When to transport a patient directly to the Royal?

Ideally any multiple trauma or suspected chest trauma within 25 miles of Belfast should be transported by ambulance directly to the Trauma Centre at the RVH. Minor rib fractures may be an exception but, frequently these are the problems least well managed, leaving the patients with unnecessary long term sequelae.

Think about chest trauma

1. •All multiple trauma patients have chest trauma till proven otherwise
   

2. •If there is head injury and abdominal trauma there is also chest trauma. (Therefore if CT scanning the other two scan the chest as well)
   

First Glance/Triage/Primary Survey

1. 1.Walking/Talking can proceed directly to secondary survey
   

2. 2.Moribund - a decision will need to be taken as to whether they are unsalvageable (e.g. dismemberment) or salvageable by emergency thoracotomy.
   

3. When to do a resuscitative ("E.R.") thoracotomy?
   Rarely is it indicated, even more rarely is it successful. It is almost never useful in blunt trauma. Successful outcome has been reported with the following:
   

1. ◦Cardiac arrest due to tamponade or exsanguination
   

2. ◦Young patient
   

3. ◦Penetrative trauma to pericardium
   

4. ◦Signs of life during transit to hospital
   

3. 3.Resuscitation required - standard ABC
   

4. •Airway
   

5. •Breathing
   

6. As part of assessment and treatment of breathing and circulation the insertion of chest drains should be considered.
   

7. •Circulation
   

When to put in a chest drain without prior chest Xray?

1. •If there is possible chest trauma and breathing is laboured or there is cardiac instability.
   

2. •Be prepared to place bilateral emergency drains "on spec"
   

3. •If you think about it!
   

4. •Emergency drains should be placed via the axillary "triangle of safety" without a trocar.
   

When to operate as part of resuscitation?

1. •Cricothyroidotomy or Tracheostomy for airway obstruction
   

2. •Massive uncontrollable air leak - thoracotomy
   

3. •Massive pleural haemorrhage (see addendum)
   

4. •Penetrating cardiac wound - leave implement in situ till in theatre
   

5. •Transversing mediastinal wound/dangerous predicted track
   

6. •Traumatic pneumothorax
   

Secondary Survey

1. Investigations

1. •ABG
   

2. •Chest Xray
   

3. •Cervical Spine Xray
   

4. •Limb Xrays
   

5. •Angiography as indicated
   

6. •Diagnostic peritoneal lavage (when it will add to the clinical examination)
   

7. •CT scan - this has replaced some of the above in certain circumstances. CT is part of the secondary survey and should not be done of bleeding, unstable patients or those undergoing resuscitation. Unstable patients should be resuscitated adequately which may mean operating before full radiological assessment.
   

2. When to put in a chest drain on the basis of a CXR post trauma?

1. •Any post-traumatic pneumothorax.
   

2. •Any post-traumatic subcutaneous emphysema
   

3. •Haemothorax blunting the costophrenic angle.
   

4. •The above are particularly important if a procedure is to be performed under general anaesthetic and positive pressure ventilation.
   

3. Positioning of formal chest drains.

1. Once the situation has stabilised formal therapeutic drains should be inserted - preferably by a Thoracic Registrar. Blunt trocars may be necessary to achieve the ideal positions:
   

2. •Antero-apical for air
   

3. •Postero basal for blood.
   

1. A ventilated patient will not be able to cough blood out through a single apical drain. There is likely to be more blood than you think lying posteriorly. Therefore a routine second posterobasal drain should be considered and the drains placed on suction. Similarly, a patient in pain will not be able to cough adequately and further drains and suction may be required.
   

4. What if a drain stops working?

1. •The most frequent cause is that the drain is surrounded by clot and further intervention is required.
   

2. •If tension exists it is usually on the basis of air. An antero-apical drain should evacuate the air.
   

3. •Otherwise formal exploration may need to be considered.
   

4. •Multiple chest drains placed into a clotted haemothorax rarely achieve anything more than bacterial contamination. Formal exploration may need to be considered.
   

5. Prophylactic chest drains

1. In general prophylactic chest drains are not recommended. The exceptions are:
   

2. •known chest injury where ambulance transfer is required,
   

3. •known chest injury where operative procedures (e.g. fracture fixation) are to be performed under general anaesthetic with positive pressure ventilation,
   

4. •where ATLS-style needle thoracentesis has been performed, with positive or negative result, and positive pressure ventilation is required.
   

6. Pericardiocentesis

1. Pericardiocentesis can be used as a diagnostic and temporising technique when pericardial tamponade is suspected:
   

2. •use a large bore needle/venflon
   

3. •after a positive result pericardiotomy is virtually mandatory
   

4. •an echocardiogram is a less invasive diagnostic method, and may avoid the need for exploration
   

7. Other indications for intervention

1. CXR signs of a ruptured aorta
   

2. •wide mediastinum > 6 cm at the level of the neck of the aortic arch
   

3. •loss of contour of aortic knuckle
   

4. •wide peritracheal stripe
   

5. •apical cap
   

6. •deviation of oesophagus (NGT) to right
   

7. •deviation of trachea (ETT) to right
   

8. These are indications for further imaging. Contact the radiologist on-call. Casualty Xray - extension 2340 (or night room extension 3283) will give the contact number. The radiologist will then recommend the imaging technique which he/she finds most useful.
   

9. Ruptured diaphragm
   

10. •Will often appear late.
    

11. •Diagnosis is clinical rather than radiological
    

12. •Repair acutely is via abdomen because of related injuries.
    

13. •Late diagnosis is common particularly in ventilated patients - late repair via thoracotomy because of presence of adhesions.
    

1. Tracheobronchial rupture
   

2. Will usually present as an uncontrollable air leak and subcutaneous emphysema. Insert bilateral drains and suitable endotracheal intubation (double lumen if necessary) and contact Thoracic surgeons immediately
   

Review

1. Chest injury patients should have a formal review 4 hours after admission with repeat
   

2. •Chest Xray,
   

3. •Blood gases and
   

4. •Clinical appraisal
   

5. All patients with chest drains should have daily chest Xrays.
   

6. When to perform an elective thoracotomy after trauma?
   

7. •Clotted haemothorax
   

8. •Empyema
   

9. •Fibrothorax
   

10. •When there remains obvious entrapment of the lung or ongoing sepsis consideration should be made to formal evacuation of the pleura. These are complex decisions and should be made by a thoracic surgeon
    

 

Thoracic on-call registrar - when called from Casualty in an emergency:

1. •Do not just drop the phone and come in!
   

2. •Stop and think.
   

3. •Ask where the patient is.
   

4. •If the patient is still in transit and the available information suggests that the patient would be best assessed and resuscitated in theatre give instructions for the patient to be taken directly to A block theatres.
   

5. •Ask who is present to commence appropriate resuscitation e.g. general surgical registrar/SHO.
   

6. •Give appropriate instructions for those present to commence resuscitation, insert chest drains and even commence thoracotomy if indicated. Minutes will make the difference between brain dead and viable.
   

7. •Inform consultant on call of the emergency. It may be appropriate to call ward 4a (90 632016), give them a quick summary of the problem and ask them to contact the consultant.
   

8. •Drive carefully to the hospital - you are not covered for breaking the rules of the road!
   

When called from another hospital:

1. •Do not travel to any hospital outside the greater Belfast area without clearance from consultant.
   

2. •Decide how urgently operative treatment is required and if it is immediate the local surgeons will have to deal with it.
   

3. •If no operative treatment is required, and good ICU facilities are available locally, it may not be necessary to transfer the patient to the trauma centre.
   

Appendix 1

Massive Pleural Haemorrhage

Penetrating Trauma

1. •> 1500cc immediately on insertion of chest drain (take into account the delay between injury and chest drain insertion)
   

2. •> 250cc per hour for 3 successive hours
   

Blunt Trauma

Adding the trauma of a thoracotomy rarely improves the patients condition in blunt trauma.

1. 1.Insert adequate chest drains to re-expand the lung to tamponade low pressure bleeding.
   

2. 2.Aggressively correct the coagulation disorder which always follows major blood loss but which is not always detectable on current haematological tests. Use more than the minimum 2 units of FFP, run them in "stat" as their effectiveness wears off if thawed more than 20 minutes, and be quick to add platelets from at least 6 donors with it.
   

3. 3.Exclude aortic tear and other major vessel injury (arch aortogram will cover all relevant vessels though a CT with contrast and 3D reconstructions is as accurate)
   

4. 4.Then, if it seems that the patient is going to exsanguinate (i.e. rate of blood loss is greater than the possible re-infusion rate), it would be reasonable to perform a thoracotomy. It is rare to salvage a patient from such a situation.