EM/ANAES/CC POSTING

CASE STUDY/ASSIGNMENT-1

1) Describe the life-threatening conditions in the chest in

this patient?

In a patient who has suffered a blunt trauma to the chest due to the motor

vehicle accident, I intend to assess for these six life threatening injuries around

the chest region: namely, airway obstruction, tracheobronchial tree injury,

tension pneumothorax, open pneumothorax, massive haemothorax, and

cardiac tamponade.

In this case, lung laceration with air leakage due to penetrating or non-

penetrating blunt injury can result in a pneumothorax, as a result of air

entering the pleural space between the visceral and parietal pleura which

causes the lung to collapse.

A hemothorax is a type of pleural effusion in which blood of less than 1500

millilitres accumulates in the pleural cavity normally caused by laceration of

the lung, great vessels or an intercostal vessel from penetrating or blunt

trauma.

On inspection, there would be limited or uneven chest movement and the

patient will also have penetrating chest wall injuries. If there is injury, the

patient may be bleeding profusely but this phenomenon is normally self-

limited.
If there are no visible injuries on the anterior chest wall, they are most likely

found posteriorly. On percussion, there is dullness on the affected side. On

ausculation, there will be limited breath sounds on the affected side leading to

uneven breath sounds in both lungs.

A flail chest occurs when a segment of the chest wall loses its bony continuity

with the rest of the thoracic cage and this normally occurs when multiple ribs

are fractured due to direct blunt trauma especially with motor vehicle

accidents.

The presence of a flail chest segment results in disruption of normal chest wall

movement, so on inspection there would be a reduced chest wall movement.

As this sign may not be as apparent, it is important to immediately recognise

this potentially life threatening condition especially in this elderly male patient

who might have a thicker chest wall musculature.

A pulmonary contusion is a bruise of the lung, caused by thoracic trauma most

often encountered with concomitant rib fractures in adults. This would also

result in an abnormal and limited respiratory motion of the chest wall. On

palpation, the presence of crepitus from the rib or cartilage fractures would

confirm this diagnosis.

A blunt cardiac injury can result in various cardiac complications such as

myocardial muscle contusion, cardiac chamber rupture, coronary artery

dissection with thrombosis and valvular disruption. Chief among this is

cardiac rupture typically presenting with cardiac tamponade.

If the patient is conscious and able to speak, he will say that he has painful

chest discomfort which is generally non-specific, but if on inspection there is a

weakening pulse (indicative of hypotension) and auscultation reveals irregular

heart sounds (indicative of dysrhythmia) these signs would point to a cardiac

rupture secondary to blunt cardiac injury.

A traumatic aortic rupture in patients who have survived will normally present

with a laceration on the chest on the lower half of the manubrium sterni. The

patient may have internal bleeding while having a progressively weakening

pulse.

Traumatic diaphragmatic ruptures are more commonly diagnosed on the left

side. On inspection there will be displaced bowels or stomach. Blunt trauma

produces large radial tears causing herniation while penetrating trauma

produces small perforations.

Oesophageal trauma is caused by a penetrating injury resulting in the forceful

expulsion of gastric contents into the esophagus due to a severe blow to the

upper abdomen. Patients normally present with a linear tear in the lower

esophagus, allowing leakage into the mediastinum. They will also present with

left pneumothorax or haemothorax without a rib fracture but will be in

extreme pain or already be in shock.

2) Describe the initial management of this patient using the

principles of the ATLS?