Which thoracic injuries are known as the ‘lethal six?’
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemothorax
- Flail chest
- Cardiac tamponade
Which thoracic injuries are known as the ‘hidden six’?
- Tracheobronchial disruption
- Aortic disruption
- Pulmonary contusion
- Blunt cardiac injury
- Oesophageal perforation
- Diaphragmatic injury
What is a flail segment?
When a no. of ribs are fractured in 2 places, the segment between the breaks is sucked in during inspiration and pushed towards during expiration –> loss of chest wall rigidity –> severe respiratory disress
How is a flail segment investigated? (3)
- Cinical
- Blood gas
- Imaging - erect CXR (Can miss haemothorax at base or pneumothorax at apex if lying down) OR CT scan if lung/splenic/liver injuries are suspected
How is a flail segment managed? (4)
- Pain relief
- Oxygen therapy
- Physiotherapy and close monitoring
- If patient shows signs of respiratory distress -> intubation and ventilation
What is a tension pneumothorax?
Collection of air within pleural space that causes mediastinal shift –> reduced venous return –> reduced cardiac output
Name 4 important clinical features of a tension pneumothorax.
- Tracheal deviation away from side of tension
- Decreased chest expansion
- Decreased air entry
- Hyper-resonance
How is a tension pneumothorax managed? (4)
- Decompression!! - 2nd intercostal space along midclavicular line
- Chest tube for residual pneumothoraces - 5th intercostal space (anterior: pec major; posterior: lat dorsi)
- O2 via mask
- Cover sucking wounds to prevent further air entering pleural cavity
When is surgical management of a pneumothorax indicated? (6)
- Reurrent
- Bilateral
- Tension
- Complicated (e.g. as a result of torn adhesion between lung and chest wall)
- Failure of conservative treatment after 5 days of damage
- Professional necessity (e.g. divers)
What are the NEXUS criteria?
Cervical spine injury cannot be excluded if any of the following are present, therefore requires imaging.
“NSAID”
Neurological deficit Spinal tenderness Altered consciousness Inebriation Distracting injuries (fractures etc.)
What is Beck’s triad?
Symptoms occurring in acute cardiac tamponade - when penetrating injury to heart causes blood to flow into in elastic pericardial sac
- Hypotension (and clinical signs of this)
- Distended jugular veins - due to increased venous pressure caused by reduced diastolic filling of R ventricle
- Muffled heart sounds
What imaging investigations can be undertaken in suspected cardiac tamponade. (2)
- CXR: globular heart
2. Echo: blood in pericardial sac
What are the three broad categories of shock?
A problem with the pumps, the fluid, and the pipes.
- Cardiac - can be both intrinsic (ACS, cardiomyopathy) or extrinsic (cardiac tamponade, tension pneumo)
- Hypovolaemic - haemorrhage or dehydration
- Distributive - anything that causes cvasodilation without increase in intravascular volume e.g. Sepsis, anaphylaxis, neurogenic
What two factors contribute to cerebral perfusion pressure?
Mean arterial pressure and intracranial pressure
CPP = MAP - ICP
CPP ideally 60-80 mmHg
What is the difference between primary and secondary brain injuries?
Primary - result of direct blow to head e.g. Brain lacerations, neuronal damage etc.
Secondary - consequence of hypoxia, ischaemia and decreased blood flow, compression by cerebral haematomata and depressed skull fractures
List 3 features of diffuse axonal injury seen on CT scans.
- Non-focal
- Loss of grey-white interface
- Intracerebral haemorrhages
How is a diffuse axonal injury managed?
Steroids and mannitol
How does an extradural haemorrhage arise?
Tear of middle meningeal artery or one of its branches
List 3 clinical features of an extradural haemorrhage.
- General increased ICP symptoms - headache, vomiting, drowsiness
- Consciousness may be lost after lucid interval
- Ipsilateral pupil dilatation, preceding contralateral hemiparesis
What does a CT of an extradural haemorrhage look like?
Biconvex - blood pool limited by sutures
How is an extradural haemorrhage managed? (3)
- Once confirmed by CT - burr hole
- Mannitol and hyperventilation
- Craniotomy to expose bleeding point and secure bleeding vessel
What does a subdural haemorrhage look like on CT?
Crescent-shaped
