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- [Dr. Edward Hochman] In this series, we are going to focus on chest trauma. And as is the case in general, as we work through trauma questions in general, we should always be sure to remember our ABCs of trauma, including airway, breathing and circulation. Additionally, in actual clinical practice, we add on the D and E, making it the ABCDEs of trauma to include disability as well as exposure, such as exposure to heat or to toxic material. And therefore, although we are going to focus
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on chest trauma in particular in these modules, we should always keep in mind our ABCs of trauma in general, when questioning what is the next step in management of our patient. When it comes to the initial evaluation of a patient with chest trauma in the emergency department, there are really three essential modalities that we are going to use to work up our patient initially, in order to rule out life-threatening injuries. These three modalities include the FAST exam,
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which includes an evaluation of the thorax for free fluid. Additionally, we should at least be able to get an AP supine x-ray, and this is often supine in the context of trauma, as the patient may be unable to sit up for the purposes of a lateral x-ray. Additionally, we should also be sure to get an EKG, as this can show changes in for example, blunt cardiac injury, which we will review in these modules in detail. Although these three modalities are really at the core
1:43
of our initial evaluation of chest trauma, we can also get additional information. For example, if we have a patient who is stable, we can also consider getting a lateral chest x-ray, as well as a CT of the chest. However, for a patients who have unstable vital signs, they need to be brought to the OR emergently and therefore, while they are in the OR, we can actually perform an inter-operative TEE, or transesophageal echocardiogram, and this can allow us to assess the heart
2:14
and the aorta while the patient is in the OR, as is often the case in emergent cases. When we mentioned the FAST exam as one of the three key modalities that we use in our initial evaluation of patients with chest trauma, we are referring to the FAST, which stands for focused assessment with sonography for trauma. With sonography, meaning ultrasound. There are several key areas that we can analyze using ultrasound very quickly in the context of this FAST exam.
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We can look up here in order to analyze the patient's pleura and look for a potential pneumothorax. We can look here with our ultrasound in order to evaluate the pericardium, and look for a fusion or tamponade. Additionally, we can also look at the flanks, both on the right and left side, as well as the pelvic region, in order to evaluate for the presence of intra-peritoneal free fluid. And although the FAST exam of course, is not always going to be able to pick up
3:14
the presence of this free fluid, as there needs to be a certain level of that fluid, in order to actually be picked up by ultrasound, this tool can still be extremely useful as if we detect the presence of free fluid, and the patient is having unstable vital signs that we already know right then and there that this patient needs to have some intervention done emergently, and often this is a trip to the OR for a thoracotomy. So if we were to think about our patient in general,
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who has blunt thoracic trauma, for the purposes of examinations, if we see this patient in the emergency department, we must make sure that we get our three key modalities in the workup of chest trauma, including our FAST exam, our chest x-ray, which is often supine in the context of trauma, as well as an EKG. And from there, we are using these in order to triage and to manage life-threatening injuries. And from there, as we work through each high yield condition throughout this set of modules,
4:14
we'll be able to see the particular management that we utilize for each specific condition. For example, if on this workup using these three modalities, for example, detecting a pericardial effusion on our FAST exam, and the patient also has a characteristic presentation of cardiac tamponade, then our management is going to be a pericardiocentesis. In the case of a patient who has unilateral absent breath sounds, this may raise our concern for a pneumothorax and therefore we may utilize
4:47
either a needle thoracostomy or a tube thoracostomy, more on this in our section on pneumothoraces. If a patient has a hemothorax that has less than 1500 milliliters in the emergency department, then that patient can get a chest tube also known as a tube thoracostomy, in order to drain that hemothorax. However, for patients who have a hemothorax that is greater than 1500 milliliters, then those patients are ultimately going to need a thoracotomy. And generally speaking this thoracotomy,
5:18
in which we essentially bring the patient to the oR, and open up their chest, or in some cases open up their chest right then and there in the emergency department, is really going to be reserved for patients who are still not stable in terms of their vitals, and are still bleeding in the context of thoracic trauma. And therefore this thoracotomy is really our last line of defense. And therefore this algorithm that we present here is really just a bird's eye view
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of how we manage blunt thoracic trauma, and as we move through each condition in particular, we'll be able to discuss the nuances of their management more closely. And although in this series, we are going to be focusing on chest or thoracic trauma, it should also be noted that patients with chest trauma may also have involvement of their abdomen or their diaphragm. One classic way in which this presents on examinations is with the seatbelt sign, in which the patient
6:15
during a car accident essentially has the seatbelt compress across their chest down past their diaphragm and into their abdominal cavity. And the presence of these ecchymosis in this characteristics seatbelt distribution is very classic for indicating that we not only have chest trauma, but also involvement of possibly the diaphragm or the abdomen. And therefore, this is certainly something to be aware of, as you approach these patient vignettes on your examinations.
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There are several high yield conditions that we'll need to cover in the context of chest trauma, both for your surgery shelf examination as well as your (indistinct) exams. Without further ado, let's delve into our first high-yield condition, which is rib fracture, including a discussion of flail chest. In a rib fracture, a classic presentation is going to be unilateral, localized chest or back pain. In addition to having pain, this rib fracture is going to be tender to palpation
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and classically the patient may also have shallow breathing. This is because as the lungs expand against this broken rib, this can often be extremely painful for the patient and therefore they will actually make their breathing more shallow, in order to avoid having that full expansion against that broken and painful rib. Additionally, not surprisingly as this rib fractures, it could ultimately injure the pleura of the lungs and therefore these patients have a high risk
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for the development of an atelectasis as well as pneumonia. In generally speaking, the pathophysiology of a rib fracture is going to be blunt trauma. In the case of a rib fracture on chest x-ray, we should be able to see a fracture of the actual bone and in some cases we may also see the presence of accompanying lung disease including atelectasis, pleural effusion, or pneumonia. Additionally, these patients may present with tachycardia, which patients can often develop in the context
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of the extreme pain from the rib fracture, as well as to tachypnea, because they are ultimately increasing their respiratory rate, as their breaths become more shallow. Overall the real hallmark of management in the case of a rib fracture, is gonna be adequate control of the patient's pain. We can accomplish this with a variety of modalities including NSAIDS, opioids, intercostal nerve blocks. Additionally, because these patients have an increased risk of the development of atelectasis,
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we must place these patients on incentive spirometry, and in very, very rare cases, as we'll discuss in the coming slides. These patients may also require surgical fixation of the ribs as is the case in flail chest. However, generally speaking, we are not performing surgery in our patients with rib fractures, and are really just going to manage their pain initially with NSAIDS and opioids. When we say that a patient has a flail chest, what we are referring to, is that the patient
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has inward movement of the chest wall during inspiration. Normally, during inspiration, as the lungs fill with air, the chest wall should actually be expanding and moving outward. However, in flail chest, the exact opposite occurs, and the chest actually moves paradoxically inward with inspiration. In order to have the development of flail chest, the patient must have some pretty severe trauma with fracture of at least three continuous ribs, and at least two locations.
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We can see this in our patient example on the right-hand side of the presentation, where we can clearly see that this patient has fractures on this side and three continuous ribs, as well as fractures on this side in what appears to be six continuous ribs. Therefore this meets the criteria of having at least three continuous ribs and at least two locations, and therefore this patient is at higher risk for the development of a flail chest.
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Because the trauma in these patients is relatively severe, these patients may also have the president of a pulmonary contusion, and may also develop hypoxia as well, and require supplemental oxygen. With this paradoxical movement of the chest, these patients are also going to find it very difficult to generate negative inspiratory pressure. And therefore in some cases, these patients may even require the positive pressure mechanical ventilation, in order to ventilate properly.
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And therefore, although the management of rib fractures generally speaking is just with the use of pain management, this is not the case for patients with this more severe manifestation of flail chest. Therefore, although generally speaking, our patients with rib fractures could be managed simply with the use of NSAIDS or opioids, in the case of flail chest this is simply not the case, with some patients even requiring mechanical ventilation.
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Moving on to our next high-yield condition, we have the hemothorax, in which the patient is classically going to present, with unilateral decreased breath sounds, as well as dullness to percussion in the area where the blood is accumulating. This is classically going to occur following chest trauma. Additionally, with the patient's loss of blood, it should not be surprising to us that the patient can also present with hypovolemic shock, in which they'll have flat neck veins,
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hypotension, and tachycardia. Additionally, these patients can also manifest with contralateral deviation of the trachea, as the blood causes the trachea to move towards the opposite side of the chest. The pathophysiology of the hemothorax is a blood vessel injury. This can happen to one of several blood vessels in the chest in the context of chest trauma, including the aorta, the internal mammary vessels, as well as the intercostal vessels. Ultimately, we can manage hemothoraces
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with the use of a tube thoracostomy. This is sufficient in cases in which the blood that we extract from the hemothorax is less than 1500 mls. However, in cases where we have more than 1500 mls coming from this hemothorax, then these patients are gonna require emergency surgery often with a thoracotomy. Now we should know right off the bat here, that when we say tube thoracostomy, this is really the same thing as a chest tube. And this is essentially a plastic tube that is inserted
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into the pleural space, hence a chest tube. And we have included a schematic of a chest tube on the right-hand side of the presentation, where you can see that we are simply inserting this plastic tube into the pleural space in order to drain fluid, for example, in the case of a hemothorax. Classically, this is placed at the fifth intercostal space at the mid-axillary line. And although this can be extremely helpful in allowing us to drain fluid as is the case with our hemothorax patients,
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there are several complications that can occur during the placement of a chest tube, including clogging of the chest tube, air leaks, pulmonary edema, as well as pleural and pericardial effusions. And lastly, I would just like to make abundantly clear that when we say tube thoracostomy, this is referring to the insertion of this plastic chest tube in contrast to a thoracotomy in which we are actually breaking open the chest, in order to be able to perform emergency surgery.
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Next up, we have an extremely high-yield discussion of the pneumothorax. It should be noted, however, that there are two major types of pneumothoraces, and these pneumothoraces differ in terms of their presentation, as well as how we diagnose them on our chest x-ray and how we manage them. These two types of pneumothoraces are the spontaneous pneumothorax and the tension pneumothorax. And we will now go through each of these in detail. In the case of the spontaneous pneumothorax,
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this is going to present with acute onset chest pain, as well as shortness of breath. And patients when they develop these spontaneous pneumothoraces, will often have these symptoms come on while they are simply resting, hence the term spontaneous pneumothorax. The spontaneous pneumothorax can be divided into two types. The first of which is the primary spontaneous pneumothorax, and the classic presentation for this is going to be a young, thin male oftentimes a smoker. In contrast, in the case
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of secondary spontaneous pneumothoraces our classic patient for this is going to have chronic underlying disease of lung, most commonly COPD. In addition to the acute onset chest pain and shortness of breath that these patients have, on physical exam they will classically have decreased breath sounds on the effected side, as well as increased resonance to percussion. And very high yield to keep in mind for examinations, the underlying pathophysiology of spontaneous pneumothoraces
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is the rupture of sub-pleural blebs. On chest x-ray are patients with spontaneous pneumothoraces, should have a clear visceral pleural line, in which they have an absence of lung markings beyond this line. This can be appreciated in this patient's right side, where we can clearly see this visceral pleural line running here, and beyond this point, we don't see any lung markings. This can also be contrasted with the opposite side, where we clearly see the presence
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of lung markings beyond that point on the opposite side. And this is highly characteristic of a spontaneous pneumothorax. We should also note here that the trachea in this case is pretty much midline, and this is also consistent with a spontaneous pneumothorax, in contrast to what we'll see in the coming slides, which is a tension pneumothorax. And the reason that we emphasize this difference between spontaneous and tension pneumothoraces, is because ultimately we are gonna have differences
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in how we manage these two distinct conditions. When it comes to the spontaneous pneumothorax, the management of this is gonna depend on the size of the pneumothorax, as well as the patient's stability. If we have a patient with a small spontaneous pneumothorax defined as being less than or equal to two centimeters, and that patient is stable, then we can simply monitor that patient and give supplemental oxygen, as this will often resolve their spontaneous pneumothorax.
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This is in contrast to our tension pneumothoraces, which are always going to require urgent intervention regardless of size. However, in the case of spontaneous pneumothoraces, which are large, defined as being greater than two centimeters, then ultimately these patients will need either a needle decompression or a tube thoracostomy. We have included these two options here of our needle decompression, as well as our tube thoracostomy or chest tube here. And in the ideal scenario, you would like
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to be able to place a chest tube or a tube thoracostomy. However, in cases where we do not have a chest tube available, or where we can perform needle decompression more quickly, then we can often go with this as our option in terms of our management. Additionally, you can even perform a needle decompression initially, and then ultimately move on to performing a chest tube later on once the patient is stabilized. And therefore overall, when we're managing a patient
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with spontaneous pneumothorax, we really have three options in terms of their management, supplemental oxygen, needle decompression, or a chest tube. However, as we move into tension pneumothoraces, we'll see that the needle decompression and chest tube are really our only two options for managing these patients. This leads us into our second type of pneumothorax, which is the tension pneumothorax. These patients are also going to present
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with acute onset chest pain, as well as shortness of breath. Additionally, these patients will have similar physical exam findings, including decreased breath sounds, as well as an increased resonance to percussion. However, in the case of the tension pneumothorax, especially with tracheal deviation and compression of the cardiopulmonary structures, these patients can often go on to develop unstable vital signs, including hypotension and tachycardia.
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And therefore these patients typically will be more sick on presentation, relative to our patients with spontaneous pneumothorax, whose primary concern is their pain and shortness of breath. Additionally, a tension pneumothorax unlike a spontaneous pneumothorax, is not going to be spontaneous but rather is going to have some sort of trigger in the exam vignette. Oftentimes this can be the result of chest trauma or in some cases iatrogenic causes such as classically mechanical ventilation.
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Our initial workup of a tension pneumothorax in the setting of chest trauma, is often going to include a FAST ultrasound assessment as this is going to allow us to assess for the presence of a pneumothorax, even before we go on to get our chest x-ray. However, if we do go on to perform a chest x-ray, you're still going to see this classic visceral pleural line as well as an absence of lung markings beyond this line. This can be appreciated in this chest x-ray
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on the right hand side of the presentation, where we can see that in this patient's right lung, we see lung markings all the way throughout the field, whereas on the left lung, we can see that we have this clear, this (indistinct) pleural line, with a lack of lung markings beyond this line. And this is highly characteristic of pneumothoraces in general. However, what you really wanna look out for on your examinations to distinguish a tension pnuemo from a spontaneous pnuemo,
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is that for a tension pneumothorax, we are classically going to see tracheal deviation away from the affected side. This can also be appreciated in our chest x-ray on the right hand side of the presentation, where we can see that this patient's left side is affected and thus the trachea is deviated towards the right, and this is highly characteristic of a tension pneumothorax. And in the case of this tension pneumothorax with deviation of the trachea, which can ultimately compress
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on local structures and cause the patient to become less stable in terms of their hemodynamics, these patients are going to require urgent intervention. We could not be simply giving these patients supplemental oxygen, and expect this defect to resolve on its own. And therefore patients with tension pneumothoraces are absolutely going to need either an urgent chest tube or a needle decompression, in order to resolve this condition. Now that we have covered pneumothoraces in detail,
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let's delve into our next high-yield chest trauma condition, which is esophageal perforation. In esophageal perforation, classically these patients are going to present with chest and abdominal pain, as well as in many cases back pain. Additionally, these patients may have systemic signs and symptoms, including fever, tachycardia, hypertension, and shortness of breath. Additionally, if they have leaking of air into the mediastinum, this can ultimately lead to crepitus as well as the presence
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of Hamman's sign on physical exam. In which during auscultation of the heart, we can hear a crunching sound, more on this in the coming slides. The pathophysiology of esophageal perforation in general is going to be trauma. This can be secondary to penetrating thoracic trauma, but can also be due to iatrogenic causes such as endoscopy or even caustic ingestion. Additionally, for patients who have Boerhaave's syndrome, excessive vomiting could ultimately lead
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to a full-thickness tear of the esophagus. Just to briefly review the histology and anatomy of the GI tract. We have four layers here including the mucosa, submucosa, muscularis propria, and serosa. As we discussed in our modules on esophageal disorders in patients with Mallory-Weiss syndrome, they will have a tear of only this mucosa layer. However, in patients with Boerhaave's syndrome, as well as these other etiologies of a full-on esophageal perforation, they will have a full thickness tear
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involving all four layers. As we stated on the previous slide, we can see the presence of Hamman's sign on cardiac auscultation in our patients with esophageal perforation. This is in contrast to Homan's sign, which is pain on dorsiflexion or deep palpation of the calf. And this Homan's sign is classically something that we see in our patients with DVT. This is in contrast to what we're focusing on for the purposes of esophageal perforation, which is Hamman's sign,
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in which we can hear a crunching sound that is synchronized with the patient's heartbeat on auscultation. This classically can be seen in pneumomediastinum in which we have free air in the mediastinum, as well as in causes of tracheobronchial injury, such as chest trauma or caustic ingestion. And ultimately, the reason that we have this Hamman's sign or crunching sound on auscultation of the heart, is because as we can appreciate in this patient
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with esophageal perforation, there's this accumulation of free air here, which can ultimately lead to this crunching sound on physical exam. In order to diagnose an esophageal perforation a gold standard test is going to be an esophagogram with water-soluble contrast. The reason that we use this water-soluble contract is because if we were to imagine here a patient who had an esophageal perforation at this point here, if we were to give this patient normal contrast and they had a leaking
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of this contrast into this space surrounding the esophagus, then this could ultimately irritate local structures and even make the patient have peritonitis. And therefore it is absolutely essential that we emphasize here, that in a case of suspected esophageal perforation that we utilize this water-soluble contrast. Additionally, when we perform a chest x-ray in these patients, we may see a widened mediastinum, pneumomediastinum, in which we see that accumulation of free air in the mediastinum,
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we may also see a pneumothorax as well as even a pleural effusion. Additionally, if a patient is stable and we are able to get a CT scan of the chest, this will classically show a thickened esophageal wall. And ultimately if we tap a pleural effusion in a patient with esophageal perforation, one classic finding is that this will be an exudate with green fluid. However, out of all of these principles, in terms of the diagnosis of esophageal perforation,
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utilizing this esophagogram with water-soluble contrast is absolutely essential to keep in mind for your examinations. In terms of management, we must make sure to keep the patient NPO, because as we discussed previously, if the patient is taking anything in by mouth and this goes down the esophagus and comes out here at this point in their esophageal perforation, then this can lead to irritation of local structures. Additionally, we should start these patients
25:23
on IV antibiotics, as well as a proton pump inhibitor. Ultimately however, patients with esophageal perforation are going to require emergency surgery, in order to repair the perforation. Moving on to tracheobronchial injury. This is classically going to present in the context of blunt thoracic trauma. For example, in a patient who has come into the emergency department following a motor vehicle accident. These patients may also present with pneumothoraces,
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as well as pneumomediastinum, depending on the nature of their chest injury. And really the classic finding that we were going to see for a tracheal bronchial injuries, is that we will see a rapid re-accumulating of air despite thoracostomy or chest tube attempts. The idea here is that we were able to place this chest tube, which is this plastic structure here, into the pleural space in patients where we are trying to drain fluid or air. Normally, when we drain that fluid or air,
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we should not see a rapid re-accumulation of that air in that pleural space. The only reason that this would happen, is if more proximately and one of the larger airways of the bronchitis, there were a lesion that is causing a persistent air leak, and thus a rapid re-accumulating of air in this space, despite our attempts to drain this with chest tube. And this is highly characteristic of a tracheobronchial injury, in which we have trauma to the bronchial tree. In particular, we have a defect
26:53
and the proximal larger airways, thus leading to a larger air leak and a persistent re-accumulation of that air in the pleural space. Therefore our first test, oftentimes in the case of suspected tracheobronchial injury is to perform a chest tube or thoracostomy tube, and this is ultimately going to show this rapid re-accumulation of air, consistent with a persistent air leak involving one of the larger airways. From this point, our best test is going to be a bronchoscopy,
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in which we can actually place a camera down in the patient's airways, and look for where this leak is coming from. Therefore, our first step here is this chest tube, followed often times by a bronchoscopy. And ultimately, once we identify the location of this persistent air leak, these patients are going to require surgery. Next up, we have a pulmonary contusion. This is classically going to present with shortness of breath that occurs within 24 hours of blunt thoracic trauma.
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These patients may also present with tachycardia as well as tachypnea, and ultimately as with contusion of any other area of the body, for example, a bone contusion. This contusion essentially represents a bruising, in this case of the lung tissue. This can lead to damage to the alveolar, and ultimately leaking of fluid into the lung interstitium, resulting in edema. And although this can occur as a result of direct trauma to the lung tissue,
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this can also be secondary to rib fracture in some patients. In this presence of a rib fracture, can also be a clue that we may be dealing with a case of a pulmonary contusion. On physical exam of our patients with pulmonary contusions, on auscultation of the lungs, we may be able to appreciate decreased breath sounds as well as in some cases the presence of rales. However, the real key in distinguishing pulmonary contusions from our other lung conditions on examinations,
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is that these patients on chest x-ray will classically have irregular infiltrates that are not restricted by usual anatomic borders. For example, what we usually see in the case of lobar disease, such as lobar pneumonia. This can be appreciated in the chest x-ray on the right-hand side of the presentation, where we can see that in this patients right lung field, that they have this non-specific fluffiness or airspace disease that is not really restricted by any particular lobe.
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And this is highly characteristic of a patient who has pulmonary contusion. Ultimately our management in the case of pulmonary contusion, is largely going to be supportive. We can give these patients supplemental oxygen often with a nasal cannula, and these patients are also going to be encouraged to have physical as well as occupational therapy. Here, we have another classic example of a patient with a pulmonary contusion, in this case a CT scan.
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And we can appreciate here that in this patient's left lung, that we can see the presence of this airspace disease. That once again is not restricted by our particular lobe. Instead, this simply represents edema, secondary to damage to the alveoli. And this is a highly characteristic image in the case of a patient with pulmonary contusion. Now that we have discussed pulmonary contusion in detail, we'll now delve into our next high-yield condition, which is the thoracic aortic injury.
30:20
In a thoracic aortic injury, a classic patient is going to have undergone a massive deceleration chest trauma. These deceleration chest traumas tend to occur in the context of falls, especially those which are from greater than 10 feet, as well as motor vehicle accidents. Following this trauma, the patient will classically present with chest pain, dyspnea and may be anxious and appearance. In addition, if they go on to have rupture of their thoracic aorta,
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they may also develop hemorrhagic shock, as well as back pain, secondary to dissection of the thoracic aorta. One high-yield principle to know for your examinations, is that in the thoracic aortic injury, the most common site of the injury is going to be the isthmus of the aorta. If we direct our attention to the right-hand side of the presentation, we can see that in this 3D model of the aorta, we have the ascending aorta, we then have the arch
31:16
of the aorta here, followed by the descending aorta. We also have some of the major artery branches, which come off of the aorta including here, where we have this subclavian artery coming off of the aortic arch. And just still to the origin of this subclavian artery, we have the isthmus of the aorta. And this is going to be the classic side of injury in the context of thoracic aortic injury. In our workup of a patient with a suspected thoracic aortic injury we're gonna get a chest x-ray,
31:49
which classically is going to show a widened mediastinum. Additionally, if the patient has stable vitals, we can also obtain a CT angio. Ultimately, however, in most cases, these patients are going to decompensate quickly, developing hypotension, back pain and ultimately a tear in their aorta, secondary to that injury to the (indistinct) And therefore these patients will often require emergent surgery with an intraoperative TTE, in order to assess the structure of the heart.
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This is because it should not be surprising to us that if we have an injury to the thoracic aorta, we can also have injury to the heart itself. This provides an excellent transition into our next high-yield chest trauma condition which is blunt cardiac injury, in which we have EKG changes following a blunt thoracic trauma. These patients may present with several key findings on their EKGs, including the presence of PACs, PVCs or ventricular fibrillation. These patients can also go on
32:52
to develop acute coronary syndrome. They may also have ventricular, septal or valvular rupture due to this direct injury to the heart, or they can also go on to develop cardiac tamponade. In all of these potential manifestations of blunt cardiac injury should make sense to us, in the sense that they really just represent disruption of different components of the heart. For example, in the case of arrhythmia, we are really just disrupting the electrical conduction system,
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through the heart from the sinoatrial node into the atria, through the AAV node and into the His-Purkinje system. Additionally, if we have a ventricular rupture, or a septal rupture, or a valvular rupture, this just represents a disruption of one of the structures of the heart, and the case of tamponade, this is ultimately resulting in a disruption in the rupture of the pericardial sac. The pathophysiology of blunt cardiac injury is once again going to be rapid deceleration,
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and classically, we are going to see this in patients who have a fall that is greater than 20 feet, or who undergo a motor vehicle collision at greater than 40 miles per hour. In our initial workup of a patient with a suspected blunt cardiac injury, we're going to obtain an EKG as well as an echocardiogram, in order to look for damage to the conduction system of the heart, as well as the structure of the heart itself. Additionally, we'll typically place these patients
34:22
on telemetry for at least 48 hours in order to monitor them for any potential cardiac complications. Therefore, the management in the majority of patients with blunt cardiac injury, is going to be to monitor them and provide support. However, we must also be sure to treat any downstream complications of the trauma. In the case of V-fib, we'll treat these patients with defibrillation. In the case of ACS, these patients may require cardiac catheterization, in the case of tamponade,
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these patients may require pericardiocentesis, and in the case of ventricular or septal rupture, these patients may require emergent surgical repair. Moving on to our final high-yield chest trauma condition. We have the diaphragmatic hernia. These patients are going to present following thoracic and abdominal trauma. Additionally, these patients will classically go on to develop respiratory distress, as well as symptoms of bowel obstruction. And it should be noted
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that diaphragmatic hernias, secondary to trauma, can present in both in immediate fashion as well as a delayed fashion, 24 to 48 hours after the initial trauma. The pathophysiology of a traumatic diaphragmatic hernia is going to be increased intra-abdominal pressure, which ultimately leads to a tear in the diaphragm and ultimately herniation of abdominal contents into the thorax. We can briefly draw out a picture to demonstrate this principle,
35:50
where if here we have this line representing the diaphragm and above this line we have the thoracic cavity, and below this line we have the abdominal cavity. If we were to have increased intra-abdominal pressure, resulting in a tear in this esophagus, then ultimately bowel and other abdominal contents can herniate their way into this left hemithorax, thus resulting in a diaphragmatic hernia. Ultimately the herniation of these contents can lead to compression of the lungs,
36:21
thus resulting in shortness of breath and tachypnea. Additionally, as this bowel works its way into the left hemithorax, we can also have compression of that bowel leading to nausea, vomiting, and diarrhea. This can also be appreciated in our pediatric population as shown in our schematic on the right hand side of the presentation, where we have this classic example of a congenital diaphragmatic hernia in which we clearly have herniation of the bowel over here and the left hemithorax.
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And we discussed this condition in more detail in our modules on neonatal respiratory distress. In the case of a traumatic diaphragmatic hernia, our first test is often going to be a chest x-ray, which is classically going to show the presence of abdominal contents for example, bowel or an NG tube in the thorax. Classically, this is going to present with a diaphragmatic hernia involving the left hemidiaphragm, thus resulting in the herniation of contents into the left hemithorax.
37:22
This is because there is often protection from the liver on the right side of the diaphragm. Whereas the left side of the diaphragm is more exposed, and thus more prone to diaphragmatic hernia. And although chest x-ray is going to be our first test in the assessment of these patients, we can also perform a CT chest in abdomen, which is going to be our best test for diaphragmatic hernia. Typically, patients with diaphragmatic hernia are going to require urgent surgery
37:49
in order to repair the defect. And the reason that this is urgent is because there is a higher risk of bowel ischemia, as well as strangulation. And that'll do it for now in our high-yield discussion of chest trauma. We have covered a wide variety of high-yield conditions, including the rib fracture, hemothorax, pneumothorax, esophageal perforation, tracheobronchial injury, pulmonary contusion, thoracic aortic injury, blunt cardiac trauma, as well as the diaphragmatic hernia.
38:21
And in our next set of modules, we'll delve into abdominal trauma. This is BoardsMD, and this is "Chest Trauma."
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