General Surgery
Thoracic, Soft Tissue and Airway Trauma
MBBS surgery notes on thoracic, soft tissue and airway trauma: life-threatening chest injuries, chest drains and compartment syndrome, mapped to NMC codes SU17.6 to SU17.10.
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Thoracic, Soft Tissue and Airway Trauma
MBBS surgery notes on thoracic, soft tissue and airway trauma: life-threatening chest injuries, chest drains and compartment syndrome, mapped to NMC codes SU17.6 to SU17.10.
This chapter details the recognition and immediate management of thoracic, soft tissue and airway injuries. It focuses on the life-threatening chest injuries, chest drain placement and the surgical airway when standard techniques fail.
High-yield: Thoracic, Soft Tissue and Airway Trauma
- The six immediately life-threatening chest injuries are airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest and cardiac tamponade.
- Tension pneumothorax presents with respiratory distress, tracheal deviation away from the side, absent breath sounds and distended neck veins.
- Open pneumothorax, a sucking chest wound, is covered with a three-sided dressing that acts as a flutter valve, then a chest drain is placed.
- Massive haemothorax is more than 1500 mL of blood in the chest and needs a chest drain and often thoracotomy.
- Flail chest occurs when two or more ribs are broken in two or more places, giving paradoxical chest wall movement.
- The underlying pulmonary contusion causes most of the hypoxia in flail chest, and treatment centres on oxygen, analgesia and ventilation if needed.
- Cardiac tamponade gives the Beck triad of hypotension, muffled heart sounds and raised jugular venous pressure.
- Pericardiocentesis or emergency thoracotomy relieves tamponade in the unstable patient.
- A chest drain for trauma is placed in the safe triangle at the fifth intercostal space just anterior to the mid-axillary line.
- Aortic injury is suspected with a widened mediastinum on chest radiograph after a deceleration mechanism.
- A definitive surgical airway by cricothyroidotomy is indicated when intubation and bag-mask ventilation both fail.
- Compartment syndrome presents with pain out of proportion, pain on passive stretch, and needs urgent fasciotomy before pulses are lost.
- Crush injury releases myoglobin, which can cause acute kidney injury, and is treated with aggressive fluids.
- Traumatic soft tissue wounds need thorough cleaning, debridement of dead tissue and consideration of tetanus prophylaxis.
- Delayed haemothorax and pneumothorax can appear after apparently minor chest injury, so repeat imaging is prudent when symptoms persist.
Immediately life-threatening chest injuries
- **Tension pneumothorax:** Distress, tracheal deviation, absent breath sounds, distended neck veins; immediate decompression.
- **Open pneumothorax:** Sucking chest wound; three-sided dressing then chest drain.
- **Massive haemothorax:** Over 1500 mL blood; chest drain and often thoracotomy.
- **Cardiac tamponade:** Beck triad of hypotension, muffled heart sounds and raised venous pressure; pericardiocentesis or thoracotomy.
NMC competencies in this chapter
- **SU17.6:** Thoracic trauma: life-threatening chest injuries
- **SU17.7:** Chest drain insertion and management
- **SU17.8:** Airway trauma and surgical airway
- **SU17.9:** Soft tissue trauma and wound care
- **SU17.10:** Compartment syndrome and crush injury
Frequently Asked Questions
What are the immediately life-threatening chest injuries?
Airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest and cardiac tamponade, all sought and treated during the breathing and circulation steps.
How is an open pneumothorax first managed?
Cover the sucking wound with a three-sided occlusive dressing that lets air escape on expiration but not enter on inspiration, then place a chest drain away from the wound.
What is the Beck triad?
Hypotension, muffled heart sounds and raised jugular venous pressure, the classic signs of cardiac tamponade, which is relieved by pericardiocentesis or emergency thoracotomy.
How is compartment syndrome diagnosed and treated?
It presents with pain out of proportion to the injury and pain on passive stretch, and it needs urgent fasciotomy before the loss of pulses, which is a late and ominous sign.
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