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Blunt chest
wall injury (Ruptured
diaphragm (Diagnosis (History
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Blunt chest
wall injury
Rib fractures
Isolated
Diagnosis
Examination
Localised chest wall tenderness
Rule out pneumothorax, multiple fractures
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Management
Medical
Analgesia (cocodamol, NSAIDs)
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Multiple
Diagnosis
History
Trauma, pain, may have SOB
Examination
Flail segment, pneumothorax, secondary pneumonia
Investigations
Bedside - obs, ECG, O2 sats, ABG
Bloods - ABG
Imaging - CXR (multi fractures)
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Sternal
fracture
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Diagnosis
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Investigations
Bedside
Obs - sats, RR, HR, BP, temp
ECG - arrhythmias, MI, contusion (ST change)
Bloods
FBC, U+E, LFTs
Troponins (MI/contusion)
Imaging
CXR - PA CXR other fractures, lateral sternal
CXR shows typically a transverse sternal fracture
CT head/neck - if suspecting vertebral fracture
ECHO - cardiac function
Pathophysiology
RTA impact to steering wheel or seatbelt
May have associated cardiac contusion,
great vessel injury or spinal injury
Forced flex can rarely cause displaced sternal
fracture plus wedge upper vertebral fracture
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Flail
chest
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Diagnosis
(clinical)
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Examination
Visible flail segment, tachypnoea, cyanosis
Investigation
Bedside - obs (low sats, high RR, high HR), ECG
Bloods - ABG, others likely nil
Imaging - CXR (fractures, haemo/pneumothorax, contusion)
Pathophysiology
Fractures of 3+ ribs in 2 places
Part of chest wall moves independently to rest
Often sig injury to underlying lung (contusion)
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Ruptured
diaphragm
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Diagnosis
History
Mechanism of trauma,
current symptoms
Examination
SOB, reduced chest exp,
cyanosis, etc.
Investigations
Bedside - low sats, high RR
Bloods - ABG (hypoxic)
IMaging - CXR (high hemidiaphragm,
bowel/stomach in chest)
Pathophysiology
Usually left sided
Major - sig trauma e.g. abdo crush injury,
causing herniation of abdo contents into chest
Minor - less traumatic insult, no herniation
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Oesophageal
rupture
Clinical presentation
Cough, SOB, cyanosis
Hypovolemic shock
Diagnosis
Examination
Resp distress, high RR, cyanosis
surgical emphysema on neck
Investigations
Bedside - low sats, high RR, high HR, low BP
Bloods - ABG (hypoxic, may be hypercapnic)
Imaging - CXR (pneumomediastinum;
L effusion or pneumothorax)
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Haemothorax
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Diagnosis
History
Trauma, sudden SOB
Examination
Resp - distress, high RR, cyanosis,
reduced chest expansion, dull percussion,
quiet breath sounds (like an effusion)
Cardio - high HR, low BP
Investigations
Bedside - low sats, high RR, high HR, low BP
Bloods - ABG (hypoxic)
Imaging - CXR (increased shadowing,
no clear fluid level)
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Pathophysiology
Bleeding into the pleural space
May have associated pneumothorax (haemopneumothorax)
Massive haemothorax - bleeding causes hypovol shock
Traumatic
pneumothorax
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Diagnosis
History
Mechanism of trauma,
likely broken ribs, SOB
Examination
Resp - high RR, cyanotic, distress,
reduced expansion, hyperresonant percussion,
reduced breath sounds, reduced vocal fremitus
Investigations
Obs - high RR, low sats, high HR; ECG norm
Bloods - ABG (may be hypoxic)
Imaging - CXR (pneumothorax, fractures)
Pathophysiology
Blunt injury with rib fracture
or penetrating chest injury
Iatrogenic e.g. CVAD insertion
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Pulmonary
contusions
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Diagnosis
History
Mech of trauma, SOB
Examination
High RR, SOB, cyanotic,
flail chest, tenderness
Investigations
Obs - high RR, low sats high HR; ECG norm
Bloods - ABG (hypoxia)
Imaging - CXR (non-specific, may show
patchy opacification with time)
Pathophysiology
High energy transfer during blunt injury
E.g. RTA, high fall; often associated flail chest
V/Q mismatch, resp distress and ARDS
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Pulmonary
aspiration
Clinical presentation
SOB, cough, signs of trauma
Diagnosis
History
Mechanism of injury,
SOB, other resp symptoms
Examination
Resp distress, SOB, cyanotic, cough,
wheeze, coarse crackles
Investigations
Obs - high RR, low sats; ECG nil
Bloods - ABG
Imaging - CXR - consolidation/opacification
in one or both lungs
Pathophysiology
Inhalation of vomit or other foreign material
e.g. post-head injury with reduced GCS,
blood and teerh after facial trauma,
water after near-drowning
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