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going to? Not great. So hello, everyone. I think some of you, um, have met me last week on, but that's from your feet back from last week. I mean, a few investments to presentation today, so I made it a little bit more case based on did a little bit more interactive, and I used more visual materials. So I think this is what you wanted a based on your feet back. So hopefully that will be useful. Uh, the topic today is, um, very important. It's a difficult topic. Um, we talk about chest injuries. Um, I'm just thinking, but I'm not to me of the off the test. You have the heart and the lungs inside the chest. So obviously the injuries can be a fatal can be quite dramatic. Um, the management is very structured on, but it's often done by the most senior people in the hospital on gets done by whole team, usually, so it's never done by one person. So I think that they will just learn about the most serious injuries that can lead to death on. But we would just learn about the structure that we used to manage things in that in order the way so that everyone involved in managing is untamed board. So everyone is doing the same following the same halfway off hand. Okay, so this is the one for the games. We will look at six life threatening just injuries. We will look at 80 or less protocol. So that's just throw my life support Practical. This is something that was developed in the U. S. On is used currently in the UK as the gold standard. So every hospital will follow this practical when they run into a trauma patient. And then we will look at one pace, we just bit longer. So it will keep changing and we will keep on half. The situation will develop and eventually will look at tests run in section and needle decompression. I so a bit of practical stuff. So all right. So when we think about just brought my thing is useful to just go back to your anatomy lessons and think about all the organs in the chest that can. So the most common one is the test wall. The rib cage on different factors will account for about half, almost half of all injuries. They're very common, and they can range from just a little crack, which is quite benign and doesn't require any treatment to quite devastating fractures. Which didn't because the formulary of the chest and injuring today to the heart and the nights, um, separate fractures are the most common one on then lungs, onda heart and important Laura supplies or space between the chest wall and the lungs. And this is a very important space for lung injuries, because this is the place where, UM, blood or AARP can accumulate and may need the chest rain to evacuate in terms of the broad, uh, split off just injuries, we think about lunch drama and the penetrating or chew on Avapro Mama. The blood trauma is most commonly things like a car accidents and cyclists. Motorcyclist, you know things. People catching the same. So being hit by a car and then penetrating trauma is a stabbing injuries on a gunshot wounds. Okay, and the mechanism of injury is hugely important because, um, the injuries are often internal sweet policy there with your eye. But knowing the mechanism can tell you a lot about work eventually, injuries are insides. Very important. Okay, so the two principles of managing your, uh, is this team work? So you never work alone? There's always a team of people who had assigned rolls, and they know exactly what they're doing. And the second principle is protocol, so it's a very it's often very messy. So there's a lot of people around. There could be blood around, You know, there's often chaos, so you have a protocol, allows you to just have a clear structure when everyone knows what they're doing. Everyone is following the same steps in their heads, and that's really allows things, too. You been smoothly, and also to avoid any which is is it's easy commitments. You know, that's our Ms Things, and these are missions can be quite serious. So So the protocol and teamwork are two things which I wanted to remember. The names of protocol used the 80 or less protocol, and that is based on especially like to see in the background here. So you have it comes with an injury. You do. A primary assessment on bats is a, but it's a very quick assessment. It's a few seconds, and this is just to identify any life threatening injuries and you dress them at the same time. So you're after the a primary assessment. You're assassinate at the same time, and you re evaluate if you've made any difference with your with your treatment, and then the second part is the second resurvey. So that's when you look at all the other things. So you're already you're happy at. The patient is not going to immediately I on. Do you want to assess the whole patient making sure you don't miss any any injuries cause injuries often are in many places are multiple places in the body is so you have to have a structure to make sure your exam in double pictures. It would just run through the eight years Practicals the primary survey again that we used a B C D system, which you might have already, uh, seen somewhere So airway is, um, eyes essentially assessing patient's airway. So whether it's painting or not, and with drama with particularly also looked at C spine, so that's your cervical or next. Fine, um, patients with trauma we had we always assume on Earth potential drama than going to the spine s so we don't want to money it's the neck too much. Does that aggravate any spinal injury? And so when we assess the airway and we make sure that the neck it's PayPal eyes and we don't move the nerve breathings of looking at the agents ventilation, we would look at oxygen saturation, how fast they're breathing. You would look at the movement of the chest, and then he would listen to the trust on the circulation. So assessing the pressure, the heart rate, looking for any signs of hemorrhage, eso that can that often means also looking around the patient. Is there any blood spillage around the patient? Is there any significant bruising on the patient? UH, which would suggest internal bleeding as well? And then, finally, the disability. In this case, this refers to by brief neurological examination, and again, we always worry about spinal injuries. So that's why we're doing this. Examination is just to briefly check that they can remove their arms and legs, but they have sensation. Um, and that's slightly later. We would also check their anal tones. We wouldn't pull them to the side and check that they can squeeze to make sure that there's no spinal injury and is exposure. So again, patient, they're often completely undressed in those you know, we'll talk about big trauma. It's not some little bit. This is a significant trauma, it or undressed just to make sure that nothing is missed. Um, now they're This is kind of the the old 80 less protocol that I understand. There is an addiction in the newest up eight, which meant that which both C A B C D. So see before a is a metastatic bleeding. So if there's any catastrophic bleeding, you would attend to that before you run through a B C d. Okay, but I think this is a good structure for you to remember. Uh huh. But that's your primary care of it. But always I'm supposed. This is a model of just identifying any life threatening injuries, and then the second resurvey. So that's when you're happy with the patient, is reasonably stable, and you want to just examine the patient had to toe and literally had. Those are looking at pet friendly and Patanase. It scratches on the scalp looking at, you know, all the fingers pose legs to make sure that there's no injury, that the Enbrel missed that point. You would also, at same time, to steak history from the patient if they're awake, or you would take history from the ambulance crew or any witnesses, and And the main thing you you're interested in is just the mechanism of injury. So all time it happened, where what were the circumstances? What was the impact if they fall in on which side? How fast was the car going? Um, you know, did they fall on that on the hard surface or soft surface? All these things were the intoxicated of alcohol, where they under insulins drugs. So kind of the whole circumstances around there, the injury, and then the last thing is both sample. I wonder if any one of you knows what ankle stands for. I opened the floor to you guys. See, um, anyone has come in. Is that ologist past present medication, medical medications was medical history here, and Excellent. Yeah, Great. Thank you. That's that's a good start. So ample is again a structured way, actually, but in Ms and so we want to make sure we know that allergies medication the patient is taking and particular blood thinners. So a lot of patients who are elderly will be taking blood thinners and obviously, with a big injuries, the risk of bleeding is huge. Past medical history. Last meal. So these patients will often end up going theater, the operating better. So you want to just know when they had the last meal is that will affect the anesthesia, Um, and then events that so again, Vince around the injury. So right. So now we'll just run through the six life threatening injuries that have to be identified during the primary survey on We'll just go slowly and then we'll move on to a case discussion times Every obstruction on can be the most common reason for every obstruction is actually beating losing consciousness. So people had head injuries will often essentially lose tone in the neck in the throat, and the tongue will collapse back and obstructed airway. Um, so that's kind of the most common reason. The other things that can be a It's a foreign object that has fallen into the further into the back of the throat into the firings that the airway and lastly, there's a large neck injury which kind of crashes the firings and that can also lead story obstruction. So this has to be I don't I really the treatment will depend on the type of injury. So if it's a loss of consciousness and obstruction presentations, unconscious and intubation would be the treatment for that. Is there significant injuries to the neck than the breathing tube may have to be put in below the side of injury? Um, the second one is continue. Correct. So you remember from your previous lectures pneumothorax, which essentially is accumulating the girl space outside the lung and most often Azarias ult of injuries to the run. But then apparently are sit into the world space and pushes the lung away. There's enough pressure. So when we got a pension, your thorax, the pressure inside the fluid space so high that it makes the lung a lot you'll see have the pleural space filled with air. The longest completes court collapse and the whole mediastinum the heart the drug here, breathing tube are moved to the other side. Azarias ult of that. If you know the heart was blood, it also reduced So this patient will eventually. If we don't address it will arrest the treatment for attention use Rx is decompression with a needle, and we will look at it off to your video. Late throne of how it's done. Okay, the next one is broken pneumothorax, so that's a slightly different mechanism. Again, you have a rash accumulates in the world space, but this time there is coming from outside. So there's often a large effect, just world. And there is a coming from outside into the oral space. But it's not. There's no way for us to go back out there. There's like a one way out. The management for that is, um, especially breasting. It's some You lose it pressing essentially, when the pitcher breathe in the dressing, cook will prolapse and want allowed that the air to go into the chest. And when the patient breathes out, dressing opens up so that they're components script. Very simple, breasting. It's not nothing fancy is just a dressing which has one side or just not. Not not speaking to the skin. Okay, then this one is Humalog wrecks. So where we talk about massive hemothorax, we talk about least 1.5 liters of blood in the chest. So a significant volume. So if you imagine the average on adult patient will have about five liters of blood circulating around the body. So if you lose 1.5, it's almost a third of your blood that has left the circulation and it's accumulating in the chest. The treatment for that is a chance brain. If you put a chest rain, first of all, do you evacuate the blood? And secondly, you will be able to monitor if there's any ongoing bleeding, which will need an operation and obviously blood resuscitation. So as you're draining the blood, you want to replace it with blood given to the next one is flailed chest. So that's a bit of a difficult concept, I think. But essentially, uh, this is describes where you have a segment off chest world, which is moving independently. So if you have risk factors in two places in several ribs on several levels, then you essentially isolates a segment of just world, which then when you breathe I/O, what kind of breathe gait so it will move against you. So the ventilation is is impaired. Um, in severe cases, the tulips require an operation to fix the ribs, and then the last one is temple now, So this is essentially a condition when a blood often injury to the heart. So there is a laceration to the heart. Uh, the blood is that coming out from the heart and collecting in with sac both pericardium surrounding the heart. And if there's enough blood and enough pressure inside the stack, then equal, it won't allow the heart fill. Okay, So the heart will essentially be slightly collapsed, some of the chambers of the heart and that's again complete what will eventually, in the rest. The treatment for that is, you know, we're talking about very serious situations which, uh, will kill the patient quite quickly within seconds. So treatment will well, that one option is to aspirated to put a needle into the sac to the skin and aspirate the blood. Really busy in the ongoing blood loss from the heart as quickly as possible. Open the chest and fix the bleeding. I saw these are quite dramatic situation. So that's your so this is wants to remember from from elected to stay the six injuries. I just want to focus on one of them out for the sake of time. We just run for one case. So your doctor, part of the for my team on the ambulance crew has brought in a 42 year old male who was cycling, and he was hit by a car and the thought was driving a 20 miles per hour. Uh, you get a hand over from the ambulance crew, Um, and bend over. Says they've done the primary survey. Uh, they don't think they're any life threatening injuries, but what they noticed that are significant pain on the right side of the chest. Okay, so again, I'll just open the floor to you guys. What would you do? What would you like to do next? Feel free to write in the chat box below. Or if you want, you can raise your hand on, I'll ask you to mute. So in the chapter books, Doctor, we've got a couple saying crx well, see, exhaust on. Got a couple saying a B C d e. I love the answer is because that's really good. We can talk about it. So, um, just so a lot of you are saying X ray, uh, the X ray will be much further down the line. A lot of you are saving a B C, the each excellent. But essentially, when you're managing a trauma patient, whenever they moved, you repeat the whole exercise. Okay, So you want to repeat hope my memory serves a and the secondary survey again. So the evidence crew have been it's in the field at the site of the accident. But you don't want to rely on their examination because the patient has, you know, probably took an hour or half an hour for them to come to the hospital on. But also, the clinical situation can change quickly. So you want to start from the beginning. So you want to do the primary survey. Okay, so we will look at, um, we'll look at the primary survey. I slipped. Lovely. Okay, Airway. So you're assessing the airway? The patient is looking good. Then I would it. They're speaking to you. And they have been the next stabilized with the color breathing wise. Um, when you put the oxygen probe the afternoons at our ninth and sent on five liters, it's a very quite high, but with oxygen. And when you examine the chest, you see there's bruising on the right side of the chest. And when you listen, the breath sounds are reduced now circulation. So the heart rate is 90 and the BP is 140 over 80. So reasonable, quite stable. He feels warm to touch base on. At this point, you're not too worried about a need massive hemorrhage because he seems quite stable at the same time. Importantly, it's got acts venous access. So can really both arms. And you're giving fluids urologically. He seems intact. So he's moving or his limbs. He's talking to you. So everything seems fine from that point. And when you expose the whole patient, you also find it's got a swollen and painful little finger on the right side. Okay, so not to miss. Great. So what would you like to do next? But just look at the traffic in Yes. Oh, before has stayed saying manage his pain on now, saying fost on crusty, saying See X saw. Yeah. Excellent. So cx s So why was you know, whoever said it's, uh, Christie. Samuel. Uh, what do you mind? Just explain why you want to do. And it's great seeing Zar. Just he has So did you say he has bruising and paying on the right side of the chest on the primary service that it's nothing obvious other than the stolen little finger. When you're doing chest X ray, you might as well like. So I figured as well. Yeah. Yeah. Good point. You manage to get the X ray people down to what you did. The chest X ray may not expect nothing. No, that's great. Yeah. So just from this picture, you most worried about breathing, right? So there's something wrong with breathing. You want to do a chest X ray, and the other thing you want to do is the second resurvey. So, you know, things happen at the same time. Often you're doing multiple things at the same time just for speed. But it's so, uh, your second reserve is this. So again you do a head to toe examination, and again, you just find that little finger which swollen, and you want to make sure that you remember it and come back with later, Um, a bit more history. So he was cycling slowly. He was hit by a car. Hey, fell on the right side and he fell on soft grass and there was no head injury in never lost consciousness. This is the history and in terms of your ample so very fit, man. No. No allergies, no medications. He last 84 hours ago, and it was a serial. So breakfast. So that's all? Nothing, really. You know, a lot of information, right? So this is your chest X ray, and I wonder if there's anyone brave who can describe it for me. Feel free to meet yourself. Will raise your hand, guys, and I'll meet you. You have You're okay to make mistakes, manner. I'm going to ask you, um, you use and then you can answer the question. Uh, okay. On the x ray shown that there are three, I think broken ribs. The want to We were the 4th. 5th sent. Six strips are are broken, so I think there might be some, like, aspiration or something into the lung. Okay, that sounds great. Thank you so much. Thank you for for those today. Christie, I'm gonna meet you. I was going to say the same thing. Is that the most toujeo rubes fracture? Oh, that's corrected. A dispenser. That's great, guys. So what? I would So what do you have done? Which is very it's a direct way to do it. You just don't straight into the abnormalities. So you went straight to describing are normal. It is. I would encourage e for the future to always use a system and again not to miss anything. So whenever you look at an X ray, it's good to just have a system. Make sure you look at all the bits, because it is it the focus on something which is kind of shouting out to you and missing something else. So the system I use is it a B C D E b. So you look at Airway A the airway, and you just look at the trachea here, making sure it's ms in central cases in the middle. That's all good. Then it's of breathing. So you look at the lung fields and you always look at all the lung fields from, you know, top to bottom. So you look at the upper zone here that looks fine. Middle zone looks okay. And the lower zone here and the things you're looking at is kind of any acidy. So if it looks more white and that would suggest blood or or contusion to the lab. And the other thing you look at, if it looks like it's kind of transparency, so if so, we're going to look on the right side now. And if you look closely here, it doesn't seem like there any lung markings, can you? Can you see that it may not protect very well. But if you look here on the middle zone in the Lorzone, you can clearly see there are these lines here, which are lung markings. Yeah, and when you look in the opposite own, it seems quite empty. But that's a newer correct. There is a there is a regulating outside the lung. If you see the if you look right closely, you could just appreciate there's a line. So the end of the lung is just running here. Okay, You got any water? X ray? If you said breath, please. But practice here. So there's almost an indentation. So the chest wall is kind of crushed inside, right? So what would you like? Business X ray? What would you like to do next? Let's have a look at the chart again. So go ahead, say, saying aspiration. Um, on a bussing chest strain in session Jasmine saying needle aspiration. Christie, I'm gonna run you. You. Uh huh. Christie, So you need it really is a needle aspiration plate they long seen. Absolutely. So, actually, in this case, you know, it's not attention your direct. So it's just a simple pneumothorax and the patients quite stable. So they're BP spine. Their oxygen level with a bit of oxygen are fine. So in this case, it's completely fine. Just put the chest brain, because eventually you have to put the chest rain. So So that would be my suggestion. So you would put the chest rain and we will have a look at how you do it in a minute. Um, is that okay? So, anyway, I would like to you comment on that. See, Ron cannot meet you. Yeah, I just got a question. If it's tension pneumothorax, would the patient not be stable at that point? So you would have to intoeing sooner. Oh, so what? I will, and let's say it's not a pension. Your rex Just thinking if it wasn't no attention new muscle. Relax. What do you have to take into account then if it waas Yeah, fine. We'll we'll find out in a minute. Okay? The list of the chest or in bursts. So that's your development. So, um so as you start preparing the chest drink, it's, you know, this, that there is a change. The agent becomes very distressed that they stop wriggling around and look well, and they say they cannot breathe. Okay, so I think you've already answered your question here. So now we worry that there's a change. And what would you like to do next? Let's look up the check. What would do so in the chat group? Got intubation, But I really love the answer. So who's saying said, Repeat, A B, C D E. And that's such a good answer. So whenever the situation changes, like we said before, whenever you move the patient where whenever something changes, you want to repeat the primary survey, this is your your protocol. So you go back to assessing and remember the primary survey takes a few seconds. So you want to make sure that you didn't have some, uh, some suspicion. So you you think Oh, I think you know maybe this or that. But you just want to basically systematic assessment again. So that's what we're gonna do now, right? So this time when you're assess the airway, the patient they speaking, but they're really struggling to come take a breath in just well when you're says breathing. Now the oxygen level is 82% dropped quite a bit, and the vision is now on maximum. Oxygen's off in liters is the maximum you can give. They breathe very fast, and when they examined the chest, the trickiest the breathing pipe is no biggie. It's it's so you just feel in the next. This is about the breast bone, and you consider it a A Jet's has shifted the left side. So I made from from the injury, okay, and when you look at the movement of the chest, the right side is blown out, so it's it looks a bit more prominent, and it's not moving I/O. Okay, when the assisted the BP and heart rate, there's a significant change. So the BP is low and the heart rate is very fast. Case of this patient is most likely going to arrest very soon. What would you like to do now. So a lot of people saying there's a pension. You are correct on the right. Right? Kristen, you're gonna meet you. We have a human Imitrex. Now, that is Yeah. I mean, that's a real shock s. So there's definitely is shock, and you're you're right there Might be bleeding somewhere. The left a possibility. But I think, um, the with tension you most Rx, you can also have a circulation problem. Yeah, so when the heart is shifted away because of the tension and the feeling off, the heart is in pad, okay. And that can also result in the circulation. Okay, I think because we know there's a track, your deviation and the right chest is not moving, and we know there's a pneumothorax. We essentially think that a simple pneumothorax has not progressed with pension Imitrex. And but that's why it's really Britain too. But these patients are examined, began in the end. And whenever something changes, you start again and assess them again because these injuries can progress. Fine. So what we What we want to do now is, um, that's your attention just to make sure everyone understands Americanism again. So you have a rescue aping from the lung and accumulating in the pleural space. And the pressure inside the raises, the longest collapsed and the whole heart that shifted. Okay, so that's why your heart is not working well, and your circulation is also impaired. So now I'm just gonna look at the video, see if I can. Sure. A video. Hard to the needle. Be compression. Uh huh. You psycho. It's what? Find the right screen. Okay, uh, able to see the video. Yes, we can talk. So didn't. The main thing is to identify the right side. Um, and it is the second intercostal space in the midclavicular line. So the patient, you will feel the sternal angle. Okay. So as a prominent bit in this one, and this is the level of the second trip. Okay, so then you just follow with your finger to decide until you come to that midclavicular line because your clavicle, you find the middle part. You just put a needle in and asked. That's just a quick video to show you how it how it's done. I think the main thing to say about this is business for tension. Your water acts Okay, so this is not for a simple pneumothorax. This is for a life threatening attention. You are correct. Uh, and there's also think a mission, Most recent 80 less guideline. I will mention that you can do it from the side as well, so you can do it just under the arm from side to side of the chest and I'll show you this. We worked through it. So there's different ways. This is the old school way. This is how we used to do it when I was learning, and I would still do it this way. But there is somebody with the guidelines and and you may be able to do it from the side. I. So once you've done that, the patient is no more stable. Um, they can re. Then the BP is better, the oxygen levels have improved, and maybe you want to proceed with just straight in search. So once you no, it's stabilized patient. You remove the tension. So then you would practice no longer causing pressure effects. It's just a simple pneumothorax again, and now you can do your chest rain so we'll just look at the video, which shows you how to insert the chest rain. So again you want to identify the safety trial where we're going to safety triangles, safety area where you put testing. So you measure a count your ribs, you find the 50 space between the ribs and then he traces to the side. So both in men and women, it's often at the level of the nipple. That's where you have your fifth space. Then you just want to live our away. So you have good access, and you always, uh, ain't did with on the sciatic solution I give a local anesthetic, and amazing is just to give it in the floor, A supply or a is very extensive tissues. So you want to give a lot of anesthetic been quite a bruise, and you make a cut and you just use your instruments to spread the issue. You just slowly go in. Go now, go in and go. Once you fill it for the pleura and the open your instrument, you were off to hear his off coming out, so that tells your intimate space and always go above the rib. You want to avoid that the nerves and the muscles that run underneath in a you know about, Okay. And this is a very important steps, and I put your finger in and in the plunge into this week. Okay, so you move, you think around and make sure there is space. Okay, so you don't want your lung to be stuck in at the side of insertion. You want to have clear space, and then if you want to direct your brain either up towards the apex less for new with your ex or down towards the base of the lungs or, uh, or Humalog. And it can be quite difficult, you know, to put it in right place. But, um, it is doable to stop it there. All right, that's I left it here was normally, so it could be more than 40 minutes. So I think, um, I'll just stop there and there's our options. Thank you so much, Doctor and eggs. Andra on. We don't have a couple questions in the chat. Fatima's asking, why are there different ways for needle decompression? Which one is the best? While the contraindications are each way of needle compression? That's good. So I think that the reason right. Traditionally we do it from the tops of second intercostal space. Midclavicular line is because it's just easier for your patients lying on the back, and it's very easy to get access to. This space is best at the front and often is quite a slim area. So our patients are getting increasingly, you know, bigger and the chest walls are getting big. Better eso underneath the arm pits on the side is often the fat pad, or the breast can actually kind of, um, being the way little bit in that area. So here is just very easy access where the chest wall is often quite been on. You can easily go in there. The problem is, it's something difficult to know exactly where the second space is, and you think of it there a lot of vessels around. So first of all, you've got your heart's. It got your veins draining the head and the neck and that the arm, um, and you have the arteries going into your coming out from here into your arm and your neck. So if you hit broke spot, you can go into a blood vessel and cause a lot of bleeding. Okay, So, um so that's why um my my inclination is to use the the second space midclavicular line the best this. So going from the side in the safety triangle, um, is a very safe way. So if you follow these luck, these markings, so the fifth, so that can the nipple level. So the 15, because it'll space in the kind of mid mid axillary line, Then you're unlikely to cause any injury because there's only longer when you know you're clean other. There aren't any profess als or any other structures, so you're unlikely to make an injury. But it may be quite difficult, especially in someone who is, you know, almost arresting to live arm up on going there. So I'll be, um I don't want to, uh I think I wouldn't make any suggestions. One is after. The other, I think, is what you're comfortable with. And again, these things is something that you will be doing later on when you're practicing, but the most often a surgeon or an any about. And you already have your wife practising in doing things to have thank you so much, Doctor, who was asking doing need to do you need a t compression as an f y one or with the senior Do it. Yeah, I haven't done one was with one. And I think usually, if someone is that on, well, uh, then you would call the arrest team. Okay, So if you're in, if one doctor and you're asked to see someone who is that on? Well, he pressed a positive, and within seconds, you have the whole arresting with you. And this is my suggestion. All of you is to never do things what you're uncomfortable doing, you've never done them. Um, if you're uncomfortable with doing something, then don't do it, Okay? You will be trained to do these things and with, you know, with time you will learn. And there are many, many doctors who have never been in that situation and never done with the compression. I've done the one when I was registered already. So the answer. The answer is a bit round about. I don't want to say, Don't do it because you may save someone's life if you do it correctly. But I think just a general point is under thinks welcome and always ask for help. Okay, so Whenever you feel like you're out of that in the hospital, you ask for help. And there's plenty of people around. Perfect. Thank you so much. Doctor is on drum. Um, Dan is asking Do you feel the wish of at when you're in the right place? Your arm? A scenic? Yeah, absolutely. You know, I know what it means. So after the both with needle decompression and with a chest reinsertion, one of the signs that tell you that you're in the right spaces Manicure that is like a wash off. So when you put your instrument inside and it spread and you hear that washing the earth coming out, that means you're in the pleura, so you can safely you want to be your finger sweep. So your finger still make sure that there's no lunch after the just Well, so you do it a finger sweep. Any researcher strain on Ben on down when you put the needle decompression. Um, you also will hear the highest, or you can see the bubbles in your syringes. You have a bit of saline. Perfect thing. So much little is asking. How do you know how far to advance the needle. Um, well, you I would say you advanced it until you get some air. And, um, like my calling has suggested, uh, some of the patients are empty. Quite. You know, large can have quite thick chest walls. So you may end up going really, really deep along the, you know, all the the whole thickness off the needle. But do you go as far as under something happens. So sometimes you have blood coming back to you. So if you're trying to decompress pneumothorax and you can steal blood coming out, that means you're in the wrong place. Okay, so you have to take your needle out and try slightly different angles, like a different spot. But you should go until you get something else. Thank you so much. Um, rituals asking Why do you put the troop upwards in the pneumothorax and downwards Inhuman? Your X question. So you know, if you think the but it but some of the lowest sat in an upright position which most patients will be sitting up. Um, the air always goes up. Guys, that that's just physics. So the air will accumulate, uh, in the off, uh, flora. So that's where you want your drain to be position there so you could drain the air effectively. And blood's just with gravity will trickle down to the base of the lungs. So he wanted me to drain facing down and obviously the different for patients were lying flat and ventilated because then the distribution on blood it's like different. But we're talking about someone who is awake and who apparently be sitting up or walking around. So you want for a put the drain up for blood and, um, in December, structure subpoenas asking, Could you please briefly repeat in management off. Open your Iraq's okay with separate session and just look at other injuries? Um, so I could probably do some, um, Bagram's and things which make it easier for you to understand, but essentially what you want to do. You want to create a one way valve. Okay, so you want to have a dressing, which will be open on one side, so you want to If you imagine a square dressing and it has got sticky bits around it, you want to cut off the sticky bit on 11 side. Okay, on day when you stick it to the chest wall and the fishing briefs in the dressing With that kind of suctioning force, Will will go against the chest wall so it will stay for the chest wall and the air from outside won't be able to get it in. Don't breathe out the dressing with the With the pressures, pressure changes and movement, the dressing will just open up that just not spect skin and any air from the floor come outside. Okay, so it's difficult maybe to just imagine it. But once you see it, um, in the video are if you see the dressing itself, it becomes quit but clear. Thank you so much. Doctor Sandra Doubt is asking Doesn't matter the side of the dressing that will be hoping in the management off open pneumothorax. Um uh, Well, I think the main thing is, just has to cover the whole wound, uh, to be effective, but it doesn't matter if it's going. If it's pacing up or down or sideways, it just has to be a non sticky. Uh, on the one side. Perfect scenario is asking for hemothorax. Do we use the 2nd and 3rd inter coastal spaces? Well, Oh, no, so definitely not as so for hemothorax. You want to put a chest rain in the safety time goes just under the armpits like we like we saw in the video and you want to aim it down? Um, there is no going first of all with Huma correct, you're not gonna attention. Is there some kind of create tension situation so you don't need to do any needle? The contractions. You just need a good big just Ray, which was brain all the blood and so your best to it from the side because it's been easy to directed around the base. Um, and like I said before the area injection late on, blood at the bottom. There's no point going high up in the chest because you you're not looking and not draining the face. Except for being so much doctor Alexandra Fatima's asking, Is it easy to identify the fifth space in Big pressed? Yeah, that's been so yeah, actually, it's It's always a bit tricky with big patients or big breasts. I I think you just need to do the counting so you start from the top. Just feel your sternal angle, too. That's where you just the prominence of up off the breast bone and you go to the side. So you know, it's just second space, and then you just go down to the 3rd and 4th. If and you get this running, the rest of it's okay, and then you just go on a truck and bound to the side. Um, you know, it's always is probably impossible to find the exact space in some. You know, if you have a slow patient, a Smiths little man, it's probably doable. If you have a large lady, it's very difficult. So you just want to roughly get that fifth space. It may end up being six or both, Uh, but you just came for the space that I think is very much Doctor. I'm a doubt is asking, Why did you not use fast in this case study? Um, yes, I, I saw last mentions a lot in the formance eso just For those who don't know fuss, fuss is a scan is like an ultrasound, which is available in most emergency partners on. But it's an easy way to identify any blood leading, though, if you put it in front of the chest you conceive, there is a pericardial effusion, so there's blood around the heart. If he put it to the side, you could see there is any blood in the pleural space. And if you scan of the abdomen or the tummy and you conceived, there's any free fluid in the tummy. So it's a very useful way to, um, identify any bleeding. Absolutely. You you could have used it in that It's up to you, Summer. I'm Rachel is asking, Why do you need to do the finger sweep? Okay, so I think the main thing is to understand that you're the chest pain is done blindly. Yes, so your your instrument in the chest, but countries see inside. So this is just one of the safe measures to use to make sure that your lung is not directly opposing the chest will, at the point where you're inserting the chest rain because what will happen is you end up putting the chest pain into the land. You know, quite a quite problematic later on. So you just want to put your finger and sweet, make sure that there's no teach you stuck to the chest wall, and you have free space when you can just direct your chest brain without injuring anything. Thank you. Summertime. Would you have a couple more question of that? Okay. Fatima's asking. Do you leave the tube in the air outside the chest after inserting it? How do you ensure the troopers inside the lung on When is it need to remove? Yeah, Excellent. Yeah, absolutely. So that's a very good point. Um, you will always a speech. It was just so you would close the wound around the drain on, and then you would just put in not around the brain to make sure it stays in place. Uh, so that's a very good And you always have to use this. It's just a security test strain on God's to be well secured because you can imagine patients off, um, end up bobo around hospital. They often have some, you know, opioids. So they may not be careful with things. So anything that's attached to the patient as a principal has to be very secure. Um, the drain is then attached with you and just goes into a bottle. Um, and the bottle is filled with, um with, say, lines or water. So what happens is that essentially stops anything going back into the pages. So if there is a recumbent out pneumothorax and there is coming out, you'll see bubbling a water in the in the test tube in the chest Also. Okay, but the won't be any air going back into the drain and into the patient. In case on receptor, Rachel is asking, Why do you need to clip the tip of the trip of surgical issue mints when inserting it? That's that's That's very observant. Um, absolutely. I don't do that. So this was just done in the video. I wasn't personally do it, Um, but I guess the reason why some people do it is just, er stole anything suddenly coming out from the brain. So if you imagine if you're doing a drain for a motor X and he put the drain inside and you can suddenly end up with the floor or your shoes or the bed just covered in blood from the drain, it so this is just the way to put the draining safely and then connected to the tubing and then allow anything that's come out, come out without making a mess. I think that's the reason why they clamped it with you. Two summers at the, um, Fatima's asking. Is that different? I'm size of test strip of chest tubes or E. He had a lots of sizes, I think, generally, for for a trauma scenario, I would always put a big drain. Uh, just because it's most effective and also for draining things like love. This always a rough loft. So it's not completely fluid as we want a big tube toe, allow everything come out. Okay, Andre. Smaller tubes. So patients who come with simple pneumothorax you can often with a very tiny tube, which is the size of it cannula. Perfect. Thank you so much. Is that any questions that anyone wants to our ask? Feel free to meet yourself. I think in the child. We've got that. Um uh, I'm having a followup question. How do you decide the size on how long will you say the's just strains? Oh, thank you. That's really actually helpful. Christian. Yes, it decides I would go so that the standard just drain, which most hospitals have in on the shelf. It's 28 French. So that's French. Is this measure of just drain size, and it just describes the diameter of the brain. 28 French is your standards brain that is useful for most most cases in trauma. I can sometimes go for a bigger drain on, like 32 for example, And then for simple new drugs. Well, the Troma indicating coming within your breasts had something to do, like 12. So it's a very tiny one. Okay. And in terms of the how long it stays, well, that depends on how the patient progresses with new authorites. The main, uh, indication of whether it's resolving is it bubbling stops. So remember when you put the drain, you put it underwater, so and hopefully you have underwater feel and you can see the bubbling coming up with every breath. Okay, so you ask the patient or cough and you'll see public coming up the left in the case, and they're still some ongoing early from the lung. So once I stopped, I would give it another day and do a chest X ray. If there's no bubbling and the longest six hunderd um, I was removed. Just rain. Super. Think is, um I took one last question before we give it a rap battle is asking what kind of like an anesthesia is used on how much should be used on Where is it injected, I think. Yeah. So you will learn all this later on. I'm sure you will have, um, kind of, you know, simulations, sessions. And so where you get the exact calculation, but often use in England is something called lidocaine. Um, and I use 1% lidocaine usually. And last night is I would give about 10 mills 10 to 15 mills to an adult patient, about 7 kg. Um, in weight. Okay. And you give it like I say, I think the most sensitive area is not a skin. It's not the fat, not the muscle, but the flora. So I would give half of it on the way in, and then the rest I would give in the flora because that's where that's where the patient can, you know, look uncomfortable. Eso always aimed above the rib and put a lot deep. Um, yes. So I want wasn't, like, okay about interesting meals, but there is a special formula, so I don't have it here on Don't know it up at the top of my head, but you will learn that. That's mistake. Thank you so much stuff that one last question sorry before is definitely a wrap. If they have previously a history of chest you, do you put it in the same sites? Oh, that's such a dilemma. I guess you can't go exactly the same side, because if you think of it, um, it's always never clean. So there's, you know, there's a drain sitting there for a few days or longer, so it's never is not sterile. So what do you want to do is put it in a new place to make sure that there's no no, but it's no infection spreading inside, so you don't want to push bucks inside the chest. So I would I would use a slightly different spot. But still, you know, going into the safety area so roughly you can go one really above when low spreading to the sides like the front. I'm just avoiding the same spot against speaking to the safety triangle. I think it's so much Doctor Alexandra for the phenomenal on interactive session on chest trauma. I think when it comes to applying to the Arrietty into clinical cases. It did actually quite amplify our confidence in terms of deciphering the assessments for chest roll. My overall on the videos were actually quite helpful for visualizing the processes for pneumothorax. So thank you very much for the session on for giving up your time. Teo, provide us with the session. We are really, really on it to have you him now. Our next session will be out two o'clock with Dr Rajni. I she will be going over rather I So what I will do is I'll keep the chart opened the session. I've been for a couple more minutes in case and will have missed out on the feedback form. Please do fill out the feedback for Mars. There's only two hours left on. But I will see a lot in the next session. Thank you so much of that. Examined once again for coming. Looking forward to the next session review. Take so much. Thank you. Bye bye. Thank you so much, Doctor. Thank you. Thank you. Bye.