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1Last updated: 3rd June 2014
,CONTENT PAGE 6 Colorectal Diseases 84
No. Title Page Number Approach To Bleeding Lower GIT
Colorectal Carcinoma
1 Trauma (Multi-Speciality) Approach 3 Stoma Principles
Advanced Trauma Life Support Algorithm | Burns Injury Management Associated Conditions
Disseminated Intravascular Coagulation (DIC) – Acute Diverticular Disease
Abdominal Trauma Meckel’s Diverticulum
Cardiothoracic Trauma Inflammatory Bowel Disease | Crohn’s Disease | Ulcerative Colitis
Neurosurgical Trauma 7 Anal & Perianal Disorders 110
Musculoskeletal Trauma Haemorrhoids
Shock | Types Of Shock | Management Anal Fistula
Perioperative Care – fluid & maintenance | CVP monitoring & ventilation | Anal Fissures
acid base & electrolytes | nutrition – re-feeding syndrome, enteral and Anorectal Abscess
parenteral nutrition 8 Surgical Diseases Of The Liver 115
Perioperative Care – an anaesthetist’s perspective Surgical Anatomy Of The Liver
Post-Operative Complications Operative Conduct
Surviving Sepsis Causes Of Hepatomegaly
2 Acute Abdominal Pain 30 Disease Of The Liver
Approach To Acute Abdomen Liver Haemangioma
Classical Signs In Patients With Abdominal Pain Hepatocellular Carcinoma
Life-Threatening Causes Of Severe Epigastric Pain Screening For Chronic Hepatitis Carriers
History Taking | Physical Examination | Investigations Liver Metastases
Differential Diagnosis Of Abdominal Pain Hepatic Abscess (Pyogenic) / Hepatic Abscess (Amoebic)
Differential Diagnosis Of Palpable Abdominal Mass Hepatic Cysts
Intestinal Obstruction 9 Pancreatic Diseases 127
Ischemic Bowel Embryology And Anatomy (Pancreas)
Acute Appendicitis Acute Pancreatitis
3 Surgical Anatomy 45 Chronic Pancreatitis
Anatomy Of The Abdomen Pancreatic Cancer
Abdominal Scars 10 Diseases Of The Biliary System 139
Clinical Effects of Tumour Approach To Obstructive Jaundice
4 Oesophageal Diseases 47 Cholelithiasis
Anatomy Of The Oesophagus Acute Calculous Cholecystitis
Physiology Of The Oesophagus Choledocholithiasis
Approach To Dysphagia Mirizzi’s Syndrome
Achalasia Carcinoma Of The Gallbladder
Gastroesophageal Reflux Disease (GERD) Cholangiocarcinoma
Barrett’s Oesophagus Periampullary Tumours
Cancer Of The Oesophagus Benign Strictures And Bile Duct Injury
5 Upper Bleeding GIT And Its Causes 62 11 Disease Of The Breast 154
Approach To Bleeding Upper GIT Anatomy
Portal Hypertension Approach To Breast Lump
Ascites Approach To Nipple Discharge
Variceal Bleeding History / Physical Examination / Investigations
Peptic Ulcer Disease Breast Cancer / Therapeutic Option / Treatment By Tumour Stage /
Gastric Cancer Follow-up / Breast Screening
Paget’s Disease Of The Nipple
Gynaecomastia
2
,12 Head And Neck 167
Neck Masses 19 Hernia 237
Causes Of Midline Mass Inguinal Hernia (Direct And Indirect)
Causes Of Anterior Triangle Mass Approach To Inguinal Hernia Examination
Causes Of Posterior Triangle Mass Approach to Inguinal Lymphadenopathy
Cervical Lymphadenopathy Femoral Hernia
13 Salivary Gland Swellings 174 Incisional Hernia
Salivary Gland Tumour Umbilical Hernia / Paraumbilical Hernia
Complications of Parotidectomy 20 Scrotal Swelling 244
Sialolithiasis Approach To Scrotal Swelling
14 The Thyroid Gland 179 Scrotal Anatomy
Approach To Thyroid Problems Examination Of The Scrotum
History Taking / Physical Examination Testicular Tumour
Part 1: Relevant Anatomy (Embryology, Anatomy, Physiology) Hydrocele
Part 2: Approach To The Solitary Thyroid Nodule Epididymal Cyst
Part 3: Thyroid Cancers Testicular Torsion (Surgical Emergency)
Part 4: Surgery In Benign Thyroid Disease Varicocele
15 Peripheral Arterial Disease 189 Scrotal Abscess
Arteries Of The Lower Limb Fournier Gangrene
Forms Of Peripheral Arterial Disease 21 Appendix 248
Diagnosis of PAD & Natural History of ATH LL PAD Syndromes Lumps & Bumps
Peripheral Arterial System (Hx / PE / Inv / Mx) Surgical Instruments & Procedures
Acute Limb Ischemia
Chronic Limb Ischemia
Non-Critical Limb Ischemia With Claudication
Critical Limb Ischemia
Arteriovenous Access
Branches Of The Aorta
16 Aneurysm 205
Aortic Dissection
Abdominal Aortic Aneurysm
17 Peripheral Venous Disease 209
Anatomy Of The Venous System Of The Lower Limb
Chronic Venous Insufficiency
Varicose Veins
Venous Ulcers
18 Urological Disease 214
Classification Of Anemia
Approach To Gross Haematuria
Renal Cell Carcinoma
Bladder Cancer
Urolithiasis
Approach To Acute Urinary Retention
Benign Prostate Hyperplasia
Prostatic Cancer
Adrenal Tumours
3
,TRAUMA (MULTI-SPECIALITY) APPROACH PRIMARY SURVEY (ABCDE) AND RESUSCITATION
ADVANCED TRAUMA LIFE SUPPORT ALGORITHM 1. AIRWAY ASSESSMENT WITH CERVICAL SPINE CONTROL
- Ascertain pathway
TRAUMA DEATHS (TRIMODAL DISTRIBUTION): (1) Foreign Bodies, (2) Facial/Mandibular #, (3) Laryngeal/Tracheal #
- Immediate death occurring at time of injury – i.e. due to devastating wounds/lacerations - Assess for airway obstruction
- Early death occurring within the 1st few hours of injury – i.e. tension pneumothorax, blood loss, IC bleed Engage the patient in conversation – a patient who cannot respond verbally is
- Late death occurring days / weeks after initial injury – i.e. 20 complications – sepsis, ARDS, SIRS, MOF
assumed to have an obstructed airway till proven otherwise
(1) stridor, (2) retractions, (3) cyanosis
MAIN PRINCIPLES:
- Establish a patient airway
- Treat greatest threat to life first
Jaw Thrust – displace tongue anteriorly from the pharyngeal inlet relieving
- Definitive diagnosis is less important
obstruction
- Time is important – the “golden hour” after trauma is when 30% of trauma deaths occur, and
Simple Suctioning / Clear Airway of Foreign Bodies
are preventable by ATLS
Nasopharyngeal airway / Oropharyngeal Airway
Establish a definitive airway
APPROACH (INITIAL ASSESSMENT)
a. Tracheal Intubation (refer anaesthesia notes for more details)
1. Preparation and Triage
o Orotracheal route using rapid-sequence induction (RSI)
2. Primary survey (ABCDE) and Resuscitation of Vital Functions
o Pre-oxygenate patient with 100% Oxygen
3. Re-evaluation of the patient and taking a History of the event
o In-line cervical spine stabilisation wither anterior portion of cervical
4. Secondary survey (head-to-toe evaluation)
collar removed
5. Post-resuscitation monitoring and re-evaluation
o Sellick Manoeuvre to prevent aspiration (there is increasing
6. Optimise for transfer and definitive care
controversy as to the utility of cricoid pressure due to concerns about
its efficacy and potential for obscuring the view of the vocal chords)
o Drugs – short acting sedative or hypnotic agent (i.e. etomidate
0.3mg/kg IV or midazolam 1-2.5mg IV) and paralytic agent
administered immediately after the sedative (succinylcholine 1-
1.25mg/kg IV or rocuronium 0.6-0.85mg/kg IV)
o ETT tube inserted through vocal chords and adequacy of ventilation is
assessed
b. Needle Cricothyroidectomy with jet insufflation of the airway
c. Surgical Cricothyroidectomy
- In a multi-system trauma patient assume cervical spine injury till proven otherwise
NEXUS C-Spine Clearance (NSAID)
a. No focal Neurological deficit
b. No Spinal (posterior midline cervical) tenderness
c. Patient is Alert and orientated to time / place / person
d. No evidence of Intoxication
e. No painful Distracting injuries (i.e. long bone fracture)
4
,2. BREATHING (OXYGENATION AND VENTILATION OF THE LUNGS) 3. CIRCULATION WITH HAEMORRHAGE CONTROL
- Assessment of breathing - Hypotension following injury must be considered to be hypovolemic in origin until proven
Expose the neck and chest: ensure immobilization of the head and neck otherwise
Determine rate and depth of respiration - Physiologic response to blood loss vary between individuals (i.e. elderly may not show a
Inspect and palpate the neck and chest for tracheal deviation, unilateral and normal tachycardia response, worse if patient is on beta-blockers, children have abundant
bilateral chest movements, use of accessory muscles and any signs of injury (i.e. flail physiological reverse and may demonstrate few signs even to severe hypovolemia)
chest)
Auscultate chest bilaterally: bases and apices - Assessment of organ perfusion
If unequal breath sounds – percuss the chest for presence of dullness or hyper- Level of consciousness (secondary to reduced cerebral perfusion)
resonance to determine hemothorax or pneumothorax Skin Colour (ashen and grey skin of face and white skin of extremities suggest blood
loss of at least 30%)
- Life-threatening conditions that require immediate attention and treatment [ATOM FC] Pulse Rate and Character (full vs. thread vs. rapid)
Airway Obstruction – i.e. Tracheobronchial Disruption Blood Pressure (if radial pulse present – BP>80mmHg, if only carotid pulse present –
Tension Pneumothorax (TP) BP>60mmHg)
o Immediate insertion of a large bore 14G IV catheter into the 2nd IC space,
midclavicular line, followed by tube thoracostomy (triangle of safety – mid- - Management
axillary line, lateral border of pectoralis major, upper border of the 5th rib) 1. Apply direct pressure to external site of bleeding
Open pneumothorax 2. Insert 2 large bore (14G / 16 G) IV catheters (antecubital veins)
o Occlusive dressing, taped securely on 3 sides to create a flutter valve effect (if 3. Labs: GXM (4-6units), FBC1, U/E/Cr, PT/PTT, ABG (if no O-negative blood is available
taped all 4 sides can result in TP) use type specific blood)
Massive Hemothorax (>1500ml) 4. Initiate vigorous IV fluid therapy with warmed crystalloids (i.e. Ringer’s Lactate, 1-2L),
o Tube thoracostomy (32Fr or larger) connected to an underwater seal-suction KIV blood replacement
device 5. Apply ECG monitor / Pulse Oximeter / Automated BP cuff
Flail chest with pulmonary contusion o Dysrhythmia: consider cardiac tamponade
o 2 or more ribs that are fractured at 2 segments – no bony continuity with rest o PEA: consider treatable causes (5Hs and 5Ts)
of thoracic cage paradoxical movement (see below) 5Hs – hypovolemia., hypoxia, H+ (acidosis), Hyper/Hypokalaemia, Hypothermia
5Ts – toxicity (drug overdose), tamponade (cardiac), pneumothorax, thrombosis
o Adequate pain control with aggressive pulmonary toilet and respiratory
(AMI), thromboembolic (PE)
support (hypoxia 20 to underling pulmonary contusion)
o Bradycardia, aberrant conduction, ventricular ectopic: ?hypoxia / hypo-perfusion
Cardiac Tamponade
6. Insert indwelling urinary and nasogastric catheters unless contraindicated
o Pericardiocentesis & Direct operative repair
o Urinary Cather insertion is contraindicated when
Blood at urethral meatus
- Management of Breathing
Scrotal hematoma
Attach pulse oximeter and administer high concentration of oxygen (non-rebreather
High-riding prostate
mask with a reservoir is required to achieve a theoretical FiO2 of 100%)
Perineal ecchymosis / hematoma
KIV – ventilate with bag-valve mask if patient requires assistance with breathing
o NG tube is indicated to reduce stomach distension and decrease risk of
Attach an end-tidal CO2 (ETCO2) monitoring device to the ETT.
aspiration – contraindications include:
CXF rhinorrhoea / otorrhea – suggestive of cribriform plate (base of
skull) fracture insert NG tube orally instead of nasally
- Classes of haemorrhagic shock! (see below ‘shock’)
Periorbital ecchymosis,
Mid-face instability,
Hemotympanum
7. Prevent hypothermia
8. Reassess frequently
1
The haematocrit value is not immediately altered with acute haemorrhage – it should not be an indicator of circulating blood
volume in trauma patients. Serial haematocrit values, however, may give an indication of on-going blood loss.
5
,4. DISABILITY / INTRACRANIAL MASS LESION SECONDARY SURVEY
- AVPUP score: - A complete head-to-toe examination to inventory all injuries sustained in the trauma after
Alert primary survey is completed.
Verbal stimuli (responds to),
Pain stimuli, 1. AMPLE HISTORY
Unresponsive, - Allergies, Medications, Past Med Hx, Last meal, Events/environment related to the injury
Pupillary size and reaction
2. COMPLETE HEAD-T0-TOE EXAMINATION
- Glasgow coma scale - Head
Eye Verbal Motor Complete neurological examination – cranial nerves
Spontaneous opening 4 Oriented speech 5 Obeys Command 6 GCS or AVPU assessment (GCS ≤ 8 – KIV intubation)
Opens to voice 3 Confused 4 Localizes 5 Comprehensive examination of eyes and ears for base of skull fractures (periorbital
Opens to painful stimuli 2 Inappropriate 3 Withdraws 4
hematomas – raccoon eyes, mastoid hematomas – battle’s sign, hemotympanum, CSF
No response 1 Incomprehensible 2 Decorticate (flex) 3
rhinorrhoea and otorrhea)
No verbal response 1 Decerebrate (extend) 2
No Movement 1
GCS: 14-15 (minor); 8-13 (moderate); 3-7 (severe) - Maxillofacial *frequently missed injuries*
- Any patient with GCS ≤ 8 should be intubated to protect the airway Bony tenderness, crepitus or discontinuity
- Call for neurosurgical consult as indicated o Mid-facial fractures – check by grasping maxilla and attempting to move it
Palpable deformity
5. EXPOSURE / ENVIRONMENT / BODY TEMPERATURE Inspect for septal hematoma
- Completely undress patient by cutting off clothing Comprehensive oral/dental examination
- Look for visible / palpable injuries o Mandibular fracture – check for mucosal violation and abnormal dental occlusion
- Prevent hypothermia – “hot air” heating blankets, infusion of warmed IV fluids Caution: potential airway obstruction in maxillofacial injury; cribriform plate # with CSF
- Inspection back / DRE – log-rolling with in-line cervical spine immobilization rhinorrhoea do not insert NG tube, use orogastric tube to decompress stomach
- Continue monitoring vitals (HR, BP, SpO2) + ECG + urine o/p (aim: >0.5ml/kg/hr)
- Trauma-X-ray Series - Neck (r/o cervical spine, vascular or aero digestive tract injuries)
(1) Lateral C-Spine, (2) AP CXR, (3) AP Pelvis Nexus C-Spine Clearance
- Other Investigations Inspect – blunt and penetrating injuries, tracheal deviation, use of accessory breathing
Focused abdominal sonography in trauma (FAST) muscles (any hoarseness of voice, stridor suggesting airway obstruction)
Diagnostic Peritoneal Lavage Palpate – tenderness, deformity, swelling, crepitus (subcutaneous emphysema) and
Computed Tomography tracheal deviation
Auscultate – carotid arteries bruit
- Chest
Inspect – blunt and penetrating injuries, use of accessory breathing muscles, bilateral
symmetrical respiratory excursion
Palpate – fractures and subcutaneous emphysema
Auscultate – quality / location of breath sounds (and also heart sounds)
o Also check EtCO2, O2 saturations, and ABG to ensure adequate ventilation and
oxygenation
CXR rule out any thoracic extra-anatomic air (subcutaneous air, pneumomediastinum or
pneumopericardium)
o Pulmonary parenchymal injury with occult pneumothorax
o Tracheobronchial injury
o Oesophageal perforation
o Cervicofacial trauma (self-limiting)
6
,- Abdomen (r/o intra-abdominal injury rather than characterise its exact nature) BURNS INJURY MANAGEMENT
Inspect – blunt and penetrating injuries (“seat-belt sign”) Minor: ≤15% TBSA, Moderate: 15-25% TBSA, Severe: ≥25% TBSA
Palpate – any lower rib fractures (liver / spleen injuries) Rule of 9: (adult) – head 9%, back 18%, chest 18%, R arm 9%, L arm 9%, perineum 1%, R leg 18%, L leg 18%
Percuss – rebound tenderness (child) – head 18%, back 18%, chest 18%, R arm 9%, L arm 9%, perineum 1%, R leg 13.5%, L leg 13.5%
Auscultate – bowel sounds
Assess Pelvis stability (palpate iliac wings) Management
Diagnostic Evaluations: FAST, DPL, CT scan - Inhalation injury: intubate and administer 100% oxygen
- Administer 2-4ml / kg / %BSA burn in 24 hours (+maintenance in children) – ½ in 1st 8hr and ½
- Perineal, Rectal & Vaginal Examination in next 16hrs (hartmann’s solution)
Perineum: contusion, hematomas, laceration, urethral blood, scrotal hematoma - Monitor urinary output
DRE: Sphincter tone, high-riding prostate, pelvic fracture (may feel fragments of bone); - Expose and prevent hypothermia
rectal wall integrity, rectal blood - Chemical burns: brush and irrigate
Vaginal examination: blood, lacerations
DISSEMINATED INTRAVASCULAR COAGULATION (DIC) – ACUTE
- Musculoskeletal – extremities Systemic processing producing both thrombosis and haemorrhage – 20 to trauma, shock, infection,
malignancy (esp. APML), obstetric complications
Back – log-roll patient
o Inspect – wounds and hematomas Pathogenesis
o Palpate – vertebral step-off or tenderness - Massive intravascular activation of coagulation (i.e. thrombin) that overwhelms control
Upper and Lower Limbs – r/o presence of soft-tissue, vascular, orthopaedic or mechanisms thrombosis in microvasculature
neurological injuries Fibrin deposition in microcirculation
o Inspect – gross deformity, active bleeding, open wounds, expanding hematoma, o Secondary fibrinolysis (due to release of tPA) ↑FDP bleeding
ischemia o Intravascular fibrin strands cause mechanical shearing of RBC MAHA
o Ischemic organ damage (due to thrombotic manifestations)
o Palpate – subcutaneous air, hematomas, presence and character of peripheral
Acute consumption of coagulation factors and platelets bleeding
pulses
Occult compartment syndrome Diagnosis
Neurological Examination - ↑PT/↑PTT, ↓fibrinogen, ↑FDP/D-dimer, ↓platelets, +ve schistocytes, ↑LDH, ↓haptoglobin
X-rays as appropriate
Ankle-Brachial Indices (ABIs) should be measured if suspicious of possible vascular injury Management
- Caution: potential blood loss is high in certain injuries (e.g. pelvic #, femoral shaft #) – aim - Treat underlying process
- Support with FFP, cryoprecipitate & platelet (aim: fibrinogen > 100mg/dL)
to volume resuscitation, reduce pelvic volume, put external fixator on, KIV angiography /
embolization
- Central Nervous System
Frequent re-evaluation
Prevent secondary brain injury
Imaging as indicated
Early neurosurgical consultation
GENERAL
- Have a high index of suspicion for injuries to avoid missing them (frequent re-evaluation)
- Rapidly recognise when patient is deteriorating (continuous monitoring)
- Any rapid decompensating by the patient should initiate a return to the primary survey
- In penetrating trauma, all entry and exiting wounds must be accounted for
- IV analgesia as appropriate for pain management
7
,ABDOMINAL TRAUMA CT SCAN
- All penetrating injuries below the nipple line should be suspected of entering the abdominal - Only suitable for stable patient as quite long time involved in imaging with only patient in the
cavity room risk of rapid decompensation
- All multiple trauma patients with hypotension are assumed to have intra-abdominal injuries till
proven otherwise - Advantages
Able to precisely locate intra-abdominal lesions preoperatively
TYPES OF INTRA-ABDOMINAL INJURY IN BLUNT TRAUMA Able to evaluate retroperitoneal injuries
- Solid organ injury: spleen, liver – bleeding (may be quite massive) Able to identify injuries that can be managed non-operatively
- Hollow viscus injury with rupture Not invasive
- Vascular injury with bleeding
- Disadvantages
INDICATIONS FOR IMMEDIATE LAPAROTOMY Expensive, time required to transport patient, use of contrast
1. Evisceration, stab wounds with implement in-situ, gunshot wounds traversing abdominal cavity
2. Any penetrating injury to the abdomen with haemodynamic instability or peritoneal irritation DIAGNOSTIC PERITONEAL LAVAGE (DPL) – RARELY DONE
3. Obvious or strongly suspected intra-abdominal injury with shock or difficulty in stabilising - Sensitivity of 97-98% with a 1% complication rate
haemodynamics - Useful in hypotensive, unstable patient with multiple injuries as a mean of excluding intra-
4. Obvious signs of peritoneal irritation abdominal bleeding
5. Rectal exam reveals fresh blood - Involves an incision in the midline, below umbilicus, dissection down to peritoneum a
6. Persistent fresh blood aspirated from nasogastric tube (oropharyngeal injuries excluded as catheter is placed and a litre of N/S is run into the peritoneal cavity bag is then planed on
source of bleeding) floor and allowed to fill
7. X-ray evidence of pneumoperitoneum or diaphragmatic rupture - All patients undergoing DPL require prior evacuation of the stomach via NG tube as well as
drainage of bladder by indwelling catheter
INVESTIGATIONS (IN THE ABSENCE OF THE ABOVE INDICATIONS) - Absolute Contraindication: indication for laparotomy already exists
- If patient is stable: FAST and/or CT scan - Involves making a cut in the infraumbilical region and inserting a catheter into the peritoneal
- If patient is unstable: FAST and/or DPL cavity, aspirate, then instillation of saline (1000ml) and re-aspiration
FOCUSED ASSESSMENT WITH SONOGRAPHY IN TRAUMA (FAST) - Positive DPL in setting of blunt abdominal trauma and (penetrating trauma)
- Rapid, reproducible, portable and non-invasive bedside test to detect fluid in the abdomen or Frank blood (>10ml) or any enteric contents
pericardium (≥ 100ml and more typically 500ml of peritoneal fluid, sensitivity: 60-95%) RBC >100,000 per mm3 (penetrating: > 10,000 RBC)
- Fails to identify injury to hollow viscus and to reliably exclude injury in penetrating trauma WBC >500 per mm3 (penetrating: > 50 WBC)
- Ultrasonography evaluation of four windows:
1. Subxiphoid: Pericardium
2. RUQ: Perihepatic Space (aka. Morrison’s Pouch or hepatorenal recess)
3. LUQ: Perisplenic Region (splenorenal recess)
4. Pelvis: Pouch of Douglas (suprapubic window)
5. (eFAST) – add b/l anterior thoracic sonography – detect pneumothorax
- Disadvantages
Does not image solid parenchymal damage, retroperitoneum, diaphragmatic defects or
bowel injury
Compromised in uncooperative, agitated patient, obesity, substantial bowel gas,
subcutaneous air
Less sensitive, more operator-dependent than DPL and cannot distinguish blood from ascites
Intermediate results require follow-up attempts or alternative diagnostic tests
8
,CARDIOTHORACIC TRAUMA
There are 5 clinical scenarios in chest trauma where bedside procedures are lifesaving: cardiac tamponade, airway
obstruction, flail chest, hemothorax, and pneumothorax.
Clinical features
Chest trauma and hypotension
Beck’s triad (hypotension, muffled heart sounds, distended neck veins) – only in 50% of
cases as hypo-vol. may prevent neck vein distension; muffled heart sounds least reliable
Pulseless electrical activity
Kussmaul’s signs (increased neck distension during inspiration, pulsus paradoxus)
Diagnostic clues
Enlarged cardiac shadow in CXR (globular heart – very rarely seen)
Small ECG voltages, electrical alternans = alternation of QRS complex amplitude or axis
between beats.
2DE – separation of pericardial layers detected (fluid exceeds 15-35ml); early diastolic
collapse of RV wall (tamponade)
Management
Aggressive fluid resuscitation – helps maintain cardiac output and buys time. *ACC/AHA definition for low QRS voltage is amplitude <5mm in standard limb leads or
Pericardiocentesis: 2D-echo guided or ECG lead-guided (Stop inserting needle when an <10mm in precordial leads
abrupt change in the ECG waveform is noted. If the ECG waveform shows an injury
CARDIAC pattern (ST segment elevation), slowly withdraw the needle until the pattern returns to Diagnostic Clues (for laryngeal trauma)
AIRWAY Hoarseness
TAMPONADE normal, as this change in waveform suggests that the spinal needle is in direct contact OBSTRUCTION
with the myocardium) Subcutaneous Emphysema
High index of
Due to laryngeal Palpable Fracture
suspicion required
injury or
posterior/fracture Management:
dislocation of SCJ Definitive airway – ETT, tracheostomy, cricothyroidotomy
Diagnostic Clues
Paradoxical movement of the chest wall
Respiratory distress (hypoxemia due to underlying pulmonary contusion, contributed to
by pain with restricted chest wall movement)
FLAIL CHEST External evidence of chest trauma
Pain on respiratory effort.
2 or more ribs are
fractured at 2
points Management:
Ensure adequate oxygenation and ventilation; judicious fluid therapy (avoid fluid
overload); adequate intravenous analgesia
Consider mechanical ventilation in high risk patients: shock, severe head injury, previous
pulmonary disease, fracture of >8 ribs, age > 65, >3 associated injuries
Management:
Ensure adequate oxygenation, establish 2 large bore IV access and fluid resuscitation
MASSIVE (KIV blood transfusion and correction of coagulopathy)
HAEMOTHORAX Chest tube insertion in the triangle of safety (bound by the lateral border of the
pectoralis major medially, a line just anterior to the mid-axillary line laterally, and the
blood >1500mls or
upper border of the fifth rib inferiorly)
on-going
haemorrhage of Be wary of sudden cessation of chest tube drainage as tube can get blocked by clot
more than 200ml / massive hemothorax, call urgent cardiothoracic consult
hr over 3-4 hours
note: think of possible damage to great vessels, hilar structures and heart in penetrating
anterior chest wounds medial to nipple line and posterior chest wounds medial to scapula
9
, PNEUMOTHORAX
(TENSION/ OPEN)
Tension pneumothorax = develops when air is trapped in the pleural cavity under positive
pressure, displacing mediastinal structures and compromising cardiopulmonary function
It is a clinical diagnosis (CXR will only delay treatment, and may cause death) – signs of
pneumothorax, hypotension, neck vein distension, severe respiratory distress
Decreased venous return caused by compression of the relatively thin walls of the atria
impairs cardiac function. The inferior vena cava is thought to be the first to kink and
restrict blood flow back to the heart. It is most evident in trauma patients who may be
hypovolemic with reduced venous blood return to the heart.
Management
Needle thoracotomy: 14G needle, 2nd IC space in the midclavicular line
Followed by tube thoracotomy at the 5th IC space between anterior and mid-axillary line.
(triangle of safety: lateral border of the pectoralis major medially, a line just anterior to
the mid-axillary line laterally, and the upper border of the fifth rib inferiorly)*
Open pneumothorax occurs in a large chest wall defect with equilibration between
intrathoracic and atmospheric pressure, producing a “sucking chest wound”.
Cover defect with a sterile dressing, taping it down on 3 sides to produce a flutter-valve
effect, letting air out of the pleural cavity but not back in
Insert chest tube (not through the wound)
* If possible (provided no cervical spine injury is suspected) the patient is sat up at 45deg and the hand is placed behind their neck
on the affected side to expose the field and open up the intercostal space. The area is prepared with antiseptic and draped. LA is
infiltrated into the skin, sub-cut tissues and down to the pleura. A 2 cm transverse incision is made in 5 th IC space (aiming above the
rib as the IC NVB sits in the groove just below the rib). Blunt dissection is then performed down to the pleura with a pair of forceps
which then are pushed through the pleura into the pleural space. A finger is placed in the hole and swept around to free any
adhesions and create the space for the tube. A chest drain is inserted using a pair of forceps; usually French gauge 24–28 (if a
hemopneumothorax exists, a larger tube size, Fr. 38, is usually used). The drain is fixed with a stitch and a purse-string or mattress
suture is placed in the wound (to allow it to be closed when the drain is removed). The chest drain is connected to an underwater
seal (this allows air to escape during expiration, but no air to enter on inspiration). Ensure that the underwater seal is below the
level of the patient, otherwise the water will enter the chest. Re-X-ray the patient after the procedure to ensure correct positioning
of the tube.
10
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