Emergency Medicine

CHEST INJURIES

234 Surgical Emergencies

5 Request a CXR.

6 Organize an echocardiogram, which may show wall motion abnormalities

but is most useful to exclude cardiac tamponade or acute valvular rupture.

MANAGEMENT

1 Give the patient high-dose oxygen and administer a cautious f luid challenge

if hypotensive.

2 Give morphine 2.5–5 mg i.v. with an antiemetic such as metoclopramide

10 mg i.v. for pain.

3 Admit all patients with unstable arrhythmias and haemodynamic instability

to the intensive care unit (ICU).

(i) Obtain an urgent echocardiogram if hypotension persists and or

cardiac tamponade cannot be excluded.

4 Refer a stable patient with ECG abnormalities, age >50 years or pre-existing

cardiac disease to a coronary care unit (CCU) for cardiac monitoring if there

is evidence of significant blunt myocardial trauma.

5 Discharge home patients <50 years with normal ECG findings, and without

a history of cardiac disease with oral analgesia.

Aortic rupture

DIAGNOSIS

1 This occurs following high-speed deceleration injury, when the aorta is torn

just dista l to t he lef t subclav ian arter y.

(i) It is increasingly being recognized in lower-speed injuries

including side-impact.

2 Always consider this diagnosis in any deceleration injury >60 k.p.h.

(45 m.p.h.) or following a fall from >5 m (15 ft).

3 Only 10–15% of patients with rupture of the thoracic aorta survive to reach

hospital.

4 Clinical signs of aortic rupture are subtle or absent and so diagnosis is

suspected largely based on the mechanism of injury, or from a history of

chest or interscapular pain, unequal blood pressures in each arm, or differ-

ent femoral and brachial pulse volume, and the initial CXR.

5 Insert two large-bore i.v. cannulae and cross-match 10 units of blood.

6 Perform a CXR and look for the following signs of aortic rupture:

(i) Widened mediastinum (≥8 cm on a 1 m supine anteroposterior

X-ray):

(a) 10% of these patients will have a contained aortic rupture

confirmed