Thoracic Trauma

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Primary Survey

History:  AMPLE

A— allergies, M— medication, P— past medical experience, L— last oral intake, E— events surrounding the injury

Physical Examination
Airway, Breathing, Circulation, Level of consciousness, AVPU: (Awake, Opens eyes to voice, Opens eyes to painful stimuli; Unarousable)
Exposure
  • Patient is completely disrobed, cutting away all the clothes.
  • Visual inspection of the entire patient.
  • Log–rolling the patient to inspect the back.
Thorough INSPECTION of the chest wall including frequency & pattern of breathing, external evidence of trauma  & structural defects of the thorax.
PALPATION to detect surgical emphysema, paradoxical movements  & a stove-in chest. AUSCULTATION & PERCUSSION to reveal the existence of TENSION PNEUMOTHORAX (look for decreased movements on the affected side with a hyper-resonant percussion note, reduced breath sounds in the axilla and shift of the trachea to the opposite side).  Haemothorax: dullness to percussion, low BP, pulse, skin perfusion, neck veins, muffled heart sounds, use of accessory muscles to breathe is noted.
RESUSCITATION:
First treat the life-threatening conditions; hypoxaemia, hypovolaemia, & cardiac tamponade on the following line.
Secure Airway
Suctioning oropharyngeal airways.  Scooping out all the foreign bodies, mud & blood.  Pull the tongue, stabilize the jaw, place oropharyngeal airway.  If the patient is unable to maintain airway then INFORM ATTENDING.
Cricothyroidotomy, endotracheal intubation or tracheostomy is needed.
BREATHING
Once the airway is securely established and maintained, maintenance of adequate ventilation is the next priority. In case ventilation is interfered then;
  • Start positive pressure breathing with (ambu-bag or anaesthetic machine)
  • To supplement it, administer 100% oxygen
Specific Conditions Leading To Ventilatory Failure are:
Compromised due to tension Pneumothorax and massive haemothorax.  Requiring emergency pleural drainage.  For TENSION PNEUMOTHORAX, as an emergency measure, insert a short wide-bore needle into pleural cavity through second intercostal space 4 cm from sternum & connect it to a water seal. INFORM ATTENDING.
Needle is to be replaced by chest intubation as early as possible.
Technique For Chest Intubation: Site: 5th intercostal space in anterior or mid axillary line.  Anaesthesia: 1% Xylocaine infiltrated locally. Incision: Made to admit a finger easily.  Procedure: Intercostal muscles are separated with artery forceps and pleura is punctured. Palpate thoracic cavity before thrusting chest tube to ensure absence of gastric / cardiac herniation through diaphragmatic rent. The chest tube is inserted and is connected with water seal.
If there are signs of ventilatory insufficiency due to flail chest, contusion or aspirations then pass endotracheal tube.
RESTORE THE CIRCULATORY VOLUME
Infuse 1-2 liters of Ringer’s lactate rapidly in case of shock, through two large-bore lines.  If B.P. does not recover, then give blood transfusion in addition.  Continued bleeding more than 60 ml in 15 min in drain then
INFORM ATTENDING, THEATRE SISTER & ANAESTHETIST
And shift the patient to operation theatre.  Resuscitative thoracotomy is needed.
INDICATIONS OF THORACOTOMY
Patient is in shock in spite of full resuscitative measures.
More than 1-liter blood at the time of initial drainage.
Continued bleeding 200 ml/hour or more.
Rupture of bronchus, aorta, esophagus or diaphragm.  Cardiac tamponade (if needle aspiration is unsuccessful).
Cardiopulmonary arrest less than 5 minutes before arrival in case of penetrating & on arrival in case of blunt injury.
IN CASE OF TAMPONADE / CLINICAL FEATURES OF CARDIAC TAMPONADE:
  • Start Cardiac massage.
  • Do needle aspiration preferably under USG guidance.
Technique:  Advance a wide-bore needle to the left of xiphisternum towards the heart.  Call ATTENDING, thoracotomy might be lifesaving.
OPEN PNEUMOTHORAX: Stitch / pad the wound.  Place intercostal drain.
SECONDARY SURVEY
Once a patient has been stabilized.
· Detailed history.
· Head-to-toe examination.
· Chest radiographs PA / AP / Lateral view.
· ECG.
MANAGEMENT
· Cardiac monitoring of all the patients.
· In patients with E.C.G. changes, monitor with telemetery for 24 hours.
· If there are signs of cardiac failure then echocardiography.
Paradoxical Movements of Flail Chest
Adequate analgesia including local infiltration, (technique given below intercostal block), intercostal block and regular physiotherapy.
Monitor for rapid & shallow respiration with cyanosis, tachycardia & hypotension (severe ventilatory interference).  Mild hypoxia produces cerebral confusion & restlessness followed by unconsciousness in severe cases.  Regular blood gas analysis.
If patient becomes hypoxic with PO2 less than 6KPa (approximately 45 mmHg)
Arrange for positive pressure ventilation for up to three weeks in the ICU
Treat the complications like pain, pneumothorax or paradoxical movements.
Analgesia: Diclofenac sodium 75 mg deep intramuscular injection.
Narcotic Analgesics: Pentazocine 30 mg / Pethidine 100 mg / Morphine 15 mg.  Titrate according to the response of patient.
Local infiltration with 0.5% Bupivacaine (INTERCOSTAL BLOCK).  Technique:  Inject 5 ml of 0.5% Bupivacaine in the intercostal space in the paravertebral region.
Fixation of Rib Fractures (If thoracotomy is being undertaken for others reasons):  Kirschner Wires or Rush nails are used.
Fractured sternum
Adequate pain relief & physiotherapy.
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