Trauma Outside the Major Trauma Centre

Here is a link to the powerpoint of the talk we gave at the regional teaching day at St Vincent's Hospital on 14th Dec 2011.

Thoracic Trauma

I like to think of chest trauma in terms of damage to great vessels and heart (bleeding), damage to the chest wall and pleural spaces (ventilation), damage to the lung (oxygenation) and something else- i.e. damage to other parts of the body that might mimic thoracic trauma (e.g. ugly CXR but the real reason for the hypotension is the belly full of blood or the real reason for the poor ventilation is the messy head).

The places you can make the biggest difference in the resus phase, especially as an occasional trauma practitioner, are to the chest wall and pleural space and to the something else section. Provision of a secure airway, control of ventilation and decompression of tension pneumothorax/haemothorax are going to do most of what you need to do for these patients in the resus room of the non-trauma hospital.

The exception is in the stab wound to the chest with a pericardial tamponade in which case you need to be prepared to decompress the pericardium, either by needle of knife (lots of controversy here, I lean toward knife but you need to have a plan well rehearsed in your head one way or another). The other big vascular injuries need to be recognised and urgently moved to a MTS but if  the reason your patient is going down the tubes is an aortic rupture or hilar tear there is not much you are going to do in resus other than pick up the phone that is going to help. 

Oxygenation problems usually become a problem late on day 1 or into day 2 in ICU when the pulmonary contusion starts to consolidate or the aspiration starts to get inflammed.

Which intervention first? There is a risk with ETT then ICC of creating or worsening a tension pneumothorax but there are significant practical problems with trying to knife the chest of a semi-consious, frightened, intoxicated, hypoxic trauma patient  with a busted clavicle and scapula. My approach depends on how many people I have and how urgent the chest wall and airway are. If there is an obstructed airway and an OPA isn't tolerated or doesn't work you just need to do the ETT first and move on to the chest second. If there is a frank tension pneumothorax and the patient is in extremis you might just need to decompress it (this is one of the few cases where I would still use needle decompression- see Scott Weingart's post on this (link below) for some more discussion around this). Most patients however are somewhat less clear cut (decreased GCS, restless, SpO2 80ish, HR 130, BP 90, airway compromised but open seems to be a pretty standard format for the patients who arrive in ED from major blunt thoracic trauma in Victoria, possibly because the more extreme cases get their major life-saving interventions from the MICA paramedics at the roadside). 

When I am the only one who can do these procedures in the place I announce to everyone that we are going to intubate and then do an ICC on such and such a side. I have one nurse set up the ICC tray and another preoxygenate while I get a gown and two pairs of sterile gloves on. After the ETT is in, pull off the outer gloves and move to the axilla and make a finger thoracostomy (remember that in a ventilated patient you don't make a sucking chest wound because the chest is under positive pressure so once the chest is open the problem is solved for now). Then I move on to other tasks and come back to place the chest tube with better aseptic precautions when the rest is stable.

When there is another person present who can help one should be all set to go with the ICC while the other passes the ETT. Once the airway is secure the ICC can go in quickly.

The tension danger come when you pass the ETT, put in an orogastric, get a CXR to check position and get distracted getting more IC access before you  deal with the pleura.

And don't forget, if there is no IV access within 30 seconds, grab the IO gun.

Remember that ribs start high at the back and end low at the front and that while the nipple line is the 4th ICS at the front it is also the top of the diaphragm (liver, sleen, juicy stuff) and not where you want to go with your ICC. In the MAL the 4th ICS is the end of the armpit hair. Everyone has some sign of where armpit hair was no matter what wonderful hair removal techniques have been used. Don't count ribs.

We didn't get a chance to look at the slides on tension pneumothorax. What I was going to say was that the traditional clinical signs of tension pneumothorax are hopeless and are based on patients from early last century who got observed dying of the disease rather than getting treated. If your patient is allowed to get cyanotic from their tension pneumothoax you might as well go and become a psychiatrist. And tracheal deviation is rarely present and when it is present people get the side of the pneumothorax right about 50% of the time! As team leader, stand at the end of the bed with your head down near the level of the patient and get a skyline view of the chest movement. If it looks ineffective or assymetrical there is a big problem. If not there might still be. I was also going to say that getting a CXR first is a very different thing in 2011 with a trauma call getting you a radiographer with a mobile machine or gantry within a minute or two and pictures available on a screen in resus a minute or two later than it was in 1960 when a patient had to go to the next building on a trolley for a CXR and wait their turn behind all the twisted ankles. CXR first will save significant morbidity from uneccesary procedures if the patient is stable enough to get one. Reasons not to are on the slide.  

Other resources

Scott Weingart at emcrit.org has done two blogposts/podcasts on needle vs knife in trauma resuscitation. Episode 1 looks at needle vs knife for cricotyroidotomy and Episode 2 looks at needle vs knife for Thoracostomy, There are a bunch of good articles related to the topic listed on his posts that are worth checking out too if this topic piques your interest. I haven't listened to this one yet but it looks like being a good discussion of traumatic cardiac arrest. Remember, you can download any of Scott's podcasts for free at itunes or you can listen straight from the web. Read the comments section too. The respondents list is a who's who of critical-care critical-thinking and elearning.