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Hello, uh Welcome to this lecture on chest and abdominal injuries. Uh My name is Regina Shepherd. I am an emergency medicine doctor based in Sheffield. Um I'll also be teaching on your um women's special responder course in September. So I hope to meet some of you there. We'll start off with chest injuries. Um So these can range from mild with bruising to catastrophic life threatening bleeding. Um If we first take an, take a look at the anatomy of the thorax, um there's a lot of important structures. So we've got the lungs, the heart, these large vessels, the esophagus, and then they're all protected by the rib cage. We have these muscles in between the ribs which help which contract to help expand the rib cage, um which lead surface tension, expands the lungs and draws air in for a normal breath. The heart muscle is covered in a protective sac that's called the pericardium. So some injuries to the chest can include um sort of blunt force injuries. Um So it's for example, a road traffic accident falling off a horse, stabbed, slash, hit with bats, that kind of thing or penetrating injuries. So, stabbed and short wounds. We'll take a look at our assessment of chest injuries. Um So firstly, um, the history for the patient. So what happened when, how it happened? Um, characterizing the pain that they had, um with Socrates, which if you'd, if you have a look at some of the um, lectures on medical assessment and medical illnesses, it will go through Socrates Pain Assessment. Um and any associated symptoms with the chest injuries, any breathlessness, any loss of consciousness and then their past medical histories, any operations, drugs allergies, and then moving on to examination of the patient. Um So starting with um the standard doctor ABCD E um making sure you're in a safe environment and then moving on to the vital signs of respiratory rate, heart rate and saturations. If you've got um the equipment to do that and then examining the chest, you want to have a look first. Um And what you're looking for is asymmetry of the chest rising and falling. So, if one side of the chest is rising and one side isn't. And that's concerning any bruising in the chest just to make sure you look at the back as well. Um Any deformity in the chest wall, any wounds maybe entry and exit wounds if needed and if you're able to listen for breath sounds, have a listen to the breath sounds. Um So here are some examples of some chest injuries. Um So what we have up here is something called a flail chest. Um So this is where you have at least three ribs broken in two places, which creates sort of a separate segment as you can see from the rib cage. Um The way that you can see this is that when a patient takes a breath in the flail segment will go, the rib cage will expand, but the flail segment will go in. So it's the flail segment is um doing the opposite of what the rib cage should be doing. Um This is some bruising on the chest and you can see that it's pooling at the bottom. Um big old n wound. Um Then this is what we call a pneumothorax. So it's what we call the circa popped lung. It's air within the lung cavity. So I mentioned before about surface tension, keeping the lungs open. When air gets into that space between the lungs and the rib cage, we lose that surface tension and the lung collapses. Um So this is what we call an open pneumothorax, which means that there is um communication between the outside and the lung. Um So when the breathe in air goes in and when you breathe out, air goes out of the lung space, and this is called a hemothorax. Um So this is blood in the space. So it fills up that space between the lungs and the rib cage and compresses the lung that way. And so we'll have a look at some of the management of chest injuries. So we aim to blunt and penetrating injuries. Um So we've got sort of three progressions of blunt force injuries. So first being um just a rib bruising or a small fracture, the patient with normal vital signs and the patient is otherwise. Well, um the main treatment for this would just be pain relief, analgesia, um breathing exercise and monitoring for infection. Uh The main risk with these sort of injuries is actually the risk of infection later down the line. Um, because patients are reluctant to take a deep breath in and open up the bottom of their lungs. Um, so ensuring that they do sort of 10 deep breaths every hour and making sure they have enough pain relief to do that is important and these people may very well be able to carry on with, with an exhibition. Um, next time would be sort of rib bruising fracture. But if they're short of breath, have a high respiratory rate, they're in severe pain, um, pain relief and monitor them closely. And these people may need evacuating depending on how they progress. They've got a flail chest, as we said earlier, they're unwell, they've got low saturations and a high heart rate. Um, pain relief again, monitor and you do something called splint in the chest, um, which can make the patient feel a lot better and help them expand their lungs and evacuate. So this is sort of a splint in the chest. It's just a pad that you press over the chest and you tape it around management of open chest injuries. Um, so you sort of your penetrating injuries like stab wounds, gunshot wounds, um, that kind of thing. Um, so an open chest wound in a well patient with. So it's such a slightly elevated respiratory rate and heart rate. Um, you what put on a, um, three sided dressing to that wound, um analgesia and monitor closely and evacuates. This is a three sided dressing. Um So this three sided dressing um essentially allows, so when the patient takes a deep breath in, it allows any air to escape from that pleural space. Um sorry, when they breathe out, it allows air to escape from that pleural space. But when they breathe in, it doesn't suck air into that pleural space. Um Next would be possible tension, pneumothorax. Um So a tension pneumothorax is um this. So this is when you have a chest wound here, which sucks in air, but it doesn't let air out when you take a breath in, it sucks air in when you breathe out, the flap closes um and doesn't let any air out. So this increases the pressure in the space and shifts the entire chest contents to one side. These patients are really, really unwell, um gasping for breath. Um because of all the pressure on all the blood vessels, they have a low BP. Um So, uh what you can do if you're competent in it, um is something called a needle decompression. Um So that is inserting a large wide bore needle into the second intercostal space um to relieve the air pressure. Um So these patients also need immediate evacuation as well. And then thirdly you look at penetrating trauma. So if the object is still in situ, so as above, um, don't touch or remove the object but stabilize it. If you can. These patients also need evacuating. Now, I'll have a look at abdominal injuries. Um, so abdominal and pelvis injuries we'll go into. Um, so if you have a look at uh the abdomen, abdomen and pelvis anatomy, um So you've got lots of organs. Um You've got your liver, um your stomach, your spleen, the small and large bowel, your pancreas and then at the back, you've got your big blood vessel, the abdominal aorta running through the back. Um You've also got your kidneys towards the back and then your pelvis, you've got your bladder pelvic bone and your reproductive organs as well. And the abdomen doesn't have a protective layer like in the chest, in the form of the ribs and, and the solid organs. So liver and spleen can be very susceptible to quite large and very difficult to detect bleeding. And most commonly, these injuries come with road traffic accidents and often seatbelt injuries as well. And it's important to consider pelvic injuries. In motorbike accidents. So when we're assessing a patient with abdominal and pelvis injuries, um a similar history to what you've done before. So a timeline what happened when characterizing the pain with your Socrates, then any associated symptoms such as blood in the urine. Um and then you want to go into the past medical history, any operations, any drugs, any allergies, um we're going on to the examination. So starting with your doctor ABCD E your vital signs of respiratory rate, heart rate saturations and then having a look at the abdomen itself. So looking for any distensions or any swollen abdomen outside of normal, um any bruising of the abdomen. Um So bruising um from bleeding can often sit um in the flanks um because it pools there and then looking at any wounds, any intra exit wounds and then having a look at the lower limbs, any limb length rotation, um limn rotation and um length discrepancies and then assessing the abdomen for tenderness as well. Um So when you're assessing for tenderness, you're looking for something that we call peritonitis, um which is actually an inflammation of the sac that surrounds your abdomen. And this inflammation can come from blood or from bowel contents. This inflammation, when you palpate an abdomen, it feels like very solid. Um and it's incredibly painful. These sort of patients won't be moving a bowel because any movement irritates that peritoneum. Um and it's, yeah, it's incredibly painful, but this is a, this is a bad sign um in abdominal and pelvic traumas. Um what we're concerned about is shock. Um So shock is it's fine in, in inadequate organ perfusion. Signs of this mean are including high heart rate, high respiratory rate and a low BP. If you're not able to measure BP in the field, you just think if the patient is feeling lightheaded or dizzy, if they have a weak peripheral pulse or if they don't have very good skin perfusion, so you could put a refill time and shock in the um context of abdominal trauma is bleeding. Um So, moving on to the uh management of abdominal pelvic injuries. Um so we'll start from the more mild, so mild pain, normal vital signs, no peritonitis. So for example, someone who has been in a road track accident has a bit of bruising from their seatbelt, but no other um adverse signs. Um So pain relief, rest hydration and just monitoring for adverse features. That's the peritonitis and the um change in the vital signs. And then second, if you got someone with severe pain and bruising low BP or high heart rate or if they just look unwell, um analgesia monitor them closely. So keep taking the vital signs, um lie them flat and raise their legs and um try to evacuate them any penetrating injury. So again, analgesia and monitor and leaving the impaled object in trying to support it if you can, so it doesn't cause any further damage and evacuate the patient and then move on to pelvic injury, slightly different. Um So pelvic injuries, which we'll cover in the next slide, um can um can cause a large amount of sort of occult bleeding. And so if they've got a low BP, high heart rate, if they're unwell, um then pain relief again, uh monitor them and if you're able to do something called a pelvic binder, the next slide and evacuate them, um these sort of bottom three are potential needing for surgical intervention. So it's good to keep them nil by mouth. So not giving them any fetal fluids depending on how long it's going to be for the evacuation. And we just got the uh picture slide coming up. So, um at the top here we have. So this is what I mean by abdominal bruising, it can be low down here. Um This is from the blood um pooling with gravity. Um So make sure you look here at the back as well. Um For any bruising, when you're examining your abdomen, you've got a good old knife in the abdomen if you just think about the um previous slide with the um anatomy of the abdomen. Um So that could be hitting liver um or small, large bowel relief from the position. And then this is what I mean by a pelvic fracture. So you get what we call an open but pelvic fracture, which is common with motorcycle injuries. Um This causes a huge amount of, this causes shearing of the blood vessels and a huge amount of bleeding. Um This is what we call a pelvic binder. So this is the one we use in hospitals which you're unlikely to be carrying with you. Um And this is sort of a makeshift form with a sheet. Um So what you do is you slide the sheet underneath both legs and pull it up to, um, just below the hip, so lower than you think, um over the graded tranter. And this and will go through um, practically during the um in the practical week and then um tying it off and putting a lot of pressure potentially to bring together the two sides of the pelvis like this. And if you've got any questions, feel free to send me an email or, um, chat to me during the, um, presidential week. Bye.