Trauma Management: Myocardial Contusion and Penetrating Cardiac Injury
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Questions and Answers

What is the primary indication for surgical intervention in tracheobronchial tree injuries?

  • Unstable airway or associated oropharyngeal injury (correct)
  • Stable airway
  • Mediastinal distortion that makes intubation easy
  • Distal trachea injury

    • Which of the following is a common location for esophageal injuries?

  • Cervical esophagus (correct)
  • Distal esophagus
  • Abdominal esophagus
  • Thoracic esophagus

    • What is the primary investigation for esophageal injuries?

  • Chest X-ray (CXR)
  • Oesophagoscopy
  • Water-soluble contrast swallow (correct)
  • Computed Tomography (CT) scan

    • What is the most common location for diaphragmatic injuries?

    <p>Left diaphragm</p> Signup and view all the answers

    What is the primary management for cardiac injuries?

    <p>Surgical repair</p> Signup and view all the answers

    What is the primary complication of esophageal injuries?

    <p>All of the above</p> Signup and view all the answers

    What is the primary indication for bronchoscopy in foreign body in the airway?

    <p>Acute foreign body aspiration</p> Signup and view all the answers

    What is the primary management for tracheobronchial injuries?

    <p>All of the above</p> Signup and view all the answers

    What is the primary investigation for diaphragmatic injuries?

    <p>All of the above</p> Signup and view all the answers

    What is the primary complication of blunt cardiac injuries?

    <p>All of the above</p> Signup and view all the answers

    What percentage of thoracic deaths are accounted for by thoracic injury worldwide?

    <p>20-25%</p> Signup and view all the answers

    What is a characteristic of pediatric thorax that makes it more resistant to injury?

    <p>More cartilage</p> Signup and view all the answers

    What type of force is responsible for injuries in acceleration-deceleration mechanisms?

    <p>All of the above</p> Signup and view all the answers

    What is a common associated injury with traumatic rib fractures?

    <p>Lung contusion</p> Signup and view all the answers

    What is a characteristic of sternal fractures?

    <p>Transverse fracture</p> Signup and view all the answers

    What is the primary goal of initial evaluation in thoracic trauma?

    <p>Prompt identification of life-threatening injuries</p> Signup and view all the answers

    What is a type of tracheobronchial injury?

    <p>Foreign body</p> Signup and view all the answers

    What is a type of diaphragmatic injury?

    <p>Transfixing injury</p> Signup and view all the answers

    What is the reported incidence of myocardial contusion in autopsy series of patients with BCI?

    <p>60-100%</p> Signup and view all the answers

    What is the most common site of blunt aortic injuries?

    <p>Isthmus, near ligamentum arteriosum</p> Signup and view all the answers

    What is the mortality rate for patients with blunt aortic injuries who survive the initial injury?

    <p>70-80% at 1 week</p> Signup and view all the answers

    What is the radiographic feature associated with thoracic aortic injury?

    <p>Loss of aortic knuckle contour</p> Signup and view all the answers

    What is the treatment for myocardial rupture?

    <p>Simple cardiorrhaphy</p> Signup and view all the answers

    What is the mechanism of blunt aortic injuries?

    <p>All of the above</p> Signup and view all the answers

    What is the clinical presentation of blunt aortic injuries?

    <p>All of the above</p> Signup and view all the answers

    What is the management of blunt aortic injuries?

    <p>All of the above</p> Signup and view all the answers

    Study Notes

    Tracheobronchial Tree Injuries

    • Can be managed conservatively or surgically depending on the location and extent of the injury
    • Surgical approach depends on the location of the injury:
      • Cervical collar incision: proximal trachea
      • Right postero-lateral thoracotomy: lower trachea, carina, right main bronchus (RMB), and proximal left main bronchus (LMB)
      • Left postero-lateral thoracotomy: distal LMB
    • Options for management: primary repair, sleeve resection, and lung resection

    Foreign Body in the Airway

    • Management: acute cases require urgent bronchoscopy with or without bronchotomy, while chronic cases require bronchoscopy with precaution and possible lung resection

    Esophageal Injuries

    • Rare in blunt trauma, more common in penetrating trauma (stab or trans-mediastinal gunshot injury)
    • Cervical esophageal injuries are most common
    • Clinical features:
      • Pneumothorax (left)
      • Haemothorax without rib fractures
      • Lower sternum or epigastric pain (severe blunt trauma)
      • Particulate matter in the ICD
      • Penetrating injury that has crossed the mediastinum
      • Odynophagia
      • Dysphagia
      • Surgical emphysema
      • Mediastinitis
    • Investigations:
      • Combination of clinical suspicion, CXR, water-soluble contrast swallow, and oesophagoscopy
    • Management:
      • Timing: debride and drain within 24 hours
      • Surgical repair or resection with delayed reconstruction
      • Via:
        • RPLT 4th ICS for upper esophagus
        • LPLT 6th ICS for lower esophagus
    • Complications:
      • Mediastinal contamination
      • Abscess formation
      • Empyema thoracis

    Foreign Body in the Esophagus

    • Types: bone, meat, battery, coin
    • Clinical presentation:
      • Acute: dysphagia, choking, hematemesis
      • Chronic: hemoptysis, coughing when feeding
    • Management: oesophagoscopy with or without mediastinal drainage and repair

    Diaphragmatic Injuries

    • Often occult, easily missed; left diaphragm most commonly detected
    • Marker of severe thoracoabdominal trauma
    • Types: blunt vs penetrating (stab/iatrogenic-ICD)
    • Clinical features:
      • With or without signs of bowel obstruction
      • Drainage of peritoneal content via chest drain
      • NGT in the chest (CXR)
      • Herniation of GIT
      • Acute, delayed, common left
    • Investigations:
      • CXR: elevated hemidiaphragm, haemo-pneumo
      • Swallow and follow through
      • Contrast-enhanced CT scan
    • Management: surgical repair via thoracotomy vs thoraco-abdominal incision vs laparotomy, or laparoscopy

    Cardiac Injuries

    • Penetrating: myocardial contusion, valve injuries, IVS rupture
    • Blunt: myocardial contusion, valve injuries, IVS rupture
    • Frequency of injury: 20-25% of thoracic deaths worldwide
    • Male vs female: male dominance
    • Age: bimodal distribution
    • Mechanism of injury:
      • Penetrating: high-velocity (gunshots) or low-velocity (stab wounds)
      • Blunt: direct (assault and blast) or indirect (falls, MVA)
      • Transfixing

    Syllabus

    • Chest wall (muscle and bone)
    • Pleura
    • Lung parenchyma
    • Tracheobronchial tree (and foreign body)
    • Esophagus (and foreign body)
    • Diaphragm
    • Cardiovascular

    Thoracic Trauma

    • Thoracic injury accounts for 20-25% of thoracic deaths worldwide
    • Male vs female: male dominance
    • Age: bimodal distribution
    • Mechanism of injury:
      • Penetrating: high-velocity (gunshots) or low-velocity (stab wounds)
      • Blunt: direct (assault and blast) or indirect (falls, MVA)
      • Transfixing

    Initial Evaluation

    • Goal: prompt identification of life-threatening injuries
    • Pathology:
      • Airway obstruction
      • Loss of oxygenation or ventilation
      • Hypovolemia
      • Obstructive shock
      • Ventilation-perfusion mismatch
    • Physiological causes of death:
      • Tissue hypoxia
      • Hypercarbia
      • Metabolic acidosis

    Acceleration-Deceleration

    • Shearing, tearing, and traction forces in relation to structures being more fixed than others
    • Aorta, heart, and esophagus are more susceptible to injury

    Initial Evaluation

    • Primary survey (Airway-Breathing-Circulation):
      • Airway obstruction
      • Tension pneumothorax
      • Open pneumothorax/sucking chest wound
      • Flail chest
      • Massive haemothorax
      • Cardiac tamponade
    • Secondary survey (with the aid of imaging, record every injury from head to toe, systemically)

    Traumatic Rib Fractures

    • Other bony fractures of the chest wall
    • Sternal fractures:
      • Up to 4%
      • Transverse, in the upper or midportions
      • Associated injuries: myocardium
      • Clinical features: point of tenderness, swelling, and deformity
      • Investigations: ECG, cardiac enzymes, formal ECHO/TEE
      • Management: supportive, surgical (help wean off MV)

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    Description

    This quiz covers the diagnosis, management, and surgical interventions for myocardial contusion and penetrating cardiac injury, including cardiac rupture and valve repair.

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