Investigation

Investigation

Routine investigation in the emergency department of injury to the chest is based on clinical examination, supplemented by appropriate imaging.

Figure 29.2 The anatomical extent of the abdomen.

with sonography for trauma (eFAST) Ultrasound can be used to di ff erentiate between contusion and the actual presence of blood. Extended focused assessment with sonography for trauma (eFAST) is becoming the most common investigation. The technique uses sonographic assess ment in the chest, looking for a cardiac tamponade or free blood and air in the hemithoraces, and assessment for blood in the abdominal cavity , in the paracolic gutters, subdiaphrag matic spaces and pelvis. Finger thoracostomy In the physiologically grossly unstable patient, where physical examination is inconclusive and there is no time for radiological investigations, bilateral finger thoracostomy can be a diagnos tic procedure as well as a therapeutic one, and the benefits of undertaking it often outweigh the risks. It is undertaken by making a 5-cm skin incision on the fifth rib just anterior to the mid-axillary line. The intercostal muscles are then separated just above the fifth rib and the pleural cavity entered. A finger is then inserted and a pleural swee p made to ensure the pleural cavity has been entered. Chest radiograph In those cases where the patient is physiologically non- compromised or the spine is at risk, an anteroposterior (AP) supine chest radiograph is usually the simplest initial investigation. It will provide good information regarding tracheal deviation, lung and mediastinal pathology as well as skeletal injury . In penetrating injury , it may be more helpful for the radio graph to be performed with the patient positioned erect, as this will best reveal a small pneumothorax, fluid meniscus, air–fluid level or the presence of free gas under the diaphragm, indi ca ting the presence of a hollow abdominal viscus perforation. Note that up to 300 /uni00A0 mL of blood may pool behind the domes of the diaphragm, and may not be visible even in the erect view . T he presence of thoracic skeletal injury should alert the clinician to the possibility of adjacent thoracic or abdominal visceral injury . Rupture of the thoracic aorta can be related to fractures of the first and second rib, bilateral clavicular fracture and fracture of the sternum, thoracic spine or scapula. Frac ture of the lower ribs can be related to injury of the liver or spleen. Fracture of the ribs, irrespective of site, can be related to injury to the lung parenchyma or thoracic wall vascula causing pneumothorax, haemothorax or lung contusion. Computed tomography scan The computed tomography (CT) scan with contrast allows for three-dimensional reconstruction of the chest and abdomen, as well as of the bony skeleton. It has become the principal and most reliable examination for major injury in trauma. In blunt chest trauma, the CT scan will allow the definition of frac tures, as well as showing haematomas, pneumothoraces and pulmonary contusion. In penetrating trauma, the scan may show the track or presence of the missile and allow the pr planning of definitive surgery . However, although the presence of an isolated rupture of the diaphragm with migration of in injury without migration the diagnosis will not be obvious. The pitfalls of investigation are: /uni25CF failure to assess tracheal shift immediately above the sternal notch clinically (deviation of the trachea occurs away from the a ff ected side in tension pneumothorax and towards the - a ff ected side in lung collapse); /uni25CF failure to percuss and auscultate both front and back in a supine patient (an inflated lung will ‘float’ on a haemo - - thorax, so auscultation from the front may sound normal); /uni25CF failure to pass a nasogastric tube if rupture of the dia - phragm is suspected; a chest radiograph will show the nasogastric tube apparently within the chest cavity; /uni25CF a supine chest radiograph can show a haemothorax as a homogeneous increase in opacity of the hemithorax – this - can cause confusion between the darker side and the lighter side as to which may be a haemothorax (less radiolucent) or a pneumothorax (more radiolucent); look carefully for lung markings and do not drain the wrong side; /uni25CF pursuing radiological investigation (radiography or CT scan) instead of resuscitation in the unstable patient. Summary box 29.2 Investigation of chest injuries /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - Management - In penetrating injury , most patients who have su ff ered injury to the chest can be managed with appropriate resuscitation and insertion of an intercostal drain. If a sucking chest wound is present, this should not be fully closed but should be covered with a piece of plastic, closed on three sides to form a one-way valve, and ther eafter an underwater chest drain should be inserted remote from the - wound. No attempt should be made to close a sucking chest wound until controlled drainage has been achieved, in case a stable patient with an open pneumothorax is converted into an ture, unstable patient with a tension pneumothorax. In blunt injury , most bleeding occurs from the intercostal or internal mammary vessels and it is relatively rare for these to require surgery . If bleeding does not stop spontaneously , the v essels can be embolised, via an interventional radiological approach, or treated operatively , during which the vessels can be tied o ff or encircled. In blunt chest compressive injury , particularly in the presence of a flail chest, there can be an associated lung contusion. - The patient in extremis with exsanguinating chest haemor - rhage is discussed in Emergency department thoracotomy or sternotomy . oper Life-threatening injuries can be remembered as the ‘deadly dozen’. Six are immediately life-threatening and should be

Directly or indirectly involved in >50% of trauma deaths More than 80% can be managed non-operatively A chest radiograph is the investigation of /f_i rst choice Finger thoracostomy can be diagnostic and therapeutic A pan-CT scan provides rapid diagnosis

Closed management of chest injuries /uni25CF /uni25CF /uni25CF sought and managed during the primary survey and six are potentially life-threatening and should be detected during the secondary survey ( Table 29.3 ). A high index of suspicion must be maintained thereafter to diagnose the potential threats to life, as their symptoms and signs can be very subtle. Early con sultation and referral to a trauma centre is advised in cases of doubt.

More than 80% of chest injuries can be managed with the insertion of an intercostal drain only Do not close a sucking chest wound until a drain is in place If bleeding persists, the chest will need to be opened and direct haemostatic control is obtained

Investigation

Investigations are driven by the cardiovascular status of the patient. In torso trauma, the best and most sensitive modality is a CT scan with intravenous contrast; however, in the unstable - patient, this is generally not possible. In patients with penetrating injury , metal markers (e.g. bent paper clips) should be placed on all external wounds before plain films are taken, irrespective of the area being radiographed, as this allows an assessment of the trajectory and helps to correla te the number of holes and the number of missiles that can be seen within the patient. This will help determine whether two holes are indicative of one missile pass - ing through the patient, or two missiles, both retained inter - nally ( Figure 29.7 ). A single hole implies that the projectile has been retained. Focused abdominal sonography for trauma and extended FAST (FAST and eFAST) Focused abdominal sonography for trauma (FAST) is a tech - nique whereby ultrasound (sonography) imaging is used to assess the torso for the presence of free fluid in the abdominal cavity , and is extended into the thoracic cavities and peri - cardium (eFAST). There should be no attempt to determine the natur e or extent of the specific injury . eFAST is usually a rapid, reproducible, portable and non-invasive bedside test and can be performed at the same time as resuscitation. eFAST is accurate at detecting >100 /uni00A0 mL of free blood; however, it is very operator dependent and, especially if the patient is very obese or the bowel is full of gas, it may be unreliable. Hollow viscus injury and solid organ injury are di ffi cult to diagnose, even in Sydney Ringer , 1835–1910, Professor of Clinical Medicine, University College Hospital, London, UK. to assess and eFAST has a low sensitivity (29–35%) for organ injury without haemoperitoneum. eFAST is also unreliable for excluding injury in penetrating trauma. If there is doubt, the xamination can be repeated. eF AST e Summary box 29.5 Utilisation of eFAST /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

(b) Figure 29.7 (a) Chest radiograph showing a gunshot wound with bullet markers. (b) Abdominal radiograph of a gunshot wound showing bullet markers. Detects free /f_l uid in the abdomen or pericardium Will not reliably detect less than 100 /uni00A0 mL of free blood Does not directly identify injury to hollow viscus Cannot reliably exclude injury in penetrating trauma May need repeating or supplementing with other investigations Is unreliable for assessment of the retroperitoneum

Investigation

Routine investigation in the emergency department of injury to the chest is based on clinical examination, supplemented by appropriate imaging.

Figure 29.2 The anatomical extent of the abdomen.

with sonography for trauma (eFAST) Ultrasound can be used to di ff erentiate between contusion and the actual presence of blood. Extended focused assessment with sonography for trauma (eFAST) is becoming the most common investigation. The technique uses sonographic assess ment in the chest, looking for a cardiac tamponade or free blood and air in the hemithoraces, and assessment for blood in the abdominal cavity , in the paracolic gutters, subdiaphrag matic spaces and pelvis. Finger thoracostomy In the physiologically grossly unstable patient, where physical examination is inconclusive and there is no time for radiological investigations, bilateral finger thoracostomy can be a diagnos tic procedure as well as a therapeutic one, and the benefits of undertaking it often outweigh the risks. It is undertaken by making a 5-cm skin incision on the fifth rib just anterior to the mid-axillary line. The intercostal muscles are then separated just above the fifth rib and the pleural cavity entered. A finger is then inserted and a pleural swee p made to ensure the pleural cavity has been entered. Chest radiograph In those cases where the patient is physiologically non- compromised or the spine is at risk, an anteroposterior (AP) supine chest radiograph is usually the simplest initial investigation. It will provide good information regarding tracheal deviation, lung and mediastinal pathology as well as skeletal injury . In penetrating injury , it may be more helpful for the radio graph to be performed with the patient positioned erect, as this will best reveal a small pneumothorax, fluid meniscus, air–fluid level or the presence of free gas under the diaphragm, indi ca ting the presence of a hollow abdominal viscus perforation. Note that up to 300 /uni00A0 mL of blood may pool behind the domes of the diaphragm, and may not be visible even in the erect view . T he presence of thoracic skeletal injury should alert the clinician to the possibility of adjacent thoracic or abdominal visceral injury . Rupture of the thoracic aorta can be related to fractures of the first and second rib, bilateral clavicular fracture and fracture of the sternum, thoracic spine or scapula. Frac ture of the lower ribs can be related to injury of the liver or spleen. Fracture of the ribs, irrespective of site, can be related to injury to the lung parenchyma or thoracic wall vascula causing pneumothorax, haemothorax or lung contusion. Computed tomography scan The computed tomography (CT) scan with contrast allows for three-dimensional reconstruction of the chest and abdomen, as well as of the bony skeleton. It has become the principal and most reliable examination for major injury in trauma. In blunt chest trauma, the CT scan will allow the definition of frac tures, as well as showing haematomas, pneumothoraces and pulmonary contusion. In penetrating trauma, the scan may show the track or presence of the missile and allow the pr planning of definitive surgery . However, although the presence of an isolated rupture of the diaphragm with migration of in injury without migration the diagnosis will not be obvious. The pitfalls of investigation are: /uni25CF failure to assess tracheal shift immediately above the sternal notch clinically (deviation of the trachea occurs away from the a ff ected side in tension pneumothorax and towards the - a ff ected side in lung collapse); /uni25CF failure to percuss and auscultate both front and back in a supine patient (an inflated lung will ‘float’ on a haemo - - thorax, so auscultation from the front may sound normal); /uni25CF failure to pass a nasogastric tube if rupture of the dia - phragm is suspected; a chest radiograph will show the nasogastric tube apparently within the chest cavity; /uni25CF a supine chest radiograph can show a haemothorax as a homogeneous increase in opacity of the hemithorax – this - can cause confusion between the darker side and the lighter side as to which may be a haemothorax (less radiolucent) or a pneumothorax (more radiolucent); look carefully for lung markings and do not drain the wrong side; /uni25CF pursuing radiological investigation (radiography or CT scan) instead of resuscitation in the unstable patient. Summary box 29.2 Investigation of chest injuries /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - Management - In penetrating injury , most patients who have su ff ered injury to the chest can be managed with appropriate resuscitation and insertion of an intercostal drain. If a sucking chest wound is present, this should not be fully closed but should be covered with a piece of plastic, closed on three sides to form a one-way valve, and ther eafter an underwater chest drain should be inserted remote from the - wound. No attempt should be made to close a sucking chest wound until controlled drainage has been achieved, in case a stable patient with an open pneumothorax is converted into an ture, unstable patient with a tension pneumothorax. In blunt injury , most bleeding occurs from the intercostal or internal mammary vessels and it is relatively rare for these to require surgery . If bleeding does not stop spontaneously , the v essels can be embolised, via an interventional radiological approach, or treated operatively , during which the vessels can be tied o ff or encircled. In blunt chest compressive injury , particularly in the presence of a flail chest, there can be an associated lung contusion. - The patient in extremis with exsanguinating chest haemor - rhage is discussed in Emergency department thoracotomy or sternotomy . oper Life-threatening injuries can be remembered as the ‘deadly dozen’. Six are immediately life-threatening and should be

Directly or indirectly involved in >50% of trauma deaths More than 80% can be managed non-operatively A chest radiograph is the investigation of /f_i rst choice Finger thoracostomy can be diagnostic and therapeutic A pan-CT scan provides rapid diagnosis

Closed management of chest injuries /uni25CF /uni25CF /uni25CF sought and managed during the primary survey and six are potentially life-threatening and should be detected during the secondary survey ( Table 29.3 ). A high index of suspicion must be maintained thereafter to diagnose the potential threats to life, as their symptoms and signs can be very subtle. Early con sultation and referral to a trauma centre is advised in cases of doubt.

More than 80% of chest injuries can be managed with the insertion of an intercostal drain only Do not close a sucking chest wound until a drain is in place If bleeding persists, the chest will need to be opened and direct haemostatic control is obtained

Investigation

Investigations are driven by the cardiovascular status of the patient. In torso trauma, the best and most sensitive modality is a CT scan with intravenous contrast; however, in the unstable - patient, this is generally not possible. In patients with penetrating injury , metal markers (e.g. bent paper clips) should be placed on all external wounds before plain films are taken, irrespective of the area being radiographed, as this allows an assessment of the trajectory and helps to correla te the number of holes and the number of missiles that can be seen within the patient. This will help determine whether two holes are indicative of one missile pass - ing through the patient, or two missiles, both retained inter - nally ( Figure 29.7 ). A single hole implies that the projectile has been retained. Focused abdominal sonography for trauma and extended FAST (FAST and eFAST) Focused abdominal sonography for trauma (FAST) is a tech - nique whereby ultrasound (sonography) imaging is used to assess the torso for the presence of free fluid in the abdominal cavity , and is extended into the thoracic cavities and peri - cardium (eFAST). There should be no attempt to determine the natur e or extent of the specific injury . eFAST is usually a rapid, reproducible, portable and non-invasive bedside test and can be performed at the same time as resuscitation. eFAST is accurate at detecting >100 /uni00A0 mL of free blood; however, it is very operator dependent and, especially if the patient is very obese or the bowel is full of gas, it may be unreliable. Hollow viscus injury and solid organ injury are di ffi cult to diagnose, even in Sydney Ringer , 1835–1910, Professor of Clinical Medicine, University College Hospital, London, UK. to assess and eFAST has a low sensitivity (29–35%) for organ injury without haemoperitoneum. eFAST is also unreliable for excluding injury in penetrating trauma. If there is doubt, the xamination can be repeated. eF AST e Summary box 29.5 Utilisation of eFAST /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

(b) Figure 29.7 (a) Chest radiograph showing a gunshot wound with bullet markers. (b) Abdominal radiograph of a gunshot wound showing bullet markers. Detects free /f_l uid in the abdomen or pericardium Will not reliably detect less than 100 /uni00A0 mL of free blood Does not directly identify injury to hollow viscus Cannot reliably exclude injury in penetrating trauma May need repeating or supplementing with other investigations Is unreliable for assessment of the retroperitoneum

Investigation

Routine investigation in the emergency department of injury to the chest is based on clinical examination, supplemented by appropriate imaging.

Figure 29.2 The anatomical extent of the abdomen.

with sonography for trauma (eFAST) Ultrasound can be used to di ff erentiate between contusion and the actual presence of blood. Extended focused assessment with sonography for trauma (eFAST) is becoming the most common investigation. The technique uses sonographic assess ment in the chest, looking for a cardiac tamponade or free blood and air in the hemithoraces, and assessment for blood in the abdominal cavity , in the paracolic gutters, subdiaphrag matic spaces and pelvis. Finger thoracostomy In the physiologically grossly unstable patient, where physical examination is inconclusive and there is no time for radiological investigations, bilateral finger thoracostomy can be a diagnos tic procedure as well as a therapeutic one, and the benefits of undertaking it often outweigh the risks. It is undertaken by making a 5-cm skin incision on the fifth rib just anterior to the mid-axillary line. The intercostal muscles are then separated just above the fifth rib and the pleural cavity entered. A finger is then inserted and a pleural swee p made to ensure the pleural cavity has been entered. Chest radiograph In those cases where the patient is physiologically non- compromised or the spine is at risk, an anteroposterior (AP) supine chest radiograph is usually the simplest initial investigation. It will provide good information regarding tracheal deviation, lung and mediastinal pathology as well as skeletal injury . In penetrating injury , it may be more helpful for the radio graph to be performed with the patient positioned erect, as this will best reveal a small pneumothorax, fluid meniscus, air–fluid level or the presence of free gas under the diaphragm, indi ca ting the presence of a hollow abdominal viscus perforation. Note that up to 300 /uni00A0 mL of blood may pool behind the domes of the diaphragm, and may not be visible even in the erect view . T he presence of thoracic skeletal injury should alert the clinician to the possibility of adjacent thoracic or abdominal visceral injury . Rupture of the thoracic aorta can be related to fractures of the first and second rib, bilateral clavicular fracture and fracture of the sternum, thoracic spine or scapula. Frac ture of the lower ribs can be related to injury of the liver or spleen. Fracture of the ribs, irrespective of site, can be related to injury to the lung parenchyma or thoracic wall vascula causing pneumothorax, haemothorax or lung contusion. Computed tomography scan The computed tomography (CT) scan with contrast allows for three-dimensional reconstruction of the chest and abdomen, as well as of the bony skeleton. It has become the principal and most reliable examination for major injury in trauma. In blunt chest trauma, the CT scan will allow the definition of frac tures, as well as showing haematomas, pneumothoraces and pulmonary contusion. In penetrating trauma, the scan may show the track or presence of the missile and allow the pr planning of definitive surgery . However, although the presence of an isolated rupture of the diaphragm with migration of in injury without migration the diagnosis will not be obvious. The pitfalls of investigation are: /uni25CF failure to assess tracheal shift immediately above the sternal notch clinically (deviation of the trachea occurs away from the a ff ected side in tension pneumothorax and towards the - a ff ected side in lung collapse); /uni25CF failure to percuss and auscultate both front and back in a supine patient (an inflated lung will ‘float’ on a haemo - - thorax, so auscultation from the front may sound normal); /uni25CF failure to pass a nasogastric tube if rupture of the dia - phragm is suspected; a chest radiograph will show the nasogastric tube apparently within the chest cavity; /uni25CF a supine chest radiograph can show a haemothorax as a homogeneous increase in opacity of the hemithorax – this - can cause confusion between the darker side and the lighter side as to which may be a haemothorax (less radiolucent) or a pneumothorax (more radiolucent); look carefully for lung markings and do not drain the wrong side; /uni25CF pursuing radiological investigation (radiography or CT scan) instead of resuscitation in the unstable patient. Summary box 29.2 Investigation of chest injuries /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - Management - In penetrating injury , most patients who have su ff ered injury to the chest can be managed with appropriate resuscitation and insertion of an intercostal drain. If a sucking chest wound is present, this should not be fully closed but should be covered with a piece of plastic, closed on three sides to form a one-way valve, and ther eafter an underwater chest drain should be inserted remote from the - wound. No attempt should be made to close a sucking chest wound until controlled drainage has been achieved, in case a stable patient with an open pneumothorax is converted into an ture, unstable patient with a tension pneumothorax. In blunt injury , most bleeding occurs from the intercostal or internal mammary vessels and it is relatively rare for these to require surgery . If bleeding does not stop spontaneously , the v essels can be embolised, via an interventional radiological approach, or treated operatively , during which the vessels can be tied o ff or encircled. In blunt chest compressive injury , particularly in the presence of a flail chest, there can be an associated lung contusion. - The patient in extremis with exsanguinating chest haemor - rhage is discussed in Emergency department thoracotomy or sternotomy . oper Life-threatening injuries can be remembered as the ‘deadly dozen’. Six are immediately life-threatening and should be

Directly or indirectly involved in >50% of trauma deaths More than 80% can be managed non-operatively A chest radiograph is the investigation of /f_i rst choice Finger thoracostomy can be diagnostic and therapeutic A pan-CT scan provides rapid diagnosis

Closed management of chest injuries /uni25CF /uni25CF /uni25CF sought and managed during the primary survey and six are potentially life-threatening and should be detected during the secondary survey ( Table 29.3 ). A high index of suspicion must be maintained thereafter to diagnose the potential threats to life, as their symptoms and signs can be very subtle. Early con sultation and referral to a trauma centre is advised in cases of doubt.

More than 80% of chest injuries can be managed with the insertion of an intercostal drain only Do not close a sucking chest wound until a drain is in place If bleeding persists, the chest will need to be opened and direct haemostatic control is obtained

Investigation

Investigations are driven by the cardiovascular status of the patient. In torso trauma, the best and most sensitive modality is a CT scan with intravenous contrast; however, in the unstable - patient, this is generally not possible. In patients with penetrating injury , metal markers (e.g. bent paper clips) should be placed on all external wounds before plain films are taken, irrespective of the area being radiographed, as this allows an assessment of the trajectory and helps to correla te the number of holes and the number of missiles that can be seen within the patient. This will help determine whether two holes are indicative of one missile pass - ing through the patient, or two missiles, both retained inter - nally ( Figure 29.7 ). A single hole implies that the projectile has been retained. Focused abdominal sonography for trauma and extended FAST (FAST and eFAST) Focused abdominal sonography for trauma (FAST) is a tech - nique whereby ultrasound (sonography) imaging is used to assess the torso for the presence of free fluid in the abdominal cavity , and is extended into the thoracic cavities and peri - cardium (eFAST). There should be no attempt to determine the natur e or extent of the specific injury . eFAST is usually a rapid, reproducible, portable and non-invasive bedside test and can be performed at the same time as resuscitation. eFAST is accurate at detecting >100 /uni00A0 mL of free blood; however, it is very operator dependent and, especially if the patient is very obese or the bowel is full of gas, it may be unreliable. Hollow viscus injury and solid organ injury are di ffi cult to diagnose, even in Sydney Ringer , 1835–1910, Professor of Clinical Medicine, University College Hospital, London, UK. to assess and eFAST has a low sensitivity (29–35%) for organ injury without haemoperitoneum. eFAST is also unreliable for excluding injury in penetrating trauma. If there is doubt, the xamination can be repeated. eF AST e Summary box 29.5 Utilisation of eFAST /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

(b) Figure 29.7 (a) Chest radiograph showing a gunshot wound with bullet markers. (b) Abdominal radiograph of a gunshot wound showing bullet markers. Detects free /f_l uid in the abdomen or pericardium Will not reliably detect less than 100 /uni00A0 mL of free blood Does not directly identify injury to hollow viscus Cannot reliably exclude injury in penetrating trauma May need repeating or supplementing with other investigations Is unreliable for assessment of the retroperitoneum