S5E9 - Chest Trauma
Welcome to this episode of thecase.report. Callum and the crew in Galway have got a cracking one for us for this episode.
Callum Swift, Gavin Healthfield-Elliot and Caitlin Crowe tackle the case. Our Adult in the Room this month is Dr James Foley. We have a little bonus segment at the end of the episode with Dr Eduard Turcuman with some tips and tricks for the most common chest nerve blocks.
Just before we get started on this month’s case, we wanted to let you know about an upcoming (free) CPD event. On Friday the 24th of October the Irish Aortic Dissection Symposium will be taking place in RCSI. Head on over to tadct.org/ireland for more info and to get your tickets!
A massive shout out to our wonderful TCR Innovation Team from Season 5, who did an incredible job of bringing our episodes to life! As they have all moved on to new roles, our show notes are slightly abridged, as I simply don’t have that level of skill! Keep an eye out on our socials for new roles in season 6.
Right then, let’s get to the case!
The case
Gavin is the first to see this 73yo female patient. The triage note says she had an explained fall from standing and hit the left side of her chest against a table. The patient has been categorised as a Cat 3 and is waiting on a trolley to be seen.
Vitals from triage
Hr 110
Bp 115/90
Rr 35
Sats 95 on RA
T 36
The history
History of presenting complaint
The patient reports she tripped on a rug, lost her footing and fell on the table. She remembers everything. No head strike. She’s complaining of significant pain over her left anterior chest, and is finding it difficult to take deep breaths.
Past Medical History
Atrial fibrillation on an unknown DOAC (last taken around 22 hours ago)
Hypertension
No surgical history
Allergies
NKDA
Social history
Non smoker
Lives at home and is independent with all her ADLs
The exam (cABC)
(c)atastrophic haemorrhage
No evidence of catastrophic haemorrhage
Airway
Chatting away, airway patent and protected
Breathing and Circulation
Increased work of breathing
Not taking deep breaths
Asymmetrical chest rise
Reduced movement on left side
Tender on left side
No evidence subcutaneous emphysema
Reduced air entry on auscultation
Updated vitals
Hr 115
Bp 105/86
Sats 95
POCUS
Lung sliding bilaterally
Spine sign
EFAST otherwise negative
No free fluid seen in abdomen or pericardium
Impression
Gavin collates all the information he has available to him and is suspicion for a traumatic haemothorax secondary to blunt chest trauma with a likely element of shock. He is concerned about the changing vitals and identifies this as a major trauma and immediately transfers the patient into Resus and alerts the ED SpR.
Management
Patient connected to oxygen
IV access established
Bloods including group and hold/cross match are sent (see discussion).
TXA given.
Analgesia given IV
Portable chest xray ordered
Blood transfused
Concerns
The patient is on a DOAC. POCUS has shown spine sign, suggesting an effusion, likely haemothorax.
Patient is haemodynamically unstable in context of likely bleed.
Patient taking shallow breaths, in part secondary to pain. Nerve block to be considered.
Senior involvement needed in this patient.
Results
CXR
Effusion with rib fractures
VBG
Ph 7.3
Pco2 7
Lactate 2.8
Hb 11.8
Glucose 5
CT thorax
Flail segment on left with moderate haemothorax
Updated Vitals
Hr 115
Bp 90/60
Sats 93
Management based on results
Cardiothoracics consulted and will review patient
Discussion with haematology re reversal of DOAC
Serratus Anterior nerve block performed
Chest drain considered
Conversation had at the bedside regarding functional baseline, social history, and any prior directives / celling of care.
Discussion time
POCUS
POCUS is not a rule out tool, but it can help raise your clinical suspicion if there are positive findings. If there was an absence of abdominal pain but free fluid was seen on POCUS, you may extent the CT to be a CT Thorax, Abdomen and Pelvis. We covered a lot about blunt abdominal trauma in S4E4: Road Traffic Collision - Trauma. Findings on POCUS can also help you manage your patient right now, by moving the patient to resus or ICU based on findings. Remember, POCUS is not a rule out tool - you’ll still need your xray +/- CT, but as Callum nicely put it, “it helps accelerate your information gathering.”
CT thorax
Chest x-rays will often miss or fail to highlight the severity of chest injuries - it’s the reality of only seeing in two dimensions - as seen by the flail segment on CT in this case. As pointed out in this case, it’s worth having a chat to your radiology colleagues to see if there is an extravasation of contrast to suggest an ongoing bleed on CT. As we discuss later, patients with silver trauma may not mount as strong a physiological or pain response as younger patients. Thus having a low threshold for CT at initial presentation can prevent morbidity and mortality later in the patient’s recovery journey.
Chest trauma pathway
Many hospitals now have a chest trauma pathway - why not check to see if there is one for your Emergency Department? IAEM have a brilliant guideline for blunt chest trauma which can be accessed here (INSERT PDF LINK HERE)
Silver trauma
We don’t shy away from Silver Trauma here at TCR and have covered it in many forms over the past five seasons! In season 1 we talked all about the major trauma audit 2021 and the CRASH-2 and CRASH-3 trials, and TXA in trauma. We also had an episode on Orbital Compartment Syndrome in season 1, Posterior Circulation Stroke in season 2, General Silver Trauma in the GeriEM Series part 6 in Season 3 that Callum mentioned.
Simply search “silver trauma” on the episode page of thecase.report et Voilá, the education leave you’ve taken for a day off is suddenly much more educational than you anticipated!
Silver trauma is a major trauma which is often underrecognised at initial presentation because of some of the ways it can present differently to major trauma in the younger population, such as the low impact mechanism of injury as seen in this case. As seen in this case, the patient was not initially sent to resus, amd there was no trauma team response, as there would for someone in there 20s who had been in an RTC for example. But silver trauma is very common. Older patients may not be able to mount the same physiological response as younger patients - this is for a variety of reasons including age related factors, pre-existing co morbidities, medications like beta blockers which mask a tachycardia etc.
DOACs and haemorrhage in Major Trauma
DOACs are now a commonly prescribed medication, particularly in the older patient population. The decision to reverse a DOAC should be discussed with the ED consultant and reg, as well as haematology. Here are some key tidbits of information to have, before you discuss this with your senior/haematology
What anticoagulant is the patient on?
Are they on a direct thrombin inhibitor? What is its name. What is the reversal agent for the specific DOAC?
When did they last take the DOAC? This is key +++. The time the patient last took the DOAC will be one of the key factors in determining if a reversal agent needs to be given. The longer the time period, the less likely a reversal agent will be given.
Nerve blocks
We actually talked all about Fascia Iliaca blocks last season and you can relive the experience here!
Takeaway points on chest trauma
Silver trauma patients may initially appear less sick than they are as they are not able to mount the same physiological response or have the same level as pain as younger patients, but then deteriorate later. Aggressive investigation and management where appropriate and as per treatment pathway guidelines at initial presentation can help improve morbidity and mortality outcomes.
Inadequate pain medication in chest trauma can lead to hypoventilation and associated complications down the line. Consider nerve blocks where appropriate (very few contraindications!).
AITR and bonus segment
Make sure you listen all the way through to the end for pearls and pitfalls from our AITR Dr James Foley, as well as the bonus segment from Dr Eduard Turcuman for his tidbits for nerve blocks in chest trauma!
References
Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management - The SABRE Randomized Clinical Trial https://jamanetwork.com/journals/jamasurgery/fullarticle/2818238
The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures
https://emj.bmj.com/content/41/9/522
A Randomized Non-Inferiority Clinical Trial of 14Fr Thal versus 28Fr Tube Thoracostomy for Traumatic Hemothorax https://pubmed.ncbi.nlm.nih.gov/39700058/
Small versus large-bore thoracostomy for traumatic hemothorax: A systematic review and meta-analysis https://pubmed.ncbi.nlm.nih.gov/39213292/
Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score
https://pubmed.ncbi.nlm.nih.gov/34766933/
Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury
https://pubmed.ncbi.nlm.nih.gov/35533604/
