PITFALLS IN MANAGING A THORACIC TRAUMA IN PRONE

Abstract

INTRODUCTION

Thoracic trauma management is a major challenge for the emergency department. It accounted for the most prevalent injury, attributing to the highest mortality within 72 hours in Malaysia.¹ 

CASE

A 48-year-old male was assaulted by a machete at the mid back. A sucking wound (20 x5cm) was visualized at the level of T10 exposing the left and right lung, diaphragm, and a thoracic vertebra. Hence, we put the patient in prone position. His airway was patent despite being tachypneic under nonrebreathing mask. A three-way seal was applied prior to the right chest tube insertion in prone position. This was to maintain the spine immobilization despite a normal focused neurological examination. An extended Focused Assessment Sonography for Trauma(e-FAST) performed in prone revealed an absent sliding sign with presence of lung point over right hemithorax with a normal finding of the left lung and abdominal scan. A Computed Tomography (CT) of the thorax, abdomen and spine revealed a large right pneumothorax with multiple posterior rib fractures, undisplaced transverse and spinous process fracture of T10. Otherwise, no evidence of pericardial effusion and tracheobronchial injury. Patient underwent an emergency thoracotomy and wound exploration. 

Discussion

The prone position led to challenges in initial management and diagnosis. Based on the site and mechanism of injury, we anticipated an open pneumothorax, lung and diaphragmatic laceration, tracheobronchial injury, and a transected thoracic spine injury. Prior to arrival of the patient, our team had diligently prepared all equipment in anticipation for intervention which included a prone intubation set, single lung intubation device and two chest tube sets which made resuscitation more effective.  However, this position made it challenging to readily access the standard safety triangle.

Ultrasound is an effective screening tool for the diagnosis of pneumothorax and intraperitoneal injury in trauma. However, there is limited literature on the role of eFAST in prone especially when intraperitoneal fluid accumulates in dependent areas and limited cardiac view. This limitation became apparent in this case. Hence, a CT scan was ordered.

Conclusion

Trauma can present unconventionally. Hence, an efficient prehospital communication, preparedness, differential diagnosis, and detailed examination will expedite the management.