TRAUMA - ADULT

ResponseCXR Findings:

• ETT just above the level of his clavicles
• NG tube in situ that migrates below the level of the right hemidiaphragm and curls around to the left above the level of the right hemidiaphragm
• Deviation of the NG tube to the right
• Elevation of the left hemidiaphragm
• Fracture left scapula(subtle)
• Left lung basal collapse/consolidation
• Left apical capping
• Widened mediastinum

DDx in order of severity:

• Aortic dissection/transection
• Diaphragm rupture
• Cardiac injury(blunt)
• Lung injury-contusion/laceration
• Spleen injury
• Fractures- scapula, ribs

ResponseEFAST

• assess for pericardial tamponade, assess for Type A dissection and assess for abdominal FF/PTx/HTx

Bloods

• FBC, G+H, coag - suspected haemorrhage and coagulopathy of trauma

CT pan scan

• given mechanism to assess for aortic injury, significant solid organ injury/abdominopelvic bleeding

Blood gas

• assess for shock - BE, lactate and response to Rx

ResponseMultiple displaced Rib Fractures – displaced rib fractures seen posteriorly
Rt TENSION Pneumothorax – expansion Rt hemithorax, deviation NGT to left, visible lung edge, subcut emphysema
Rt Pulmonary Contusion – Increased opacification throughout Rt lung field
Lt Pneumothorax – subcutaneous emphysema
Left Clavicle fracture – comminution of mid-clavicle

Measures to improve oxygenation

• Rt thoracostomy tube
• Lt Thoracostomy tube
• Increase FiO2
• Increase PEEP

ResponseWidened mediastinum
Opacification both lung fields L > R
L rib #s (2-8)
L subcutaneous emphysema
N.B Intubated is not an acceptable answer as the ETT is adequately positioned. Consider accepting L ICC malpositioned or kinked as a possible abnormality.

ResponseDiaphragmatic Rupture: NGT insertion, referral for operative repair
Left Haemothorax; ICC (careful insertion given diaphragmatic injury)
Multiple Lt rib fractures: analgesia, PCA, ?intercostal blocks

ResponseMain pathology: Mediastinal haematoma – likely great vessel injury
Reasoning
Wide mediastinum
Loss of aortic knob / Loss aorto-pulmonary window
Depressed left main bronchus
Widened right paratracheal stripe
Left apical pleural cap

ResponseMultiple left-sided rib fractures including displaced fractures of 5th and 6th Ribs posterolaterally.
Comminuted # of the mid-third of the left clavicle with 13mm craniocaudal offset
Patchy airspace opacification at the left lower lobe – likely contusion.
No significant haemo- or pneumothorax
No subcutaneous emphysema
Cardiac contour appears normal

Further investigations (List + justify)
CT chest - Further define injuries seen and evaluate for subtle PTx, HTx, mediastinal haematoma, radiological flail.
ECG - Cardiac contusion (dysrhythmia or ST segment changes)
FBE, UEG, LFT, lipase, G&H, coags - Evaluate Hb (and baseline), G&H in case of transfusion
Blood gas - Early signs of hypoventilation secondary to rib # pain (raised pCO2).

ResponseLeft pneumothorax – subcutaneous emphysema
Multiple rib fractures – left lateral displaced fractures visible
Left Haemothorax -veiling of left hemithorax (subtle)

ResponseBlunt aortic injury - widened mediastinum/abnormal aortic contour, perhaps L apical capping
L sided haemothorax - diffuse L sided opacification. ? would also accept contusion, though heart border v. well defined going against this.
Ring on finger across chest

immediate emergency department management?
Finger thoracostomy +/- ICC

ResponseRight large haemothorax

• Veiled opacification of right hemithorax
• Substantial rim of blood around outside of lung edge

Left hemi-diaphragm rupture

• Stomach clearly evident superiorly displaced in thorax
• Loss of diaphragmatic outline

Left lung contusion (also accept haemothorax)

• Opacification of visible left lung in upper zone

ResponseLeft haemothorax – veiled hemithorax, pleural cap
Mediastinal haematoma – wide mediastinum, rightward displacement NGT, paratracheal stripe, depressed left main bronchus
Right pulmonary contusion – right midzone opacities/consolidation
Right PTX – lucent right hemithorax, subcut emphysema

ResponseLeft tension pneumothorax

• Lung edge visible left upper lobe approx. 2cm in from chest wall
• Deep sulcus sign – basal air accumulation
• Mediastinal shift to right
• Definitive treatment = 32 Fr left ICC

Left pulmonary contusion = Alveolar (fluffy will do) infiltrate left lower zone

ResponseRight sided pneumothorax with mediastinal shift indicating signs of tension
Multiple right sided rib fractures
Needle from chest decompression attempt in situ right side of chest, possibly extra-thoracic
Extensive subcutaneous emphysema right chest wall
Small heart size – possibly from tension or massive blood loss
Increased opacity of collapse lung suggestion lung contusion

ResponseIdentify ongoing source of bleeding – blush on CTA - eg intercostal vascular focus
Identify other associated intra-thoracic injuries ie contusions, pulmonary lacerations
Quantify PTX to aid decision making around need for/ type of ICC
Quantify size of haemothorax and need for intervention
Identify evidence of radiologic flail and inform possible need for rib fixation
Exclude thoracic spine fracture

ResponseAtelectasis
Hypostatic pneumonia
Empyema
Progressive pneumothorax
Pleural fibrosis – restrictive lung disease

ResponseIV opiate ie fentanyl 50mcg repeated to comfort
PCA ie fentanyl or oxydodone ie oxycodone 1-2mg with 5 min lockout
Ketamine infusion
Intercostal nerve block under USS guidance
Serratus Anterior plane block under ultrasound
Oral drugs – paracetamol, ibuprofen, oxycodone doses

ResponseInitial dump >1500mL from ICC
Refractory shock
Tamponade
Tension pneumomediastinum

ResponseHypoxia
Hypovolaemia - ie shock. Only one point for blood loss.
Drugs - taken prior to arrival or during ICC insertion
Intracranial pathology
Hypercapnoea Hypoglycaemia

ResponseDecreased dose of induction agent – Ketamine 0.5mg/kg to mitigate haemodynamic depression
Hi-Flow Oxygen throughout induction – NP O2 @ 15lpm + BVM @ 15lpm through induction/apnoea
Avoid apnoea – bag through induction to avoid acidosis and hypoxia
Fluid load to counter vasodilation – 1u PRBCs during induction

ResponseTube in wrong place
Blocked ETT/sputum/blood Anaphylaxis
Tension PTX
Ventilator dysynchrony
Primary lung pathology - contusions
Think DOPES

ResponseSurvival poor <2%
Potential indication - Blunt trauma + arrest <10 min WITH pericardial effusion + cardiac activity on PoCUS

Response**Controversial area** / no evidence
If medical cause of arrest – has a role
If important procedures NOT done – likely no role / inhibits
If important procedures done – maybe role

ResponseThe use of biomarkers is unclear. Patients with haemodynamic instability and/or abnormal ECG/dysrhythmia will need echo & admission for monitoring regardless of troponin results. If there is no haemodynamic instability, no physical signs suggesting cardiac injury and no ECG abnormality an elevated troponin is non-specific & has little prognostic value. Moreover, troponin elevation occurs frequently in the setting of trauma (without cardiac injury) from catecholamine-induced stress, hypovolaemic shock with hypoperfusion/reperfusion injury, microcirculatory dysfunction etc) so and likely results in unnecessary admissions
(Nsyd 2021.1-13)