1. Management of Surgical Emergencies Part 1 : Critical Care
Chest Trauma
Trauma causes of Breathlessness
and
Emergency Management
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2. Learning Outcomes Primary Survey
“B” - Breathing with ventilatory support
Life threatening breathing problems & Specific injuries
Features, signs and treatment
What we plan to cover in this session. Run through this quickly

3. Primary Assessment (Survey)
Rapidly identify immediate life threatening and reversible injuries
Airway, Breathing, Circulation, Disability
Treat problems as they are identified
Systematic
Repeatable
Worth reminding the participants of this important point

4. Primary Assessment: Expose (remember the back)
Look, feel, percussion, auscultation (remember the back if possible)
Treat life threatening problems
Reassess following intervention
Vital Signs, oximetry and CXR (if available)
Step-by-step guide to a simple routine for checking the Breathing and Ventilation in the Primary Survey. You could demonstrate it on one of the participants as you talk?

5. Penetrating chest injury
Primary Assessment:
Life-threatening injuries:
Penetrating chest injury
-v-
Blunt chest injury
Airway Obstruction
Tension Pneumothorax
Open Pneumothorax
Massive Haemothorax
Flail Chest
Cardiac Tamponade
ATOMiC

6. Primary Assessment:
Potentially life-threatening injuries to look out for:
Penetrating chest injury:
Tension pneumothorax
Massive haemothorax
Cardiac tamponade
Open pneumothorax
SIGNS
MANAGEMENT
Allow about 1 minute each for the participants to list these 3 injuries, plus their clinical presentations.

7. Diagnosis? Tension Pneumothorax
History of penetrating trauma, PPV or chronic airway disease
Common signs
Air hunger (tachycardia, tachypnoea, agitation, cyanosis – Sats<92%, SBP<90, RR <10)
Late / rare signs
Hyper-resonance , hypotension, neck veins, deviated trachea

8. Tension pneumothorax Clinical diagnosis X-ray not necessary
Management – Immediate Needle Decompression
How, where
Intercostal drain

9. Needle decompression

10. Needle decompression

11. Large haemothorax
Supine
Erect

12. Haemothorax Up to 40% blunt injuries Up to 90% penetrating injuries
Multiple sites
Potential to bleed up to 50% of circulating volume into each hemithorax
Massive Haemothorax = mL or 250ml/ hour over next 3-4 hours
400mL – blunting of costophrenic angle

13. More than one pathology!

14. Chest Drain insertion

15. Open Pneumothorax Definition Pathophysiology? Wound diameter?
Treatment?

16. Primary Assessment:
Specific, potentially life-threatening injuries to look out for:
(b) Blunt chest injury
- Flail chest (90% associated with pulmonary contusions)
- Ruptured aorta
- Ruptured diaphragm
Again, only a minute each to list these and brief discussion about pathophysiology

17. Multiple rib #s with flail segment

18. Flail chest

19. Wide mediastinum due to ruptured aorta

20. Wide mediastinum due to ruptured aorta

21. Ruptured left diaphragm

22. Act to fix what you find:
Oxygen (if available)
Needle decompression & secure
Chest drain v non-tube thoracostomy
?Thoracotomy: Indications in haemothorax? Penetrating injury
NB: Getting a CXR and calling the surgeons are non-therapeutic manoeuvres
Emphasise that the participants must act to save a life, and consider the timing of CXR and calling for help (call early, but act before help arrives)

23. Questions?

24. Summary: How to assess ‘B’ in primary survey
Specific injuries to look for and how to recognise them
Indications for chest drain
Timing of the CXR
Potential dangers of # ribs…
Remember to look at patients back
Go through these quickly: less than a minute each
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