1) Flail chest occurs when three or more ribs are broken in two or more places, causing a segment of the rib cage to become detached from the rest. 2) The detached or "flail" segment loses its attachment to the chest wall and becomes free floating. 3) A characteristic finding is paradoxical movement, where the flail segment moves in the opposite direction of the rest of the chest wall during breathing. 4) This paradoxical movement can significantly impair breathing and cause injury to the underlying lung. Aggressive pain management and respiratory support are usually required for treatment.

1. Chest Trauma
Dr. WASEEM HAJJAR, MD, FRCS.
Associate professor &
Consultant thoracic surgeon
Thoracic Surgery Division
KKUH
This lecture was given by Dr. Waseem Hajjar to all groups
Done by: Atheer Alrsheed, Laila Mathkour, Aroob Alhuthail, Atikah Kadi,
Rawan Alqahtani

2. INTRODUCTION
 The chest contains vital organs which are
essential for life
 Damage to these vital organs threatens life.
 Most common consequence is hypoxia.
 Chest injuries result in a significant number of
deaths each year.
 Locally, one in every 4 cases of trauma death
caused by chest injury which is responsible for
25% of RTA/trauma death cases

3.  Mechanism of injury: we divide it to 3 parts
1) Blunt chest trauma
 Most common cause of serious chest injuries. Common in KSA
 Post RTA, falls, direct blows, and crushing injuries.
 Many injuries are not immediately apparent
in physical exam.
2) Penetrating trauma
 Common in the west e.g. stabbing by any sharp object (gunshot)
 Immediate result can be severe bleeding or impaired breathing.
 Any chest wound can involve underlying organ injury.
 No matter how superficial it looks.
 Injuries to the heart, lungs, and great vessels can quickly lead to shock and
cardiac arrest.
3) Iatrogenic
We cause it from a medical procedure and it’s preventable, common
example in ICU while inserting a central line they might cause a
pneumothorax, or chest tube insertion penetrating the lung cuasing lung
injury
Explosion injuries are considered both blunt and penetrating

4. Common Example

5. This is what happened exactly
when someone is not wearing the
seat belt (unrestrained by seat belt)
he will have sudden impaction 
sudden blow of the chest and
because of this there will be rib
fractures, cardiac mediastinum
injury, blunt lung injury, and could
be penetrating chest injury because
of the fractured ribs penetrate the
chest. All of these can happen
depend on the force and
mechanism of the injury.

6. Mechanism of injury can be:

7. This is an example of young boy
after he fell he had penetrating
chest injury.

8. This patient has stab wound injury in the epigastric area. Patient has good cardiac out put and he is relatively stable,
conscious and able to talk you. His vital is:
Pulse: 120
O2%: 95 in room air dropping to 88% on oxygen
BP: 95/60
What would you do?
- Start with ABC
- Do FAST (Focused assessment sonography in trauma) to look for any bleeding. You have to asses 4 windows: epigastric
window, right hypochondrium, left hypochondrium, and hypogastric. In right hypochondrium asses the morison pouch,
hepatorenal pouch, hepato-diaphragmatic pouch (bellow the diaphragm between kidney and liver looking for any fluid
that indicate it’s blood), in left hypochondrium asses the spleno-renal pouch, in epigastric asses the pericardium for any
fluids (blood) around the pericardium, and in hypogastric asses the douglas pouch and in females we asses the pouch
between the urinary bladder and the rectum (recto-vesical pouch) for any fluids.
Then, what should we do? Should we removed this knife in ER? NO
If we remove it, the patient might bleed and might not, we don’t know, so we take the patient to the OR under control
situation and we need to have thoracic, cardiac, vascular, upper GI, liver surgeons involved.
We put the patient in bypass because the knife maybe inside major vessel and once you remove it, patient will bleed to
death

9. This is a penetration injury in the right chest. He was fixing one of the nails, and
during that it flew one into his chest. The right one length is about 7-12cm while
the left one is 4mm. sometimes the penetration is small but has a huge impact
because of its location or its depth
Remember: do not remove the object outside the OR! never ever even if it’ small

10. X-ray of the previous patient shows that it’s interring the heart

11. So we need to open surgery. We open the chest after putting him on bypass
machine

12.  Signs and symptoms
 Most common symptoms: pain and difficulty breathing
(dyspnea).
 Signs are obvious injury to the chest wall (don’t forget to look
at both the front and back and sides of the chest).
 Note any subcutaneous emphysema, or air present under the
skin It is called surgical emphysema
Pain is the most important symptom while hypoxia is the most
common consequence of trauma

13.  Assessment
Follow all steps in the assessment of the trauma patient:
 Primary survey:
 ABC (A. Airway + Cervical B. Breathing C. Circulation)
 Resuscitation.
 FAST looking for things that we discussed earlier
 Detailed secondary survey: when the patient is stable enough
 Take history, head to toe front and back and sides examination “full
exam”
 Investigation: trying to look for other injuries
 Adjuvant survey (investigation) at the end of the primary or during
the secondary survey, when the patient is staple and this will not
delay the transfer of the patient. We can do CXR, ABG, ECG, CT
Chest, Aortogram trying to look for other injuries. We choose
between them depends on the on the injury and stability and
transfer of the patient.

14. This is an example of unstable patient in hemorrhagic shock but when you
look to him there is no obvious wounds or sites of bleeding, but when you
examine his from the back we found multiple stab wounds and one of them
going to significant vessel and that the reason why he is on hemorrhagic
shock.

15. Next Slide

16. This slide is very important for OSCE
This patient eyes are closed, he is not able to talk, he didn’t take any medication or
eat something (not anaphylactic shock), he had fall and complain of sever pain on
the right chest with multiple rip fractures when he start to talk his voice pitch will
change ‫جددددا‬ ‫ناعم‬ ‫الصوت‬ ‫ر‬
‫يصي‬
On examination there will be crepitus sensations on the chest under the skin, the
patient will be edematous, can’t breath, can’t see (looks like anaphylactic shock), he
will very worried about what happened to him
What is this?
Subcutaneous emphysema (surgical emphysema): The air goes into the
subcutaneous tissue after injury of the lung
From where the air is coming?
95% from respiratory system and 5% from esophagus.
Causes: after trauma, iatrogenic (like endoscopy, sphincterotomy), or
spontaneous rapture of esophagus (boerhaave syndrome)

17. This slide is very important for OSCE
Emphysema can be air leakage from lungs or esophagial .
Example of esophageal cause is spontaneous esophagial rupture
Boerhaave syndrome, is a spontaneous perforation of the esophagus that results from a sudden
increase in intraesophageally pressure combined with negative intrathoracic pressure (eg,
severe straining or vomiting)
Boerhaave syndrome is common in west, due to eating a lot of meals and drinking alcohol.
The explanation is: the patient feels like he wants to vomit causes massive peristalsis from
down to up, so he will close the upper sphincter intentionally, and there will be massive power
especially in the weakest areas lower esophageal sphincter (LES), that’s will cause rupture.
Symptoms:
They will present with sever massive anterior chest pain after vomiting and nausea. They
present usually with anterior chest pain which mimic MI
Signs:
- ECG shows tachycardia only, troponin is negative
- CXR shows left plural effusion, surgical emphysema, subcutaneous emphysema, mediastinal
emphysema
- CT or barium swallow shows extravasation in LES
- Chest tube shows gastric content (diagnostic)

18. This slide is very important for OSCE
Treatment:
- Stop the procedure if it iatrogenic
- Resuscitate if the laceration is big and he starts bleeding
- Bilateral chest tube and drain within 8h
- Treat the underlying cause, if you removed the air without treating the cause of air
coming out  the air will accumulate again
When to start to worry and treat him aggressively? When he is hemodynamically
unstable and it’s affecting his vitals or if it is expanding or if he has compression
symptoms like hypoxia

19. This is an example of how the x-ray will be.
Pink area  this is how the air looks like, we see fibers of pectorals major muscle
because the air is beneath it  we call it surgical emphysema.
When we do any chest x-ray, we don’t
Could happen with/out pneumothorax.
In this case we don’t know from which side exactly the air came, so we treat it
bilaterally.

20. We don’t need to do CT scan routinely
Margined area = air

21. Management
 You have to treat the primary cause or underlying cause such as
pneumothorax or ruptured esophagus
 Ensure patient has adequate oxygenation and
perfusion
 Provide high-flow oxygen, ventilating when necessary
 Halt any obvious bleeding
 Support circulation when needed
 Rapidly transport patient to definitive care
We start with ABC and but bilateral chest tub. In OSCE they may bring a chest
tube and ask you what is coming out and the amount of it “comments about
the bubbles is it massive and is there any blood presence”, differentials,
treatment.

22.  Life threatening chest injury
identified in the primary survey:
Important to know them
1) Airway obstruction
2) Flial chest.
3) Tension pneumothorax.
4) Open pneumothorax.
5) Massive hemothorax.
6) Cardiac tamponade.

23.  Potentially lethal chest injury:
1) Traumatic aortic rupture.
2) Myocardial contusion.
3) Tracheal bronchial injury.
4) Rupture diaphragm.
5) Esophageal trauma.
6) Pulmonary contusion.
Which you detect them on secondary survey usually

24. Case: Patient has hemoptysis, dyspnea,
cyanosis, tachycardia, tachypnea, he is
hypoxic, chest x-ray shows lung collapse which
indicate tracheal injury and we saw massive
large pneumothorax.
Diagnosis: patient has left main bronchus
injury caused by fall
We put chest tube and we see what coming
out. If we don’t put a chest tube the patient
will have tension pneumothorax and die
within 10-15 min.
Then we go for emergent surgical repair of
the bronchial rapture.
You have to suspect rupture of traces or main
bronchi if you have patient with clinical
picture of pneumothorax or emphysema and
after resuscitation and chest
tube there is no improvement, most
commonly left bronchi because it is longer
and curved and exposed more than the right.

25. Rib Fracture: it come usually in the exam
 Most common chest injury.
 More common in adults than children. Why? Because in
adults the bone is calcified and they are prone to fracture
while in children the bones are cartilaginous. The opposite is
lung contusion we see it more in children because the
calcifies bone that the adults have will limit the force coming
from the chest wall to the lung while the cartilaginous bone
of the children is more resilient, so the force will transmit
easier that the adult.
 Especially common in elderly. Why? because deficiency of
vitamin D and osteoporosis or COPD with persistent sever
cough. From simple force or injury they can fracture their
ribs.
 Ribs form rings, Consider possibility of break in two places.

26. Rib Fracture
 Most commonly fractures ribs are 5th to 9th
ribs. Why? Because of poor protection.
 Fractures of 8th to 12th ribs can damage
underlying abdominal solid organs:
 Liver
 Spleen
 Kidneys

27. Rib Fracture
 Fractures of 1st & 2nd ribs doesn’t matter if it uni/bi lateral
 think about sever injury and do more investigations.
Think about aortic, bronchial or tracheal, mediastinal injury
and roll it out. In aortic injury, patient's usually are stable,
then after two days, the mediastinal starts to expand.
These two ribs require high force to damage it because they
are small, wide, short and very powerful, well protected by
the shoulders, clavicles and scapula, so the force which is
able to fracture these two ribs most be huge force and able
to do more hidden damage.
30% will die not because the rib fracture itself but because
of the other injuries

28. Rib Fracture
Sign and symptoms
 Local swelling and tenderness may be the only sign of a broken
rib.
 Can be very painful. Increases when patient:
 Coughs
 Moves
 Breathes deeply
 Patients often presents with guarding and shallow breathing.
 Chest wall instability
 Deformity, discoloration
 Associated pneumo or hemothorax

29. Rib Fracture
Management
 Move the patient carefully to prevent the bone ends from puncturing the lung.
 Administer O2.
 Allow patient to self-splint by assuming the most comfortable position possible.
 Encourage patient to limit movement.
 Analgesia like Morphine, PCA, Epidural.
Routinely we do conservative management by giving:
1. Analgesics. Epidural is the best with pubivacain +/- phytoline for 3-4 days,
or PCA “the patient control it”, we put morphine 50mg in 50ml in a pump then we continue with oral
analgesics or patch's or opioids at home with weekly appointments to readjust the painkillers.
2. O2
3. Chest physiotherapy.
And it heal by itself.
For epidural analgesic we don’t give them in high concentration because if we do that we will block both
sensory and motor intercostal nerves so he will have respiratory failure due to chest muscles paralysis
When do we need to fix it by surgery? If we open the chest for another reason like to fix the bleeding or
to save the patient life, if it was bilateral, multiple, sever flail chest, if it’s affecting the oxygenation and
are unable to extubate the patient from the ventilator and if he has another intrathoracic injury

30. It was done in the past to fix the ribs. We
don’t do it any more
Another old model of rib fixation
‫ي‬
‫الهيكل‬ ‫الشد‬
If we need to fix it, we fix it by open surgery based on the indications that we
mentioned in the previous slide

31. Flial Chest
 They will have Flail segment
 When three or more ribs are broken in two or more
places, a rib-cage segment may detach from the rest.
)
‫اكي‬‫او‬ ‫ن‬ ‫ر‬
‫ضلعي‬ ‫يكون‬ ‫والزم‬ ‫ن‬ ‫ر‬
‫جهتي‬ ‫من‬ ‫ينكرس‬ ‫الواحد‬ ‫الضلع‬ ‫ي‬
‫ن‬
‫يعن‬
(
 Flail segment is free floating. It lost the attachment to
the wall.
 After flail segment happen it will have something
called paradoxical movement: movement of flail
segment in opposite direction of the rest of the chest
wall.
 Paradoxical movement can significantly impair
breathing and cause injury to the underlying lung.

32. Example of multiple rib fracture after RTA  Flail chest
This is an AP view, PA is more accurate and clear but since this patient here is unable to walk, so
we did AP.
Fractures here are posterolateral.
Why we can’t see the anterior ribs? Because of costochondral junction
This picture shows multiple fractures in 4,5,6,7,8 ribs in two ends
And don’t misinterpret the medial scapula border as fracture

33. Intubation tube
ECG line
ECG line
Chest tube
Black area =
radio-
lucency
indicating air
 surgical
emphysema
Black area =
radio-
lucency
indicating air
 surgical
emphysema

34. Flial Chest
They will have flail segment loos there attachments to the chest wall so they will have
paradoxical breathing, during inspiration when the lung is expanded normal ribs goes
up but that segment goes in and so it prevents the normal expansion of the lung,
during expirations the chest wall will return
If that flail segment is large it will cause ventilation-perfusion miss match and so the
patient will be hypoxic.
If you put him in ventilator he will improve.
How to demonstrate that paradoxical breathing?
You have to let him to breathe spontaneously and
don’t give him muscles relaxant or while he is on
ventilator, it should be spontaneous breathing

35. This is the paradoxical movement

36. Flial Chest
Surgical emphysema.
There is multiple ribs fracture
in the right side
Also it could be hemothorax
or lung contusion

37. Very sever injury and massive hemothorax
All the ribs are inside the lung, this is need very emergent surgery (thoracotomy and
exploration) or he will bleed to death

38. Flial Chest
Management
 ABC, non-rebreather mask, rebreather mask, positive
pressure ventilation and intubation are the last options.
Usually conservative management
 Quickly stabilize flail segment by placing gloved hand
over injured area.
 After manual stabilization, place folded universal
dressing over segment and tape securely.
 Fixation (External, Internal). Not anymore If there is any
of the indication that we discussed with fractured rib

42. This is the collapsed right lung
Sever injury after RTA

43. Post Traumatic Pneumothorax
Types:
1) Opened pneumothorax.
2) Close pneumothorax.
Lung collapse is a vague terms you have to be more specified like lung collapse
secondary to pneumothorax or lung collapse secondary to foreign body

44. What is the difference between right and left chest?
The lung marking of the right side is reaching the periphery while in the left side is not,
also there is radiolucency in the left lung indicating air  left side pneumothorax.

45. This is a PA view
The lung marking of the left side is reaching the periphery while in the right side is not,
also there is radiolucency in the right lung indicating air  right side pneumothorax.

46. Large massive left pneumothorax

47. Large massive right pneumothorax

48. Bilateral pneumothorax

50. When you examine a patient with tension/massive pneumothorax you will find the chest is
overinflated with no movement & hyper hyper hyper resonance in percussion.
In examination, to check the symmetrical chest , inspect the patient from his feet

51.  Open pneumothorax
 A sharp object penetrates the skin on the chest wall,
so there will a communication with the atmospheric.
 Or if penetrating object has pierced pleura, outside air
can enter the thoracic cavity.
 As the volume of air in the thoracic cavity expands, the
lung starts to collapse .
 Air within the pleural space is called a pneumothorax
 As air passes in and out of an open wound, it can
create a sucking-type sound.
 Sucking chest wound means possibility of
pneumothorax.
 Signs of pneumothorax: difficulty breathing, cyanosis,
diminished breath sounds on the affected side.

53. Open pneumothorax

54. Sever injury with very heavy instrument.
The wound is open through the chest wall,
so the air inside pleural cavity be affected.
Need to be repair or excised

55. Open pneumothorax
Bilateral pneumothorax

56. Open pneumothorax
 Management
 Cover open chest wounds with occlusive dressing
 Gloved hand is an effective temporary occlusive
dressing
 Secure dressing on three sides
 High-flow oxygen
 Transport with unaffected side slightly elevated
Pulseless electrical activity (PEA) refers to cardiac arrest in which the electrocardiogram
shows a heart rhythm that should produce a pulse, but does not.
Some conditions causing that (Tension pneumothorax, cardiac tamponade, massive PE,
hyperkaliemia and other electrolyte imbalance

57.  Tension pneumothorax
 Build up of pressure in pleural space resulting in decrease in
blood pressure.
Closed “tensions” mechanical ventilation increase its
progression, compresses the lung
Potentially life-threatening condition that must be treated
immediately.
 Can occur in blunt or penetrating chest trauma.
 Signs
 Include all those of a pneumothorax.
 Jugular venous distension (JVD).
 If ventilating becomes more difficult, significant lung
compression is indicated.

58. Tension Pneumothorax
 One-way valve forms in lung or chest wall
 Air enters pleural space; cannot leave
 Air is trapped in pleural space
 Pressure rises
 Pressure collapses lung

59. Tension Pneumothorax
 Trapped air pushes heart, lungs away from
injured side
 Both Vena cavae become kinked
 Blood cannot return to heart
 Cardiac output falls

61. Tension Pneumothorax imp slide for exam
 Signs and Symptoms
 Extreme dyspnea
 Restlessness, anxiety, agitation
 Decreased breath sounds
 Hyperresonance to percussion (overinflated lungs)
 Cyanosis
 Subcutaneous emphysema
 Rapid, weak pulse
 Decreased BP
 Tracheal shift away from injured side
 Jugular vein distension
 Early dyspnea/hypoxia - Late shock
 Electrical pulseless activity (QRS is seen put the patient is dead, you have 7min
to act) is seen in tension pneumothorax, massive PE, massive pericardial
tamponade, hypokalemia, hyperkalemia, calcium disturbance
Clinically diagnosed, there is 2 systems involved CVS and respiratory, so both them
symptoms can be found

62.  Tension Pneumothorax
Management: (common in MCQs)
When suspect tension pneumothorax, the first step in management is neddle decompression
But the definitive treatment is chest tube but it takes time so start with neddle first
In tension pneumothorax we need to act fast, and chest tube will take time, so we do needle
decompression first at the second intercostal space mid clavicular line above the 3rd rib or
midway between the second and third rib. Decompress allow the air to come out and relieve
the pressure on the mediastinum, on the heart, the major vessels and on the other lung then
put chest tube 5th ICS midaxillary line.
Needle size is at least 5-7 cm
Needles diameter:
- 12mm in cricothyroidotomy to establish airways
- 14mm in needle decompression in tension pneumothorax
- 16mm in pericardial tamponade aspiration
- 18mm diagnostic peritoneal lavage (DPL)
‫ر‬
‫اكي‬ ‫االبرة‬ ‫تكون‬ ‫الرقم‬‫صغر‬ ‫ما‬ ‫كل‬

63. Why the patient die quickly?
Because they will have acute major change and compression on the major vessels, on heart,
pressure to the mediastinum and no cardiac output lead to LOC very quickly, the other lung will
also collapse and you need one lung to survive.

65. Massive building up pressure in the pleural cavity in left side
X-ray in this case done only for teaching purposes, we never ever do x-ray to diagnose tension
pneumothorax, it’s clear clinical diagnosis

66. Massive building up pressure in the pleural cavity in right side, collapsed lung and trachea is
pushed away.
X-ray in this case done only for teaching purposes, we never ever do x-ray to diagnose tension
pneumothorax, it’s clear clinical diagnosis

67. Tension Pneumothorax

68. Haemothorax
 Blood in pleura space
 Most common result of
major chest wall trauma
 Present in 70 to 80% of
penetrating, major non-
penetrating chest
trauma

69. Haemothorax
 Signs and Symptoms
 Rapid, weak pulse
 Cool, clammy skin
 Restlessness, anxiety
 Thirst
 Chills
 Hypotension
 Collapsed neck veins

70. Haemothorax
 Source of bleeding
 Intercostal vessels
In case of pneumothorax don’t insert the chest tube bellow the rib directly because
there is intercostal vessels so you will convert the pneumothorax to hemothorax
 Internal mammary vessels
 Lung parenchyma
 Broncheal arteries
 Major pulmonary vessels unfortunately they die
immediately
 Heart and great vessels unfortunately they die
immediately

71. Hemothorax
 Management ABC
 Secure airway
 Assist breathing with high concentration O2
 Rapid transport

72. Hemothorax
We put a chest tube for all patients 32-36 in adult, but we
don’t do thoracotomy to all patient
Indications for Thoracotomy: (we ask about it in OSCE)
 If the initial output of the chest tube is > 1250 ml
 If the Initial output of the chest tube is > 1000 ml
and the patient has hypotension (hemorrhagic
shock)
 If the chest tube output > 200- 250 ml/h for 3
consecutive hours

73. Radio-opacity, mediastinal shift to the other side,
tracheal shift to the other side, the other lung
collapse

75. We see mediastinal window show radio-opacity

76. Chest tube
indicated to drain the contents of the pleural space. Usually this
will be air or blood, but may include other fluids such as chyle or
gastric/oesophageal contents.
There is a triangle in intercostal space not covered by muscles like pectoralis or
latesmmas dorssi , this the best place for chest tube you can find it even in
obese patients
In any chest tube you need to know ; The content is it air, blood or others The rate
and amount
Is to drain something in the plural cavity, we put it in the 5 ICS midaxillary or
anterior axillary line, identified area *triangle area have small fat amount* away
from the pectoralis major muscle and latissimus dorsi muscle.
Give local anesthesia, O2, monitor, 1-2cm incision, dissect until you reach the
pleural cavity (indicators are blood coming out, hear gash of air, pus coming
out) then put your finger to make sure that there is no adhesions, close it and
attach it to underwater seal - chest drainage system -.

77. Chest tube
Absolute Indications
 Pneumothorax (tension, open or simple)
 Hemothorax
 Traumatic Arrest (bilateral)
Relative Indications
 Rib fractures & Positive pressure ventilation
 Profound hypoxia / hypotension & penetrating chest injury
 Profound hypoxia / hypotension and unilateral signs of hemithorax
When we remove the chest tube?
When we achieve the goal which led us to put that chest tube and there is no
specific duration it is variable depending on the cause and when examination and
imaging and clinically show stability of the patient

85.  Pulmonary contusion
 Bleeding into the lung itself is a pulmonary contusion
 Bleeding and edema can impair gas exchange, causing
hypoxia and respiratory faliure.
 Soft crackles may be heard over injury site
 Chest pain, point tenderness, and localized swelling
over area of impact
Management
Always is conservative unless if there is other indication for surgery
 Support ventilation as needed
 Supply high-flow supplemental oxygen
 Transport to hospital--- ventilation

87. The doctor skipped the rest of the slides in our group

92.  Diaphragmatic injury
 Types
1) Acute blunt injury
2) Acute penetrating injury
3) Chronic diaphragmatic hernia

100.  Cardiac contusion
 Can impair heart’s ability to pump
 Bleeding into heart tissue can cause heart to beat irregularly
 Irregular pulse should alert to possibility of a cardiac contusion
Diagnosis
 Fracture sternum
 ECG----- ST& T abnormality + Dysrhythmias
 CPK-MB
Management
 High-flow oxygen
 Ventilation support as needed
 Support of circulation if appropriate
 Prompt transport
 Request ALS backup

101. Cardiac contusion

102.  Pericardial tamponade
 Bleeding around heart and into pericardial sac
that encloses the heart can cause pericardial
tamponade
 Usually results from a penetrating chest trauma
with laceration to the heart itself
 Blood filling the pericardial sac compresses heart,
causing blood to back up
 JVD is a telltale sign of pericardial tamponade
 Narrowed pulse pressures

103. Pericardial tamponade
 Management
 High-flow oxygen
 Treat patient for shock
 Transport rapidly to ER
 Request ALS intercept
 Notify hospital so staff can properly prepare

106.  Aortic injury
 In sudden decelerations such as high-speed head-on
MVCs, body organs are thrown forcefully against the front
of the body
 Most significant tear: aorta
 If tear is complete, patient will die in minute
 Management
 High-flow oxygen
 Treat patient for shock
 Transport rapidly to ED
 Notify hospital so staff can properly prepare

107. BAI: investigations
BAI: investigations -
- CXR
CXR
 Wide mediastinum
MS ration >0.25-0.4
 Blurred aortic knob
 Pleural effusion
 Apical Capping
 NG deviation
 1st or 2nd rib #
 Depressed left
mainstem bronchus
 Blunted AP window
 HTX, PTX
 Enlargement of the
paratracheal stripe

116. Conclusion

117. Conclusion