15.06.2015

Chest pain protocol rbwh

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The SC joint connects your clavicle (collarbone) to your sternum, which is the large bone down the middle of your chest. Like most joints, the SC joint is made up of two bones covered with a material called articular cartilage. It seems like this construction would make SC joint dislocation common, but a dislocation is actually very rare. The intra-articular disc ligament attaches to the first rib and divides the joint into two separate spaces.
A part of the clavicle called the physis does not turn into bone until you are about 25 years old. Direct force against the front of the clavicle can push the end of the clavicle behind the sternum, into the area between the lungs.
Posterior dislocations can be very dangerous, because the area behind the sternum contains vital organs and tissues. In rare cases, patients have a stable joint but a painful clicking, grating, or popping feeling. Closed reduction involves pulling, pushing, and moving the clavicle until it pops back into joint.
After closed reduction for anterior dislocation, your SC joint will need to be held perfectly still. If your doctor suspects posterior dislocation, you will need to have a complete physical examination right away. A figure-eight strap is used for at least six weeks after closed reduction for a posterior dislocation of the SC joint. Sometimes closed reduction for a posterior dislocation does not work, or SC joint problems become chronic. Osteoarthritis of the SC joint usually responds to treatments such as rest, ice, physical or occupational therapy, and anti-inflammatory medications.
If you don't need surgery, you should start range-of-motion exercises as pain eases, followed by a program of strengthening. Some of the exercises you'll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities.
Nathan Cotterman1 and Michael Firstenberg1[1] Ohio State University Medical Center, Department of Surgery, Division of Trauma, Critical Care, and Burn, Columbus, OH, USA1. This attachment is the only bony joint linking the bones of the arm and shoulder to the main part of the skeleton. This ligament keeps the sternum end of the clavicle from pointing up as the other end of the clavicle drops down. The heart and its large vessels, the trachea, the esophagus, and lymph nodes can all be seriously damaged in a posterior dislocation of the SC joint.
Dislocation causes severe pain that gets worse with any arm movements.In anterior dislocation, the end of the clavicle juts out near the sternum. Usually the doctor is suspicious of an injury to the SC joint when there is pain and swelling over the joint. Ice packs can be placed on the sore joint for 15 minutes at a time during the first few days after the injury. When the ligaments are too severely damaged, the clavicle is surgically attached to the rib instead of the sternum. If the symptoms of osteoarthritis do not respond to basic treatment over six to 12 months, surgery may be needed.
A resection arthroplasty involves removing the surface of the clavicle next to the sternum. But if the ligaments are damaged and loose, a tendon graft may be used to tighten the connection between the end of the clavicle and the first rib. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. These exercises focus on improving strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder. Franaszek, Emergency diagnosis, resuscitation, and treatment of acute penetrating cardiac trauma. Moore, Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes.
Dislocating in the opposite direction is less common because the ligaments on the back side of the joint are so strong. It takes a lot of force to cause a posterior dislocation due to the strength of the ligaments behind the joint. Most doctors treat the anterior dislocation by letting it heal where it is or by performing a closed reduction.
Most patients are given general anesthesia before the procedure, or at least some form of muscle relaxant.
Your doctor will probably recommend that you take pain medication and wear a figure-eight strap for at least six weeks.


It is important that your doctor have as much information as possible about what organs may be affected by the dislocation.
The most common type of closed reduction involves lying on your back, with your dislocated joint near the edge of the table. The joint will still probably be unstable, but the displaced clavicle no longer compresses the organs behind the sternum.
Surgeons use a piece of tendon taken from the wrist or a piece of fascia taken from the thigh. The program advances to include strength exercises for the rotator cuff and shoulder blade muscles.
The first few therapy treatments will focus on controlling the pain and swelling from surgery. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems. History of cardiac traumaThe treatment of trauma to the heart has been written about since 3000 BC and had an inauspicious beginning. Immediate medical help is required to get the SC joint back into position after a posterior dislocation. The strap protects the joint from another injury and lets the injured ligaments heal and become strong again.
The intense pain and muscle spasms caused by the dislocation can make reduction almost impossible without some form of anesthesia.
Posterior dislocation has been known to cause a ruptured esophagus, laceration of major veins, and pressure on major arteries, among other complications.
Placement of horizontal mattress sutures through the myocardium underneath the cardiac wound-occluding finger and underneath the coronary artery adjacent to the wound (B). These sorts of traumatic injuries can also cause injuries to the physis in people under 25 years old.
If the symptoms last for six to 12 months, some type of surgical treatment may eventually be needed.
In young adults, there is less of this straightening effect because their bone growth is nearly complete. Your physical or occupational therapist will give you tips on controlling your symptoms, which may include using tape to help hold the SC joint in place. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain. Like many surgical advances, times of war brought about new innovations and techniques for treating injuries.Around the time of World War II, it was recognized that cardiac tamponade could be successfully managed by pericardiocentesis.
Posterior dislocations can cause difficulty breathing, shortness of breath, or a feeling of choking.
Posterior dislocation has also been known to cause hoarseness, a sudden onset of snoring, and voice changes with arm movement. With the advent of cardiopulmonary bypass by Gibbon in 1953, repair of more complex injuries became possible. Diagnosis of cardiac injury and tamponade has also been facilitated by portable ultrasound becoming the standard of care in the evaluation of trauma patients. The focused assessment with sonography for trauma (FAST) scan allows for simple, quick, and non-invasive assessment and recognition of cardiac trauma [1]. Cardiac trauma, especially penetrating injuries to the heart, still carries a very high mortality, but certainly is no longer considered uniformly fatal and attempt at repair is now the standard of care in patients presenting with signs of life upon arrival to the hospital[2, 3].2. Initial assessment and general assessmentThe initial care of the trauma patient with cardiac injuries does not vary from standard Advanced Trauma Life Support (ATLS) protocols.
The primary priority is ensuring the patency of the airway and establishing adequate oxygenation and ventilation.
This may include tube thoracostomy for drainage of hemothorax from the pleural space to allow re-expansion of the lung. If tamponade physiology is present, treatment for immediate drainage of the pericardial space should be initiated.
This can be accomplished percutaneously by pericardiocentesis or via open pericardial window.The treatment algorithm for cardiac injured patients branches at this point depending on the mechanism of injury and hemodynamic status.
As is the standard in all trauma care, cardiac injuries are categorized as either blunt or penetrating and we will explore their assessment and treatment separately.3.
Penetrating traumaPenetrating trauma to the heart most frequently occur with trauma to the anterior chest, but should also be suspected with wounds to the upper abdomen, chest, back, and neck [5]. Of the patients that do present to the hospital, the majority of the injuries are to the low pressure, anteriorly located right side of the heart (Table 1) [6]. Survival following penetrating trauma is often dependent on the state of the pericardial wound.[7] When the pericardial wound is open and blood is able to flow freely into the pleural space, the patient can often be supported with fluid resuscitation and chest tube thoracostomy.
Persistent drainage from the thoracostomy tube should warn of possible cardiac injury and surgical exploration is indicated. Conversely, if the blood is retained in the pericardial space, cardiac tamponade and physiology will ensue if not drained immediately. Management of the stable patient (systolic blood pressure greater than 90 mm Hg) allows for a more complete evaluation including chest x-ray and echocardiography.
Surgeons should be prepared to do a median sternotomy if an injury is identified in order to definitely address the wound. Upon opening the pericardial sac, any blood or fluid should be evacuated to allow the heart to properly fill and contract.


The surgeon’s finger can be used to apply pressure and temporarily control hemorrhage while further exposure is gained. This will also allow for replacement of blood volume and restoration of tissue perfusion.Repair of the myocardium should be done with interrupted sutures utilizing pledgets and performed in a horizontal mattress fashion [7, 8]. Iatrogenic injuriesAnother form of penetrating cardiac injury that has increased in the modern era is iatrogenic injuries. As the fields of interventional and electrophysiology cardiology continue to increase the number of percutaneous procedures performed, there is a concomitant increase in iatrogenic injuries to the heart.
Pacemaker and ICD placement, ASD occlusion devices, coronary catheterization, pericardiocentesis, and even central line placement can cause cardiac trauma. Cardiac fistulasAlthough hemorrhage and tamponade are the most common injuries seen in penetrating cardiac trauma, cardiac fistulas are another uncommon yet dramatic complication from cardiac trauma (including iatrogenic injuries). Fistulous connections can occur between coronary arteries, aorta, and directly with the cardiac chambers.
Patients, if symptomatic, usually present with congestive heart failure and surgical repair is usually required.[10, 11].
Echocardiography and coronary angiography are the cornerstones of diagnosis and necessary to plan surgical repair.4. Background (mechanism, incidence, and pathophysiology)Blunt cardiac injury (BCI) is a spectrum of traumatic heart diseases with severity that can range from myocardial contusion and EKG changes to septal rupture and death.
Earlier in the century, cardiac contusion or concussion were terms used to diagnose cardiac changes from blunt thoracic trauma. More recently, BCI is the term used to better incorporate and classify the myriad of cardiac injuries that result from blunt trauma. BCI is estimated to occur in 20% of motor vehicle collisions and in greater than 75% of thoracic blunt injuries independent of the mechanism. The primary mechanism of injury to the heart is from high-speed motor vehicle collision, but any injury that applies force in the form of kinetic energy to the chest wall and heart can result in a form of BCI. The following mechanisms of injury may result in BCI: direct precordial impact, a crush injury between the sternum and spine, a deceleration injury causing injury from the fixation points of the aorta and vena cava, a hydraulic effect from an intraabdominal injury that sends force to the great vessels and heart, or a crush injury [12]. Since blunt cardiac injury is a spectrum of injuries to the heart, a classification scheme was developed to allow clinicians to categorize the types of injury based on outcomes and treatment options. These categories are as follows: 1) BCI with free wall rupture, 2) BCI with septal rupture, 3) BCI with coronary artery rupture, 4) BCI with cardiac failure, 5) BCI with complex arrhythmias, and 6) BCI with minor ECG or cardiac enzyme abnormalities.
The American Association for the Surgery of Trauma (AAST) has also published a cardiac injury scale (Table 2) that may help to codify injury for diagnosis and research. Injuries sustained with blunt cardiac injury (BCI) include contusion, ruptures, septal defects, valvular injuries, and coronary artery injuries. Table 3 lists each of these types and the incidence seen from both autopsy and clinical series.
Contusion is the most common type of injury with left atrial chamber rupture being least common.
Injuries can often occur concomitantly; approximately 20% of injuries with chamber rupture will have another chamber involved. The right heart is the most commonly injured as it is closest to the sternum which is impacted anteriorly by the steering wheel in motor vehicle collisions. DiagnosisThe best test for diagnosing blunt cardiac injury has been debated for many years. Cardiac enzymes, radionuclide scans, EKG, cardiac ultrasound and continuous monitoring are some of the major methods that have been investigated.
Although cardiac enzymes and radionuclide scans have had many supporters these have not shown reliable predictability in diagnosing blunt cardiac injury and have therefore been left out of the Eastern Association for the Surgery of Trauma (EAST) guidelines (figure 6). Cardiac enzymes, specifically serial troponin measurements are mentioned in the suggested BCI algorithm by Schultz and Trunkey 2004 (figure 7) as an adjunct to increase the negative predictive value of the normal EKG when you have a patient who has either a history of cardiac disease or increased age.
There are no pathognomonic findings; however, the presence of a new arrhythmia is a sign that workup needs to be escalated. If the EKG is negative in a young hemodynamically stable patient without a history of cardiac disease there is no further need for workup [12].
If the EKG is abnormal, and the patient has a history of cardiac disease, increased age or hemodynamic instability then continuous telemetry monitoring for 24-48 hours is recommended. Any arrhythmia may be detected after BCI including sinus tachycardia, supraventricular arrhythmias, ventricular arrhythmias, any type of heart block, ST-T changes or Q waves [13]. Although, these patients are likely to have had a FAST exam in the emergency room, it is important to figure out who needs a formal echocardiogram.
The key indication is hemodynamic instability and a possible diagnosis of blunt cardiac injuiry. There has been debate over whether to use transthoracic or transesophageal echocardiography.
If transthoracic echocardiography is used and adequate imaging cannot be obtained, then a transesophageal echocardiogram should be initiated immediately.



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