Penetrating Chest Trauma

Dr Peter Snelling – Paediatric Emergency Registrar

  1. Assessment of low vs high velocity injury
  2. Investigation of penetrating chest trauma
  3. The Role of the Emergency Department Thoracotomy

Low Velocity

  • Generally a sharp object causes injury along its entry track and may damage any intrathoracic organ in its path
  • External wounds may appear deceptively innocuous (“Ice pick” wound)
  • “The Box”
  • Identify and treat life-threatening causes

High Velocity

  • Less predictable pattern of injury
  • Trajectory of a missile may not follow a straight course
  • Kinetic energy transferred as missile decelerates [ k = ½ mv2 ]
  • Tissues sustain injury not only from the direct path of the bullet but from shock waves (temporary vs permanent cavities)
    • Pulmonary contusion/haemorrhage
    • interstitial oedema peaks 24hrs
  • Chest instability & pulmonary haemorrhage à ventilation difficulties

Bullet Removal

  • Rare to perform surgery for purposes of bullet removal
  • Retained bullets rarely cause complications
  • Surgery can cause more harm than good

Investigations

  • E-FAST
    • hemopericardium (100% Sn, 97% Sp – in absence of MHTx)
    • pneumothorax, hemothorax, and peritoneal fluid
  • CXR
    • PA erect, AP supine
  • CT
    • Trajectory of a penetrating object crosses the mediastinum or middle of the chest.
    • Symptoms or signs concerning for oesophageal or tracheobronchial or vascular injury are present.
    • Chest pain, shortness of breath, or other symptoms consistent with injury are present that are not explained adequately by a plain chest radiograph
  • Other
    • ECHO, Endoscopy, bronchoscopy, angiography

Emergency Department Thoracotomy

  • Control injury related bleeding from heart or great vessels
  • Allow direct cardiac cardiac compressions to restore cardiac output
  • Release pressure on the heart caused by cardiac tamponade
  • Cross-clamp the aorta to gain haemorrhage control in major abdominal trauma

Indications

  • Penetrating thoracic injury with loss of cardiac output for <10 mins (accepted)
  • Penetrating non-thoracic trauma with loss of cardiac output for <10 mins
  • Blunt thoracic injuries with loss of cardiac output for <10 mins
  • Contraindicated: blunt thoracic trauma with no witnessed cardiac activity, blunt multi-trauma, severe head injury

Procedure

  • Left anterolateral thoracotomy 5th ICS
  • +/- Extended to clamshell
  • Divides internal mammary arteries
  • Pericardium opened
  • Cardiac wounds controlled
  • Internal cardiac massage (2 hand technique)

 

A Brave New World – Traumatic Cardiac Arrest

Dr Alistair Hamilton – Emergency Medicine Advanced Trainee

Section 1 – ICC Insertions

  • Complications of ICC’s are wide ranging, and potentially catastrophic
    • Malposition is the most common
      • Includes diaphragm perforation, abdominal tube, intraparenchymal tube, and tube outside the pleural space
    • Tube migration / dislodgement
    • Organ & neurovascular injury
    • Pneumothorax:
      • persistent / late / at removal
    • Others: pain, infection, provider injury, chylothorax, allergy, APO
  • Prevention of compilications
    • Global strategies
      • Awareness of risks, meticulous care
      • Protocolised insertion
      • Teaching and supervision
    • Technique
      • Positioning and identification of safe triangle
      • Secure the tube well
      • Assess the drain and tubing
      • Assess the CXR
        • Act if the position is incorrect!
      • Re-assess the patient

Section 2 – Traumatic Cardiac Arrest

  • 2 main controversies
    • Role of external chest compressions
    • Timing, location and indications for thoracotomy
  • ARC does not provide guidelines
    • Clearly, though, we need to recognise this situation requires entirely different management from the usual ALS algorithm.
  • HEMS were first service to provide us with a useful, simple algorithm
    • Outlined by Lockey et al 2012 (see below) – for both arrest and peri arrest trauma patients
    • Immediate thoracotomy for TCA in penetrating trauma
    • Focus is on rapid treatment of reversible causes: “HOT”
      • Hypovolaemia
      • Oxygenation
      • Tension pneumothorax
    • Does include CPR in algorithm
  • Many cutting edge trauma clinicians have stopped using CPR in TCA
    • See article below by Cliff Reid and colleagues
      • Read this if it’s the only one you have time for
    • This, along with thoracotomy in blunt trauma, is the future of TCA

References (in order of importance / utility)

  1. Reid, C. Sherren, P. Habig, K, Burns, B. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Critical Care. March 2013.
  2. Lockey DJ, Lyon RM, Davies GE . Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation. 2013 Jun;84(6):738-42.
  3. Lockey D1, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006 Sep;48(3):240-4.
  4. Website: trauma.org
  5. Reade, Michael. Video: Optimal Management of Traumatic Cardiac Arrest. Grand Rounds, RBWH – May, 2014
  6. Website: Medscape
  7. Kleber C, Giesecke MT, Lindner T, Haas NP, Buschmann CT. Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation. 2014 Mar;85(3):405-10.
  8. Huber-Wagner S, Lefering R, Qvick M, et al. Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest. Resuscitation 2007;75:276–85
  9. Tube Thoracostomy: Complications and Its Management
  10. Emeka B. Kesieme, Andrew Dongo, Ndubueze Ezemba, Eshiobo Irekpita, Nze Jebbin, and Chinenye Kesieme. Tube Thoracostomy: Complications and Its Management. Pulmonary Medicine. Volume 2012 (2012)

 

 

 

 

Blunt Chest Trauma

Dr Titiosi Adegbija – Emergency Medicine Registrar

Blunt Aortic Injury is the 2nd commonest cause of death in BCT patients – 80% on scene

The mechanisms involved in BAI include 1) Osseous pinch 2) Water-hammer effect 3) Stretching/ shearing and 4) Torsion

Management is either open surgery or endovascular repair

Blunt Myocardial Injury occurs in 13% BCT patients

Myocardial rupture is commonest in the right atrium with septal/ valvular injury occurring most commonly in the aortic valve

ECG is used as screening tool and further specific diagnostic and therapeutic measures are limited to cases where cardiac complications develop

Indication for Surgical thoracotomy in Blunt Chest Trauma – immediate drainage of >20ml/kg or shock + persistent, substantial bleeding (>3ml/kg/hr)

Rib fractures occur in 67% of MVC patients with BCT

  • ≥6 rib #s – double incidence of pneumonia & ARDS
  • ≥45y + ≥4 rib #s = longer intubation, ICU stay, hospital stay

Indications for Rib Plating:

–   flail segment + failure to wean

–   Painful, moveable ribs refractory to pain management

–    Significant chest wall deformity or tissue defect

–   Instability due to non-union

Contraindication: – severe pulmonary contusion

Lung expansion modalities include: 1) Deep breathing & Incentive spirometry 2) Intermittent Positive Pressure Breathing 3) Continuous Positive Airway Pressure

CT remains gold standard for investigation of blunt chest trauma

For Blunt aortic injury, if CT is equivocal, then Angiogram may be done as more specific (though not as sensitive) than CT scan.

NEXUS Chest Decision instrument may safely reduce need for chest imaging (SN 98.8%, NPV 98.5%, SP 13.3%)

Advantages of Epidural Analgesia

– Significantly improves subjective pain perception

– Significantly improves critical PFTs

– causes less respiratory depression, somnolence, GI symptoms

– Safe, negligible mortality

– improves outcomes of ventilator days, ICU & hospital LOS

Types of Intercostal blocks include: 1) Intercostal block 2) Intrapleural anaesthesia 3) Thoracic paravertebral block

TAKE HOME PEARLS…

  • Maintain a high index of suspicion for lethal injuries!
  • If the patient has ≥3 OR high (ribs 1-3) #s: 1) search rigorously for other lethal intrathoracic injuries 2) consider admission especially if elderly
  • Actually give the physiotherapist a call!
  • Involve APMS early if challenging pain control anticipated

 

KEY REFERENCES

  • Kea, Bory, et al. “What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?” The American journal of emergency medicine8 (2013): 1268-1273.
  • McGillicuddy, Daniel, and Peter Rosen. “Diagnostic dilemmas and current controversies in blunt chest trauma.” Emergency medicine clinics of North America3 (2007): 695-711.
  • Neschis, David G., et al. “Blunt aortic injury.” New England Journal of Medicine16 (2008): 1708-1716.
  • Rodriguez, Robert M., et al. “NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma.” JAMA surgery10 (2013): 940-946.
  • Simon, Bruce J., et al. “Pain management guidelines for blunt thoracic trauma.” Journal of Trauma and Acute Care Surgery5 (2005): 1256-1267.
  • Traub, Matthias, et al. “The use of chest computed tomography versus chest X-ray in patients with major blunt trauma.” Injury1 (2007): 43-47.

Burnout and Depression in the ED

Dr Anna Singleton, Emergency Medicine Advanced Trainee

WHO defines burnout as a ‘state of vital exhaustion’

  • Burnout amongst doctors is as high as 50%
  • Associated with negative outcomes for patients, institutions and the physician
  • In some studies, >50% physicians reported that exhaustion/sleep deprivation had a negative effect on the care they delivered

The Maslach Burnout Inventory:

  • Standard research tool composed of 3 dimensions
    1. Emotional exhaustion from work demands
    2. Depersonalization (eg compassion fatigue)
    3. Perceived lack of personal accomplishment.
  • Compilation of scores
    • Low/medium/high risk burnout

Features of burnout

  • Physical symptoms
    • Insomnia, fatigue, headaches, GI upset
  • Psychological symptoms
    • Irritability, cynicism, guilt, decreased concentration, poor judgement

 Complications of burnout

  • Anxiety, depression, substance abuse, addiction, suicide
  • Disrupted personal and family life
  • Impaired patient care and increased medical error
  • Decreased productivity and job satisfaction
  • Increases in absenteeism, health care costs and personnel turnover

Arora m et al. Review article: burnout in emergency medicine physicians Emerg Med Australas. 2013 dec 25 (6)

  • Summarises available literature on burnout among ED physicians
    • ED physicians had burnout levels >60%, compared with physicians in general (38%)
    • Despite this, most ed physicians (>60%) are satisfied with their jobs.
    • Both work related (hours of work, years of practice, non clinical duties) and non work related factors (age, gender, lifestyle factors) associated with burnout.
    • Despite heavy burnout rates among ED physicians, little work has been performed in this field.
    • Recommends determining factors responsible for burnout and appropriate interventions to reduce burnout.

Shanafelt et al. Burnout and satisfaction with work-life balance among us physicians relative to the general US population Archives of Internal Medicine. 2012. 172 (18)

  • Survey of 7000 doctors (mixture of specialties) compared with 3500 people working in other fields.
  • More than 65% ed physicians reported burnout compared to 55% internists (next highest) and 27% general population
  • Emergency physicians experience burnout at a rate of more than three times that of the average doctor and more than anyone else inside or outside of the medical field!!

Why?

  • Hypotheses:
    • Ed physicians usually can’t choose
      • Who they work with
      • Whom they treat
      • How heavy their workload is
      • How heavy the emotional toll of the workday might be
    • Erratic schedule/night shift
      • Shift work associated with health problems such as diabetes, depression, heart disease and breast cancer.
      • Adversely affects personal life, especially if has a partner/children

The Beyond Blue Study:

  • National mental health survey of doctors and medical students 2013
  • Aims:
    • Understand mental health issues of Australian medical students and doctors
    • Increase awareness across medical profession and broader community
    • Development of mental health services and supports for the medical profession
  • Anonymous, self complete survey
  • Topics
    • Specific and general mental health status
    • Substance use and misuse
    • Suicidal ideation and self harm
    • Workplace and life stressors
    • Levels of burnout
    • Impact of mental health symptoms
    • Treatment and coping strategies
    • Barriers to seeking treatment and support
    • Attitudes regarding doctors with mental health conditions
  • Sample of 42942 doctors and 6658 medical students
  • Response rate 27%
    • 12252 doctors, 1811 medical students
  • Demographic profile of participants similar to general australian doctors population, based on data from 2011 census

Key findings

Doctors reported substantially higher rates of psychological distress and attempted suicide compared to both the Australian population and other Australian professionals

  • 21% doctors reported having had depression
  • 9% doctors having had anxiety
  • 8% doctors reported suicidal thoughts previously
    • 4% had suicidal thoughts in previous 12 months
  • 2% doctors had attempted suicide
  • Young doctors and female doctors reported higher levels of mental health problems and reported greater work stress
  • Young doctors reported higher rates of burnout compared to older doctors

Maslach Burnout Inventory Responses:

  • The most common source of work stress related to balancing work with professional responsibilities (26%)
  • Too much to do at work (25%)
  • Responsibility at work (20%)
  • Long work hours (19%)
  • Fear of making mistakes (18%)

Doctors Appear To Have A Greater Degree Of Resilience To The Negative Impacts Of Poor Mental Health

  • Whilst rates of mental health problems were high, many doctors self reported they were able to limit the impact of these problems
  • Few doctors reported being highly impacted by their mental health symptoms in the domain of work or self
  • Doctors reported high rates of treatment and medication use for depression and anxiety compared with general population

Barriers To Seeking Treatment

  • Fear of lack of confidentiality/privacy (52%)
  • Embarrassment (37%)
  • Impact on registration and right to practice (34%)
  • Preference to rely on self or not seek help (30%)
  • Lack of time (28%)
  • Concerns about career development/progress (27%)

 Recommendations

  • Initiatives to address the stressful working environment
    • Increasing resources
    • Increasing size of workforce
    • Limiting excessive work hours
    • Mentor/mentee relationships
  • Social marketing programs that promote importance of mental wellbeing and early treatment
  • Targeted medical student education on the importance of good mental health care both for physicians specifically and broader community

Management/Prevention Burnout

  • Evidence based approaches to managing burnout are lacking
  • Common sense preventative measures
    • Self care – exercise, healthy eating, meditation, holidays
    • Learn how and when to say no
    • Time management and setting limits
    • Recognising the symptoms of burnout and to ask for help
    • Strengthen personal and workplace relationships (eg team building)

 

EATING DISORDERS – What to know and expert update.

Link

EATING DISORDERS

As summer approaches, we all want to have a great beach body, but for some, it can be a life-threatening obsession. Today’s TED explored Eating Disorders and we were lucky enough to have Dr Warren Ward, Director of RBWH Eating Disorder Service as a guest presenter and the venerable Dr Charles Denaro, Director of Internal Medicine, RBWH to offer his perspective of the management of these patients on the ward.

To put things in perspective, Dr Maya Aoude, Emergency Registrar, gave us “the skinny” on current state of affairs of presentations in the local RBWH context.

  • 32 patients over the last six months were seen at RBWH, ninety percent were female. 1 in 20 Australian suffer from an eating disorder.  There was some surprise from the local audience that the largest age demograph was in the 25-35 year age group. Dr Denaro and Dr Ward pointed out, the disease is chronic and that although the age of onset is around 14-20, it takes time to develop the physiological abnormalities that manifest in a need to present. Most are referred by their GP or community mental health.
  • About 50 % of all eating disorder admissions start out requiring medical admissions. Our network partners eluded that presentations to their EDs of patient with eating disorders requiring admissions are rare. The majority were voluntary patients

 

Anorexia Nervosa and Eating Disorders

Dr Ward took some time to offer some educational pearls and wisdom on the treatment of this group. Here are some of the key points as I saw them:

Three types of eating disorders

-> Anorexia Nervosa

-> Bulimia

-> Eating disorders associated with increased weight (binge eating disorder)

15 % of females in Australia will have an eating disorder in their lifetime

10-20% of anorexia nervosa patients will die – it has the highest mortality rate of all psychiatric illnesses. However it also has a 70% cure rate within 5 years, with a multidisciplinary team approach.

The biggest risk for patients with an eating disorder is unintentional death due to starvation.  Someone can feel well and have normal bloods, but can suddenly drop dead from an arrhythmia.

 

Indications of cardiac risk:

BMI < 14

No oral intake for 1 week

Purging several times per day

SBP < 90

HR <50 or >110

Postural hypotension

Electrolyte abnormalities

ECG changes

 

My pants don’t fit me, how did it let myself go … without eating??

Culture, genetics, female gender and abuse or disturbed attachments in the first five years of life all play a role in the development of anorexia.  And we can all can probably appreciate the effect of peer pressure and media on developing a negative self-image. The biggest cause however is dieting!!

 

Dr Ward showed two interesting studies:

1.) Eating attitudes and behaviours prior and post introduction of TV to a culture (Fiji)  previously without this media

http://www.ncbi.nlm.nih.gov/pubmed/12042229

-> 60 % increase in abnormal eating behaviour in adolescents who were exposed to TV compared to those that were not

2.) More interestingly, the Minnesota Starvation Experiment, Ancel Keys, just post war

-> Participants dropped 25 % of body weight

-> increases in depression and hypochondriasis and preoccupation with food

-> so dieting a major risk factor for developing anorexia nervosa

-> participants became obsessional and detailed in their thinking, lost libido

This means that behaviours of anorexia nervosa initially more likely to be related to biochemical effects of starvation syndrome, rather than underlying primary psychiatric problems.

 

SO WHAT CAN I DO??

Assessment of Eating Disorder Patients in ED

  • Should only really take 5-10 minutes despite being emotionally charged
  • History is the key -> the process of how they got to ED. They are here for a reason
    • If they are in ED, they are more than likely further down the slippery slope than we realise

-> episodes of fainting key indicator need admission

-> often will tell you “everything is ok” if asked generalised questions on welfare, but be honest when asked specific questions about eating 

-> Get collateral from family members and GP

-> Fainting, light-headedness, chest pain, palpitations, ankle swelling, weakness, fatigue, regular periods -> I send young, articulate, well-looking patients with non-specific symptoms like this home all the time!! Protection for you and your patient is to correlate with quick eating history

 

****LETHAL COMBINATION****

(No it’s not Mel Gibson and Danny Glover)

Patient and doctor denial of seriousness of condition

 

EXAM

Easy -> postural HR, BP, weight and height.

-> Can add in a request to do a squat – de-conditioned patients find this hard to do

-> In patients with eating disorders, HR increases with standing/walking, as opposed to athletes who can maintain bradycardia with mild exertion

 

INVESTIGATIONS

Once again, pretty straight forward

-> ELFT (including phosphate), FBC, ECG

 

TREATMENT 

Fix what is not normal -> Na, K, Glucose, Phos preferentially IV -> they are more depleted and these parameters, particularly K likely to get worse with refeeding.

Myocardium de-conditions as well as skeletal muscle, just watch how much fluids you give them, especially if already puffy

DON’T FORGET THIAMINE, again IV

Start continuous NG feeds, 50mL/hr NGT of nutrison protein plus or liquid supplements in ED. Need 6300kJ/1500kCal per day.

Use the RBWH guidelines for assistance

Eating disorder admission guide

“WE DON’T NEGOTIATE WITH TERRORISTS”

Eating disorder patients are often high achievers as they are obsessional and detailed. They will provide a good arguments not to be admitted. Use the mental health act to keep them against their will and Guardianship act to treat their starvation syndrome. If you think they will leave, do a Request and Recommendation, even if they will agree to stay, even if PEC says not to. Use their guardians (parents are guardians in the event of them being assessed as incompetent to make decisions) and often do not need to use more aggressive measures to keep these patients.

Anorexia is a chronic disease, needing long-term help.

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