TRAUMA

Question	Answer
Chest trauma Patterns of injury	First and second rib fractures •deceleration injuries in unrestrained occupant Middle rib fractures •compression force •pulmonary contusion Lower rib fractures •abdominal injury •diaphragmatic injury
criteria for admission	1/clinical fractures of ≥ 3 ribs -respiratory comorbidity (COPD, asthma, smokers) 2/complications of fracture (pneumothorax, haemothorax, pulmonary contusion) 3/pain not controlled by oral analgesia (must be able to deep breath and cough) 4/inability to cope at home (fractures due to simple falls at home are common in this group)
HDU / ICU admission for high risk groups	> 3 fractures -flail chest -elderly -respiratory comorbidities
Intercostal nerve blocks	Bupivacaine analgesia: 8-12 hours Bupivacaine 0.5% with adrenaline -2 mL for each segment -20 mL maximum 1.5% incidence of pneumothorax for each rib blocked
Chest wall stabilisation surgery	possible indications -flail chest with ≥ 3 ribs fractured in ≥ 2 places -fractures displaced ≥ 2mm (reduces hospital and ICU length of stay and duration of ventilation) -chest wall deformity -open rib fractures -post emergency thoracotomy for treatment of traumatic thoracic injuries -isolated fractures with severe pain unable to be controlled by standard analgesic therapy
Sternal fracture	motor vehicle crashes -post-menopausal females at highest risk -extremely low mortality when an isolated injury
Sternal fracture Ix	ultrasound -more sensitive than lateral chest views CXR site and degree of displacement are of no prognostic significance -Isolated fracture with no obvious cardiovascular complications does not require an extensive cardiac work up -cardiac contusion in haemodynamically stable patients is of almost no clinical significance ECG new ST changes in the absence of other injuries are usually significant Troponin -not routinely required -may be of limited value if haemodynamic instability & echocardiography is unavailable -to dx cardiac contusion Echocardiography -the investigation of choice if hypotension -normal contractility reliably excludes a significant cardiac contusion, irrespective of ECG or troponin changes
Haemothorax	Size •minimal -< 350 mL -small effusion visible on erect CXR -usually not visible on supine CXR •moderate -350-1,500 mL -moderate effusion visible on erect CXR -diffuse increased opacity on supine CXR •large -> 1,500 mL -ground glass appearance of affected hemithorax on supine CXR
Indications for thoracotomy	•if blood loss from ICC in a stable patient : -> 200 mL/hour for 3 hours -> 1,500 mL in total •if blood loss from ICC in an unstable patient : -> 100 mL/hour -> 1,000 mL in total
Pneumothorax	Ultrasound •7.5-MHz linear transducer • 3.5 MHz curvilinear transducer •loss of sliding lung sign on respiration •at mid clavicular point anteriorly or 4th intercostal space at the anterior axillary line = small •at the mid axillary line = medium •at the posterior axillary line = large •has higher sensitivity (> 90%) than supine CXR with similar specificity (> 95%)
Pneumomediastinum	CXR •supine CXR only 20% sensitive •air stripe around mediastinal contents •heart border prominent •gas most easily seen in the upper mediastinum -may extend into neck •dark line also may be seen along the superior surface of the central diaphragm and cardiac base making the diaphragm look continuous from right to left hemithorax CT •> 95% sensitive, 85% specific for aerodigestive injuries following blunt trauma
Tension pneumomediastinum	exceedingly rare •elevated JVP, but equal breath sounds bilaterally •decompression required -incise skin in the suprasternal notch -insert finger into superior mediastinum until gas escapes
Tracheobronchial injuries	Bronchial injuries •80% of blunt injuries occur within 2.5 cm of the carina
Pulmonary contusion	-75% of patients with flail chest -can also occur following blunt trauma without rib fracture (especially children) -clinical and X-ray findings usually do not fully develop until 24 hours after injury -lung compliance lowest 3 days following injury CXR -patchy parenchymal opacification -diffuse linear peribronchial densities ,may progress to diffuse opacification -pneumatocoeles may be present severe contusion -> 20% of lung volume -80% develop ARDS -50% develop pneumonia
Pulmonary injury grading	•increase one grade for bilateral injuries up to grade III •haemothorax is scored under thoracic vascular injury scale Grade I •unilateral contusion, < 1 lobe Grade II •unilateral contusion, single lobe •simple pneumothorax Grade III •contusion > 1 lobe •persistent (> 72 hours) air leak from distal airway •non expanding intra parenchymal contusion Grade IV •major (segmental or lobar) air leak •expanding intra parenchymal haematoma •primary branch intra pulmonary vessel disruption Grade V •hilar vessel disruption Grade VI •total uncontained transection of pulmonary hilum
Mediastinal injuries	Aortic Myocardial contusion Esophageal perf
Aortic injury	Classification •Grade I - intimal tear only •Grade II - intramural haematoma -an intact adventitia provides 60% of the tensile strength of the aorta •Grade III - pseudoaneurysm •Grade IV - complete disruption of the entire aortic wall
Aortic injury	-occupants involved in side-impact crashes -proximal descending aorta 65% -associated with myocardial injury -erect CXR 95% sensitive for aortic injury Helical CT -95% sensitive -80%specific -if normal, no further investigation usually required Aortic angiography •indicated if CT demonstrates mediastinal haematoma requires transfer to vascular suite for a prolonged period (60-90 minutes) Transoesophageal echocardiography •100% sensitive, 98% specific contraindications -no spinal clearance -oesophageal injury limited views of the ascending aorta & branches
Myocardial contusion	-lack of a gold standard test -chest pain is only present in 50% of conscious patients -ECG abnormalities 95% sensitive for clinically significant contusion ST elevation highly predictive of myocardial injury •other changes only 30% specific for clinically significant cardiac injury nonspecific ST and T wave changes are occasionally seen in leads V1-3 -may be due to acute right heart strain secondary to pulmonary contusion TOE •diagnostic test of choice •indications -evidence of pump failure -features of pericardial tamponade -new cardiac murmur -as part of anaesthetic assessment prior to high risk operative procedure Troponin test if haemodynamically unstable, ECG abnormalities present and echocardiography not available abnormal results should rarely (if ever) alter management
Cardiac arrhythmias following blunt chest trauma	-ventricular fibrillation on impact -delayed arrhythmias are atrial fibrillation -Delayed haemodynamically significant ventricular arrhythmias in the non shocked patient are exceedingly rare
Oesophageal perforation	penetrating trauma associated with injuries to -trachea -third or fourth thoracic vertebrae
Oesophageal perforation Assessment	•dysphagia •regurgitation of blood •subcutaneous emphysema •features of pneumomediastinum •food / fluid draining from ICC •fever within hours of injury
CXR	•mediastinal gas or widening •pleural effusion or hydropneumothorax -usually on the left •gastrograffin swallow demonstrates the site of perforation in 70% •gastroscopy should follow if gastrograffin swallow is non diagnostic -although there is a risk of enlarging the perforation
Management	•NGT •broad spectrum antibiotics •acid suppression therapy •immediate exploratory surgery without CT for -deep penetrating neck wounds -transmediastinal gunshot wounds -delay to repair strongly correlated with worse outcomes •stenting is usually the repair method of choice •pleural drainage with large-bore catheters
Diaphragmatic injuries	Epidemiology •90% due to motor vehicle crashes •10% dx after 48 hours of injury •80% have other abdominal injuries •mean ISS > 30 •50% have pelvic fractures •33% mortality rate -mainly due to blood loss from associated injuries Pathology •left side involved in 70% •right side involved in 30% -the liver cushions the right side
Most likely organs to herniate	-omentum -transverse colon -stomach -small bowel •delayed presentations are as a result of -obstruction -infarction -fistula 50% present with delayed rupture
Diaphragmatic injuries CXR	•70% have at least one abnormality, most are non specific -elevated hemidiaphragm -pleural effusion -lower rib fractures -diaphragm shadow does not reach the chest wall -hemithoracic opacity with displacement of mediastinum despite properly placed ICC •10% are diagnostic -NGT/gas filled bowel in chest -ECG: left axis deviation in large left sided ruptures with cardiac displacement

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	Created by DrMoriarty over 9 years ago