Emergency Medicine

CHEST INJURIES

236 Surgical Emergencies

4 Perform a CXR and look for the following signs seen in diaphragm rupture:

(i) Haemothorax, pneumothorax, elevated hemidiaphragm and coils

of bowel or a nasogastric tube curled up in the left lower chest.

(ii) The diagnosis is often missed, as the CXR appears normal in up

to 25% of cases.

MANAGEMENT

1 Decompress the stomach with a nasogastric tube.

2 Carefully insert an intercostal drain for an associated haemothorax or

pneumothorax, using blunt dissection down to and through the parietal

pleura (see p. 473).

(i) Never use the trocar introducer to insert the drain.

3 Refer the patient to the surgical team following resuscitation.

Oesophageal rupture

DIAGNOSIS

1 This rare injury is most commonly associated with penetrating trauma or

following blunt trauma to the upper abdomen.

(i) Other causes include instrumentation, swallowing a sharp

object, and spontaneous rupture from vomiting (Boerhaave’s

syndrome).

2 The patient complains of retrosternal pain, difficulty in swallowing and

occasionally haematemesis. Look for cervical subcutaneous emphysema.

3 Establish venous access wit h a large-bore i.v. cannula.

4 Request a CXR to look for a widened mediastinum with mediastinal air, a

left pneumothorax, pleural effusion or haemothorax. These findings in the

absence of rib fracture should suggest the possibility of rupture.

5 Request a CT scan to better define air in the mediastinum.

MANAGEMENT

1 Administer oxygen and replace f luids. Give morphine 2.5–5 mg i.v. for pain

with an antiemetic.

2 Commence broad-spectrum antibiotics if rupture is considered likely, such

as gentamicin 5 mg/kg i.v., ampicillin 1 g i.v., and metronidazole 500 mg i.v.

3 Carefully insert an intercostal drain if there is a pleural effusion. Particulate

matter in the intercostal tube drainage would confirm the diagnosis.

4 Refer the patient to the surgical team for a Gastrografin swallow and/or

oesophagoscopy, followed by surgica l repair if feasible.