Descripción de Casos de Uso

3. What do these CXRs show?

4. You decide to take this patient to theatre. What position would you place him, what are the possible complications and what post-operative procedure would you perform?

40

Post chest stab pain Answers

1. What are the possibilities for the cause of his chest pain?

As he only had primary suturing performed at the clinic, they may have missed several acute pathologies; pneumothorax (tension or simple!), haemothorax, associated rib

fractures and possible lung contusions. It is also important not to forget pulmonary embolus as a cause for chest pain post trauma. Cardiac injury is always a possibility, hence an

ultrasound of the heart to exclude a haemopericardium should be organised at the nearest convenience.

2. What investigation would you order primarily?

An erect CXR

3. What do these CXRs show?

This CXR shows a knife blade located in the lateral right hemithorax. There is no obvious associated haemopneumothorax visible on these films. The mediastinum appears normal.

4. You decide to take this patient to theatre. What position would you place him, what are the possible complications and what post-operative procedure would you perform?

It is safer to remove this blade under anaesthetic due to its size and the presence of serrated edges which may cause further bleeding. In the event of any complications occurring the patient should be positioned in the left lateral position in preparation for a posterolateral thoracotomy.

What happened next..

The knife was successfully removed by extending the wound incision inferolaterally by a few centimetres, and dissecting down to the knife handle. The knife blade was then removed with pliers. A chest drain was inserted post-operatively to monitor for secondary bleeding and to drain the chest cavity. He was discharged home a few days later after removal of the drain without complications

Learning Points

 All patients with thoracic injuries should have a plain film chest XR regardless how ‘well’ the patient looks.

 Removing foreign bodies from the thorax is potentially very dangerous due to the proximity of several vascular structures, therefore it is advised to do this under controlled conditions in the operating theatre. Always prepare for the worst case scenario!

A left sided red tap

A 30 year old male was stabbed anteriorly in the left hemithorax 3^rd intercostal space laterally.

He presented with a pulse of 100, BP 105/72, saturating at 92% on air. The wound did not appear to be actively bleeding but he had some subcutaneous emphysema.

After administering oxygen, inserting a wide bore cannula, taking appropriate blood and starting a fluid challenge, a left sided chest drain was inserted which immediately drained 500mls of blood.

1. Describe what the CXR shows.

2. Describe where you would insert a chest drain and how you would perform the procedure.

3. In the subsequent hour he drains another 300mls of blood. What concerns do you have?

4. What would be your management options?

42

A left sided red tap Answers

1. Describe what the CXR shows.

The CXR shows a large left sided haemopneumothorax nicely delineated with an air-fluid level at the top

2. Describe where you would insert a chest drain and how you would perform the procedure.

In trauma situations, a large bore chest drain (approximately 32G) should be inserted in the

‘triangle of safety’ which is bordered by the anterior border of latissimus dorsi, the lateral border of pectoralis major, the inferior border is an invisible horizontal line at the level of the nipple or 5^th intercostal space, and the superior border is the apex of the axilla.

Borders of the ‘Triangle of Safety’

The patient should be consented adequately for the procedure. Local anaesthetic should be infiltrated after a bleb in the skin just above the rib and then deeper into the soft tissues down to the parietal pleura. Aspiration and injection can be performed until either air or fluid from the pleural space is aspirated. Make an incision with a blade down to the subcutaneous fat large enough to admit the chest drain. Then use blunt dissection with forceps to separate muscle fibres and moderate amount of force until breach of the parietal pleura is achieved.

Remember to perform this procedure just superior to the rib as the intercostal

neurovascular bundles run inferiorly. Perform a finger sweep to break down any adhesions and to ensure the cavity is free. Grip the proximal end of the chest drain with forceps and

clamp the distal end. Insert the drain, usually superiorly for pneumothoraces and inferiorly for haemothoraces. Suture the drain to the skin either using a non-absorbable suture, then connect it to an underwater chest drainage system. If a large amount of haemothorax is anticipated, it is advised to use heparinsed saline in the bottle in the event it may need to be re-transfused if there is a massive haemorrhage.

3. In the subsequent hour he drains another 300mls of blood. What concerns do you have?

Patient may have a significant vascular injury. There is also a possibility that you may have inadvertently inserted your drain into the heart (a well documented complication!), however this would be very obvious on initial insertion of the chest drain.

4. What would be your management options?

If the patient is relatively stable, you should order blood for cross match and consider a CT angiogram to determine the site of the vascular injury. The patient should be continuously monitored in a high care setting. If the patient continues to bleed >200ml per hour from the drain, and/or becomes haemodynamically unstable, it would be prudent to perform a thoracotomy.

Learning Points

 Indications for thoracotomy include a chest drain output of 200 ml per hour or more for 3-4 hours and/or an initial drainage of 750mls or more.

 Insert heparinised saline into your chest drain bottle in the event you may need to autotransfuse your patient if a massive haemothorax is anticipated.

Further Reading

ATLS Advanced Trauma Life Support for Doctors (8th Ed.) (2008) American College of Surgeons

44

Haematuria after blunt abdominal trauma

A 29 year old female was in the backseat of a car, which impacted against a tree. You assess her in casualty using ATLS principles and your clinically significant findings were frank haematuria on urinary catheterisation, which subsequently cleared, and some pelvic tenderness.

Observations were otherwise normal.

1. What is this image? How would you perform it and what does it show? What are its limitations?

2. What is the likely differential diagnosis for the haematuria in this case?

3. Which other investigations could you arrange to image the rest of the renal tract?

4. What would be your management for the patient?