Pestana’s Surgery Review, Ep. 2 – Trauma

All right, the first few vignettes we're going to see on neck trauma are penetrating trauma to the neck. We made the point a little earlier that most penetrating trauma we end up operating the patient to repair injuries. But let me try to be now a little more specific and give you first what are the absolute indications to pick the answer that says go to the operating room. Okay, this would be any penetrating injury of the neck where the patient is rapidly deteriorating. So whether it happens to be a gonciord wound or a star wound, if the vignette says blood pressure is going down, not responding to fluids, a patient is dying, then the only answer is run to the operating room and open the neck and try to stop what's going on. There is a second pretty much absolute indication. All gonciord wounds to the middle part of the neck end up in the operating room. That particular location on the neck is crammed with important structures that shouldn't have holes in them. And if we have a gonciord wound to that part of the neck, the middle song, we always have to operate. We also have to operate clearly on any penetrating injury of the neck, whether it's evidence of injury of an important organ. For instance, if the vignette says there is a big expanding hematoma, that's obviously coming from a big block vest so that we need to be repair. The vignette might say the patient is speeding up blood, coughing up blood, well there's being an injury to the trachybronchial tree or to the esophagus. So that's another reason. However, if we're giving a vignette, that is a stab wound to the neck. We really have to look then, is there every day of injury like I just described, because otherwise the stab wound to the neck has more flexibility on the management than the gonciord wound. With that little background, let's begin to read the vignettes and we'll now see the various examples. Vignette number 15. A man has been shot in the neck and his blood pressure is rapidly deteriorating. There is only one answer here and that's rushed to the operating room. Easy. Vignette number 16. A 42-year-old man is shot once with a 22-carbure revolver. The entrance wound is in the anterior left side of the neck at the level of a thyroid cartilage. X-ray shot at the bullet is embedded in the right scale in muscle. He is speeding and coughing up blood and has an expanding hematoma under the entrance wound. His blood pressure responded promptly to fluid administration and he has remained stable. We can see in this vignette three clear indications that this patient needs to go to the operating room. The first one is he has a gonciord wound to that middle part of the neck. We already agreed that's one reason. We're also told he has an expanding hematoma under the entrance wound. Well, that's another reason. And we're also told that he's speeding and coughing up blood. So there is no question. The only correct answer here is go to the operating room. Explore the neck. He doesn't have the fourth one that we exemplified on the previous one. His blood pressure is actually responding and he's stable but he still ends up in the operating room. Now let's begin to look at the exceptions. Number 17, a young man is shot in the upper part of an eff. The valuation of the entrance and exit wounds indicates that the trajectory is all above the level of the angle of an animal. A steady trickle of blood flows from both wounds and does not seem to respond to local pressure. The patient is strong and combative but seems to be otherwise stable. Now we have the upper most part of an eff. You know, that's not very friendly surgical territory. Even though we search and like to think that we can solve any problems anywhere, all we have to do is get in there. When we deal with vascular injuries, there is an essential concept that the first thing we have to do in a vascular injury is gain proximal and distal control. Before we go to where the injury is. This high in the neck with the base of the skull right there is very difficult to get that proximal and distal control. We can get the proximal one but the distal is inside the head. And so we would rather not operate in this area. Fortunately, this area doesn't pose a problem with a hierodigestic track. It's too high. So a conchalbuna that level wouldn't have to worry about the esophagus and the trachea of an injury. The only thing we have to worry about is a major vascular injury. So we prefer to deal with this one if at all possible by angiographic means. And otherwise we would prefer that what we do here is an emergency angiogram. The angiogram, the arteriogram identifies the injuries and then hopefully allows the radiologists to enbolize the bleeding vessels and stop the bleeding in that fashion. Let's go to another exception. The near number 18. A young man suffers a conchalbuna to the base of his neck. The entrance and exit wounds are above the clericals but below the crycord cartilage. He's in what an amyclist table. Well, this is a conchalbuna to an area of the body that is full of vital structures. We are going to want to operate on this young man. But if at all possible, we like to do every diagnostic study we can before we operate. Because the base of an egg is one of those boundary areas. It's the lower neck, it's also the upper chest. And the surgical approach may in fact be quite different depending on where exactly are the injuries. So if at all possible, we like to do an arteriogram on this patient. We like to do an esophagusogram. We like to do an esophaguscopy. We like to do a bronchoscopy. And then we can determine whether we can operate through the neck, whether we need to do a medium-strone otomor, whether we need to do both neck and perhaps an upper chest exposure as well. We need to know where to put our incision, what surgical approach to use, and therefore if at all possible, we want those studies. Now we're going to move to the stab wounds, being adamant-19. And the chorus of a bar fight, a young man is stabbed with one's and the neck. The entrance wound is in front of a sternomastoid muscle on the right at the level of a thyroid cartridge. The patient is completely asymptomatic and his vital signs are completely normal. This is one that we can just observe clinically and see how it is. Now if we had been told his blood pressure was deteriorating, we would have needed to operate. If we had been told an expanding hematoma, we would have need to operate. If we had been told he was speeding up blood, coughing up blood, we would have had to operate. But with a stab wound that is completely symptomatic, even when it is in this middle of the neck, that had it been a gonchered wound, we would have wanted to operate. We can then have a more flexible approach. Alright, let's talk about blood trauma to the neck, near number 20. The patient who was the unbelted right front seat passenger in a car flies through the windshield when the car crashes into telephone pole at 30 miles an hour. He arrives in the yard strapped to a headboard and with sandbags and bold sights of the neck. He has multiple facial lacerations but is otherwise stable. Examination of the neck reveals persistent pain and tenderness to palpation over the posterior midline of the neck. Neurological exam is not. If somebody flies through the windshield, it sustains this kind of trauma and then says my neck hurts here. We have every reason to believe he may have a bony injury to the cervical spine. But we're told that it is neurological, in fact, and that in fact is the critical example. If we had been given the same identical being yet, and we've been told the patient is quite replegic. Well, there isn't that much now that you can do, that you can show an exam, that you understand what the problem is. The problem is already irreversible problem. But in this particular situation where the patient still is neurologically intact but saying it hurts here and you know that the mechanism of injury could very well abdominis cervical spine. This is the one where your answer has to be to look at that cervical spine before anything else is done. and this would be either. There are cervical spannics raised, AP and lateral, including the autoid views, including from C1 to the first thoracic vertebrae. Or if you had reason to do a CT scan of the head, you could extend it to include the neck. Or I might add, if you had no reason for scanning the head, you do this cervical spannic raise and they are equivocal and the patient is still saying it hurts there. You actually might want to do a CT scan of the neck because that's actually a more reliable way to look at the C-spann injuries of the audit riser. Well we've been talking about spinal cord injury. We may in fact encounter some questions on the exam, where spinal cord injuries are the subject. Let me give you a little background as to how this might come about. I gave you earlier, told you that the emphasis on the questions is either very common or very high impact conditions. But there is another potential reason for a question being on the exam. If a very important principle of basic sciences finds expression in a clinical situation, it makes for a good breach between step one and step two. So we may find questions in step one that are at the horn with a clinical flavor and we may find questions in step two that are a clinical situation, but there is an underlying basic science principle. An atom is a good example of that. Spinal cord injuries are an excellent way to demonstrate that an atom is a spinal cord. In that context, the question will not be a complete transaction of a spinal cord because that one is too easy. Nothing works below the level. But the various syndromes of incomplete damage to the spinal cord are excellent ways to test for an atomic knowledge. That's what it has been at number 21. An 18-year-old street fighter gets stabbed in the back just to the right side of the midline. He has paralysis and loss of proprioception, distal to the injury on the right side and loss of pain perception distal to the injury on the left side. Now if you remember all the anatomy of all the tracks in the spinal cord, you should recognize that this is a hemisection of a spinal cord, the famous brown sequins in there. But even if you don't remember the anatomy in detail, you should still be able to identify because there are two clues here. One is there is one set of functions that is interrupted on one side and a different set of function that is interrupted in the other. Anytime you see that, you know it's a hemisection. But in addition to that, the only way to get a hemisection is with a clean cut. Another patient who jumps from a diving board into the shallow end of a pool and ends up with spinal cord injury. He doesn't end up with a hemisection. Hemisection requires a clean cut. So when you began reading this vignette and you read that the patient came in with a knife sticking out of his back or his neck, you already know this is going to be a hemisection. And then you see it because you have one set of functions on one side, a different set of functions on the other. In January 22, the patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distant to the injury while showing pressure evasion of vibratory scenes and position. Now, even if you don't remember an awful lot, it was spinal cord anatomy. You should remember that the spinal cord is behind the vertebral bodies. So if a mechanism of injury is something happened to vertebral bodies, the part of a spinal cord that will get damaged is the anterior part. You should also remember that vibratory scenes and positional scenes travel in the most posterior part of the cord. So this is an anterior cord syndrome. Let me point out incidentally that the anterior cord syndrome can also be seen in vascular injuries of the vascular supply of the spinal cord because it comes from the front. Okay. We need number 23. An elderly man is involved in a rear end or a wheel collision in which he hyperextends his neck. He develops paralysis and burning pain on both upper extremities while maintaining good motor function in his legs. This one is a central cord syndrome. Two things identified. The mechanism of injury was a hyperextension. And the other thing is this rather bizarre situation where the arms are in deep trouble but the legs are still working relatively well. This doesn't make sense if you think the brain is up here. The nerves go down this way. How could you still have nerves reaching the leg if they are not reaching the arms? Well the reason is the way the fibers are in the bundles and the ones that are closer to the center happen to be the ones that go to the arms. So this one is the central cord issue. Let me repeat this three spinal cord syndrome. If there is a nice sticking out of the back, something doesn't work on one side. A different set of function doesn't work on the other. That's handy section. If there's a blow out of a vertebral body, the only thing left working is vibratory and positional sense. That's the anterior cord syndrome. If the mechanism is hyperextension, the arms are severely damaged. The legs are still relatively intact. That is a central cord issue. Now what about management for any of these? Probably two complex for step two. I'm not reassuring you that step two was not an exam design for neurosurgeons and their board or orthopedic surgeons or general surgeons. It was designed actually for fourth year medical students. So these are relatively elemental levels of information that are needed and all the intricate detail of how to handle a damaged spinal cord are not required. You should know though that the best way to look at the spinal cord is with MRIs. Now obviously all of these patients will get x-rays first and probably the x-ray would already be in the vignette, the x-ray of the neck or one. But if we're then pressed, what would be the best way to see the spinal cord, the degree of damage to it, it would be with an MRI. In one little additional detail, there is some evidence that high dose zeros, if given as soon as possible after the injury, may end up with a better outcome for the patient or if it hadn't been done. So you may find that I'm served in your question as the first thing you do before the neurosurgeons or the orthopedic surgeons get involved. Alright, let's move on now to chest trauma. I need a little introduction to chest trauma. I have been mentioning so far that penetrating trauma and blonde trauma are two very different things. But in the case of a chest, there's a little bit of an overlap, a little bit of a blending of the two in two ways. One is that there are a number of conditions that happen when there is penetration to the chest in the standard way, a gonshot one, a stab one, and I speak. But almost every one of those things that we see with gonshot ones that we see with the stab ones, we could also see with blonde trauma. Because when you have severe blonde trauma to the chest and you get many broken ribs, the jagged edges of a broken ribs can be driven in by the trauma and becoming essence penetrating weapons. And so that clear distinction between what blonde trauma produces on one hand, what penetrating trauma produces on the other, we may not see it on the chest. The second exception has to do with the management. I mentioned that in most parts of the body, penetrating trauma requires operative intervention to repair the injuries. And the chest, in fact, is very seldom does. Let's go ahead and begin reading the windows. Pull man's sleeves and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct participation over the seventh rib at the level of the anterior axillary line. Chest and trache confirms the presence of the chest. of a rib fracture with no other abnormal findings. In our rib fracture, first of all, is the most common blood injury that we see in the chest. And we have a tendency to think of it as a relatively trivial injury. And in a young healthy person, it is a relatively trivial injury. In a 75-year-old man, it can be infact deadly. And the way it would kill the patient is it hurts when you breathe. You cannot expand that chest. You avoid the afforded breathing. You get at the lectoses, you get pneumonia, and that's what kills our own men. So the answer for this vineyard for the management, we need to take away that pain. But in a way that doesn't interfere with the patient breathing. Don't pick the answer where you bind the chest. That's an effective way of eliminating the pain. You bind tightly the chest and you cannot breathe anymore and it doesn't hurt anymore. But the pain is going to get the atleast this isn't any money. Don't pick the answer either where you give in so much narcotic medication. You take away the pain because you take away respiratory drive as well. So the correct answer here is a local block. The correct answer is a local anesthetic and nerve block that takes away the pain where the fracture rebees but it still enables the patient to breathe. All right, let's move on. In January 2, the 25-year-old man is stabbed in the right chest. He's moderately short of breath and has stable vital signs. There are no breath sounds on the right and that's hyper-resonant to per caution. Well this is a penetrating injury. There are no breath sounds on one side. It sounds like a drum when you bark off. This is clearly a pneumothorax, the most common thing that happens with penetrating injuries to the plural space. But let me emphasize that this is a plain pneumothorax. This is not the tension pneumothorax we reviewed earlier. And the tension pneumothorax we reviewed earlier air was getting into the plural space and then putting it out. With every breath the patient took more air was added. High pressure developed that pushed the media's time to decide and that patient was in shock and dying. This isn't happening here. This is just air in the plural space. Ecolapse long and you know, more very short of breath but less free to vignette again, stable vital signs. So the first thing you want in this patient is the chest x-ray. And I have to point that out because on the previous one and one of the tension pneumothorax I had wanted you not to pick the answer where you got a chest x-ray of log gaseous because you had to save the life of that patient. This patient has time. So you start with the chest x-ray. It's going to show that there is no pneumothorax. And then again there is no need here to rush, farest with a needle and then with the chest tube. The next thing after the chest x-ray will be the chest tube. And the chest tube if I ask you where it will go in for a pneumothorax, we put it high second intercostal space in the front of the chest. Or a vignette number three. A 25 year old man is stabbed in the right chest. His moderate short of breath has stable vital signs. All breath sounds at the base on the right chest, faintly this of breath sounds at the apex, dull to per caution at the base. This is a good example of an exam question that may in fact give you physical findings that we may or may not be good enough clinicians to detect. But at any rate, if you have a penetrating injury and rather than having complete absence of breath sounds and a chest that sounds like a drum when you per cause, you have this breathing sounds going only at the base and it's dull there. Then you probably have blood rather than air. And so this would be clinically suggestive of a hemothorax rather than a pneumothorax. Now what do we do about it? Well, let's start with the chest x-ray again. We don't have here a patient that is dying. So a chest x-ray will confirm that the gentleman indeed has a hemothorax. And now comes the interesting part of what we're going to do about it. Let me give you a little background. Let's go into some baseline information. Most patients that bleed into a plural space from a penetrating injury are bleeding from a lung because the lung is the biggest target that one could hit when getting into the chest. And so that bleeding comes from a low pressure circuit. This is not blood coming out of a left ventricle or 120 millimeters of mercury. This is blood coming out of a right ventricle at 30 or 35. And furthermore, when the lung is injured, it tends to collapse. One line is that the bleeding usually stops by itself. We very seldom have to operate a patient to stop the bleeding when a penetrating injury has produced a hemothorax. But that doesn't mean we don't have to do anything because having blood in the plural cavity, contaminated blood, and this one is contaminated. It was a knife that got in there. And contaminated blood in the plural cavity is an invitation for that blood to become infected for an impanema to develop and an impanema is a very bad condition. So trauma surgeons and thoracic surgeons are very compulsive about evacuating all that blood in the plural space, which they will do with chest tubes one or more. So again, the answer for this being yet in terms of a therapy, after we turn the chest to the tray, is going to be chest tube. The case of the new mothorax, we put it preferentially at the top and the front. In the case of the hemothorax, it'll be at the base lower down on the side. But again, we need the chest tube to evacuate the blood. The chest tube goes in though, the chest tube will provide us also with very valuable diagnostic information because you have to realize that even though the lung is the biggest target, it's not the only target. And the patient could in fact be bleeding from something that bleeds far more vigorously than the lung does. Let's go to the next thing. Number four, a 25-year-old man stabbed in the right chest. No breath sounds on at the base in the right chest. Fain distant breath sounds at the apex. His toll to precaution at the base. We assume your chest tray has been taken and now our toll, the chest tube plays at the right plural base, recovers 120 cc's of blood, drains another 20 cc's in the next time. And 120 cc's of blood is not an enormous amount of blood and 10 cc's in the next hour is even less. So this confirms the fact that the blood is indeed coming from the lung. It's a small amount. It's already beginning to quit. All we need here is that chest tube. Let's look at the next one. The number five, a 25-year-old man stabbed in the right chest. His moderate short of breath has blood pressure 95 over 70. There is a clue there already. That's a little bit on the edge. A pulse rate of 100. No breath sounds are heard over the right chest, which is dull to precaution. The chest tube plays at the right plural base, recovers 1250 cc's of blood. That's a ton of blood. That's not the amount of blood we expect to see from a small, parinkymo lung injury. This patient is bleeding from a systemic vessel. In fact, a systemic vessel, more commonly, is an intercostal, right there where that knife went in. The presence of this much blood says to us, we have to go in and stop it. So the correct answer on this gentleman after we realize that he's bleeding that much, is he needs a thoracotomy for control of the bleeding side. And every time we make this decision, a small amount of blood doesn't require a thoracotomy, big amount of dust. There's always that need to know where is the divide in line. Actually I've read different divide in lines in the literature that deals with this. Some people say a thousand ccs is a good divide in line. Some people say 1500 ccs. I think to be safe from the exam, if it's over a thousand ccs, we ought to be thinking that a thoracotomy is the thing to do, as it was here. We could encounter. remember that everything's of being a systemic vessel in a different way. It could be that we don't get that much blood to begin with, but on the other hand it keeps draining at a pretty, pretty big clip. This could be net number six. A 25-year-old man is stabbed in the right chest. His mortal short of breath has stable vital signs. No breath sounds at the waist on the right chest. The brain distorts the breast sounds at the apex, the daltu per caution at the waist. A chest tube plays at the right plural base, recovers 350 cc of blood. Let me stop right there because with that no one would be jumping to the operating room. 350 cc's is not a lot, not a lot of blood. But here comes the critical part. Over the ensuing four hours he continues to drain between 200 and 300 cc's of blood per hour. This is adding up to a lot of blood. This is not coming from the lung. This patient also has a systemic vessel. Again probably an intercostal. He will need a thoracotomy. And in fact he's clearly need for a thoracotomy because if you read what the books say about this, they say if it adds up to 600 cc's in the next six hours that's a good enough reason to go in, a hundred cc's every hour. So this one needs the thoracotomy. Well we talked about pneumothorax, talked about hemothorax. Of course both could coexist. The number seven and 25 year old man is stabbed in the right chest. This model is short to breath, has stable vital signs. No breath signs on the right. His hyper-restonant to per caution at the apex of the right chest, dull at the base. And the chest x-rays shows one single large-year-old fluid level. You've got blood at the bottom, you have air at the top. And we need to manage each of the two conditions. We need to get rid of the air, we need to get rid of the blood. Again we're going to begin with chest tube. And here some people would put two chest tubes. One at the top to take care of the air, one at the bottom to take care of the blood. There are others who would say we can put it to you at the bottom. We push it all the way up to the top, the tubeless holes at multiple levels so it drains both the air and the blood. And I don't think that's a terribly important issue. They would offer you only one of those two potential correct answers. But let me point out because we're going to see another vignette-lull later on. The significance of that single large-year fluid level. Because if what you see in a trauma patient is multiple air fluid levels in the chest, that probably means bowels up in the chest. So this is one single large-year fluid level. All right. Now in the next vignette, we have a clinical condition that we should be able to recognize. And I think the challenge will be for us to understand how did it happen. That should be easy too. The 33-year-old man, which is a woman, is involved in a high-speed automobile collision. She arrives at the yard gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest and tenderness suggestive of multiple rip fractures. Blood pressure is 60 over 45. Straight is 160 feet. She has distended neck and forehead veins. She's diaphoretic. The left hemithorics has no breath sounds. It is hyper-resonant to percussion. Here's a trauma victim who's gone into shock, who has big, distended veins, and who's got trouble breathing. And no breath sounds on one side. And we already visited that issue a little earlier. And that is attention, pneumothorics. But you say, wait a minute, where is the penetrating injury? It's right there. Multiple rib fractures. And remember, we made the point that the jagged, etch, or broken ribs can in fact become a penetrating weapon as they're driven into the patient. This patient has attention, pneumoth. And she needs, of course, a needle too. And the side of the chest that is full of air, followed by etch, etch. That's she's going to need more. Because actually this vignette is our introduction now to belong trauma to the chest. And I need to go into a rather extensive background information here. And we have a question on the exam that gives us belong trauma to the chest. And this is major, big time belong trauma to the chest. There are three issues that we have to pay attention to. There may be an obvious injury. In this case, it was attention, pneumothorics. But in addition to that obvious injury, there are a couple of injuries in the chest due to severe belong trauma that may not show up right away, but show up later. And therefore we have to monitor for them the include pulmonary contusion and myocardial contusion. So this particular case that we already read, we know the immediate therapy is the needle to the chest and the chest tube because we have to deal with that obvious tension pneumothorics. She has. But over the ensuing day or two, we're going to be repeating chest x-rays and doing blood gases to identify pulmonary contusion should it become obvious later. And we're also going to be doing EKGs and perhaps cardiac enzymes to identify myocardial contusion in case it doesn't show up until later. But that's not the end of it. There is also the possibility in severe deceleration injuries of a hidden injury that doesn't show up at the beginning and will not show up until the patient suddenly dies. And therefore we have to actively look for it. And that is the famous traumatic transaction of the aorta. As we mind ourselves what this is all about. The patient is going at 30 miles an hour or 50 miles an hour and comes to a starting stop. At that moment of a deceleration, the arch of the aorta which is free to move keeps going forward that the descending aorta which is fixed doesn't. And at the junction of it to the aorta can crack. Now you might be thinking what if the aorta cracked in two, the patient's going to exign we need at the site and indeed that often happens. But that patient will die at the scene of the accident. That patient will not make it to the hospital. And that patient will not make it to the USMLE because the USMLE doesn't deal with the people. But there is a subset of patients that get the traumatic transaction of a aorta that have a transaction of the intima, a transaction of the media. But the adventitious stays intact. A big hematoma forms but it is contained. That patient may be completely asymptomatic. But that adventitious cannot hold. You know the pounding of the arterial pressure very long. A few hours later that is going to blow and the patients are to die. So any question on the exam or a patient has suffered severe deceleration injury which is trauma we have to actively look for a traumatic transaction of the aorta. Let me tell you how we do that. The first thing we do is we look at the chestache rate which is always one of the first things that a patient like this gets to see there is a wide media stine. The chestache rate shows a wide media stine and we have a very high index of suspicion that the patient may have a traumatic transaction of the aorta. We don't know that that's the case. The wide media stine is not diagnostic. Neither is for that matter the absence of a wide media stine sufficient to roll it out. But the wide media stine tells us this is very likely to be the case. The next thing we do is a spiral CT scan of the chest. Spiral CT scan is a high quality, high definition, very elegant CT scan that gives us all cuts at very close to one another with a great deal of detail. That spiral CT scan may in fact be able to establish diagnosis and show us yes the patient has a traumatic transaction of aorta and then the repair is not immediate. But if that spiral CT scan is negative, we know that spiral CT scan is not 100% diagnostic. If we had the wide media stine to begin with and then we have a negative spiral CT scan We're not going to. quit there. We're going to keep moving to a more aggressive story. We would do an arteriogram and a u-autochrome to be sure that the patient does or doesn't have the traumatic conception of the order. On the other hand, if a patient doesn't have the wide media stand-up to begin with and now we don't have a high index of suspicion, we're not going to quit, we're going to do the spiral city but that will be as far as we go. So if that spiral city and the patient who didn't have the wide media stand-up is negative, we quit at that point and we do not feel compelled to continue with a more invasive and more risky arteriogram. All right? Well, let's move on to the next vignette and we're going to have this issue come up time and time again. The end of the night. The worker has been injured at an explosion in a factory. He has multiple cuts and lacerations from flying debris and is obviously short of breath. The paramedics at the scene of the accident has a certain that he has a large flap like wound in the chest wall, about 5 cm in diameter and he sucks air through it with every inspiratory effect. This is actually a special kind of injury. It's included here because the first aim is a very important facet of it. When you have that flap like wound and as the paramedics are looking at the patient they can see that with inspiration air goes in but with the exploration of the flap closes and the air stays in. This is a patient who left alone is going to develop attention no more thorax. This is a classical sucking chest wound and so this patient needs to have an opus addressing put over that wound. A good way to do this would be a big dress you know Vaseline Goss that sticks to that chest wall that prevents the air from going in when the patient inhales. But an elegant detail that may identify the best times around the exam is that that dressing gets taped on three sides rather than four. So when the patient might push and expel some of the air out during exploration the air can find a way out because you lift both the flap and the chest wall and you lift that flap that was left on tape on one side of it. Let's move on to the next one. Pinette 10. A 55 year old woman crashes her car against a telephone pole and high speed. On arrival at the yard she's in moderate respiratory stress. She has multiple bruises over the chest and multiple sides of point and earnest over the reach. X-rays from multiple refractors on both sides. On closer observation it is noted that a segment of a chest wall on the left side caves in when she inhales and bulges out when she has head. Now this is not a loose fragment like the previous one. This is not a sock in wound of the chest. There is a still an intact skin but the ribs are damaged underneath and the chest wall has lost the stiff integrity that it normally has and in fact you should have already recognized that this is a physical find in the we'll call paradoxical breathing leading to the diagnosis of the clinical entity that we call flail chest. So let's go back to our thinking here. This lady had big blunt chest crown. She may have an obvious injury. She may have the injuries that don't show up until later. She may have the injury have to look for. The obvious injury at this time is a flail chest. Now what do we have to do about the flail chest? At one time we used to think that the problem in the flail chest was mechanical. It had to do with the fact that that piece of the chest wall was moving the right way. So when that was the feeling the treatment was directed at that piece of the chest wall. We used to put traction to it, hang pulleys and wades from the chest wall maybe wire the ribs together or tape them or something. And we now recognize that in fact even though the chest wall is moving in a funny way, that in itself is an affecting much the respiration of the patient. If this patient isn't respiratory stress that is because she has also suffered pulmonary contusion underneath those broken ribs. So in reality the treatment for the flail chest is the treatment of the underlying pulmonary contusion. Now contuselong is very sensitive to fluid overload. So part of the therapy for the contuselong and therefore therapy for the flail chest is fluid restriction perhaps diuretics. If fluids are needed because of other problems of the trauma, we prefer colloid rather than crystalloid. That is a fluid that will have protein in it that will make it stay in the vascular tree more than leak into the lung paraceter. But perhaps even more important than that. The treatment for pulmonary contusion is the treatment for the ensuing pulmonary failure. And that will be evidence that will be measured by blood gases. So the management on this patient we have to make sure we don't overload her with fluids because she's a high risk for pulmonary edema. So we need fluid restriction perhaps the use of diuretics. And then monitoring blood gases because blood gases begin to deteriorate. P or 2 is going down, P or 2 is going up. This lady will need to be intubated and placed on a respirator so that the machine breathes for her. But there is a very important detail. This patient needs a respirator because of a flail chest. We have to keep in mind that she's got multiple broken ribs that may have punctured the lung. As long as she's breathing on her own, those little puncture sites may not be a problem. But one she's intubated and one there is positive pressure going into her trachybronky untree. Those puncture sites may leak air and she may develop a tension new mothorax either on one side or the other depending on where the broken ribs are. So she if she's going to go on a respirator needs a chest tube on that side where the broken ribs are and they have broken ribs on both sides she may need chest tubes on both sides. We're not done yet with the management of this patient. We've taken care of the obvious injury, the flail chest. We still have to monitor for the other ones. We're already taking care of pulmonary contusion because that's the treatment for the flail chest. We need to monitor EKG, cardiac enzymes in case she develops signs of our cardiac contusion and we have to look for the traumatic transsection of the old. So on that chest x-ray I'm going to say it again. On that chest x-ray there's already been taken. We need to see there is a wide media standard. We're going to follow that with a spiral CT scan whether there was a wide media standard or not we're going to do the spiral CT but if there was a wide media standard on the spiral CT's negative we're going to continue with an archaeogram. All right let's move on. The N-A-A-L-E. 55-year-old woman crashes her car against the telephone pole at high speed. On arrival at ER she's breathing well. She has multiple bruises over the chest and multiple sides of point tenderness over the ribs. X-rays show multiple rib fractures on both sides but the long parankham is clear and both lungs are expanded. So at this time we have no reason to be intervening for her breathing. She's breathing on her own the lungs are expanded but we are mindful of the fact that she could show up when we're going to have a contusion at her later time. We're mindful of the fact she could show up my car to contusion at her later time and so the vignette now goes on two days later her lungs quite out on X-rays and she's in respiratory stress. So the follow-up here shows one or two days later that she's developing the signs of a pulmonary contusion. If they had not been monitored already she now needs blood gases because we need to and the determining if she may need to go on a respirator. She may need now the fluid restriction and the diuretics, you know, all of the management that we mentioned before. Here's another reminder of the Espignade 12. 54-year-old woman crashes her car against the telephone pole at high speed. On arrival at the yard, she's breathing well. She has multiple bruises over the chest and is exquisitely tender over the sternum at a point where there is a gritty feeling of bone, great in bone, elicit it by polepage. You know, that's a clinical description of a fracture of a sternum. That's significant chest trauma. What lies right beneath the sternum? The heart. This lady doesn't have signs of my carnal condition right now. She may develop them in the near future. So here's an example of a lady that is going to need EKG monitoring and carriacan signs because she may show up with signs of my carnal condition. Incidentally, we treat my carnal condition very similar to the way we treat an MI. Except we do not use clot boster because that's not the problem. But, you know, we treat all the complications as you would treat the complications of an MI. You should also be actively looking on this lady for the traumatic transaction of your time. Let me use this being yet to make an only interesting point. I've been talking about how when there is big gigantic chest trauma, blunt trauma, that we have to wear not only about the obvious injury, but the ones that could show up later and the one that could never show up until the patient dies, which is the chromatic transaction of your time. Now we may have evidence on the being yet. But the trauma was a significant advantage. The being yet may say it was a car accident that 50 miles an hour. In fact there was another clue, very favorite one of people who had questions. The lady was in a car accident. Three of the four people that were in the car were dead at the site. She's the only survivor. Well, that means that was a big crash. But there are three other clues that I want to urge you to. There are three bones in the chest that are very hard to break. The sternum, the first rib, and the scapula. So any exam question that tells you, blunt trauma to the chest, there is a sterrenal fracture. Or blunt trauma to the chest, there is a fracture of a first rib. A blunt trauma to the chest, there is a fracture of the scapula. There are telegraphs in you in cold. Look, this was a big and norimous gigantic trauma. Because you don't break those bones by falling off your tricycle. Okay? The name number 13. So we pointed out, yeah, let me go back up to 1247. We've not pointed out then that because this is big trauma, we need to look for the trauma to the chest. You know how to do that. Okay, pinion number 13. A 53 year old man is involved in a high-speed automobile collision. He has moderate respiratory stress. Physical exam shows no breath sounds over the entire left chest, but a caution is on the mark. Chest x-ray shows multiple air fluid levels in the left chest. You remember this one from early on? No, this man doesn't have multiple little hemotoruses and pneumothoruses on top. If you have multiple air fluid levels, that's bowel, bowel up in the chest. And the mechanism of injury here is a traumatic rupture of a diaphragm, which incidentally is always on the left side. The right side has a big gigantic liver between the belly and the chest and you don't get the chest full of your bowel and the right side. So this is a traumatic diaphragmatic rupture. It's always on the left. It needs surgical correction, which is done from the abdomen typically. You might have an additional load clue here. They may tell you that an asogastric tube is placed and the tip of the tube curls up into the chest. Well, then it's even more obvious when you don't really need that. All right, let's move on to in the number 14. The motorcycle there, they will attempt to jump over the 12-fountains in front of Caesar's palace hotel in Las Vegas. This is an actual case and happen. As he leaves the ramp at a very high speed, his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a ragdoll. At the end, he's found to be remarkably stable, although he has multiple extremity fractures. The chest extends those fractures of the left, fair strip and widened media stining. Now the clues are all over the place. You already know this is big time trauma because you're given the circumstances, you know, a motorcycle at high speed. If I didn't register, you've been told the first rib is broken and that immediately says to you, this is big time trauma. And then you're told that that same X-rays shows a wide and media stine them. The meaning of that is this is very likely a traumatic transaction of your time. And even though this patient is relatively asymptomatic as far as the chest is concerned, we got to go look for that age. In fact, when this real case happened, this is in fact the gentleman who had a traumatic transaction of your time. This is in the days when the only way to diagnose that was an arteriogram. Nowadays we don't need to begin with the arteriogram, we begin with a spiral CT. If it is positive, move on to the repair, but if it were negative, then push on and do the arteriogram because you have a very high index of suspicion that the traumatic transaction of your time has occurred here. Alright, we move now to the net number 15. A 34-year-old woman suffers severe, long trauma in a car accident. She has multiple injuries to her extremities, head trauma and pneumothorax on the left. Shortly after initial examination, it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck. You know, we visited this briefly at the very beginning of the review when we mentioned that this is one of the reasons why we need an airway. Let's review now what other circumstances that may lead to air bubbling up into the lower neck and upper chest. They are three. We can see that happen when there is a perforation of the esophagus, but the setting would be completely different. The setting would be the patient had an endoscopy and shortly thereafter has a hair. The second possibility is attention pneumothorax actually. But we didn't even mention this when we were talking about attention pneumothorax because attention pneumothorax, there are many other things far more impressive and alarming. The patient isn't shocked. The patient is in respiratory stress. The patient has big, distant events. You're not going to have a patient who's just smiling at you with air in the neck and be attention pneumothorax. And the third possibility for this one is a major trait kill bronchial age. The trait here is ripped into or a major bronchus is ripped into. So this patient needs a fiber-opted bronchoscopy both as the way to guide the insertion of an airway and as a way to consume the diagnosis and then surgical repair after that. Let me point out that sometimes a major trait of bronchial injury is not obvious at the beginning. The patient may not come with air in the neck. There's another way to suspect them being at number 16. The patient who had received a chest tube for a traumatic pneumothorax is noted to be putting out a very large amount of air through the tube. This is what the chest surgeon's call a large air leak. When he's called a long is not expanding. That's another indication of a major bronchial injury. When we have a pneumothorax and we put a chest tube and we put it to suction, typically the long expands and within a few days there is no more air leaking from the lung and that's the end of that. The lung doesn't expand and there's an enormous amount of air coming from that tube. That air is coming through that big bronchial injury right from the lung. So this is another indication then for the fiber optic bronchoscopy and the surgical repair. Now, in year number 17, this is a pretty rare one. We should be able to identify it. The patient will sustain a penetrating injury of the chest, has been intubated and play. on the respirator and the chest tube has been placed on the appropriate plural cavity. The patient had been hemodynamically stable throughout and then suddenly goes into cardiac arrest. And now when people die from trauma because they are bleeding or because they have attention to mothorax we know they are going to die. In other words there is a deterioration of vital signs. We realize that we're loosening the patient. The trauma patient who dies is not a person smiling and talking to you and suddenly drops them. Even the trauma transsection of aorta when it blows out the patient goes into shock and then dies. When we see sudden death like you turn on the switch in a trauma patient think of air embolism. Air embolism can do it and in fact the mechanism in this case. There was an injury to a major to a major bronchers and to a major vessel next to one another. As long as the patient was breathing on his own there was no pressure within the airway nothing happened. Once the patient is on a respirator and air has been blown into that lung that air leaks out gets into that major vessel that is nearby gets into the atria gets into the ventricle and you get the sudden cardiac arrest of the air embolism. Actually there are other circumstances that might make for an easier setting to lead to this. I have two more vignettes that will exemplify this. Vignano by 18. During the performance of a supra-clavicular node biopsy under local anesthesia. Suddenly a hissing sound is heard and the patient drops dead. Vignano 19. A patient was receiving total parental nutrition through a central venous line becomes frustrated because the nurses are not answering this call button. So he gets up and out of bed. This connects his central line from the IV tube in and with the open catheter dangling he takes two steps in the direction of an aerosol station and drops dead. You have here two examples where a major vein near the superior Vina Cava becomes open to the air. In a patient was awake. One was a supra-clavicular node biopsy under local anesthesia the other one is a patient with a central line and if that happens and it happens at the moment when the patient is inhaling rather than exhaling and there is a negative pressure in the chest it may suck enough air through that either search for an injury of a vessel in the first example or the open catheter on the second to get enough air into the ventricle that will be about 120 cc to make the foam that stops the heart immediately. In either of these cases we put the patient in in in trendellum verb we put them with a left side down right side up. Soap in the air stays in the atrium rather than the ventricle. If you have the tube in place like the patient with the central line we try to suck the air out of there. We obviously do cardiac massage and attempt resuscitation. Many of these patients die however. And the last vignette that we have on the chest trauma is actually not chest trauma. I included it here because the manifestations at P or at TPE those are chest trauma. Vignette number 20. A patient who sustains severe long trauma including multiple fractures of long bones becomes disoriented about 12 hours after admission. Shortly thereafter he develops fatigued rashes in the axilla neck, fever and pachycardia. A few hours later he has a full-blown picture of respiratory stress or hypoxemia. Chest x-ray shows bilateral patch infiltrate and it's bloodlet countage low. This is actually fat embolism. What identifies that is multiple long bone fractures followed within a few hours by respiratory distress. I have a host of all the details here. A particular hemorrhage and so on. But if you simply have multiple long bone fractures and a few hours later a low p or two the respiratory stress that is fat embolism. We used to think at one time that we have specific therapy for fat embolism. We used to use intravenous heparin or alcohol or local acrylatex tran. So it used to be essential for us to confirm the diagnosis we would look for fat droplets in the fondness of the eye. But we now realize that in fact the only thing that works in a patient has fat embolism. The only thing the patient needs is respiratory support. That low p or two is praying for intubation and a respiratory. That's what we do. And so once we diagnose that the patient has a hypoxemia that this patient has this patient needs respiratory support and it makes no difference whether you have the address to the picture or not. So if the question on this being yet on the exam is what is the diagnosis when you put together the multiple long bone fractures and the subsequent respiratory distress the answer is fat embolism. But the question is management the margin revolves around monitoring of blood gases and respiratory support as needed. And that wraps up then the chest the nuts and the next chapter then will deal with abdominal trauma.