiography; gold standard and may be used when CT equivocal Requires immediate repair unless there are more urgent issues requiring laparotomy or craniectomy Endoluminal stent or surgical repair (complication; spinal cord ischaemia or renal failure) Treat hypertension to reduce shearing forces with b -blockers