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Questions and Answers
Which structure is located at the apex of the Triangle of Safety?
Which structure is located at the apex of the Triangle of Safety?
The chest tube is filled with air to assist with air suction during inspiration.
The chest tube is filled with air to assist with air suction during inspiration.
False
Which of the following is a clinical feature of tension pneumothorax?
Which of the following is a clinical feature of tension pneumothorax?
In tension pneumothorax, the percussion note is dull.
In tension pneumothorax, the percussion note is dull.
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List two layers pierced during a chest tube insertion.
List two layers pierced during a chest tube insertion.
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The __________ anteriorly forms the anterior axillary line.
The __________ anteriorly forms the anterior axillary line.
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What is the primary emergency management for tension pneumothorax?
What is the primary emergency management for tension pneumothorax?
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In children, the chest X-ray indicates pneumothorax at the ___ intercostal space, mid-clavicular line.
In children, the chest X-ray indicates pneumothorax at the ___ intercostal space, mid-clavicular line.
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Match the following layers with their order of insertion during chest tube placement:
Match the following layers with their order of insertion during chest tube placement:
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Match the condition with its characteristic percussion note:
Match the condition with its characteristic percussion note:
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What is the primary purpose of applying pressure to a scalp laceration?
What is the primary purpose of applying pressure to a scalp laceration?
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Bleeding below the aponeurotic layer can cause a black eye.
Bleeding below the aponeurotic layer can cause a black eye.
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List the layers of the scalp indicated by the mnemonic SCALP.
List the layers of the scalp indicated by the mnemonic SCALP.
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In case of a scalp laceration, definitive treatment involves suturing with a No _____ suture.
In case of a scalp laceration, definitive treatment involves suturing with a No _____ suture.
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Match the following conditions or treatments with their descriptions:
Match the following conditions or treatments with their descriptions:
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What is the first line medication for traumatic thoracic aortic injury (TTAI)?
What is the first line medication for traumatic thoracic aortic injury (TTAI)?
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Pericardiocentesis is indicated in cases of traumatic cardiac tamponade.
Pericardiocentesis is indicated in cases of traumatic cardiac tamponade.
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What is the goal mean arterial pressure (MAP) when managing traumatic thoracic aortic injury?
What is the goal mean arterial pressure (MAP) when managing traumatic thoracic aortic injury?
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The most common site of Traumatic Thoracic Aortic Injury (TTAI) is distal to the ______.
The most common site of Traumatic Thoracic Aortic Injury (TTAI) is distal to the ______.
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Match each type of thoracic injury with its characteristic feature:
Match each type of thoracic injury with its characteristic feature:
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What injury is more likely associated with fractures of the left 10th-12th ribs?
What injury is more likely associated with fractures of the left 10th-12th ribs?
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Anterior rib fractures are oriented horizontally.
Anterior rib fractures are oriented horizontally.
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Define flail chest.
Define flail chest.
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The leading cause of death associated with flail chest is __________.
The leading cause of death associated with flail chest is __________.
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Match the following terms related to thoracic trauma with their descriptions:
Match the following terms related to thoracic trauma with their descriptions:
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What is a common symptom of hemothorax?
What is a common symptom of hemothorax?
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The percussion note in a hemothorax is typically resonant.
The percussion note in a hemothorax is typically resonant.
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What is the primary management for hemothorax?
What is the primary management for hemothorax?
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In cases of significant bleeding, an emergency thoracotomy may be indicated if there is bleeding greater than _______ upon chest tube insertion.
In cases of significant bleeding, an emergency thoracotomy may be indicated if there is bleeding greater than _______ upon chest tube insertion.
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Match the clinical signs with their descriptions:
Match the clinical signs with their descriptions:
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What is a primary treatment method for managing a tension pneumothorax?
What is a primary treatment method for managing a tension pneumothorax?
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A simple pneumothorax shows a change in hemodynamic status.
A simple pneumothorax shows a change in hemodynamic status.
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What causes the trachea to shift in the presence of a tension pneumothorax?
What causes the trachea to shift in the presence of a tension pneumothorax?
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The __________ is a key sign indicating a tension pneumothorax due to the mechanism involved.
The __________ is a key sign indicating a tension pneumothorax due to the mechanism involved.
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Match the following terms with their definitions:
Match the following terms with their definitions:
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What is the most common cause of cardiac tamponade?
What is the most common cause of cardiac tamponade?
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Beck's triad includes hypotension, increased jugular venous pressure, and muffled heart sounds.
Beck's triad includes hypotension, increased jugular venous pressure, and muffled heart sounds.
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What should be less than 100 cc in a 24-hour period for chest tube removal?
What should be less than 100 cc in a 24-hour period for chest tube removal?
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Cardiac tamponade typically requires a minimum fluid accumulation of _______ cc in the pericardial space.
Cardiac tamponade typically requires a minimum fluid accumulation of _______ cc in the pericardial space.
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Match the following clinical features to cardiac tamponade and tension pneumothorax:
Match the following clinical features to cardiac tamponade and tension pneumothorax:
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Which of the following is a clinical feature of trauma that suggests diaphragmatic injury?
Which of the following is a clinical feature of trauma that suggests diaphragmatic injury?
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Breathlessness is a clinical feature of neck trauma.
Breathlessness is a clinical feature of neck trauma.
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What is the first intervention recommended for Zone 1 neck trauma?
What is the first intervention recommended for Zone 1 neck trauma?
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Subcutaneous emphysema is classified as a __________ sign of neck trauma.
Subcutaneous emphysema is classified as a __________ sign of neck trauma.
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Match the following zones of neck trauma with their features:
Match the following zones of neck trauma with their features:
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Which of the following is a clinical feature of a fracture in the anterior cranial fossa?
Which of the following is a clinical feature of a fracture in the anterior cranial fossa?
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CSF otorrhea is a clinical feature associated with fractures of the anterior cranial fossa.
CSF otorrhea is a clinical feature associated with fractures of the anterior cranial fossa.
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What is the recommended prophylactic medication to prevent meningitis in case of skull fractures?
What is the recommended prophylactic medication to prevent meningitis in case of skull fractures?
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A fracture of the posterior cranial fossa may lead to _______ nerve injury.
A fracture of the posterior cranial fossa may lead to _______ nerve injury.
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Match the following cranial fossa fractures with their respective clinical features:
Match the following cranial fossa fractures with their respective clinical features:
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Study Notes
Tension Pneumothorax
- Characterized by increased respiratory rate, decreased cardiac output, tachycardia, decreased systolic blood pressure, and increased jugular venous pressure.
Comparing Tension Pneumothorax to Other Conditions
- Tension pneumothorax, cardiac tamponade, hemothorax, and simple pneumothorax present with different clinical features, percussion notes, breath sounds, and jugular venous pressure.
Chest X-Ray and EFAST for Diagnosis
- Chest X-ray helps identify air in the pleural space.
- EFAST (Echocardiography) can rule out cardiac tamponade by observing the loss of the seashore/barcode/stratosphere sign.
Management of Tension Pneumothorax
-
Emergency Management:
- Needle thoracocentesis.
-
Definitive Management:
- Tube thoracocentesis: Placement of a chest tube within the triangle of safety.
- Open wound: Applying a 3-sided occlusive dressing to create a one-way valve.
Triangle of Safety
- Used for chest tube insertion.
- Defined by boundaries:
- Apex: Axilla
- Posteriorly: Mid-axillary line
- Anteriorly: Anterior axillary line (formed by Pectoralis major)
- Base: 5th intercostal space
-
Layers pierced during insertion:
- Three layers of intercostal muscles
- Endothoracic fascia
- Parietal pleura
Chest Tube Insertion and Functioning
- Functioning is assessed by the movement of the water column under water seal.
- The chest tube is filled with water to prevent the suction of air during inspiration.
Anatomy of the Scalp
- SCALP mnemonic:
- Skin: Includes blood vessels that cannot vasoconstrict, leading to bleeding during scalp lacerations.
- Connective tissue: Lacerations in this layer can cause bleeding.
- Aponeurosis: Bleeding below this layer can result in a black eye.
- Loose areolar tissue: This area is prone to retrograde spread of infection from the dangerous area of the face, potentially leading to cavernous sinus thrombosis.
- Periosteum:
Skull Fractures and Treatment
- Non-depressed fractures: Conservative management.
- Depressed fractures: Investigated with NCCT (immediate observation of the injury).
Thoracic Trauma: Traumatic Thoracic Aortic Injury (TTAI)
- Site: Most common location is distal to the ligamentum arteriosum.
- Clinical Features: Chest pain, difference in blood pressure between limbs, absent pulsations in one limb.
-
Imaging:
- CXR: Widened mediastinum and (Lt) main stem bronchus.
- CT Angiogram: Recommended for stable patients.
- Transesophageal echocardiography (echo): Recommended for unstable patients.
-
Medication:
- First-line treatment: Short-acting β-blocker (esmolol).
- Goal: Permissive hypotension (MAP: 60-70 mmHg).
- Repair: Open or endovascular methods.
Sternal Fractures
- Associated with high-velocity impact and possible myocardial contusion.
- ** Monitoring:** Cardiac enzymes and a 12-lead ECG.
- No surgical intervention is required.
Diaphragmatic Injuries
- More common on the left side due to liver protection on the right.
Hemothorax
- Accumulation of blood in the pleural space due to intercostal vessel injury.
- Clinical Features: Tachypnea, decreased cardiac output, decreased systolic blood pressure, tachycardia.
- Imaging: Chest X-ray and eFAST.
- Signs: Dull percussion note and absent breath sounds.
- Management: Chest tube insertion in the triangle of safety
Indications for Emergency Thoracotomy
-
1-1.5 L of bleeding upon chest tube insertion.
-
200 cc/hr for ≥ 3 consecutive hours.
- Aortic injury.
- Tracheobronchial/Esophageal injury.
- Cardiac tamponade.
- Note: Emergency room thoracotomy is obsolete currently.
Chest Tube Removal
- Performed when the lung is expanded, output is less than 100 cc/24 hours, and during peak inspiration with the patient holding their breath to prevent air suction.
Cardiac Tamponade
- Rapid accumulation of blood in the pericardial space (minimum: 60-70 cc).
- Most common cause: Penetrating trauma > blunt injury.
- Clinical features: Hypotension, Beck's triad (increased jugular venous pressure, muffled heart sounds), deteriorating cyanosis, tachycardia, agitation.
- Investigations: FAST/eFAST.
- Additional findings: Hypoechoic collection in the subxiphoid (Cardiac window).
Diaphragmatic Injuries
- Etiology: Penetrating trauma > blunt abdominal trauma.
- Clinical Features: Breathlessness, bowel sounds heard in the thoracic cavity.
-
Management:
- Never insert intercostal tube blindly.
- Laparotomy → Bring down bowel → Repair of diaphragm with prolene sutures → Insert chest tube under vision.
Right-Sided Diaphragmatic Injury
- Management: Requires laparotomy, bringing down the bowel, repair using prolene sutures, and inserting a chest tube under vision.
Neck Trauma
-
Zones of Neck Trauma:
-
Zone 1: Thoracic inlet to cricoid cartilage:
- Highest mortality due to vital structures.
- Most exposed and injured.
- Most surgically accessible.
- Management: Angiography & embolization.
-
Zone 2: Cricoid to angle of mandible:
- Majority of injuries managed conservatively.
- Surgical exploration may be required.
-
Zone 3: Angle of mandible to base of skull:
- Management: Angiography & embolization.
-
Zone 1: Thoracic inlet to cricoid cartilage:
Indications for Intervention in Neck Trauma
-
Hard signs of neck trauma:
- Subcutaneous emphysema.
- Air bubbling from a penetrating wound.
- Expanding neck hematoma.
- Hoarseness of voice.
Base of Skull Fractures
-
Anterior cranial fossa fractures:
- Bilateral black eyes (raccoon eyes): Posterior/superior border of subconjunctival hemorrhage not visible.
- CSF rhinorrhea: Target/Halo sign (+), batransferrin.
- Epistaxis.
- Anosmia.
- Frontal lobe contusion.
-
Middle cranial fossa fractures:
- Temporal lobe contusions.
- Battle sign.
- Hemotympanum.
- CSF otorrhea.
- Facial nerve injury.
- Paradoxical rhinorrhea (Rare).
- CSF into Eustachian tube, into nose.
-
Posterior cranial fossa fractures:
- Visual problems.
- Occipital contusion.
- VIth nerve injury.
- Vernet syndrome/Jugular foramen syndrome (Rare): IX - XIth cranial nerve injury.
Base of Skull Fractures: Clinical Features
- Anterior: Bilateral black eye/raccoon eyes, posterior/superior border subconjunctival hemorrhage, CSF rhinorrhea (target/halo sign), batransferrin, epistaxis, anosmia, frontal lobe contusion.
- Middle: Temporal lobe contusions, Battle sign, hemotympanum, CSF otorrhea, facial nerve injury, paradoxical rhinorrhea (rare), CSF into the Eustachian tube, into the nose.
- Posterior: Visual problems, occipital contusion, VIth nerve injury, Vernet syndrome/Jugular foramen syndrome (rare) IX - XIth cranial nerve injury.
Base of Skull Fractures: Imaging and Treatment
- Imaging: NCCT (immediate observation of the injury).
-
Treatment:
- Managed as open fractures.
- Prophylactic 3rd generation cephalosporin to prevent meningitis.
- Do not pack the nose/ear to avoid aiding bacterial growth in anaerobic conditions.
Thoracic Trauma: Rib Fractures
- Most common in adults due to MVCs.
- In children, pliable ribs often damage underlying organs.
- Clinical Features: Pain and bruising on the chest.
- Management: Adequate analgesia.
Flail Chest
- Definition: Fracture of 2 or more consecutive ribs in at least 2 places.
-
Complications:
- Underlying pulmonary contusion (leading cause of death).
- Paradoxical chest movement (flail segment moves in opposite direction of the chest wall).
- Imaging: Chest X-ray showing the location of the rib fracture.
Thoracic Trauma: Rib Fractures: Anterior vs. Posterior
-
Anterior:
- Located further from the midline.
- Obliquely oriented.
-
Posterior:
- Located closer to the midline.
- Horizontally oriented.
Thoracic Trauma: Rib Fractures: 10th-12th Ribs (Floating Ribs)
- Left: Splenic injury.
- Right: Liver injury.
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Description
This quiz covers the key features of tension pneumothorax, including its clinical presentation, diagnostic methods like chest X-ray and EFAST, and emergency management techniques. Understand the differences between tension pneumothorax and other conditions, as well as the triangle of safety for chest tube insertion.
