1. A case of blunt thoracic trauma Author DR SUEN KIN WING August 2013 HKCEM College Tutorial

2. History ▪ 78/M ▪ Riding Bicycle along the road ▪ Hit by a van of unknown speed ▪ Thrown away several meters ▪ Primary trauma diversion for decreased Glasgow Coma Scale

3. Physical Examination ▪ GCS 6/15 ▪ BP 105/ 43 ▪ SpO2 86 % on Non-rebreather mask (NRB) ▪ Forehead hematoma with Lt ear bleeding ▪ Surgical emphysema on Lt chest wall ▪ Abrasion over lower limbs

4. What are the potential causes of airway obstruction in trauma setting? ▪ Loss of upper airway muscle tone from CNS depression ▪ Foreign body such as avulsed teeth ▪ Oral bleeding ▪ Significant facial fracture ▪ Laryngeal injury ▪ Expanding neck hematoma ▪ Airway burn

5. What physical signs should be looked for during assessment of thoracic trauma? ▪ Cyanosis ▪ Distended neck vein ▪ Breath sound ▪ Surgical emphysema ▪ Bony crepitus ▪ Paradoxical chest wall movement ▪ Tracheal deviation

6. WHAT ARE THE ABNORMALITIES?

7. CXR findings ▪ Multiple ribs fracture on Lt side ▪ Fracture of Lt scapula ▪ Fracture of Lt clavicle ▪ Lt lung haziness ▪ Patchy consolidation suggestive of pulmonary contusion

8. ▪ For trauma patients, X-ray is usually taken in supine position. ▪ Look for deep sulcus sign suggestive of pneumothorax ▪ Diffuse haziness indicates the presence of haemothorax ▪ Chest x ray may also provide clues of aortic injury. ▪ Suspect aortic injury with deceleration mechanism

9. What bedside investigation is useful in our patient? eFAST-Extended Focused Assessment with Sonography in Trauma ▪ To detect fluid in pericardium and abdomen ▪ Region of examination : RUQ, LUQ, suprapubic region and subxiphoid view of pericardium ▪ Examination can be extended to detect the presence of traumatic haemothorax and pneumothorax http://www.youtube.com/watch?v=EVQTI7ivhFM

10. Ultrasound for pneumothorax ▪ Normal lung displays pleural sliding and comet tail artifact ▪ Absence of these findings is suggestive of pneumothorax ▪ On M mode, normal pleural is displayed as seashore sign ▪ Significant surgical emphysema may make examination difficult

11. Pneumothorax on USG Sliding pleura and seashore sign on normal lung Absence of sliding pleura and barcode sign on pneumothorax http://www.youtube.com/watch?v=ebCbewLBNGM

12. Haemothorax on USG

13. Progress ▪ Patient was intubated and put on mechanical ventilation in view of unconsciousness and desaturation. ▪ X-RAY trauma series showed no abnormalities in cervical spine and pelvis while the CXR finding has been described. ▪ eFAST was negative ▪ Chest drain was inserted

14. THE POSITION OF ALL DRAINS AND TUBES SHOULD BE VERIFIED ON CXR

15. What are the indications for Chest drain? ▪ Tension pneumothorax ▪ Simple pneumothorax ▪ Haemothorax ▪ Patient with ribs fracture on positive pressure ventilation ▪ Minimal pneumothorax or haemothorax can be treated conservatively

16. ▪ The triangle of safety refers to the area surrounded by the anterior border of latissimus dorsi, the lateral border of pectoralis major muscle and the horizontal level of nipple. What is the " triangle of safety " for chest drain insertion ?

17. What are the important steps for chest drain insertion? ▪ Use blunt dissection ▪ The chest drain should be inserted just above the rib to avoid damage to the intercostal vessels and nerves ▪ Chest drain is placed apically for pneumothorax and posteriorly for haemothorax

18. ▪ Insertion of chest drain should be done without substantial force ▪ Use of trocar is discouraged ▪ Any functional chest drain should not be repositioned simply because of its radiological position Chest tube insertion (NEJM) http://www.youtube.com/watch?v=hQlt57AyQmg

19. What are the potential complications of chest drain insertion? ▪ Tube malposition ▪ For example: Intraparenchymal tube placement and subcutaneous tube placemen ▪ Nerve injury ▪ For example: Horner’s syndrome and phrenic nerve injury ▪ Cardiovascular injury ▪ Intercostal artery injury ▪ Esophageal perforation ▪ Arrhythmias ▪ Emphysema

20. Penetration of lung parenchyma by chest drain

21. What will you consider if there is continuous air bubbling via the chest drain and pneumothorax is unresolved after chest drain has been inserted for pneumothorax?

22. A tear at right main bronchus ▪ Large tear of lung parenchyma or tracheobronchial injury may result in persistent air leakage

23. Progress ▪ Whole body CT was performed ▪ Admitted ICU ▪ Continue mechanical ventilation ▪ Chest physiotherapy and antibiotic for pneumonia ▪ Opioid for pain relief ▪ Extubated and followed by prolonged course of rehabilitation

24. Progress Orange arrow : Pulmonary contusion Blue arrow: Haemothorax Green arrow: Surgical emphysema Coronal view showing the extent of injury

25. Pulmonary contusion ▪ Hemorrhage and alveolar edema leading to impaired gas exchange and lung compliance ▪ Avoid excessive fluid and aim at euvolemia ▪ A trial of CPAP in selected patients ▪ Independent lung ventilation for severe unilateral lung contusion

26. Flail chest and ribs fracture ▪ Two or more ribs are fractured in at least two places ▪ Pathophysiology results from underlying lung contusion and splinting caused by pain ▪ For first, second rib or scapula fracture, consider the possibility of significant intrathoracic injury ▪ Fracture of lower ribs are associated intra abdominal injury ▪ Fracture of sternum is not necessarily a indicator of cardiac injury

27. Consider intra-abdominal injury in thoracic trauma

28. Haemothorax ▪ Each haemithorax can hold several liters of blood ▪ Bleeding from intercostal artery or thoracic vessel can results in massive haemothorax ▪ Major lung parenchyma may also bleed significantly ▪ Chest drain is both diagnostic and therapeutic

29. ▪ Retained haemothorax is potentially complicated by empyema and fibrothorax ▪ Indication of emergent thoracotomy: ▪ 1500ml blood on initial drainage ▪ Ongoing bleeding of > 200ml/hr for 4 hours ▪ Unstable hemodynamics secondary to thoracic bleeding

30. Summary

31. Immediate Life Threatening Conditions in Blunt thoracic Trauma ▪ Airway obstruction ▪ Tension pneumothorax ▪ Pericardial tamponade ▪ Massive haemothorax

32. Potentially life threatening conditions Pulmonary contusion Traumatic rupture of aorta Major tracheobronchial disruption Blunt cardiac injury Diaphragmatic tear Esophageal rupture ( rare )

33. Five Core ED Management ▪ Airway protection ▪ Adequate oxygenation ▪ Chest drain insertion ▪ Fluid resuscitation for hypovolaemia ▪ Pain relief

34. Image Sources ▪ Slide 11 Occult Traumatic Pneumothorax Diagnostic Accuracy of Lung Ultrasonography in the Emergency Department Chest. 2008; 133(1):204- 211 ▪ Slide 12 EMresource.ORG ▪ Slide 16 BTS guidelines for the insertion of a chest drain Thorax 2003;58:ii53-ii59 ▪ Slide 20 Rosen's Emergency Medicine, 7th Edition ▪ Slide 22 The CT fallen-lung sign. Eur Radiol. 2000;10(5):719-21. ▪ Slide 27 Atlas of Human Anatomy by Frank H. Netter

35. Thank You