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Um OK, so we did, let's stop. Uh le let's, let's let's resume here. So, Thoracic trauma, a couple of simple statistics, uh less than 10% of blunt trauma and not more than 30% of penetrating injuries require proper surgical intervention, which means that most of clinicians with some basic set of skills can be efficient in treating, in treating uh chest trauma. Uh with, with we have a decent uh decent uh efficacy and decent prognosis. Uh This is just a quick reminder, we all, we, we all know all of us or most of us uh had the B LS training. So we know this uh very basic protocol ABC ABC pattern, which is really valid and it really works also in uh in uh cardiovas trauma and it gives us a proper order of priorities. So ABC is valid very much in, in, in thoracic trauma. Now, uh again, most of most of you at some stage will undergo the a proper ATL S training, especially uh the ones who are interested in, in surgery or in, in emergency medicine. So, uh and frankly, this, this presentation uh quite, quite uh quite a bit of it is based on the ATL A guidelines because they are really well thought and very well validated uh all over the world. So, uh and it uh gave us some uh ATL S ATL S guidelines, gave us some, some some unique knowledge. So we know now that doing so called primary survey at A&E department when, when we have to face the patient after, after trauma. There, there are a few uh especially uh thoracic trauma, there are a few uh life threatening injuries which should be picked and addressed immediately and even uh they let us stop the survey, deal with them and then be before, before continuing the survey because otherwise we are going to lose the patients. So, so, so as you see, II am quite dramatic in terms of the color of and and size of a font about tension, pneumothorax and cardiac tamponade because these are I call them fast killers. So these are like proper or I would say super emergencies which have to be addressed immediately, which requires several procedures. Massive hemo is a bit uh is a bit less nerve wracking. Uh We have some time to rethink and regroup and open pneumothorax and especially lay chest, which here I have highlighted in amber. Uh they um they give us even more time and for example, fla chest can be usually successfully approached and operated on after a couple of days. There is also a number of uh of uh injuries which are potentially life uh threatening. Uh It's quite a list uh like simple pneumothorax, hemothorax, pulmonary contusion. As you can see, I put a question mark next to tracheobronchial injury because obviously, if tracheobronchial injuries associated with uh with loss of airway or significant obstruction of airway, then uh then uh it uh it is a directly life threatening injury but in many situations, a tracheobronchial injury injury can be treated uh with some delay or can be even treated conservatively. Uh So, so it is uh there are many grades, many phases of this injury, ne next kind of contusion and aortic disruption. Again, we have a question mark. So it sounds very serious aortic disruption. Uh And uh let's be honest if proper aortic disruption, most patients, most people die on, die on the scene. But uh if the patient is uh it's ST enough uh to have been transported to hospital, usually we have some time for, for some investigations, us usually uh angio or angiography and, and uh and again, we can plan the treatment and because aortic disruption usually happens uh below the origin of a left subclavian artery. Uh it's, it's a, it's a classic classic side of disruption. Uh It is usually the domain of hyper cardiac or vascular surgeons and nowadays, very often uh endovascular surgeons. Uh so it is a bit less uh uh thoracic issue and diaphragmatic injury and esophageal injury. They are, they can be very often and most often treated in a more elective manner. So let's let's go to the most scarring. Again, one of the, as I say, fast killers, tension pneumothorax. Uh again, I'm a bit dramatic. So, so the rationale, the best way, the only way to treat tension pneumothorax is a decompression of tension pneumothorax. It's, it is due to its, its physiology or part of physiology. Uh It's a situation when uh due to injury or the air is getting into the pleural space but not is and due to valve, uh due to um that effect is not able to get out of the pleural space. So this results in accumulation of error, collapse lung and eventually shifting of the metastin. And this is now we are only a step from disaster because the shifting of the megasin and especially its most important element of the heart can result in in, in, in uh well, in many things, it compromised feeling of the heart, especially the right ventricle a bit like in cardiac tamponade, in severe ri and esse essentially in acute, in acute uh heart failure. So, so this is a peri peri arrest situation which must be approached immediately. And I believe literally each of us can do it with a very simple maneuver, so called needle decompression. Uh The textbook side of newly compression is um meet clavicular r in the, in the second intercostal space. So we find the angle of Louis, we find the second re and we go beyond the beyond the second reap people often have tendency to go too, me, too close to a stand room. And uh this is a bit dangerous because, because uh thoracic arteries are not so far. I mean, mammary arteries and also sinus structures are not so far too, it's better to go rather a bit laterally towards the uh anterior axillary line uh than majorly. And if you go 1st, 2nd space or first space, it's still OK. As long as you manage to puncture the, the pa the pleura and then, and then you can hear the hissing and you know that you saved, you saved a life. It's a beautiful, believe me, it is a beautiful sound. So uh uh an interesting practical tip, longer needle eight centimeter needle is way more, way more effective. It is effective in more than 90% of of cases. So don't be if you suspect tension in the for us, even if you are not completely sure, don't hesitate to, to do to do needle decompression. The morbidity, the morbidity of this procedure is really low. It's even if there's no pneumothorax, you will not cause a lot of damage. But if there is tension pneumothorax, you will literally save a life within, within seconds. OK? I need to stop once again and please do confirm uh it is, please do confirm uh on the chat box. If, if, if you could hear my see my slides properly. I would be very grateful if you could all working. Well, I can hear a message from, from, from Mister Bone. Ok. So I continue. It's a terrible feeling because I'm not sure if, if you, if it's, if you can hear me properly and see my slides, they're very frustrating. Uh ok. Um From current slide. Ok. II believe I'm back in business and my apologies once once again. Ok. And a needle decompression should be followed by chest drain, a proper surgical chest drain in the safety triangle. We should speak about it in a, in a moment. Now, cardiac tamponade, it is a bit more complex and usually re requires a more complex procedure. But uh first, first, we have to, to, to diagnose, to diagnose, to recognize the cardiac tamponade. So there was a classic classic textbook back tr with muffled heart sounds elevated CBP low systemic pressure. Of course, the patient will also present with low cardiac output with cold peripheries, et cetera. But we have to remember one thing that, that in a trauma setting, let's say this is a a and DA ND room. Uh When we've got an emergency situation with a patient who has just been transferred by the paramedics. This is really a very noisy setting and even um even an experienced clinician can struggle to, to, to uh observe all the elements of, of the triad. And so, so again, you have to trust your gut if you, if you suspect cardiac tamponade, even if we are not completely sure. But if there is a strong, a strong suspicion, just act. If it, if it was cardiac tampon, the the the bigger mistake is missing correct tamponade than when attempting a procedure. Not quite necessarily, usually you will be right. If you suspect it, usually it is tampon. And again, uh the most crucial word decompression, it is about the physiology of cardiac tamponade. The problem of cardiac tamponade is feeling of the heart, feeling of the, of the, of the right uh ventricle which when results in uh low feeling pressures of the left ventricle. So left ventricle is going crazy. It's contracting extremely well because it's trying to do all it can to, to pump the the the remnants of the, of the volume, but it's not given enough volume. So it's tachycardic, it's, it's uh contracting as much as it as it can, but it hasn't got driving pressure. And now how, so we have to decompress the decompress the, the pericardium. You, you have to give a space to the right ventricle to the right heart. So it can supply through the pulmonary circulation, the left heart, this is the only way uh volume resuscitation um and not tropical support. It's only temporary short term measure. It, it it it is not able to, to, to treat you need physical decompression, which can be uh two ways. Now, uh it can be done in a medical way uh by so called pericardiocentesis. So, this is uh percutaneous, usually under fluoroscopic guidance, but it can be also done blindly using anatomical marks, landmarks. Uh So pericardiocentesis. So essentially putting a needle into the pericardium uh and and thoracotomy and in trauma, cardiac tamponade. The only way is the only way is uh thoracotomy, pericardiocentesis can be, can be used when you've got mm long term pericardial effusion um with imminent tampon. Uh let's say this is metastatic malignant effusion. But in, in um and it's very, it's very useful, very, very successful, very efficient. But in uh traumatic cardiac tamponade, the only way to treat it is surgical way proper surgical way with, with frac and physical decompressing of tamponade. And then because it's not only about decompressing, then you have to find the source of bleeding and you have to secure the source of bleeding. And the only way to do it is the surgical way. Uh Now another life threatening situation, massive hemothorax. You can see some numbers here. So essentially, it's a situation when patient is bleeding in one of the pleural spaces. Usually one. Uh So you've got two, you've got 22 factors here, blood loss. Um but also, but also compromising the ventilation on the, on, on, on the side, you, you can see 222 numbers here. Uh I I wouldn't treat any numbers religiously. Ok. 1500 or one inhibitors of uh hemothorax drained immediately, it is a classic, it is a textbook indication for, for, for, for, for surgical intervention. But um as I say, don't treat it religiously in some patients, 1 L, even less can be enough, can be enough to, to diagnose massive hemo. So you always have to read the whole clinical uh clinical context. Uh 200 minutes per hour for the for the consecutive two hours. It is a helpful number to a point. But again, always, always look at the whole situation at the clinical context. Uh It may be 200 it may be less, it may be more. 200 is only to give you some 200 m to give you some orientation and treatment. Uh Actually, I made a small mistake here because chest drain is, is the main, is the main uh way not to treat but to well to treat in a way but to diagnose because usually when we suspect hemothorax, we put the drain with drain immediately over 1 L0 over 1.5 L. And you know, it's a massive hemothorax. So we have to do something and we have to do something surgical with massive hemothorax. With this number be 1500 or a bit more or a bit less uh conservative treatment like transfusion like antifibrotic treatment is not enough. You have, you need a surgeon uh and you need you, you need surgery, ok. Uh And you can see that. Ok. Now, the red turns into amber open pneumothorax. It can be life threatening in some patients, but usually it is not as scary as the previous three, especially previous two situations. So what is opening for us? It is a situation when we've got a communication between the pleural space and the outer space and with the, the, the defect in the chest wall, its diameter is bigger than the two third of a tracheal diameter. So let's say an average diameter in a male is uh of inner diameter of trea is about, let's say 2021 millimeters. So two thirds would be like 14 millimeters. So actually less than 1.5 centimeters. So uh uh ta hole saying col putting it colloquially a hole in the chest wall not much bigger or, or than, than than 1.5 centimeters is enough to equilibrate the the pressures between the uh pleural space and, and atmospheric and uh and and outer space and to, to take this uh lung out of the equation. OK. So the most people who were previously treated well can tolerate it can tolerate it quite well. But remember this, this is usually a patient, uh a person who is usually deconditioned, who is in a very acute setting is, is, is often in a shock and and with a blood loss. So taking the lung out of the equation can be too much and especially in in an elderly patient So, and there is a very, very simple trick and you really don't need to be a surgeon in it to, to, to apply it just a bit of physics when you apply is a very simple dressing, not what can be simpler. So, occlusive free sided dressing and you create a very beautiful and clever flatter type valve and it works like a valve, but in a proper way. So it doesn't allow the air get into the chest, but it allows it allows the air to get out of the chest. So it can, it can treat the open pneumothorax very, very um effectively, very efficiently. Now, we have to be careful as not to be too enthusiastic, not to do. You need to leave one side free. Don't do the four sided occlusive dressing because when then you lose without effect and then you can tension uh instead of uh turning the open pneumo fora into a simple pneumothorax, you can turn it into tension pneumothorax. So, so you you worsen the situation. So remember the physics, remember the the the design of a valve, but whatever you do, it should be followed by part of a proper chest drain. And again, as you see in the last few slides, I used a word chest rain and I highlighted it and I'm quite dramatic about chest pain. II cannot stress enough how important it is. And so and no, no, no, no. Now chest is a beautiful is a beautiful measure. It's a beautiful weapon in our hands. I'm not sure if weapon is, is a good word. But so it's an in old days we used to say that every, every doctor, not only surgeon should be able to uh to deliver a baby. I mean normal delivery to read E CG. Well, you can debate about this and every clinician should be able to put a drain. Uh This is not always the case. Sometimes even surgeons do struggle with a drain. Uh but every surgeon, every cardiothoracic surgeon, no doubt every uh a nd doctor. And uh and ideally, ideally, every doctor dealing with any sort of emergency should be able to, to, to put a drain. Uh You'll be surprised our respiratory colleagues, they are very good at put so called even surgical drains, not only image guided but proper surgical drains, but they do it very, very well. So this is a very basic skill which can be, can be taught, can be learned and is really life saving in many situations. In many, it is not only life saving, it is also problem solving very often. Uh the the proper proper intercostal chest drain uh is a different treatment, solve the problem completely. No. Yeah, a few. But I remember my mentor from, from, from Manchester, from Manchester, a very experienced surgeon. I don't want to retire. He, he used to say, remember bar drain can kill and, and he was fuming fuming and somebody put a drain into his patient, which for example, a lobectomy without consulting with him. And, and uh I, uh I confess, uh, it, it happened to me that I II put 100s of drains uh as a card and as a thoracic surgeon. And it happened to me that I, that I nicked the intercostal artery. And uh it happened to me that they put a drain in the lung guilty as charged. Luckily, there were no more uh severe consequences, but they say that drain can be and has been put in any structure, even the chest and even even the abdomen. So, uh so II heard about and I II know a surgeon who pulled a drain, a very experienced surgeon who pulled the drain left ventricle. Uh people put the drain uh in, in the right in the high in the pulmonary artery in the subclavian artery. You wouldn't. And of course, of course, in the liver and spleen, you wouldn't believe you wouldn't believe uh where, where the drain, whoever drains can be placed and they can be and they can be deadly. So we have to remember this, remember the beauty and simplicity of a drain. But also we have to remember how, how dangerous and even deadly it can be. Now, there are a few rules. So if you follow them, uh we can, we can be really, really safe. I love this picture. I love this picture. Uh it has been given to me by, by my, by Mr Fantorin, a retired excellent Belgian surgeon who spent a few years in, in, in South Africa. He really knew about, about trauma and he knew about drains too. And this is a beautiful picture. So this is the left side. You can, can you see my curs um I have you see, you can see my arrow. Uh you can see the the nipple line. You can see the anterior axillary line, the middle axillary line, the posterior axillary line, you can see that pectoralis. So you can see the latissimus. So I believe this is probably the fifth, the fourth. So more or less you can see the safety triangle. Of course. No, I think it's not an ideal triangle, but you can see the triangle which is created by pectoral muscle, artis dorsal and a th rib or more precisely the line uh the line uh at, at vertebral level. So if you, if you do, if you remember these landmarks, you can put a relatively safe drain into in within so called safety triangle. It, it, it, it earned its name for, for a reason. Uh My rural farm is a drain and II put it on here on the left side, don't go too low. If you, if you have doubts, go space higher, you will never go too high. It's extremely unlikely to, to, to, to go too high. Uh Why, why would I be so concerned about going too low. Ok. So the costal margin is over here. I four is probably somewhere somewhere here. So the diaphragm is somewhere here and, and in abnormal situations can be even higher. So, so it's not far and here we are on the left side. So, so, so the the spleen is waiting is waiting for your, for your, for your drain. So you can, you can make situation way worse for a patient if you go too low. And oh God, I remember, um, not so long ago we were doing uh it was elective procedure decortication. We are putting the report we saw in university and, and, and the diaphragm didn't seem to be too low. And we put elective uh elective utility port and we landed under the diaphragm and it took us some time before we, before we realized it. Of course, we, we fix it all, but we have to repair diaphragm. We have to, we have to do for aom. Everything ended well, but it was quite embarrassing. It happened and it was, it was in a very elective situation. So it's easy to do it to do it in emergency situation. So my simple rule don't go too low if you have doubt, go a space higher. And the last f finger sweep, no surgical instrument is more delicate than your finger. Your finger is quite safe. If you, if you are reasonable, you will not, you put your finger, even if you are in a wrong space, you will be you, you, you will not cause any more damage finger sweep. And, and when you, when you feel the diaphragm and you feel the lung, you know that you are in the right, in the right space. So trust, trust your finger. Now, 84 let's go, let's go a little higher. 80 for a. So this is a complex procedure and this is EDI mean emergency department for AOM. And this may be done only by uh so only by a trained surgeon, proper trauma surgeon or cardiothoracic surgeon, it should be done by somebody who did 100s of thousands of elective thoracotomies or stenotomus. Um So this is a form of ATL ATL S guideline, but it must be done by a trained or certified surgeon. And as you see the prognosis after ed four because we do Ed four AOM. So it means that you had no time to, to take the patient to theater, you had no time to take uh to treat the patient. Uh The patient is in extremist. This is a, this is uh this is uh and you are in the and you are in the and in a rush, this is the only way to save a life. So obviously, the mean survivor can be, can be uh impressive in in penetrating step or cancer wound is 13% I believe in, in experienced trauma centers. It can be higher above 20 up to maybe, maybe 30% in selected cases. Uh in plant uh chest trauma mean survival is 1%. So, essentially, uh essentially plant chest trauma is a contraindication to, to go for. Now, uh I was always taught by the uh the best surgeons know when not to operate. So, so if a patient comes to, to, to A and D room, um after five minutes of nonintubated CPR or after 10 minutes, so it is a much longer 10 minutes of intubated CPR. What does it mean? Because if a patient is intubated, so a patient who is able to, sorry as somebody who is able to intubate, the patient is usually able to deliver a high quality CPR. So this, this uh CPR is more reliable so we can, we can give, give it a credit, give it a bit more time like 10 minutes, but not as you said, it's not much longer, even if any, even in, in intubated uh CPR. So we have to also know when to when and not to do Omy. But again, if you have doubt, we should go for it, we should go for it because essentially we haven't got much to lose. No, what would be the best approach. And again, this is my, my main rule, do what is safe in your hands and also what you can do safely. What, what do you have the facility for? So there are many ways to get into, into the chest. I came from cardiac surgery when I did originally have thousands of stenotomus, but I was doing it in a, in a very elective, comfortable setting. It's not the best approach, men Steny. It's not the best approach for ed uh setting because usually you don't have a proper, a proper. So and it's not easy to do me with a chisel or, or with a, with a, a GG. So, so I II believe the best way of for, for acute, for emergency entrance into the chest is left lateral thoracotomy for the four of fifth space, as you can see here. Well, let's count the spaces number 1234 and this is the fifth rib. So I fourth or the fifth rib and uh it shouldn't be too low. You should go at least one space or two spaces above the xyphoid. And when you do the left thoracotomy, you land immediately on the, on the um on the pericardium. And when the pericardium is distended with uh uh with uh with the blood, you almost immediately decompress the tampon. And so you achieve, you achieve goal, number one, you decompress the tampon. Uh and this is the main reason you do, you do for a tampon. So, so you, you get into where you go, you, you open the break card to decompress the tamponade. Now, there is a reason why this blood is in, there must be some injury, usually injury to, to the heart. Why is the blood in the, in the pericardial? So now you have to find the source and, and repair it and secure it. It, it, it will be very tricky to do it just through, through lefty. So you have to extend it, go through the stent with, with, with transverse stomy and do the same racy on the, on the contralateral side, on the right, right side. And then when you've got two anterior fract and transverse stot, you've got what is called clams incision. It's a very traumatic, it's a very, it's a very extensive incision. Uh But it's a beautiful approach and you can do it essentially with the knife with scissors and with your, with your finger. When you secure the, the, the, the scissors, and you've got a beautiful approach to both to our spaces to, to metastin, we can open the pericardium actually, usually it is already open. Uh You can, you can, well, people do double lung transplants through, through clamp incision. People do many procedure. You, you, you have a very good access to, to, to, to, to, to, to everything within the chest and you can repair almost every structure, every vascular structure. Uh Not to mention, you can repair, uh you can repair, repair the, the heart if you, if you know how and you, if you have enough time. So, so clamshell is uh for, for emergency fot toy clamshell or clamshell following the left omy is a very good sensible, sensible approach and it can be successful in experienced hands. Uh ok. Uh Now we maneuvers II call these like desperate times, desperate measures, maneuvers, uh quite tricky ones. And, and uh if e even experienced surgeons can, can struggle with this, uh which sometimes can make the difference and can change the tide. It can and can help to save the patient. So, occlusion technique, let's say we could, we have a penetrating uh heart trauma and it is very difficult to, to, to sometimes to secure, to repair it on a beating, hyperdynamic heart uh bleeding and you have to put a proper suture. So it's not to compromise. Let's say the coronary, let's say led into the coronary vessels because when you compromise the coronary vessels, all, all your efforts are futile and and patient usually dies in, in, in va. So, so you can do and this is really tricky. You can do like a controlled, controlled uh cardiac arrest. Um But without a cardiopulmonary bypass. Unfortunately. So when you clamp, as we see super vena cover, when you, when you clamp IVC, then the, the, the heart is emptied within, within a few beats, within a few seconds, then when you clamp ascending alter. So look, it, it is very, very, I would say brutal procedure when the heart is not refused and it goes almost immediately into, into VF and when, when, when the, the ventricles are even uh uh uh fibrillating. The situation is more stable. You've got a bloodless field and you've got a heart which is not contracted dynamically. You've got a better, if you experienced surgeon, you've got a better situation to, to put a, a more precise suture. But of course, you got only a couple of minutes normally. Well, you can, you can say, but you can tolerate categorized uh in normal temperature. Well, you've got four minutes max, but this is a deconditioned patient whose brain is already m perfused. So four minutes is a bit excessive. You've got, I believe a couple of minutes to do what you have to do and then you have to take the clamps off and, and restart the heart. Uh either with internal p or, or, or with starting with um direct, direct uh massage. OK. Clamping descending aorta. So II only did this occlusion technique only when I was uh in an elective manner. When I was retrieving the heart, I know how to do it. OK. When I was retrieving the heart for, for, for heart transplant as, as a transplant fellow, I didn't have to do it in, in a, in an emergency, in emergency situation. Now, clamping descending aorta, it is also quite a desperate measure. But when, when the patient is uh is exsanguinating and you are trying to, you have to, you have to, you have to save what is the most important for patients to survive so that you have to save brain and brain and, and at heart. And by some time. So when you, when you clamp thoracic aorta, you, you have to know how to do. It's not so easy even if your chest is open. Uh again, II II know how to do it because I did it again during organ retrieval when I was clamping the thoracic aorta descending aorta for, for abdominal surgeons. So they could properly perfuse uh perfuse the organs for retrieval. Uh But when you clamp aorta, then uh you centralize the, the perfusion of the brain and, and the heart, the coronary perfusion, it can buy you some time to, to do something. Not too, not too much time, but I think a few minutes uh and it can make the difference, clamping hilum to secure bleeding or, or prevent air embolism again with, with massive bleeding from the hilum when it's very, very difficult to, to localize it to, to not to mention to repair it. When you clamp the hilum and mass, you can, you can secure the bleeding and then you have time. OK? The, the, the, the this lung is out of business for the time being, but the bleeding should stop because you, you CCL you clamp everything and, and you have time to rein re out, ask for help, do something. So you don't have, you don't buy too much time, but sometimes you buy enough time to make, to make the difference. Ok. And now, uh, let's have a few. So these are very extreme situation, very extreme maneuvers. I really don't have any of, uh, any of you and probably any of us who will have to do it, but it is a possibility. And now, uh, a couple of real life, real life cases, uh, tampon. So it, it was an interesting case and I, I'm never sure if I should be proud of it or I should be embarrassed of it because we saved the life, but we make a couple of mistakes. I mean, the whole team. Uh So it, it was uh I think this case, I had it three years ago. Uh So a 62 year old gentleman previously reasonably fit and well, but we send risk factors for, for uh ischemic heart disease, but I treated well. Uh Suddenly he collapses and he, he is brought by ambulance uh to, to, to our A and D uh he collapses but, but the response to fluid resuscitation, uh he's having CT and the, the, the CT appearance is quite, is quite uh confusing. So here, uh you can see that it is a Coronal view. It's uh you can see the, the left ventricle with the contrast in it because it was uh CP uh be because, because we are trying to, to rule out the PP ART and you've got, you see, uh this is uh the left when to grow. And here you've got connection quite a significant collection around the heart. So the provisional diagnosis was, was uh tampon it. But why? But no history of trauma, no history of malignancy. Quite, quite uh no, you know, this quite, quite confusing. Uh and then uh radiologist misguided us a bit because here you can see again the, the again the colonel view but it a different, a different um plane And this was interpreted this this um contrast feeling defect in the S VC. And in the right, it was, it was interpreted by the on call radiologist at a massive clot, the massive clot in the, as we see and in the right atrium. So our massive clot in the in the right heart collapsing patient, our first for pe so so we are dancing between pe and cardiac tamponade because the treatment is completely different for both situations. And I also asked, I remember because II was in the building. So I went down to and I asked the cardiology ridge guys, do you see any, any a acute Coronary syndrome? And he said, no, no. And I said, can you can you do the pericardiocentesis? Because it's not a surgical patient, we say no, no, it seems organized. No, no, we can't, we can't do it. So, so at the end of the day, patient went to ATU first but because he was, he started crashing. So I had so it is a classic. It wasn't, it was a classic, it was a trauma, trauma, a trauma uh tamponade. I would say it was a classic contraindication to, to uh to surgical intervention. But I had no choice. My hands were tight. So I took him to theater and did emergency left thoracotomy and decompressed the tamponade and the patient improved literally within seconds. And, and the next day he was, he was, he was extubated. He was, and she recovered very quickly. After a couple of days, he was looking around there were some, some uh emails even for the management circulating. Oh, well done. Well done. You, you, you, you saved, you saved a man. But to be honest, we all made a mistake in a way. The cardiologist didn't because what happened? Uh we, we, we found this out later what happened. He had uh acute coronary syndrome. He had uh well, my infection which resulted in an a pericardial effusion. It usually so called Drax syndrome, which is resulted in tamponade. And this, this appearance here imitating the clot. It was just the, the proof of tamponade because it wasn't, it wasn't the clot. It was the um it was uh a poor perfusion of, of a, of a contrast, a poor. Uh So, so it was, it was actually, it was consistent with tampon, not with pe, it was no pe it was later later reviewed by, by, by our experience ra radiologist. So radiologist uh misguided that we asked with pe with pulmonary embolism cardiologist. Uh Miss, uh, did not rec did not recognize uh acute coronary syndrome. And II guys to be clear, I'm not judging because everybody is very clever in, in hindsight. And I myself, I did against the textbook surgical procedure, which I shouldn't do because he should have a but I had no choice. So at the end of the day, we, we saved the life doing things in a slightly unorthodox way. This patient later he went to and he had proper cardiac surgery with coronary, with coronary grafting and with, with uh with the treatment of LV LV aneurysm. And he, and uh to my knowledge he did well, he did well. So we saved his life. We bridged him to to further treatment. Oh dear, I'm sorry, this is wrong. Uh uh Right. Uh And this is his x-ray after surgery with a normalized uh silhouette of the heart with a drain in the left with the left pleura because when I, when I opened the pericardium, I created the window before between the pericardium and and the left pleura. And then if there's any reaccumulation of the fluid, it could be easily drawn into the pleura. So he was safe and he recovered, he recovered in a very spectacular way after this. Ok. I have a situation. Uh So this is a proper trauma. This is a proper trauma. So this is a man, uh a gentleman in his twenties brought to a ND after multiple stab wounds, it was, uh it was um uh substu situation between the drug, drug gangs and he was trapped, uh stabbed several times. Uh He was very well managed by paramedics. And when, by, when I went down to ND, he was very well managed by, by A and D team with fluid resuscitation with transfusion. Uh So, so, so we had a few situation and a few injuries in one in one patient. First, we couldn't hear initially, we couldn't hear the, the left side, we suspected of work. It would be. So our registrar, our experience, one put the drain and you can see it's a beautiful drain. It's in this, in uh 123, the fourth space classic drain with angle. Look how far he is from how far he is from, from, from the diaphragm, beautiful drain and good effect lung is fully expanded, drain, swinging. Well, that's fine. But what about the right side? So you can see it actually is a white out. So you can suspect uh clinically. And also, and also looking at the X ray that there is significant hemothorax on the right side. OK. Uh But he was stable enough to have city. So especially I, I'm, again, I'm, I'm I'm a bit dramatic here because I use the plane at the level of this person is in a supine position. I used the plane at the level of the spine. Uh So, so where, where the most fluid is in the supine position. So you can see it, it's the, the, the, the pleural space is filled with, with blood. Oh, sorry, I didn't want this uh in a, in a different plane. You can, we also put the drain. You can see the drain, the drain did some job, but only to a point there is still quite a significant residual hemo hemothorax. And so, um and we were not sure what was bleeding inside. So, so it was a classic, it was a massive hemothorax, ok? Because we drained well above the liter. And uh it was uh it was a classic indication for, for, for aom. But again, we did it as emergency. So, so after, but we had a couple of hours to prepare. So II didn't have to do it in and I, we could take the patient to through ct scan to, to, to the theater. We could drape the patient. We could also liaise with general surgeons because there was some question about liver laceration. I mean liver injury. But eventually it was decided to treat it conservatively. So he had right for Ahoy. Uh I secured, I secured the bleeding from intercostal artery. Uh I washed out the the remaining clots and blood and there was also a four centimeters incision on the, on the diaphragm and I repaired it. And here you can see II put two drains the basal one, the apical one, the lung is fully expanded. You can see a nice costophrenic angle. Uh There's no, there's no collection and now it's, it's a like this X ray. And I often some of some of you probably have seen it before or more previous presentation. You can see the left sided drain put by a registry at. And so in a way, put blindly very nicely, very high in the form of intercostal space ve very safely. And here these drains, you can see why are we put so, so low because I did a low ph and I did it under direct vision. The chest was open. My left hand was in the chest between the chest wall of the diaphragm and I can, I could put them safely. I knew the diaphragm was safe. Look at the basal drain. It's at the level. Actually, the top of the diaphragm is above it. You have to be, you have to be aware about the anatomy of diaphragm, especially diaphragm and abdomen. So these drains, we have put very low, let's say let's 1234566 or maybe even seven space. So very low, unacceptable for, for uh, bedside drainage or A&E drainage, but absolutely acceptable for intraoperative drainage and the drains are positioned very nicely and the lungs nicely expanded. He did well, he did well, he recovered quickly. But, um, uh, unfortunately, he had to go. Uh, he had a custodial sentence. He had to go to, to custody after from hospital. But we, but we saved him. Uh ok. And now blanche trauma. Also, my patient quite a lucky, uh, he was a, a young gentleman. He was completely drunk and he was uh riding a bike and he was hit by a van. So we were, we were, we were wondering how he survived this, but he survived. He survived quite well. But he came to, he came to um uh to, to A and D with mainly mainly complex chest trauma with multiple rib fractures on the right side. And even here on the, on the X ray, this drain was put again, a nice drain. A nice drain was put by the A and D team. They did it very well. But what, what can you see? You can see even on xray multiple rib fractures, um uh shape of a chest is a di di di deformed chest. Uh You can see consolidation, we will be lung. You can see surgical air in the air, in the, in the uh in the subcutaneous tissue. So, multiple refractures, some uh pneumothorax, surgical emphysema, uh and consolidation uh consolidation of the lung. So, so we've got lung contusion. You've got pneumothorax, you've got and no, I can't see any hemothorax but quite, quite a few things uh on, on c it looks even more dramatic. So again, pneumothorax, a simple pneumothorax displaced, massively displaced uh rib fractures, contusion of the lung. You see this lung is congested, it is not a healthy lung. This L is out of out of equation out of business and you can see a bit of effusion as well. So at least a few things which should be, which should be approached properly. And with this displacement of, of the ribs, the only, the only way to, to treat it is, is, is, is the surgical way. Now, I remember it was Sunday evening, my my register called me and he said, oh Mrs, we have to take him to, we have to take him to theater tonight. I said, no, we do not. So this was the, this was the, these are the injuries from a secondary survey. These are not immediate killers. So from my experience and also II liaise with my fellow consultants, sometimes you have to do operate, operate on them immediately. But usually uh you can, you have, you have more time and you can take the patient to you. You can let our colleagues intensities, optimize him, transfuse him, give him antibiotic and give some physiotherapy. And I took him to theater after two days in a in an I would say semielective manner. And he did, he, he did a proper right for AOM and he had rib fixation with multiple matrix blades. II wasn't able to, to, to reduce all fractures and stabilize all fractures, but I stabilized all because you know, like, I think about 11 ribs, I fractured, but I stabilized all essential fractures. So I reshaped his chest and, and, and, and reconstructed his chest and now his chest has a more or less normal shape. It is still an epical drain. Basal drain, the lung is expanded, no effusion. And you see the consolidation is done because the shape was reconstructed, the lung could be re reinflated properly. He had proper, proper physiotherapy and even a few days after surgery, the this consolidation and confusion looks, looks better. And now um I was talking mainly about mainly about um thoracic emergencies related to to to trauma. However, I was cheating a bit because in the first case, it was the trauma, cardiac tamponade but it was a good ii believe it was a good example of, of um thinking out of box. Uh but sometimes we, so this, this is only to mention it because this is not the subject of a presentation. Sometimes uh thoracic surgery. Thoracic surgeon is is useful in, in other type of emergencies. So-called airway emergencies when by means of rigid bronchoscopy, we can we can um restore the airway. So here we've got a patient, the patient is quite a sad story. Uh with massive esophageal mass, you can see with esophageal mass is infiltrating the trachea. And so this is trachea and you can only see the, the lumen of A is only a slea, it's so was a critical, he was, he was an extremist. He was extremely breathless, stridorous. It was, he was like pre essentially. So we took him to theater and of course, this is a procedure under the general aesthetic. And we've reason bronchoscopy, we put the endotracheal stent, look how nicely we reopened the trachea. Of course, uh he was referred to oncologist. So, so this um this, this, he's not among believing, but uh this was essentially a palliative procedure. But the next day, he was so happy because he could breathe freely without oxygen and he was extremely grateful and, and we, we improved the quality of his life for, for, for the last two weeks of his, of his life. So OK, this is not trauma related, but this is definitely for endobronchial, endobronchial um endobronchial um conditions like critical stenosis uh or, or for example, critical hemoptysis are very successfully treated with RB rigid bronchoscopy and so called endobronchial procedure. This is just a signal uh that we, that we may be useful for something, something else. Now, I will cheat again because I will, I will uh show you the clam incision. So, clam incision, which as you, as you could hear is our ultimate weapon is our ultimate line of defense in, in, in, in, in cardio trauma. And it's a beautiful, very traumatic, very extensive um uh incision. So, here again, I will cheat a bit because uh this is the video which was presented a act s is done by my colleague, my fellow consultant Mr Cutlet. So he's, he is the incision for a huge left sided teratoma, ok. This is a very elective. See, this is a very elective uh procedure in theater planned uh or investigations done. Uh uh accordingly patients, uh surgeons have go to the headlight. A patient is properly draped. So this is not an this is not emergency uh clamshell, ok? But I think this is a good video because in a very civilized setting, we can show you how, how big this incision is, how extensive it is, how traumatic it is and what a good approach it gives you. So I will, I will show you some fragments of this. So this is a a young patient with massive teratoma was very happy for me to to use it to show it to you. So I'm not a crime. Incision was the chosen position. The patient is placed in a supine position, a crime. Supine position in sorry inflam incision and proper clam incision with transverse transverse uh stomy. OK. Let's let's the chosen surgical approach. The patient is placed in a supine position. Both arms of the patient are abducted by the elevated to s are identified edge or clipped and divided during emergency during emergency, clamshell don't have a time to to worry about in mammary artery just cut it. Division of the sternum is performed either with a transverse or an inverted incision. So it all, I believe all this incision, it must have taken well, 1015 minutes before we go into the chest and the underlying ligamentous between the media are divided. And now we are dissecting retractors are placed in both the right and left, excellent exposure to the right and left, the heart and other mediastinal structures. Let me see. OK. Let's see here. This is still the teratoma. So this is not, this is teratoma, The mass was attached to the posterior base. This is how it looks upon restoration of two lung ventilation. Ok. Here, so here I want to show you this, that was reinflation of the left lung upon restoration of two lung ventilation. One second. Ok. All right. This is what you see after after because the lungs are inflated, right lung, left lung. So you can't even see the metastin. It is so nicely covered by the lungs. So this is, you see, you've got a, you've got access to everything right? Pleural, left pleural when the lungs are deflated, you can have a very nice access to the metastin. When you open the pericardium, which Jacob didn't have to open in this procedure, you have a very nice access to, to the heart. Uh And now let's see the OK. So he's doing some tidying after, after the procedure, some, some washout. So as I say again, the you can see both lungs and closure. Ok. Chest tubes are used to drain the mediastinum and the spaces clamp incision is which can be used by by us in some extreme situations in emerge emergency setting, incision is usually close to 3 to 4 weeks placed across the sternum with a possible figure of a modification, no running, no shouting and very elective. It is important that the fascia over the sternum is approximated tightly not emergency, which is not trauma. But I think this is a beautiful, beautiful procedure done by my colleague. Closure of the bilateral thoracotomies is performed using six equidistant holes are drilled into the inferior ribs are passed through the drill holes and around the of the superior and prevent compression of the intercostal nerve and alleviates postoperative pain. Twos a place in the subcutaneous no muscles are opposed with vocal one, subcutaneous tissue with vital two and skin with vital four is not of our present. But this this patient did very well after teratoma and, and uh she's OK, but everything comes at the price. So she's got a, a big scar but it heals nicely. Ok? And now the II try to jump a bit. The recovery of the patient was uneventful and she was discharged on postoperative day 11, right? And the last chest X ray, it looks really, really, really nice a follow up chest X ray. OK. So this is, this is uh I believe uh this is thank you from your co and this is OK. Oh, dear. Um This is thank you. From, from me. This is, this concludes our present my presentation. I am incredibly sorry for the, for all the disaster in the beginning. I still, I still don't know if you could see my slides and if you could, if you could hear me properly. So, so I'm quite frustrated. I have to say. Uh but yeah, I'm, I'm.