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256
A. Farag et al.
Log Roll
This require several people to help with spinal stabilization, injuries through the
back are important and easily missed parts of the trauma assessment. With the
patient rolled, you must.
Look: assess for any penetrating, lacerations, or bruises to the back of the chest
and abdomen. Have a scribe handy documenting your ndings as you dictate your
ndings as this step is often painful for the patient and should be done quickly and
thoroughly.
Feel: palpate the patient’s entire spine for tenderness and document any areas of
pain. Ensure sensation of their back is intact, and nally check their perianal sensation and ask them to squeeze their buttocks together.
**a convenient time to do this is when transferring a patient between beds (from
ambulance trolley to the trauma bed or similar).
Special Examinations
Spinal injuries: in the setting of a suspected spinal injury: a full upper and lower
neurological examination is required (assessing tone, power, sensation, reexes and
coordination). Documentation of this is often protocolized depending on your hospital and spinal service.
Pelvic injuries: If a pelvic injury is suspected then the patient requires a PR
exam, PV exam and retrograde urethrogram.
In all severe trauma a whole of body contrast CT scan is an essential part of the
examination but is directed by clinical examination.
Tertiary Survey
The tertiary survey essential and as important as the primary and secondary survey.
It is performed at least 24 to 48h after the trauma admission, when the patient is
stable, or has had their denitive trauma imaging and emergency primary surgery
performed. It involves 2 phases.
First Phase: Examination
This examination is identical to the secondary survey, but in more detail. Without
distracting injuries (pain from long bone fractures, shock from the initial accident),
other injuries will often be identied. Typically missed injuries are non-displaced
24 Examination ofaMass intheHead andFace
fractures, however in the authors experience craino-cervical dislocations and open
book pelvic fractures have been identied at this stage, especially when the patient
was intubated or non-communicative on arrival. Any bony tenderness should be
considered fractured and imaged unless already performed. If the patient’s examination is incongruous with their imaging, look harder at it! Tibial plateau fractures
can be subtle, as can hairline fractures. Trust the patient’s examination more than
X-rays, and be kind to your radiologist because the answer is not always obvious.
257
Second Phase: Imaging
Any new injuries need to be imaged appropriately. Additionally all the patients
imaging up to this point should be re-reviewed and documented. All traumatic injuries should be documented, along with the plans for that injury. Ideally all imaging
should be formally reported at this stage to ensure nothing is missed.
Tips inManagement ofTrauma Patient
• Consider the position of the victim during the injury specially the bullet injuries
“Like bending forwards for example”, which can make the bullet move in the
body in an unexpected path. An example is an entry point of bullet injury just
above the iliac crest caused an injury in the mid-rectum which had been missed
during the initial and second operation.
• Inspect the neck veins at early examination of trauma patient if distended we
have to suspect intra-Thoracic cause of Shock e.g. Tension pneumothorax or
Pericardial tamponade which will need immediate conrmation by auscultation
and urgent intervention.
• All major trauma patient should be suspected to have a cervical spine injury and
stabilization of the neck in relation to the body should be done through all the
stages of transportation or examination. The use of Cervical collar may be
advised or alternatively, the so called longboard, on which the patient is laid and
then attached by the straps, until conrmation or exclusion of Cervical spine
injury by X-ray.
• The contour of the abdomen when abnormally distended, after a major injury in
a shocked patient who failed to be resuscitated using the initial 2 liters of initial
resuscitation has to lead to an aspiration bedside examination of the abdomen
with or without FAST “Focused Abdominal sonography for trauma”, for suggested massive intra-abdominal exploration as a part of resuscitation to stop a
massive intra-abdominal bleeding from a major vessel to allow for
resuscitation.
• A scaphoid abdomen after a major blunt trauma like compression injury of the
abdomen between a car and the wall has to raise the possibility of a ruptured
258
A. Farag et al.
diaphragm and herniated intra-abdominal viscera “mainly stomach and Colon
into the left thoracic cavity. A misinterpretation of a plain X-ray chest as a
Pneumo-Hemothorax may lead to a mistake of insertion of A Chest tube into
those viscera.
• Bed-side Diagnostic Procedure such as needle aspiration from the chest or
abdomen or DPL “Diagnostic Abdominal Lavage” can be considered as a
Clinical skill or an investigation among radiology.
Chapter 25
Clinical Examination ofThoracic Surgery
SandhyaChalasani
Abstract Aims of clinical exam: to identify disease, to plan surgery and to identify
problems that may delay recovery. Surface Anatomy includes Bony landmarks: The
rst rib is not palpable. Second rib joins the manubrium just above the sternal angle.
The rst rib space is just above and lateral to the sternal angle. Costal margin is
formed by the 7–10 ribs along with 11 and 12.
Keywords Chest · Lung · Thoracic · Pleura · Heart · Examination · Sheet ·
Anatomy · Landmarks · Auscultation
Aims of clinical exam: to identify disease, to plan surgery and to identify problems
that may delay recovery.
Surface Anatomy (Table25.1)
Bony landmarks: The rst rib is not palpable. Second rib joins the manubrium just
above the sternal angle. The rst rib space is just above and lateral to the sternal
angle. Costal margin is formed by the 7–10 ribs along with 11 and 12.
Incisions
• Median sternotomy—gold standard midline incision used for most cardiac procedures and for heart-lung transplant.
• Anterior mediastinotomy—This incision is a transverse incision along 2nd intercostal space laterally from parasternal edge. Its often used to perform a
Chamberlain procedure and care should be taken to avoid damaging the internal
mammary artery.
S. Chalasani (*)
General Surgery, SVUH, Dublin, Ireland
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_25
259© The Author(s), under exclusive license to Springer Nature
260
Table 25.1 Landmark structure
Landmark Structure
C6 Cricoid cartilage
T2 Suprasternal notch
T4/5 Sternal angle of Louis and bifurcation of
T9 Xiphisternal joint
T8 Inferior angle of scapula
T3 Spine of scapula posteriorly
T3—6th costal cartilage Oblique ssure
5th Rib Horizontal ssure
1cm lateral to sternal edge Internal thoracic arteries
Second and 3rd right costal
cartilages
Upper right 5th rib at midclavicular
line
Lower left 5th rib at midclavicular
line
trachea
SVC origin from Innominate veins
Right hemi-diaphragm
Left hemi-diaphragm
S. Chalasani
• Anterior thoracotomy—transverse incision from parasternal edge along the
inframammary crease to the anterior axillary line in the 4th interspace. The pectoralis major muscle can be elevated off the chest.
• Thoraco-sternotomy (‘clamshell’)—incision from anterior axillary line along
inframammary crease bilaterally elevating in the midline to the level of the nipple. The pectoralis major is raised as a ap and the sternum is divided transversely.
• Lateral ‘muscle-sparing’ thoracotomy—lazy ‘S’ incision along the submammary crease starting below nipple passing upwards towards the axilla.
• Lateral thoracotomy—curvilinear incision passing from the anterior axillary line
to 2cm below the tip of scapula.
• Posterolateral thoracotomy—curvilinear incision from anterior axillary line
passing 3–4cm below tip of scapula and continuing superiorly halfway between
medial border of scapula and spinous processes of vertebral column. This incision involves dividing the latissimus dorsi and serratus anterior.
• Thoracoabdominal incision—oblique incision similar to the posterolateral incision but extending anteriorly across the costal margin at the level of the 7th
intercostal space towards the midline.
Physiology ofBreathing
Breathing is stimulated by the rising levels of carbon dioxide in the blood. When the
diaphragm descends there is an increase in the intra-thoracic pressure. The intrapulmonary pressure decreases drawing air into the lungs as the pressure outside of the
lungs is greater than the pressure inside. Lungs are elastic and naturally tend to
25 Clinical Examination ofThoracic Surgery
recoil with pleura. The elasticity creates a negative pressure and causes the lungs to
inate.
Lungs are surrounded by pleura which have a thin layers of uid between them.
The Intra-pleural pressure is always negative (−4cm H2O) but during inspiration is
more negative (−8cm H2O). On expiration its less negative (−4cm H2O). Loss of
the intra-pleural pressure due to penetrating trauma can cause the lung to collapse
and a chest drain with an underwater seal may be required to restore the correct
pressures.
261
Examination
General Inspection
• Medications and bedside paraphernalia of lung
• Disease (spirometers/inhalers)
• Cyanosis
• Dyspnea
• Signs of COPD (barrel chest, use of accessory muscles of respiration—“pink
puffers” or “blue bloaters”).
• Cough—nature of cough (productive or dry).
• Sputum—color of sputum (whitish, yellow, green, bloody).
• Stridor.
• Wheezes.
• Hoarseness.
Hands
(a) Clubbing—Hypertrophic Pulmonary
(b) Osteoarthropathy (lung cancer)
(c) Nails (nicotine staining)
(d) Pallor (anemia)
(e) Flapping tremor/asterixis (CO2 retention)
(f) Pulse—rate/bounding pulse (CO2 retention)
(g) Wasting and weakness—T1 nerve compression from Tumors e.g.
Pancoast’s tumor.
262
S. Chalasani
Face
(a) Plethora—SVC syndrome
(b) Leathery skin and wrinkled—smoker
(c) Horner’s syndrome—Pancoast’s tumor (ptosis, miosis and facial anhidrosis)—
C8/T1 compression of nerve root due to tumor
(d) Tongue for central cyanosis
(e) Pufness—central cyanosis
Neck
(a) Trachea displacement.
• Towards Lung collapse, brosis, pneumonectomy.
• Away Tension pneumothorax, Massive effusion Retrosternal goitre.
(b) Lymph nodes.
(c) JVP—raised JVP—Venous hypertension—caused by pulmonary hypertension,
Heart failure, pericardial Tamponade. In an acute situation it may indicate a
pericardial hematoma or Tension Pneumothorax.
(d) Use of accessory muscles of respiration such as the Sternomastoid, Pectoral
muscles and Latissimus Dorsi.
Chest
Patient should be positioned at 45 degrees at the edge of the bed and appropriately
exposed.
Inspection
Deformities
• Barrel chest (COPD).
• Kyphoscoliosis.
• Pectus Carinatum.
• Pectus Excavatum.
• Poland syndrome .
• Cleft Sternum—rare genetic disorder due to failure of fusion of sternum.
25 Clinical Examination ofThoracic Surgery
263
• Thoracic Ectopic Cordis—complete or partial Displacement of the heart outside
the thoracic Cavity.
• Asphyxiating thoracic dystrophy (Jeune syndrome)
• Spondylothoracic dysplasia (Jarcho Levin Syndrome)
Tumors
• Primary chest wall tumors: Benign/malignant - Sarcoma, Desmoid tumors.
• Secondary chest wall tumors—breast, lung and Thyroid cancer” Follicular type”.
Thoracic Outlet Syndrome
• Adson test—Loss of the radial pulse in the arm by rotating head to the ipsilateral
side with neck extended on deep inspiration.
• Halsted test—loss of radial pulse when arm is abducted to 45 degrees and should
extended at 45 degrees and externally rotated upward extremity while applying a
downward distraction to the arm.
• Wright test—Loss of radial pulse with arm.
• Hyperabducted and externally rotated.
• Roos test—patient ex their arms and elbows to 90 degrees with their elbows
braced somewhat posteriorly. Have the patient open and close their sts at a
moderate speed for 3min.
Chest Trauma
• Paradoxical movement of chest wall—Flail chest/diaphragmatic paralysis sec-
ondary to trauma or nerve damage.
• Bleeding.
• Foreign body impaled.
• Open pneumothorax.
• Unequal sides of the chest as a sign of tension Haemothorax, Pneumothorax, or
Haemo-Pneumothorax.
• Tracheal shift and or Laryngeal tilt.
Palpation
• Tenderness (fractures pathological or trauma, tumors invasion, shingles).
• Tactile fremitus.
264
• Chest expansion normal being 5cm—Hoover sign in Over-expanded COPD.”
I.e. lung hyperination leading to a attened diaphragm which causes the lower
rib cage to move paradoxically during inhalation, in an inward direction rather
than normally outwards”.
S. Chalasani
Percussion
• Dullness—effusion (transudative or exudative) or haemothorax or pneumonia.
• Hyper resonance—COPD.
• Traub’s area.
Auscultation
• Intensity of breath sounds—reduced in collapse, pleural effusion, neoplasm,
COPD, pneumothorax.
• Bronchial breath sounds—pneumonia, brosis, effusion, lung collapse.
• Added sounds:
• Wheeze (Expiratory).
• high pitched with Asthma.
• Low pitched with COPD.
• Stridor (both inspiratory and expiratory)—obstruction.
• Early inspiratory crackles—COPD.
• Late inspiratory crackles.
• Fine crackles—ILD.
• Medium crackles—left ventricular heart failure.
• Coarse crackles—bronchiectasis.
• Vocal resonance—Pulmonary consolidation.
• Whispered pectoriloquy refers to an increased loudness of whispering noted
during auscultation with a stethoscope on the lung elds.
• Despine sign: It is a bronchial breathing heard over the vertebral spines (on
the back) below the level of tracheal bifurcation; below the fourth thoracic
spine in adults if there is subcarinal (Mediastinal) lymphadenopathy.
25 Clinical Examination ofThoracic Surgery
265
Chest Drains
Principles ofUnderwater Seal Drainage
The main aim of a chest drain is the remove air/uid from the intrapleural space and
preventing it from re-entry. Negative pressure during inspiration causes the water
level in the tube to rise and positive pressure during expiration pushes the uid out.
Air bubbles out of the tube into the underwater seal. Fluid drains via gravity mixing
with water and raising the uid level.
How toInsert aChest Drain—Step Wise Approach (Fig.25.1)
Relevant anatomy—Triangle of safety: posteriorly is the anterior border of latissimus dorsi, anteriorly is the lateral border of the pectoralis major, and inferiorly is
the fth intercostal space and apex below the axilla.
British Thoracic Society guidelines for insertion of surgical chest drain
1. Position—patient at 45 degrees and arm elevated above head.
2. Ensure all required materials are opened in a sterile fashion and ready to use.
3. Identify landmarks—palpate 5th intercostal space and identify triangle of
safety. It often helps to draw out the triangle of safety in patients.
4. Surgically prepare the area.
5. Administer local anaesthetic layer by layer.
6. Incise skin parallel to the upper border of the chosen rib.
7. Blunt dissect using a Roberts forceps until you feel a give into pleural cavity.
8. Widen the hole and place nger into the cavity and do a nger sweep.
9. Stay sutures/closing suture are generally place in a horizontal mattress suture
format to help swift tying off the skin when chest drain is removed at a later
stage once its served its desired purpose (Fig.25.2).
10. Hold the tube with the clamp and direct it superiorly for pneumothorax or inferiorly for pleural effusions while ensuring the other end of the tube is clamped
off using non crushing chest drain clamps so that air doesn’t enter chest cavity.
Ensure the sentinel eye is well within the chest. The black dots
should (usually two of them on wide bore surgical drains) must not be visible.
11. Holding suture placed onto tube. Ensure that this suture is not pulling on the
skin - a thick bite but not tight should be taken using 1 ethilon or heavy
silk suture.
12. Drain is connected to the under-water seal and one should look for “swinging”
of the uid. If there is no swing as soon as the tube is inserted it often means
that the tube is misplaced or kinked and this needs to be looked into immediately.