Chest Trauma Case Discussion

Outline
• Brief case History
• Primary survey: Initial assessment and
management
• Secondary survey: head to toe
• Investigation
• Definitive management
• Disposition
• Procedure and equipment
 Case
• This is a case of 34yrs female patient G2T2A0 who
was involved in a road traffic accident. She was
involved in a head on collision which being the
driver of a car. It was noted that she had her
seatbelt on.
• On observation she is moderate respiratory
distress, she open her eyes to verbal stimuli, is
disoriented in time and place but obeys command.
His bp is 85/40 mmhg ,S02 89%, pulse145bpm.
 Priorities
• From the case history what are your main
concerns?
• Does this change the order of your
assessment and management?
• Can this information be used to determine
future needs?
 Primary Survey
• What is your initial management of this patient?
Assess; how? What order ? Why?
• Look
• Listen
• Feeling
• Axillary investigation?
• management=resuscitation (ATLS Principle)
• You must assess, manage immediately if need, you
must reassess .Why?
 Airway-C-spine
How assess?
• Look for what ?
• Listen for what?
• Feel for what?
How will you manage the airway?
Suction, maneuvers(indicated>contraindicated),
adjuncts What type? Advance airway vs surgical
airway(indication>contraindication)
Is there an airway issue in the patient?
 Clinical findings
• Look- signs of respiratory distress .
• Listen – clear voice, no abnormal sounds
• Feeling- good air flow
 Breathing
• how to assess?
• What to look for?
• What to feel for?
• What to listen for?
• Describe the mechanism of breathing?
• What are the systems involved?
• Briefly explain the function of these organs
 Breathing
• What are the life threaten problems that can
affect breathings? In this patient ? In another
patient?
• What is the role of investigation in this patient
• How do your manage the breathing problems
in this patient?
Chest X-ray
Chest X-ray
 Clinical findings
• Look: rate 44bpm, rhythm :regular, deep:
shallow with minimal abdominal breathing,
paradoxical movement of the left chest
• Feel : tenderness with crepitation to the left
anterio-lateral hemithorax.
• Listen: decrease BS in left hemithorax with
crackles.
 Breathing
• What are the possible problems with breathing?
Flail chest?
Fracture ribs, how much blood is lost from a
fracture ribs? will the pain affect breathing?
Pulmonary contusion: what is the management
tissues with it?
• What are the other life threatening chest
injuries?
 circulation
How to assess?
Look for what ?
Feel for what?
Listen for what?
Is he in shock? If so what types? Does it matter?
How much shock is he in? where is the blood? What
adjunct can help?
How do I manage it? What type of fluid? Saline?
Blood? How much? How to I know it is helping?
 Clinical Finding
• Look: pale+++, stuporous? Absent urine output
• Feel: pulse 144bpm, rate:irregular, volume:very
low-thready, CPR>4,only carotid ,distented neck
veins,
• Listen: S1S2M0, decrease heart sounds with
absent of palpable apex beat
Additionally: full(mildly) distended abdomen,
decrease BS,generalized tenderness with guarding.
 Circulation
• What are the possible circulation issues?
Hemorrhage shock, spinal shock, cardiac shock
What is FAST? How is it done?

What is a trauma series?

Circulation
FAST
Cardiac Contusion
Fast
 Laboratory
• HB 5.0g/dl-is old or new?
• Creatinine 2.4mg/dl
• Bun 40mg/dl . Is he in renal failure? What
type?
• K 6.4mmol/l
• Na 127mmol/l
• Cl 110mmol/L
• HCG:positive
 Circulation
• She has minimal increase in blood pressure
despite 4l ringer lactate.
• What is your next step?
• How much urine do you expect with proper
fluid resuscitation?
• What is the role of pressors?
 Deficit/Disability
GCS, AVPU
Pupillary size and reaction
Motor or sensory deficit
Reflexes
RBS
 Clinical Finding
• E? M? V?
• Pupils 3mm equal and sluggishly reacts to light
• Moves all limbs equally
• Decrease lower limb power, sensation(umbilicus down) and reflex
What are some lateralizing signs?
Where and what is the lesion?
How do you grade must power?
Name the spinal tracts
What is myotomes ? Dermatomes?
List the reflexes you can perfom?
Muscles power
Spinal Tracts
Myotomes
Dermatomes
Reflexes
Reflexes
 Exposure
Remove all clothes
Temperature
Complete examination including back
How do you perform a log roll?
Abdomen with lower distention
Dre: absent sphincter tone with blood on glove,
blood at the urethral meatous and introitus.
 History
A
M – acceleration vs deceleration, temporary
cavitation, blunt vs penetrating ,high vs low
velocity
P
L
E
Primary Survey
 Differential diagnosis
• What are your differential diagnosis?
• What are the specific clinical feature of each?
• What type of investigation you will use to
make a definitive diagnosis?
• How will you manage them?
 Secondary survey
Vital signs: bp110/68mmhg, pulse 80bpm,So2-99%
Head to toe examination
Heent: Neck supple, Perrl, trachea central
Chest: lungs and cardiovascular system
Abdomen: generalized tenderness with guarding , decrease bowel
sounds, DRE: decrease sphincter tone with blood on glove, lower
abdominal mass HF 16wks
MSK: loss of lower limb power1, sensation and reflexes
Skin: nad
Lymphatics:nad
GU: VE: CX soft, short 3mm os
 Abdominal injuries
• What is injured? Hole or solid? Name them?
• Solid-bleed =shock, peritonitis
• Hole-spill blood, urine, fetus, feces, bile etc
• What is peritonitis, is it local or generalised?
• What are the signs and symptoms?
• What is the difference in the pain?
• which one of the above produces a more intense
peritoneal reaction?
• How to you treat? Pt stable vs unstable
Abdominal Xray
Spinal X-ray
Ultrasound
Secondary Survey
 Equipment for Chest placement
What are the equipment you will need to
perform a DPL?

What are the equipment needed to perform a

pericardiocentesis?
Equipment
Equipment-Pericardiocentesis
 Procedure-DPL

Describe the procedure(DPL)

How do you interpret the results?

Describe how you would perform a

pericardiocentesis?
Pericardiocentesis
 Disposition
• Admit or discharge
• Referral for definitive management
• Admit to ward
• Admit ICU
• Admit MOT