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Week 1: Chest injuries
Diagnosis Haemothorax Pneumothorax Tension Open Flail chest Pulmonary Bronchus Cardiac Traumatic
pneumothorax pneumothorax contusion rupture tamponade rupture of
the aorta
Definition Blood in the Air in the thoracic Leak in the lung Air collecting in 3 or more ribs are Lung bruising Rupture of Blood, pus, air or Rupture of
thoracic space space causing air to leak the thoracic space fractured loose bronchi effusions leaking the aorta due
compresses the out into the due to a sucking thorax segment into the to puncture
lungs thoracic space chest wound paradoxical breathing pericardium or tearing
with each breath restricts filling and
eventually cardiac output of
leads to lung the heart
collapse
Tests: X-thorax = with X-thorax Before diagnosis Often treatment Clinical diagnosis X-thorax X-thorax fallen X-ray: rounded Chest X-ray:
Which? large bleeds Decreased PaO2 by X-ray: before diagnosis X-thorax often misses it lung sign for heart shadows widened
What do they (400-500mL) CT-thorax = gold decompression to Abdominal early in the complete Ultrasound: free mediastinum
show? Echo-FAST: even standard let air out ultrasound disease bronchial fluid around the with massive
small amounts otherwise lethal X-thorax or CT CT = more transection + air pericardium haemothorax
are visible sensitive in mediastinum
Video-assisted CT = more
thoracoscopy sensitive than X-
(VATS): to assess ray
location and Fibreoptic
severity of the bronchoscopy:
bleed location and
extent of the
injury
Clinical Pulse↑ Often Dyspnoea Dyspnoea Dyspnoea Symptoms Dyspnoea Acute = within Sudden,
examination: RR↓ asymptomatic Chest pain Sudden chest pain Thoracic pain take a few Saturation↓ minutes: sharp pain on
Hypoxia Dyspnoea Tracheal deviation Rapid + shallow Pulse↑ hours to Hyperresonance Dyspnoea the chest
signs and
Hypotension Chest pain to non-affected breathing RR↑ develop on percussion Chest pain radiating to
symptoms
Tachypnoea Pulse↓ side Pulse↑ Saturation↓ Asymptomatic Decreased/absent Subacute = within the back and
Dyspnoea Hypersonic Haemodynamic Hypoxia Paradoxica breathing Saturation↓ breath sounds days-weeks shoulder
Ipsilateral percussion on instability: Hyperresonant movements Cyanosis Hypotension Dyspnoea blades
decreased affected side RR↓ percussion on Haematoma around Dyspnoea Tracheal shift to Chest pain Dyspnoea
breathing sounds Decreased breath Pulse↑ affected side flail segments RR↑ unaffected side Fatigue Cough
Ipsilateral dull sounds on Saturation↓ Decreased breath Pulse↑ Distended neck RR↓ Dysphagia
percussion affected side Signs of shock sounds on the Increased veins Pulse↑ Hoarseness
Asymmetric Cyanosis affected side breath Persistent CVP↑ BP = high in
breath Sweating sounds: pneumothorax Hypotension upper body
movements Unilateral crackling Inaudible heart and low in
decreased breath Bronchorrhea sounds lower body
sounds = watery Distended neck Systolic
Hyperresonant sputum veins murmur
percussion on Wheezing Paradoxical pulse
affected side Coughing Pericardial friction
Central venous Coughing up Peripheral
, pressure↑ blood oedema
Hypotension
Tender chest
wall
History: Trauma + Dyspnoea + young Penetrating Sucking chest Blunt high-energy MVC + Persistent Trauma + High speeds
relevant dyspnoea and skinny male trauma + severe wound trauma + paradoxical asymptomatic pneumothorax + dyspnoea + chest impact
information dyspnoea breathing with flail worsens fallen lung sign pain trauma +
segment over hours high BP in
upper body
and low BP in
lower body
Patient: - Often in young - Risks: -
Medical history and skinny males Malignancy
Medication can occur Pericarditis
Intoxication spontaneously Auto-
immune
disease
Trauma Blunt or sharp Not commonly Sharp, penetrating Blunt or High-energy blunt Blunt trauma Blunt chest injury Sharp trauma to Sharp or
mechanism trauma to the due to trauma: trauma penetrating trauma often MVCs the chest blunt trauma
chest or lung can be because of trauma to the chest
changes in often high
pressure speed
impact:
deceleration
Treatment Often self- O2 Thick needle Three-way Analgesics Mainly Surgical repair Pericardiocentesis Thoracotomy
limiting supplementation between 2nd and dressing: air can Positive pressure supportive Severe cases: = draining the Endovascular
Prophylactic ABs Aspiration by 3rd rib to let air go out, but not in ventilation to re- care pneumonectomy pericardium repair
Thorax drainage needle or drain out Chest tube inflate the lung Positive not with trauma
VATS: when Chemical Then: place a Surgical repair Surgical rib fixation pressure due to clots
haemothorax pleurodesis = to drain ventilation Pericardiostomy =
persists after prevent After: treat like opening up the
drainage recurrence pneumothorax pericardium
Thoracotomy = Surgery = bleb
when the blood resection
loss >1500 mL
exploratory
surgery
NOTE Watch out for Can develop into If not treated Can develop into Other co-occurring Often resolves Beware of Watch out for Usually fatal
hypovolaemic tension immediately: tension thoracic trauma = spontaneously obstructive shock! cardiogenic or due to
shock pneumothorax! death due to pneumothorax! (tension)pneumothorax within 5-7 obstructive shock massive
acute cardiac and lung contusion days blood loss
tamponade 85% dies
Watch out for before
obstructive shock making it to
the hospital
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