“You could cut the tension with a knife…..”

If you are reading this blog, I must reiterate that I am by no means an expert in emergency medicine. I am a new EM Consultant, which essentially means i still have a lot to learn!

One of the most important changes  I have made to my clinical practice was improving my chest assessments in trauma patients. These tips were given to me from some very experienced clinicians  and I wanted to share them with you. I hope I’m not teaching you to suck eggs and that by the end of reading this blog, you would have learnt something new…..

With the move to “Pan CT” trauma patients in MTCs, I think our ability to assess patients for injury perhaps is not as robust as it should be. However if you work in a hospital where it is not so easy to get a patient into a scanner immediately or there may be difficulty arranging a scan, then doing a thorough assessment can pick up injuries which otherwise may be missed.

The mechanism of injury is also important in trying to predict the injury pattern in patients. If you are working pre-hospitally, spend a little time looking at the scene and asking yourself what the mechanism of the RTC was. Eg: a T-boned car with impact on the drivers side would be concerning for a Rt Pelvis/ liver/ chest injury…..

What do Craig David & Sting  and the movie “Twelve” have to do with performing a chest assessment?

Craig_David_Featuring_Sting_-_Rise_&_Fall_(CD)

A lot as it happens….

The mnemonic “RISE N FALL” and “TWELVE” can be used to remember the different components of a chest exam. (Granted it may not be the easiest mnemonic to use, but just try it when you’re next assessing a chest, after all repetition is the key to learning something new and how often do you examine a a patient’s chest!)

Respiratory rate: it is age dependant. Tachypneoa can indicate hypoxia/ shock as a metabolic acidosis compensation. Reduced rate can mean fatigue and reduced respiratory drive.

Injuries: Look for bruising/ deformities and wounds.  Remember to check the posterior chest wall if you can or run you fingers down the patients back if they are supine to see if there is any blood from wounds. Check the neck & axillae.

Symmetry:  Look for reduced movement on one side of the chest which can indicate a pneumo/ heameothorax. However if the patient has bilateral pathology, both sides of the chest will have reduced movement. The best place to see a flail segment is standing beside the patients feet and looking at their chest. The hyperlink is a video of a flail chest.

Effort of breathing:  Use of accessory muscles in COPD patients and children

Neck signs (I was terrible at remembering to do this as part of my chest assessment. Now i do it for every patient). The second mnemonic “TWELVE” is used here:

Trachea- central

        Wounds/ haematoma

                    Emphysema (subcutaneous)

    Laryngeal crepitus

                                        Venous distension ( cardiac tamponade)

                 Examine fully- open collar

Feel: In my experience, this isn’t done as well as it could be. I was told by a very experienced doctor to imagine my hands were covered in paint and after feeling the patient’s chest there should be no areas left uncovered by the paint. You also need to press on the chest harder than you think to pick up crepitus from rib fractures and surgical emphysema. Start by feeling the neck and work your way down including the clavicles. I tend to speak out as I’m doing it so others around me also know what i have found and think about what is wrong with the patient. It also helps me to remember!

Assess resonance

Listen to both sides of the chest: this may be difficult in the prehosital environment due to ambient noise. However once the patient is in the back of an ambulance, try and listen then. Unilateral wheeze is an early sign of an evolving pneumothorax. This is generally only heard pre-hospitally, early on in the disease process. Remember that just because you are treating a trauma patient, doesn’t mean their pre-existing airways disease doesn’t need attention.

Look in both axillae and back. I think we sometimes forget to sit trauma patients upright if they can and there is no concern about spinal injury because we are used to transporting them supine.  It helps their breathing and enables us to examine the posterior chest wall.

To me, USS of the chest forms part of my primary survey. It does not rule out a pneumothorax but rules in one. Although there is data to suggest the sensitivity and specificity is changing. The above hyperlink is to a great 10 min video from the awesome ultrasound podcast guys.

If the patient is awake, ask them to cough. If it’s painful, that is a sensitive indicator that they have an underlying lung injury.

Here’s a brief musical interlude…….Classic Bryan!

Imagine this scenario: You are in resus of a rural emergency department and a trauma call comes in. A male driver of a car has crashed onto a tree. He has a reduced GCS and frontal haematoma. You examine the rest of him and find no injuries including performing an USS chest. The nearest MTC is and hour away by road. You liase with them and decide he needs to be intubated for the transfer. The RSI is uncomplicated.

In back of the ambulance, how do you or the anaesthetist determine whether your intubated patient has a rapidly evolving pneumothorax?

  First the signs and symptoms of a pneumothorax are:

  • Patient may scream “I can’t breathe!, I can’t breathe!…” or “I think I’m going to die!”: think tension pneumothorax
  • Surgical emphysema
  • Bony crepitus to chest wall
  • Flail chest
  • Decreased air entry
  • Wheeze
  • Dyspnoea (often described as tightness in breathing not shortness of breath)
  • External signs of trauma with significant mechanism of injury

 Here are some top tips to help diagnose that pneumothorax in intubated patients: (Remember your CT scanner may be at the other end of the hospital or the transfer time to the nearest MTC should be some distance)

  1.  If you RSI a patient, THINK TENSION, TENSION, TENSION! FOR EVERY RSI PATIENT! Keep thinking “does my patient have a pneumothorax?”- this is not to say perform thoracostomies on every intubated patient! Just be vigilant.

2.  Make a note of the initial airway pressures when you put the patient on the ventilator. If they start to increase, think tension!

3. ETCO2 is a surrogate marker for cardiac output. During transfer, BP readings can be unreliable. In the words of a great HEMS doctor: “If the ETCO2 starts to fall, there is only so much ventilator knob fiddling you can do to try and correct it…..Think Tension!

4. Obviously falling oxygen sats is a concern. I was taught the best way to trouble shoot it is to follow an imaginary O2 molecule from the O2 supply, through the ventilator, circuit, ETT and into the lungs. Are there any faults along that chain. Think Tension!

5. If you have difficulty obtaining oxygen sats or unexplained hypotension: Think tension!  Performing finger thoracostomies/ chest drain are not with out their complications. Click on these links for more information on thoracostomies, the indications and how to do them: Emcrit and LIFTL.

Top Tips:

1. Crosscheck the site of your thoracostomies either with someone else. If you have difficulty doing the thoracostomy or unsure whether you are in the pleural cavity, get someone else to double check it. .

2. Get down to the level of the patient. Kneel if you have to, it is so easy to try and do these standing up, but you need to be down at the level of the patient or raise the trolley bed to your level to ensure your tract is straight and perpendicular to the patient.

3. Make a Large incision & blunt dissect down to ribs: 5cm mid axially line 4th/5th intercostal space. I tend to use a Sharpie to mark the site on the chest prior to RSI. Remember to cross check that site!

4. Strip the muscle of the rib: you want to be able to get 2 fingers into the pleural cavity.

5. If the patient is hypotensive: Refinger the thoracostomies! Not forgetting to think about hypovolaemia shock ( check the pelvic binder is still tight and any splints used haven’t moved)

One last thing:

prometheus-eagle-eating-liver

This is Prometheus who had his liver eaten by an eagle daily…. Think about liver/ splenic injury if a patient has a chest injury!

So to sum up:

1. Be better at examining the chest: Think Craig David, Think RISE N FALL!

2. In an intubated trauma patient: Constantly THINK TENSION!

3. Finger thoracostomies: Crosscheck the site, Get down to the level of the patient, big incision, blunt dissection, strip the muscle off the rib, get 2 fingers into the pleural cavity.

Simples! Hope this has been useful. Certainly reminded me of a few things whilst writing it!

KR

N

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