Answer

Initial assessment and management should follow Advanced Trauma Life Support (ATLS) guidelines [1] - A, B, C, D, E. A cervical spine injury should be assumed in any patient with multi-system trauma.

Airway maintenance (with cervical spine control)

Speak to the patient - do they respond? If the patient is able to communicate verbally the airway is unlikely to be in immediate danger. Repeated assessment of airway patency should still be performed. All patients must receive oxygen (10-15 L/min from a reservoir bag if breathing spontaneously). If airway obstruction is present simple measures to clear the airway, chin lift or jaw thrust, should be undertaken immediately. Reduced conscious level (Glasgow Coma Score of 8 or less) airway disruption or inability to oxygenate the patient by face mask indicate the need for a definitive airway. Endotracheal intubation (with 130 stabilisation of the cervical spine) can be performed with a rapid sequence induction and cricoid pressure, or with awake fibre-optic intubation depending on the clinical circumstances. When assessing and managing the airway in patient's with blunt chest trauma it is important to look for other injuries to the head, face, cervical spine, and potential sites of injury to the larynx, trachea or lower airway. Laryngeal or tracheal injury may require placement of a surgical airway below the level of the injury.

Breathing and ventilation

A careful physical examination of ventilatory function is particularly important in chest injured patients. This should include inspection of ventilatory rate and chest movement looking for paradoxical respiration and other obvious injuries. Palpation is important to identify crepitus from rib fractures, surgical emphysema and areas of focal tenderness. Auscultation should be performed with particular reference to signs of pneumo- or haemothorax. Percussion may demonstrate the presence of blood or air in the chest.

Assess, oxygenate and ventilate as necessary. Injuries that acutely impair ventilation are tension pneumothorax, flail chest with pulmonary contusion, massive haemothorax and open pneumothorax. These should be treated as found, a tension pneumothorax is a life-threatening emergency which must be treated immediately, X-ray confirmation should not be sought.

Circulation

The main causes of hypotension in the setting of blunt thoracic trauma are hypovolaemia, pneumothorax, cardiac tamponade and myocardial contusion. Haemorrhage is the predominant cause of post-injury deaths that are preventable. Hypotension following injury must be considered to be hypovolaemic in origin until otherwise proven. Fluid should be given (2 L of warmed Hartmann's solution) through large peripheral cannula while the underlying aetiologies are explored. The presence of cardiac arrhythmias should raise the possibility of cardiac contusion. A central line may be needed for therapy and monitoring.

Disability (neurologic evaluation)

A rapid neurological examination can be based on

■ V respond to vocal stimuli,

■ P respond only to painful stimuli,

■ U unresponsive to stimuli and assessment of the patient's pupils.

Exposure/environmental control

The patient should then be completely undressed for thorough examination and assessment. Attention must be paid to maintenance of the patient's temperature. 131

Aggressive resuscitation and the management of life-threatening injuries, as they are identified, are essential to maximise patient survival.

X-rays should be used judiciously and should not delay patient resuscitation. The AP chest film and AP pelvis may provide information that can guide resuscitation of the patient with blunt trauma. Chest X-rays may detect potentially life-threatening injuries that require treatment and pelvic films may demonstrate fractures of the pelvis that indicate the need for early blood transfusion. A lateral cervical spine X-ray that demonstrates an injury is an important finding, whereas a negative or inadequate film does not exclude cervical spine injury. These films can be taken in the resuscitation area, usually with a portable X-ray unit, but should not interrupt the resuscitation process.

Blunt chest trauma (see Fig. 3.5)

The example demonstrates bilateral pleural effusions, a left pneumothorax, contusion of the left lung and a left-sided chest tube. There is also a burst fracture of T9 vertebral body. This is seen in sagittal section in Fig. 3.6. Blunt thoracic trauma such as steering wheel injury has a high potential for causing life-threatening thoracic injuries. Approximately 20% of trauma-related deaths are attributable to chest injuries. The mechanisms include rapid deceleration, direct impact and compression. Systematic evaluation of the chest X-ray is an important facet of early management after the primary survey and initial resuscitation.

The chest X-ray or CT for blunt trauma can be divided into systems for the purposes of ensuring that all areas are looked at.

Fig. 3.6 Chest trauma. Thoracic spine reconstruction sagital plane. This shows a burst fracture also seen on axial images (see Fig. 3.5).

Potential sites of injury in blunt chest trauma

Skeleton

Rib fractures The positive identification of rib fractures means that the underlying lung must be examined for contusions, haemothorax, pneumothorax or laceration (Figs 3.7 and 3.8). The presence of multiple fractures or the combination of anterior and posterior fractures can cause a flail segment (see Fig. 3.9). The upper ribs (1-3) are protected by the bony

Fig. 3.7 Chest trauma. There is extensive contusion involving the left lung, a left-sided pneumothorax and extensive subcutaneous emphysema. Several pockets of gas are noted within the left lung contusion at the level of a left-sided rib fracture; these are pulmonary lacerations.

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