Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. It's been a minute since we touched on the trauma curriculum on the podcast, but today I'm pleased to announce that we have the incredible guest, James Mackay, joining us to talk about chest trauma. We cover...
Most topics you'd need to know about this and James has really broken down some of the more tricky aspects of this for us. I'm really grateful for his time today and I hope you learn as much from this episode as I did. To start us off with, would you please tell us a little bit about yourself? Yeah, thanks very much for having me on. I'm James, I'm a trauma surgeon intensivist in Christchurch in New Zealand.
A bit of an unusual combination for New Zealand and Australia anyway of combining surgical training with intensive care, but it goes well into my... passions which have become trauma and complex hernia. So that's where my pathways led me down and currently working as both in Christchurch. recently taken on some director roles for the South Island Trauma Network as an evolving thing here in New Zealand. We're chasing Australia in that regard but other than that it's good.
Outside of work, my hobbies, I'm trying to pick them back up. I've lost them over the years with surgical training and things, but I enjoy skiing. just come back from holiday, which has been great. And then otherwise, most of the outside of work time is focused on family. I've got three kids, all of them play sport and other things, so I've lived vicariously through them.
You very graciously offered to come to talk to us about chest trauma today. And we have a few topics I wanted to touch on. The first one was just starting simply, probably the most common type of chest trauma that we see. I thought we'd talk a little bit about rib fractures. Do you want to tell us about them and maybe what the sort of keys are for a general surgical person to know for management? Yeah, so you've already touched on the fact they're incredibly common.
And I think if we nail down every trauma patient, a lot of them would have rib fractures. A lot of them go unnoticed or just treated clinically. So people have got some chest wall pain. What's become a lot more apparent over time though is that the aggressiveness of which rib fractures should be recognised and treated has increased. By that I mean it's become more important to diagnose them, and not only that, to diagnose how many there are and the positions of them.
and whether there's displacement or flail and more serious things, because the treatment options have become a lot more varied. I think in short, general surgery is the default trauma specialty in Australasia in most centres, and even outside of ones with...
trauma services and as part of that it's a core part of managing rib fractures particularly in more rural centres where you don't have cardiothoracic specialties and I'm not sure about Australia but certainly in New Zealand cardiothoracics is becoming a lot more cardiac focused and less thoracics and so the importance of trauma and general surgery and thoracic trauma is probably going to increase over time
And in general, say for your stock standard couple of rib fractures, what would be the management algorithm for those? Yes, I think two things come into play. One is how many ribs and the morphology of those, i.e. are they flail or displaced. And then the second part is the patient, particularly their age. So multiple rib fractures, say more than four or five, and a young, fit, healthy person has the same outcomes and morbidity as one or two in someone who's 70.
So it's quite important to individualise it. What I think the important thing will be is that if they're symptomatically okay, pain's well controlled, they can cough and deep breathe well. Apart from flower chest, most rib fractures can just be treated with analgesia.
And most of us are familiar with an analgesic ladder of some description. But certainly if there's a concern about pain, the risk of pneumonia and other complications increases dramatically with the number of red fractures and the age of the patient. you have to be more aggressive with their pain relief. So most institutions now, they would introduce some form of scoring like a rib fracture score, which means that if you're over 65 or three or more rib fractures or a flail segment,
you automatically should go up your ladder and involve a pain service or anaesthesia for regional blocks or epidurals or something more advanced, at least the PCA. And data has indicated that if you aggressively treat pain early... the outcomes are better. Other than that, chest wall physiotherapy and early mobilisation is probably the key. And I think if people have well-controlled pain, getting them mobilised, getting them coughing and deep breathing.
and punishing them with physiotherapy is going to pay off dividends and certainly has shown to reduce their hospital stay and risk pneumonia. When I was studying, I always found it difficult to figure out the difference between a radiological flail and a clinical flail and whether you actually treat them differently. Can you comment on that? Yes and no. Certainly radiological flails are commonly reported.
And it's like a lot of things in surgery. I've always found it useful to look at scans myself. And you get an impression over time because you can clinically correlate what are the things you should worry more about. Radiological flowers are not uncommon.
But the same principles apply, particularly if they're younger, they can cough in deep breath and their pain's okay. You probably don't worry about the majority. But certainly if they have a clinical flail, whereas you can see paradoxical movement of the chest, or if they've got...
impairment of ventilation particularly or severe pain. There are certainly ones that need treatment regardless of what the radiology says. The changing paradigm over the last decade particularly is the involvement of surgical management of rib fractures. which is particularly in those with flail chest. The evidence is lacking to some degree, but flail chest is the one area where surgical rib fixations actually become an important tool to have.
particularly in those that are high risk, so severe pain or elderly. And is that plating the ribs to stop the movement of the chest wall? Yeah, correct. There's been an evolving way to do it, but most trauma centres now, and in the biggest part in Australasia, it's general surgeons that do it.
It's usually linear plates to bridge fractures either because of severe pain or to stabilise flail. The exact person to do it in and how many to plate and which ones are all up for discussion. But I think most people would recognise that.
If you've got a flail segment or you're in severe pain and it's between the fourth and the eighth ribs, particularly lateral, they're the ones that are easily accessible surgically and most of us would have quite a low threshold in repairing those. Without going into the details of the operation, it's quite a...
simple undertaking. Given that general surgeons do it, you don't need to be an orthopedic surgeon. And so most of us would do those. And I think once you start doing them, you realise that the pain benefits overall are sometimes quite remarkable. The other group outside of that, we do a lot in this intensive care. and at least the data showing that you can reduce the amount of ventilation and length advice you stay if you play their rips early.
So the other really common thing that we see in chest trauma are patients presenting with pneumothoraces and haemothoraces. Can you... Talk to us a little bit about when you should intervene for a pneumothorax, when you should intervene for a hemothorax, and then maybe we could do a sort of operative viva type thing for finger thoracostomies and chest tubes.
Sure. I think out of all of the chest injuries, most surgical people would have the most experience with pneumothoraces and hemothoraces. The common doctrine you're taught through EMST and over time and through training is that they will require a drain.
And I think that's changed a lot over the years. So if we start with pneumothorax alone, most people know the definition of a pneumothorax, which is air essentially in the plural space where it shouldn't be. And they're remarkably common the more you look for them.
They probably haven't changed in incidence, but because of our scanning, we pick them up a lot more. What has become evident is that small pneumothoraces often require no treatment at all. And the definition of small is up for debate. But if I've got no... oxygenation or breathing impairment. A pneumothorax of a couple of centimetres on X-ray or CT often doesn't need any treatment at all. And the morbidity from putting in any sort of drain probably outweighs any benefit you get from draining it.
most of those people will benefit just as much from treating their pain and giving good chest physio. The ones that you do need to drain fall into two groups. The obvious is tension pneumothorax. which most people have an algorithm to deal with in terms of immediate decompression they will chat about finger thoracostomy shortly but then the moderate size pneumothorax often requires drainage
There's a paradigm difference between medical and surgical drainage and I think historically we've always been taught an open drain and for the majority of people that's probably what they're more comfortable putting in. There's been a trend over time for smaller and smaller drains for pneumothoraces.
And I think the data would suggest that that's probably appropriate for most people to drain small to medium ones. But data would also suggest that the complication rate may be higher with Seldinger drains versus an open drain. But different hospitals have their preference. I think...
some form of drainage and most people in the surgical field would be happy putting in a small open drain rather than a saldinger drain but it's up to the institution as to what they prefer haemothorax is slightly different and i think unless very small most people an open drain would be an appropriate one again it doesn't need to be huge gone are the days of having 36 french drains in they're just making 18 to 24 french is more than appropriate
But the secret to haemothoraces is once there's a drain in, that you have to keep going until the haemothorax is gone. Just because once you've instrumented the collection, if you take the drain out and there's still a moderate and small haemothorax there, the chance of getting infection in that is high.
the time as to when the injury was for haemothorax becomes important. Because if it's acutely draining, logic would say the blood's liquid, it'll come out nice and easy. If it's more than a couple of days old, the likelihood of being able to drain that... with a drain alone becomes more and more unlikely unless it liquefies so usually if it's a older hemothorax i more than 72 hours and the asymptomatic you tend to leave it alone unless it's really large
But if it's really large, you're much more likely to need some form of surgical drainage, either a video assisted thoracoscopy or... decortication or something like that so usually it's uncommonly needed these days because we tend to conservatively manage most hemothoraces as in either with a small drain or no drain at all You have to have a pretty big hemothorax to have an upfront surgical intervention and the emergent...
Massive haemothorax and massive haemorrhage I think falls into a totally different group and you get into thoracotomy territory but for barn store haemothorax I think most people's practice would be. to leave it alone entirely, or if it's at least moderate, to drain it with a moderate-sized drain, sort of an 18 to 24 fringe. Talking about the sort of major bleeding and haemothorax, there's some numbers we get taught in EMST about...
When the patient needs a thoracotomy, can you talk us through that? And surgically, if we did have to do a thoracotomy, what are we looking to control? Yeah, and I think each institution has their own guidelines, but the classic teaching is if you put a chest drain in and there's 1,500 mils or more immediately, or if there's a certain amount of bleeding per hour.
And I think people may correct me on the numbers, but it's 200 to 300 mils an hour over a few hours. They usually indicate it to say that person needs intervention. How emergent the intervention is, is the question. It ranges from people in hemodynamic shock. loss of clinical output and blood pressure in the emergency room may well require resuscitative thoracotomy versus those who have just continuing ongoing bleeding either occultly or
continual hemoglobin drop and blood transfusion requirement. Some of those require more semi-elective thoracotomy. And certainly the evidence would suggest that the outcomes are much better if they're done in the operating theater than the ED. So unless they're dying, don't do it in ED would be the only suggestion. The most common cause for massive haemothorax in that setting is not major vascular injury of the lung or anything. It's usually intercostal injury.
And I think people can bleed a lot from their intercostal arteries. So it's not uncommon to open a chest to find the lung's not bleeding much, but it's all from an intercostal artery. So I think if you've got time for good imaging beforehand... in big centres who have rapid CTs available and you show an intercostal bleed, by far the morbidity is reduced if you can embolise that. But that requires timely intervention that some people don't have.
But if the patient is stable, that would be my strong suggestion is to rule that out first, given how common it is, before you open someone's chest. We'll talk about resuscitative thoracotomy later. Going back to pneumothorax and haemothorax, could you talk us through how to perform a finger thoracotomy and how to insert a chest tube? Sure. I think the teachings changed over years that most people now have abandoned needle thoracostomy.
It used to be you do second intercostal space, the clavicular line. Most studies now, and even EMST, would now recommend that you do it all in the same place. So the triangle of safety in the axilla, with the lower part of that triangle being the fifth rib.
So my only advice would be higher the better. People get afraid of going higher in the axilla because of what you're taught with breast surgery and axillary clearances and things, but you're much more likely to get into trouble if you go too low. So the teaching now for decompression of tension. is a finger thoracostomy. And essentially, where you go on the technique is exactly the same to put in a chest drain. Identify landmarks, the triangle of safety above the fifth rib.
you can't identify that in males it's a little bit easier to use the nipple line as the lower aspect and females the inframammary fold and if you go above that you're usually going to be okay from there you make small decision if they're wide awake and you're doing this a good dose of local anesthetic and analgesia is helpful if they're unconscious you just crack on and do it the goal is that if you're doing an open drain or a finger thoracostomy you cut down as far as you can onto the rib
And then with your finger or with usually a Roberts or some form of curved blunt instrument, you push with force with a guiding finger so you don't plunge into the chest. And you start on the rib and go above the rib rather than below. And I think classical teaching, most people will recognise that the major intercostal bundle is below the rib. So it doesn't eliminate the risk, but it reduces your risk of causing problems with bleeding. And once you're through...
spread the instrument and then get your finger inside the chest to confirm that that's where you are. I think if it's a tension you should have an immediate gush of blood or air depending what it's for. with finger thoracostomies most people in an emergency situation will just put a drain straight in the same hole unless it's been done pre-hospital then sometimes there's an increased infection risk but nonetheless to thread the drain and after you've made that hole
most people would connect the drain to the same curved instrument and thread it alongside their finger. Of course, being careful not to pull the finger of your glove off inside the chest and direct it posterior superiorly for... pneumothorax and inferiorly for blood. And that's essentially it. I find it's always difficult, especially in larger patients. You've got the tissue all kind of folding onto you and keeping that straight track to get the tubing can be really difficult.
Using your finger or another instrument to hold them all straight as you guide it in is really helpful. Correct. And I think that feeds back to the preparation of your kit. And if you've got time, preparation and setup is important. And most of us, well, I certainly do have the... drain pre-loaded on the instrument so you can essentially leave your finger in the chest and thread it along beside it rather than take your finger out you may never find the hole again and particularly big people
So moving on to a little bit of a rarer injury that maybe is rarer, maybe we just don't pick it up as well. I wanted to talk about diaphragmatic injuries. So what are the common mechanisms that cause diaphragmatic injuries? How would they present and how do we identify them? It's a good question. I think we don't see a lot of them, but I think part of it is because we don't look for them.
The algorithm I got taught on trauma fellowship is A, B, C, D, and the D is, don't forget the diaphragm, in terms of thoracrodominal trauma. By far the most common... cause in terms of incidences and penetrating. You're much more likely to see a diaphragmatic injury with penetrating trauma, which we don't see a lot of in New Zealand and Australia, thankfully. And if we do, most of it's low velocity, like stab wounds. But you're much more likely to have...
a diaphragmatic injury if you've got penetrating trauma. So part of it's having that index of suspicion. With blunt trauma, it's a lot less common. The ones we diagnose more are left-sided diaphragm, but I think that's because you can see them a bit easier on imaging.
nothing to do with the diaphragm on the left being weaker. On the right side of course most people have a big liver there that blocks any holes or at least makes them really hard to see on imaging. So always have a look at the diaphragm in all traumas.
In terms of what to do if you discover one, they all need repairing. When you repair them is different. I think if you discover one when you're in there for a trauma laparotomy or thoracotomy, you repair it immediately. The longer you leave them... and they become chronic the much harder they are to repair but unfortunately most that we repair are unrecognized acute diaphragmatic injuries either because they weren't seen because they're against the liver
or weren't reported at the time and by the time you've got half the bowel etc in the chest it becomes a lot more difficult to repair but there's nothing complex about repairing the diaphragm most of the repairs aren't along the ribs or anything that will require grafting, and there's very little tissue loss usually. So most of the time, just interrupted closure. Most people would use an Ethibond or something easy to close sutures with, given that you're having to often close it right up the top.
If it's just that you're repairing, there's no other injuries, then laparoscopic's often the favourite approach, because getting high up in the diaphragm is easier with a camera than it is open, most people would tell you, and certainly I find easier from the abdominal side than the thoracic side.
it's much harder to see to get down to the diaphragm through a thoracotomy than it is through the abdomen in my experience but most would use like an oethy bond interrupted sutures to close those and you usually don't need to leave a drain afterwards unless there's some
concurrent hemineumothorax. Interesting. I haven't seen that many of those. And the ones that I have seen are often quite late where you've got this big hole that they're often bridging with mesh and things like that. Correct. Yeah. And if they recognize them picked up early.
then repair them early would be the plan. Early, not immediately, but certainly during that hospital stay if you at all can. If you're going to bring them back for an elective procedure, then contrary to incisional hernias and complex ventral stuff, you probably want to do it earlier rather than wait.
But unfortunately, as we see most people present late. The caveat to the diaphragmatic repair is if it's an uncommon injury, either involving the hiatus or hiatus hernia mistaken, then certainly I'll... My practice would be to send those to esophagogastric surgeons, given that they operate there much more frequently. The last group is diaphragmatic eventration, so on trauma fellowship.
It wasn't necessarily that uncommon to operate on what we thought was a diaphragmatic injury to find that it's just a diaphragmatic palsy or something else that you've just got an odd bulging on radiology and the diaphragm's intact. But you'd much rather find that out on laparoscopy than leave it and have them come back six months later. So that's not necessarily uncommon finding either. You usually do nothing about it.
Okay, so getting into the meaty part of thoracic trauma, what are the indications for an emergency trauma thoracotomy? So the term over years has changed, but it's currently a resuscitator thoracotomy. And I think that's... highlighted so that people see it as part of resuscitation rather than a surgical procedure. Most people who do these around the world are not surgeons, either ED physicians. And if they are surgeons, they're usually trauma surgeons rather than cardiothoracic surgeons.
But I think the important thing is to notice that this is a life-saving procedure to a patient who is otherwise going to die before they can reach a formal operating theatre for hemorrhage control. The guidelines have changed a bit over years, but... In summary, the indication is that this person's lost signs of life, which are a combination of pulse, blood pressure, pupillary reactions, breathing, etc. And they need to have lost that within the last...
10 to 15 minutes. So the majority of people that have success from this are ones that lose their clinical signs of life or clinical output within the emergency department or just before. Hence why the places that do a lot of them generally have very short.
pre-hospital times. In short, most guidelines would say that you need to have lost clinical output and that person would not make it to the operation in the theatre environment. The patient also needs to be of a status that would benefit from a potentially life-saving procedure.
a slight judgment call on the comorbidity of that patient and there does need to be a relatively accurate time frame albeit some of the thoracotomies i've been involved with or or seen done have probably been inappropriately done on people that are by far past what would be considered a salvageable time frame but
They were young or they had a story of a possible breathing episode 10 minutes earlier and things that most people in the trauma environment would advocate for attempting it. The outcomes are significantly better for penetrating versus blunt trauma. to the point where some institutions that are smaller, such as those in New Zealand compared to worldwide, probably wouldn't do it very often for blunt-based trauma, just because the outcomes are dismal regardless. The best outcome is for...
penetrating thoracic trauma and penetrating causing cardiac tamponade. So a knife wound to the cardiac box causing cardiac tamponade has the best outcomes if you were to do one. The best institutions in the world may get a survival rate of about 20% in those people if it's done early, as opposed to certainly less than 2% for blunt trauma, regardless of mechanism and who does it.
So the primary indication for resuscitated thoracotomy is stopping hemorrhage in those who have lost signs of life, particularly in those with cardiac tamponade. So the sequence would usually say a left side of the antilateral thoracotomy. or a clamshell thoracotomy and most places would opt for a clamshell although it seems more morbid the exposure you get particularly people with a non-surgical background is much better the primary thing to then do is
Hopefully release any tension haemothorax or pneumothorax that has occurred and hopefully would have released that earlier. But you open the pericardial sac in an inferior to superior position toward the phrenic nerve. reduce any tamponade and usually if that's the cause releasing the tamponade returns their blood pressure even if they're still bleeding through a hole in the heart and most of those holes can have gentle digital pressure to stop them and then that buys you time
The second is any bleeding coming from inside the thorax itself, and usually this is lung or intercostals, which can either be packed or clamped with whatever you've got available. Great vessel vascular injuries in the chest are usually fatal, so most people wouldn't survive. to be having this done um so that's really uncommon to encounter those the third option is that you clamp the aorta because you've got bleeding below the diaphragm and again this is less likely to have survival compared to
cardiac tamponade and thoracic trauma, but certainly the outcomes are slightly better for penetrating versus blunt. And so the third thing to look for when you open up a chest for resuscitate a thoracotomy is to clamp the descending aorta to prevent inferior blood loss. In big institutions around the world, what's evolving now is that if you've got subdirophragmatic bleeding, they use ROBOA.
And the jury is out a little bit as to who should be using that. But certainly the big centres who do a lot of them and study them, particularly in Japan and the United States, show good outcomes. But it hasn't really... made its way into normal practice within Australasia because of the rarity of these events and also the ability to have enough trained people staffed at all hours to be able to do them safely given that they're not a simple procedure to undertake properly.
But the technology is advancing and so it's becoming more accessible with smaller and smaller catheters that it may well become like putting a test drain in in the future. And certainly when you work in an institution that does them, they work really well. but they are just a clamp on the air water, so they're not a definitive treatment. And so would you suggest an algorithm if a patient comes in and loses signs of life that you would...
you know, get your chest X-ray, get your pelvic X-ray, do your bilateral thoracostomies, intubate them, do your E-fast. And if, you know, there's signs of tamponade or, you know, severe chest trauma, that that would be the point that you would. go ahead with the thoracostomy or is it usually an earlier decision than that? It's usually earlier.
and everywhere slightly different my practice on fellowship and even now is if someone presents with no signs of life then the first question you ask is when did they lose it and if it was within the ambulance right on the way in
automatically I'm considering what can I immediately do to relieve that and if they're an appropriate person, resuscitated thoracotomy is on the table. But most institutions would say you do an e-fast, but what you're really looking for is do they have cardiac activity and do they have tamponade?
Everything else about the eFast, you could probably avoid. So there's no point seeing if there's a spleen bleeding or not, if they're already lost clinical signs of output. And bilateral finger thoracostomies. So my algorithm would usually be loose signs of life.
Efau is looking at the heart and finger thoracostomy is bilaterally. So that relieves all tensions and says if there's a tamponade or not, which we know is the best outcome if you were to do it and the easiest essentially to release and confirms the heart's working.
Because if the heart's not beating at all, then the likelihood of any salvageability from opening the chest is rare. What you hope to see is that it's working fine, it just needs volume. And I think that's where it brings briefly onto the topic of CPR and trauma. Most trauma centers would recommend that you don't do chest compressions for haemovolemic traumatic cardiac arrest for two reasons. One is that you're flogging a dead horse to some degree with the heart that's empty.
But second, it takes resource and focus away from what is actually needed, which is stopping bleeding and giving volume. So you're more likely to get vascular access without people doing chest compressions, and it frees people up. to get vascular access and clamp in a order etc if you're not having to do chest compressions it's hard to eradicate that thinking from people and i don't think
Anyone would be critical of people doing CPR and traumatic cardiac arrest at all. But most big institutions who are well drilled on it wouldn't routinely do that anymore. Can you take us through the steps of a resuscitative thoracotomy? Maybe starting with an anterior lateral and then describing the difference between that and a clamshell. So in theory, the difference is an anterior lateral thoracotomy is on the left-hand side.
Usually in most people you use just below the nipple line as the marker and you start by the sternum and you potentially just make a transverse directly straight incision down onto the bed. Most people in that scenario that you're doing it are going to have... severe hypotensions aren't going to bleed that much but you can use your scalpel to cut straight down to the ribs or between usually then a blunt pair of shears or scissors to cut the intercostal muscles through to the sternum and
Then get your fingers in to pull the ribs apart. If there's a big hemothorax, you'll know straight away. But then you get the finishetto rib retractor in. And my only advice with that is that the handle bit of it should go super early, only because putting it in fairly is very hard to then wind it up when you're against the bed, unless you've somehow rolled the patient slightly.
If you were to convert to a clamshell from there, then essentially it's performing a concurrent right-sided antilateral thoracotomy. So the easiest way is to continue your straight line all the way across and do the same on the right-hand side. Coming across the sternum, you can usually... cut across it just with the same pair of blunt mayo scissors or trauma shears. You don't need jiggly saws and things in most people, but most thoracotomy kits would have them available.
So you can base these cuts straight across. And then the finish shadow retract is put on the sternal edges, and then the whole anterior chest will be visible after that. After you've opened the chest, whichever way you do it, the first thing is to identify the heart with...
hopefully a tense pair of cardium indicating a tamponade because you know that you're more likely to be doing something useful you grasp the pair of cardium if you can't because it's too tense you just use the scalpel blade to cut into it and then use a pair of blunt scissors to go
inferior to superior and you do that in that direction rather than transverse because you have a high chance of hitting the left phrenic nerve if you come transversely. You release any tamponade that's there and as I said earlier you have gentle digital pressure on a hole in the heart if you see it or
If it's in the atrium, they're a lot more stretched and often dilated, and particularly the atrial appendage, that if you see those that are injured, you could just put a clamp across them. You can't usually do that with the ventricles, just given the muscular nature. And then for most people at that point, when you've relieved the tamponade,
and stopped any major bleeding, can just wait for help if that's what's required. If you then go on to repair, then usually any interrupted suture, usually with a proline like a 4-0, can be used. Whether you use pledges or not is individual, but most people, if they had time, would probably want to put pledges in. In times where we haven't had time on fellowship, we've just used a normal skin stapler and it stops the bleeding and it's fine.
don't have a cardiac tamponade or any cardiac bleeding then you can assess how well the heart's filled and if need be perform internal cardiac massage which is much more effective than external cardiac compressions And in that scenario, I think most people would go on to clamping the descending aorta. And I think that's a different level to get to because even when you talk to emergency physicians, they draw the line at tamponade.
And anything above that, they don't feel comfortable doing. But if you were to clamp the descending aorta, you have to mobilise the left lower lobe of the lung first. And if you reach down laterally... around the inside of the thoracic cage onto the diaphragm. Usually between your fingers we'll find the inferipulmonary ligament which connects the lung to the diaphragm. You can get scissors down there to cut it or in most emergency situations you can just tear it.
And if it tears a bit of the lung, that's fine. It'll bubble and you can fix that. You just don't want to cut or pull too medially because most of the time it leads into the... pulmonary veins or the IVC on the right side and that means you can rotate the whole lung upwards and from there you can see the descending aorta along the spinal column at the back
And then, if need be, you can just apply digital pressure. Grab your thumb and forefinger and just compress it. If you're wanting to put a formal clamp on, you usually have to break the adventitia either side to get a clamp across. Bearing in mind there's an esophagus there as well.
which is not that unusual to injure. Well, it is unusual to injure, but it's quite easy to do it if you don't recognise it. But once you're at the territory of clamping a descending aorta, you automatically know the patients in a much lower chance of survival regardless of what you do.
And hence why most institutions may not go that far, but certainly we have here in Christchurch done that before, and most of those patients still don't ultimately do well, but at least have given them the chance to get to the operating room. What about if you see bleeding from the lung or from the hylum? Are there any other techniques you can use to control that? So it's just from the lung. Parenchyma is usually easy. Most people are happy using some form of clamp just to clamp across.
If it's for an emergency situation, you just clamp across whatever's bleeding and you deal with repairing it later. If it's from the high limb, the chances of most people, even general surgeons and trauma surgeons, being able to do some complex repair is really low.
And luckily this is rare to survive to that point. But if you do see it, the two techniques that are advocated for is either a hyaline clamp, which is where you can clamp directly across the hyaline, including the bronchi and the vascular structures.
which is easier to get to than you would think because it's quite a discrete structure, or to do a lung twist. And I've never personally done a lung twist outside of a cadaver lab, but I have clamped a high limb before, and as you can imagine, it's very morbid.
thing to do and one person has survived who happened to be very young who ended up having a total pneumonectomy afterwards but most people don't but essentially your goal in that scenario is to stop bleeding and get a output back with blood pressure and then deal with what happens afterwards so they're the two techniques but luckily it's really rare there's an interesting talk i watched a while ago by a guy called john hines who if people are in their sort of resuscitationist field
that ed loves to be in he used to present at smack conferences and things and unfortunately he died. He was an anesthetist. He died during a motorcycle accident in his 30s. He was all in the Isle of Man TT and things like that. But nonetheless, he does a brief talk on resuscitative thoracotomy. and decision-making around it, which the hardest decision is to do it. And then the second hardest decision is how to handle the criticism afterwards. Because if the person survives, you celebrate it.
but still criticized. And if the person dies, people will say, well, they weren't going to survive unless the wider waste resource doing that. I think that in my experience, the other two hardest things is having the bravery, I guess, to do it. and then be knowledgeable enough about what you've done and the reasons for doing it that you can defend it afterwards to critics. Most of those critics are pretty uninformed as to why you did it, so you just need to learn to ignore them to some degree.
And I think the key is what you can actually achieve. You can decompress a cardiac tamponade. You can fix bleeding by clamping a lung, which is so morbid in itself. You need somebody who's going to survive that. And you can clamp an aorta to help with that.
intra-abdominal bleeding, but that's really all you can achieve. So making sure that you think that it's one of those problems that you could actually give them a chance of being able to address is really the key, I think. Yeah. And I think having a good knowledge of the indications.
is therefore the best key so if they don't fall within those strict guidelines don't attempt it would be my only advice so moving on to our last topic for chest trauma cardiac contusions i find this a little bit of a sort of a magical topic where we can't
really see it that well and I don't really understand how to diagnose it that well, apart from I send a troponin for every trauma patient. Can you tell us what it is and how it happens and what we're actually supposed to do about it? Yeah, it's a good question. It falls under the umbrella of... blunt cardiac injury or BCI and it's like everything it's a spectrum either from cardiac contusion which as you've pointed out is some mythical sort of type injury through to blunt
ventricle rupture, atrial rupture, valvular injury, etc. The last group are vanishingly rare, particularly with blunt trauma. More common with penetrating, but they've got quite a high mortality as you'd expect around them. The bit that people grapple with the most is what to do with people who you suspect mild blunt cardiac injury, which used to be called cardiac contusion. The riskiest injuries for those historically have been sternal fractures.
If you take all injuries, by far the most common associated injury is moderate haemoneumothorax. But nonetheless, if you suspect any sort of chest trauma or neck trauma, and some studies head trauma, then you should rule out. lung cardiac injury. How to rule it out though is the difficult thing and I think most guidelines of the very few that there are would seem to indicate that the most sensitive test is an ECG. So if you have a patient
with a suspicion of blunt cardiac injury and you do an ECG and it's completely normal then they don't need any further investigation. Gone are the days where you'd put every single person on cardiac monitoring for a period of time. Unfortunately, what constitutes a normal ECG is exactly that. So if you have any sort of tachycardia, etc., which is not uncommon in trauma, that technically is abnormal, according to these very few observational studies.
What to do with that group then is a bit difficult. The use of troponin you brought up, which most people would still send as a screening panel, has got pretty poor sensitivity and specificity to it for blunt cardiac injury. So most places, although it's still part of the panel.
wouldn't recommend using as a screening test. You would probably send one off if you've got an abnormal ECG as part of a confirmation, has there been any significant cardiac injury? Saying that most people with a raised... troponin and trauma we do nothing about anyway so a lot of places don't bother doing it if you really strongly suspect some form of cardiac injury either radiologically
or the troponin seems to be massive or they've got an abnormal ecg then echocardiograms the diagnostic imaging of choice because what you're wanting to know is has it caused any wall motion abnormalities in the heart Has it caused any coronary artery thrombosis? Is there any valvular injury? Which are the three things that are going to require treatment. Everything else doesn't usually require any treatment.
Most institutions these days, however, would still have some form of cardiac monitoring as part of their guidelines. And it's like CPR and trauma, it's very hard to get away from. But it has implications. And Christchurch Hospital has implications to where the patient can be nursed. Because not everywhere has cardiac monitoring. And the places that do are usually not surgical-based wards. So I think it does need to be looked at a bit further. So my algorithm would be high index of suspicion.
Do an ECG if the ECG is completely normal. They do not require any further cardiac monitoring or imaging of any sort. If it's abnormal, do a troponin. If that's abnormal, order an echo. My brief evidence-free summary. Perfect. So that really completes all of the topics for chest trauma. Cool. Thanks so much for talking to us about this today. You're welcome. Thanks very much.
It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback, send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!