Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina

🚑 Introduction

• Thoracic trauma accounts for ~25% of trauma deaths.
• In the UK, 90% follow blunt trauma (often MVCs). Penetrating injuries (e.g. gunshot wounds) are more common in the USA.
• Blunt vs penetrating injuries → very different courses. Penetrating injuries more often require surgery.

⚡ Mechanisms of Injury

• Direct blunt force: steering wheel, bat, fist.
• Acceleration/deceleration: sudden kinetic change (e.g. RTC).
• Shear forces: torsional in RTCs.
• Compression: crush by wall/tree/building.
• Blast wave injury: concussive wave from explosion.

🩺 Clinical Features

• Breathlessness & pain: fractures, flail chest, lung contusion.
• Hypotension & shock: causes include haemorrhage, tension pneumothorax, tamponade.
• Chest pain: rib fractures → need strong analgesia.
• Vascular damage: check major pulses & capillary refill.
• Raised JVP: tamponade, tension PTX, or heart failure.
• Subcutaneous emphysema: pneumothorax or oesophageal rupture.

🫁 Life-Threatening Injuries (ATLS priorities)

• External haemorrhage: direct pressure, dressings.
• Airway obstruction: suction, adjuncts, intubation; consider surgical airway if needed.
• Simple pneumothorax: air in pleural space → chest drain.
• Rib fractures (≥3): high risk of deterioration, esp. elderly → admit & monitor.
• Flail chest: paradoxical rib movement; suggests major injury with contusions & haemopneumothorax.
• Diaphragmatic rupture: blunt/penetrating; L > R; may be missed on CXR.
• Blunt aortic injury: deceleration force → suspect with shock not responding; may need endovascular repair.
• Oesophageal injury: subtle signs; requires surgical repair.
• Open pneumothorax: cover with 3-sided dressing, insert chest tube away from wound, then close definitively.
• Tension pneumothorax: one-way valve effect → tachypnoea, hypoxia, shock, tracheal deviation.
  • Needle decompression: 5th ICS mid-axillary line (preferred) or 2nd ICS MCL → then chest drain.
  • NICE: consider open thoracostomy if expertise available.
• Massive haemothorax: >1500 mL blood in chest → shock. Chest drain, blood products, likely thoracotomy.
• Cardiac tamponade: Beck’s triad (hypotension, muffled heart sounds, raised JVP).
  • Definitive: thoracotomy & repair.
  • Emergency pericardiocentesis if no surgical option.

🔬 Investigations

• FBC, clotting, U&E, glucose, lactate, amylase.
• Group & crossmatch 6–10 units blood.
• CT Traumogram.
• POCUS/Echo → pericardial fluid, cardiac trauma.
• Toxicology screen if indicated.

🛠️ Management

• ABC resuscitation, oxygen, IV fluids (prefer blood to crystalloids), analgesia, massive transfusion protocol if needed.
• Insert chest drain for PTX/HTX; consider resuscitative thoracotomy in penetrating trauma with tamponade.
• Ventilate carefully in contusions → low tidal volume, avoid barotrauma.
• ≥3 rib fractures, flail chest, age >65, ventilator need, or comorbidities → transfer to Major Trauma Centre.
• Needle decompression can fail (blocked/kinked) → finger thoracostomy more reliable.
• Chest tubes 28–32F are effective for draining haemothorax.

🩻 FAST & Imaging

• eFAST can rapidly detect PTX/HTX; negative scan doesn’t exclude PTX.
• Thoracic CTA → used for blunt aortic injury; stable partial tears often managed endovascularly.
• Medical management of aortic injury: beta-blockers → HR <80 bpm, MAP 60–70 mmHg.

📚 References

• Major Trauma Guidelines & Education
• NICE Guidelines on Trauma