Thoracic Surgery and Trauma Surgery
The trauma and thoracic domain tests the first 30 minutes of resuscitation, the immediately life-threatening chest injuries, and damage-control principles. Questions are built around the ABCDE sequence with one specific action for each lethal finding.
Primary survey
- ABCDE: catastrophic haemorrhage control, airway with cervical spine protection, breathing, circulation, disability, exposure.
- Tension pneumothorax: tracheal deviation, absent breath sounds, hypotension - immediate needle decompression (second intercostal space midclavicular or fifth space anterior axillary), then a chest drain. Never wait for a radiograph.
- Massive haemothorax: >1500 mL immediately or >200 mL/hour; drain and consider thoracotomy.
- Cardiac tamponade: Beck triad, distended neck veins, pulseless electrical activity - pericardiocentesis or thoracotomy.
- Open pneumothorax: three-sided dressing, then a chest drain. Flail chest with hypoxia: intubate, ventilate, provide analgesia and physiotherapy.
Secondary survey
- FAST for free fluid; CT only for the haemodynamically stable patient.
- Splenic injury grade I-V: non-operative management with embolisation when stable; splenectomy when unstable.
- Damage-control laparotomy: packing, temporary closure, correction of the lethal triad of hypothermia, acidosis and coagulopathy.
- Massive transfusion 1:1:1 red cells, plasma and platelets; tranexamic acid within three hours of injury.
Worked example
A 25-year-old motorcyclist has BP 80/50, distended neck veins, muffled heart sounds and a positive FAST. Reasoning: tamponade plus intra-abdominal haemorrhage. Give blood products rather than large crystalloid boluses, and go to the operating room - the definitive treatment is sternotomy or left thoracotomy, not a chest drain alone, which may worsen the tamponade by releasing the pericardial constraint.
Traps
- Ordering a chest X-ray before decompressing a tension pneumothorax.
- Giving 2 L of crystalloid before blood in haemorrhagic shock, worsening coagulopathy.
- Failing to recognise the lethal triad in a cold, bleeding, acidotic patient.
- Sending an unstable patient to the CT scanner.
- Neglecting analgesia and chest physiotherapy in rib fractures - pneumonia and hypoventilation are the real killers.