5.1 K) Surgical Chest Trauma

Front 1

What are the 3 "Signs of Life" In patients

presenting in extremis post thoracic trauma?

Back 1

The 3 Signs Of Life :

1. GCS > 3
2. Evidence of reflexes

[ Pupillary ; corneal ; gag )
3. ECG: electrical activity

Front 2

What are the Objectives of EDT

{ Emergency Department Thoracotomy } ?

Back 2

1. Release Pericardial Tamponade
2. Control Cardiac haemorrhage
3. Control intrathoracic bleeding
4. Perform open cardiac massage
5. Temporarily occlude the descending

thoracic aorta. (Cross Clamp Aorta )

Front 3

What are the survival statistics for Emergency Department Thoracotomy (EDT) with

penetrating chest wounds ?

Back 3

- 35% survival with penetrating CARDIAC wounds

( Dunn states 66% surviving neurologically intact with penetrating chest trauma and sign of life within previous 10 minutes)

- 80% survival intact for stab wound +

tamponade.

- 15% with ALL penetrating thoracic wounds. ( Dunn 55%)

Front 4

What are the Classes of shock in regards to EDT ?

Back 4

Class I : Absence of signs of life
Class II : No Blood pressure / pulse BUT ECG electrical activity
Class III : SBP < 60 mmHg
Class IV : SBP 60-90 mmHg

Front 5

Which Classes of shock are considered

indications for EDT with penetrating thoracic trauma ?

Back 5

Class II and III

Front 6

What are the Indications for EDT ?

Back 6

Signs of Life +
Class II or III shock +

Evidence of
1. Pericardial tamponade
2. Intrathoracic haemorrhage

Front 7

What are considered "Poor Predictors" of

outcome with patients presenting in extremis with thoracic trauma ?

Back 7

Poor Predictors of Outcome with Thoracic

Trauma :

1. No signs of life
2. Blunt trauma
3. Pre-Hospital CPR > 5 min
4. Associated severe head injury /

multi system trauma

< 2% survival rate

Front 8

Which is incorrect regarding Sternal fracture and Blunt myocardial injury ?
A. A high risk patient is one with an abnormal ECG and raised troponin.
B. A normal troponin AND a normal ECG have a 100% negative

predictive value (NPV) for myocardial contusion.
C. The incidence of arrhythmias with sternal fractures are < 1.5 %
D. The mortality of sternal fracture and blunt myocardial injury is 2%.

Back 8

D. Sternal Fracture + Blunt cardiac injury

= mortality < 1%

Front 9

In regards to Sternal fracture and blunt myocardial injury, which of the following is

incorrect?
A. A normal ECG and normal troponin (Troponin I), requires no further

Investigations.
B. An abnormal ECG OR abnormal troponin requires monitoring +/- Echocardiography.
C. An abnormal troponin PLUS ECG requires admission to ICU / CCU and echocardiography.
D. The incidence of arrhythmias with sternal fracture and blunt

myocardial injury = < 0.5%

Back 9

D. Arrhythmias with sternal fracture and blunt myocardial injury = < 1.5%

Front 10

ETM Course Manual

In regards to Massive Haemothorax, what are the 3 indications for Emergency Thoracotomy

following insertion of a chest drain?

Back 10

1. > 1500mL blood drained at insertion

2. > 200mL/Hr drained for 3 consecutive hours

3. > 100mL/Hr drained for > 6 hours.

Front 11

Tintinalli

In regards to Pneumomediastinum, which of the following is correct ?

A. 20% cases may demonstrate tracheobronchial injury

B. It is usually the result of alveolar rupture

C. The pathophysiological Macklin Effect is found in 20% cases.

D. Hamman's crunch is a crunching sound during diastole.

Back 11

B.

A = 10% Tracheobronchial injury

C = 40% have Macklin effect

D = Systole

Front 12

Tintinalli

what is the Macklin Effect with

pneumomediastinum.

Back 12

Macklin Effect = Alveolar rupture leads to

dissection of air along the bronchoalveolar sheath and spread of air to the mediastinum.

Front 13

Tintinalli

In regards to pulmonary contusions in trauma, which of the following is incorrect ?

A. Pulmonary contusions are haemorrhage and oedema of the lung.

B. Patients with contusion > 20% of lung volume have an 80% chance of ARDS.

C. 50% contusions are not visible on the initial CXR.

D. Lung opacification on CXR within 6 hours of blunt trauma is diagnostic of pulmonary contusion.

Back 13

C. 70% of Pulmonary contusions are not visible on initial CXR

Front 14

Tintinalli

List 4 important management considerations with pulmonary contusions.

Back 14

1. Avoid unnecessary fluid administration

2. Use Optimal analgesia

3. Use aggressive chest physiotherapy

4. Avoid "obligatory" mechanical ventilation

Front 15

Tintinalli

What Analgesic options are available for

pulmonary contusion.

Back 15

1. Parenteral analgesia

2. Intercostal nerve blocks

3. Epidural analgesia

Front 16

Tintinalli

Which of the following is incorrect regarding

Pulmonary Contusion management?

A. Pain control is of paramount importance.

B. Patients with < 1/3 total lung volume contused ( one lobe) usually do not require mechanical ventilation.

C. Mechanically ventilated patients can be managed with the non-injured lung "down".

D. Independent lung ventilation is a consideration is unilateral contusion.

Back 16

B. < 1/4 (25%) total pulmonary contusion

> 1/4 of lung contused = mechanical

ventilation requirement need.

Front 17

Tintinalli

List the indications for ventilatory support with flail chest.

Back 17

1. PO2 < 80mmHg despite supplemental oxygen

2. Fracture > 8 ribs

3. Comorbid lung disease

4. Severe head injury

5. Shock

6. Multiple (severe ) injuries

Front 18

Tintinalli

Which is correct regarding Commotio Cordis?

A.It is the third most common cause of death in young athletes- with HOCM being the most common.

B. It is a primary electric event , resulting in Ventricular tachycardia.

C. The blow is 10-30 msec before the peak of the P wave - a time of

vulnerability to VF.

D. Smaller balls /projectiles are more significant than larger balls.

Back 18

D.

A = Second most common

B = VF

C = Blow prior to peak of T wave.

Front 19

Tintinalli

In regards to cardiac trauma, which is

incorrect?

A. Penetrating trauma affects the ventricles most often, with right > left involved.

B. Patients with stab wounds to the heart are 17 times more likely to

survive than gunshot wounds.

C. Up to 80% of stab wounds may develop Cardiac tamponade.

D.The most common artery involved with blunt cardiac injury is the right coronary.

Back 19

D. Most common artery involved with blunt

cardiac injury = LAD (Left anterior descending)

Front 20

Tintinalli

What is the Negative Predictive Values (NPV) and Positive Predictive Values (PPV) for ECG and serial troponin in Clinically significant Blunt cardiac injury?

Back 20

NPV for normal ECG and negative troponin

= 97-100%

PPV for abnormal ECG +/- Elevated troponin (s)

= 62 % [ 100% sensitivity ]

Front 21

Tintinalli

List the clinically significant blunt cardiac injury complications ?

Back 21

1. Cardiogenic shock

2. Arrhythmias requiring intervention

3. Structural cardiac abnormalities

Front 22

Tintinalli

List 3 immediately necessary important pieces of equipment for ED thoracotomy (EDT).

Back 22

1. Scalpel

2. Mayo scissors

3. Finochietto retractor

Front 23

Tintinalli

List 4 immediately important interventions once access is made to the left hemithorax in Emergency Department Thoracotomy.

Back 23

1. Direct pressure to intrathoracic haemorrhage

2. Pericardiotomy to evacuate tamponade blood

3. Digital occlusion of cardiac muscle defect

4. Stapling of cardiac muscle defect

5. Foley catheter insertion into cardiac defect

6. Cross clamping of descending aorta for

abdominal haemorrhage.

Front 24

Tintinalli

List 4 fractures on CXR that can be suggestive of a great vessel injury in Trauma.

Back 24

1. Sternum

2. Scapula

3. First rib

4. Multiple ribs

5. Clavicle ( with multi-system injuries)

Front 25

Tintinalli

List 4 CXR mediastinal clues suggestive for great vessel injury in trauma.

Back 25

1. Abnormal general appearance of mediastinum

2. Widening of mediastinum

3. Obliteration of aortic knob contour

4. depression of left mainstem bronchus. [ > 140 degrees]

5. Loss of paraverterbal pleural strip

6. Lateral displacement of trachea

7. Calcium layering at aortic knob

Front 26

Tintinalli

List 4 Common MDCT findings for Traumatic

aortic injury.

Back 26

1. Aortic pseudoaneurysm

2. Periaortic haematoma / haemorrhage

3. Rightward displacement of oesophagus and trachea.

4. Intimal flaps projecting into lumen.

Front 27

Dunn

What are the contraindications to resuscitative thoracotomy in trauma ?

Back 27

1. Blunt trauma without signs of tamponade

2. No vital signs within previous 10 minutes

3. Multiple wounds

Front 28

Dunn

When should the Resuscitative Thoracotomy be performed in the ED versus theatre ?

Back 28

Emergency Department

1. No perfusion on arrival ( Class II or III shock)

2. Unresponsive secondary to shock.

Theatre

1. Perfusion present on arrival

( Class IV shock)

2. Responsive

3. Temporary improvement post

pericardiocentesis

Front 29

Dunn

List 3- 5 key specific pieces of equipment that are required for initial Resuscitative

thoracotomy ? ( "getting into chest" )

Back 29

1. Universal Precuations -double glove - strict

2. 2 high volume suction sets

3. Scalpel - Size 10

4. Mayo Scissors

5. Rib retractors ( Finochietto )

And GOOD lighting ! ( head torch)

Front 30

Dunn

List 3-5 specific pieces of equipment required for Resuscitative thoractomy ?

( "Once in Chest" )

Back 30

1. Mayo scissors ( cutting pericardium)

2. Artery forceps

3. Staple gun (rapid ventricular repair)

4. Foley catheter

Front 31

ETM Course manual

List 5 Complications of Intercostal catheter placement.

Back 31

1. Trauma to intercostal neurovascular bundle.

2. Extrapleural placement ( s/c tissues )

3. Intrafissural placement

4. Intrapulmonary placement.

5. Mediastinal placement-penetration.

6. Trans diaphragmatic placement- organ injuries.

7. Infection

8. Local anaesthetic toxicity.

Front 32

ETM Course manual

List possible causes of failed pneumothorax

resolution after ICC placement.

Back 32

1. Misplaced catheter (ICC)

2. Disconnection of ICC from drain

3. Occluded ICC / drain tube

4. Persisting air leak from pulmonary

laceration OR tracheobronchial injury

Front 33

ETM Course manual

In regards to oesophageal perforation in

trauma,list the symptoms and signs.

Back 33

Symptoms

1. Odynophagia

Signs

1. Crepitus / surgical emphysema in neck

2. Pneumomediastinum on CXR

Front 34

ETM Course manual

What are the 4 Classic CXR features of

oesophageal perforation in trauma?

Back 34

1. Pneumomediastinum

2. Widened mediastinum

3. Pneumothorax

4. Left pleural effusion

Front 35

ETM Course manual

What are the percentage (%) complication rates for the following post sternal fracture ?

Myocardial contusion

Spinal fractures

Rib fractures

Back 35

Myocardial contusion 1-6%

Spinal fractures < 10%

** Rib fractures 21% **