00:01
Thank you for joining
me on this discussion
of thoracic injury in
the section of trauma.
00:07
Just as a reminder,
trauma-related principles are
extremely high-yields or
a common place for questions
on USMLE examinations.
00:15
So pay particular attention
to the trauma series.
00:19
Let’s start with a
clinical scenario.
00:22
You have a patient
who is 24 years old.
00:24
He is at a night club and engages in a
verbal confrontation with another patron.
00:29
When he exits, unfortunately
he is stabbed in the back.
00:33
Emergency medical services are
called and rushes to the scene.
00:37
They find a patient who is alert,
complains of difficulty breathing.
00:41
The patient is intubated in the field
by EMS and arrives at your trauma bay.
00:46
And upon arrival this
is what you find.
00:50
Pretty startling.
00:51
What’s going on in your mind?
How are you going to
manage this patient?
Let’s start with a question.
00:58
What’s the next
step in management?
Remember, many USMLE questions
end with this very question.
01:04
What is the next
step in management?
I’ll give you a second
to think about this.
01:10
Of course, ABCs.
01:12
That’s the beginning of
every trauma patient.
01:15
Airway, breathing, circulation.
01:18
As you can imagine, with the
stab wound to the chest,
airway and breathing are
particularly important.
01:26
Remember, just because the
EMS intubated the patient
doesn’t mean that the ET tube is
actually in the correct place.
01:34
You must begin with ABCs
again and not assume
that the patient has
a definitive airway.
01:40
Now, do you remember from our
initial assessment lecture module
how to quickly check if the
patient has an intact airway?
Of course this doesn’t apply to our
patient because he is already intubated.
01:51
I’ll give you a second
to think about this.
01:54
That’s right.
01:56
I simply go up to the
patient and say,
“Hello sir, I’m Dr. Pei.
Please tell me your name.”
And if your patient was able
to tell you their name,
you know they have an intact airway and
they’re moving air through this conduit.
02:12
Now, let’s get to B.
02:15
Let’s say that you’ve confirmed
the ET tube by end-tidal CO2.
02:20
Again, let me repeat that.
02:22
Placement of an ET tube is confirmed
by end-tidal CO2, not breath sounds.
02:28
You’ve moved on to
B for breathing.
02:30
And as this picture depicts,
you don’t hear any breath sounds on the
left side where the stab wound was.
02:38
What’s going on in your mind?
And what are you
going to do next?
I’ll give you a second
to think about this.
02:46
Of course, it’s time for a
chest tube or thoracostomy.
02:51
Don’t get confused.
02:52
This is an ostomy, thoracostomy
not a thoracotomy.
02:56
So we put the chest tube in when
there are decreased breath sounds.
03:00
And remember, absent or
decreased breath sounds
in the trauma bay is
presumed a pneumothorax.
03:07
You should not have additional studies and
do not delay placement of a chest tube
particularly if the
patient is unstable.
03:16
When presented with this
clinical scenario and you don’t
hear breath sounds, assume
that there is a pneumothorax.
03:22
Of course, there’s always the
option of needle decompression.
03:25
Needle decompression is
performed in the midclavicular
space about the second
intercostal space.
03:31
This draws the air out, but
sometimes you need a bigger
bore chest tube like the one
that’s shown in this image.
03:38
After chest tubes are inserted, it’s
usually connected to a drainage system.
03:42
In the blue on the left side of the
image, that’s what’s called a water seal.
03:47
The water seal prevents
direct communication from
the intrathoracic component
to the atmosphere.
03:54
Now, let’s say you had
time to get a chest x-ray.
03:58
Can you see the pneumothorax?
That’s right, it’s
on the left side.
04:03
Now, where is the
pneumothorax on this one?
Just for practice.
04:08
I’ll give you a second to
take a look at this image.
04:12
That’s right. It’s
on the right side.
04:15
Now, special cases where the chest
x-ray clearly looks like there
is no pneumothorax like the one
on the left side of your screen
but when you get a cross-sectional
CT chest for whatever reason,
you actually see that there is a
small pneumothorax anteriorly.
04:31
This is not uncommon.
04:32
Remember, small pneumothoraces like
this may not be clinically relevant
unless the patient is about to undergo
positive pressure ventilation.
04:42
For whatever the reason that the
patient has a pleural disruption,
positive pressure ventilation may
actually make this pneumothorax worse.
04:49
So remember, if your patient’s
going to the operating room
for whatever reason, just keep
a close eye on the patient.
04:54
He or she may need a chest
tube at some point.