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Penetrating chest trauma

Clinical Discipline(s)/Organ System(s)
Emergency Medicine, General Surgery, Respiratory System, Ethics
Progress Test Topic(s)
Seriously ill patient
A 23 year Indian medical student is brought by ambulance to the resuscitation room of the Emergency Department after a high-speed road traffic crash. He has major injuries including a fence post lodged in his chest. There is evidence of splenic trauma.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Anatomy of the abdomen and thorax
   - Pathology of pneumothorax
   - Pathophysiology of a tension pneumothorax
   - Mechanisms controlling haemostasis: platelets and coagulation factors
   - Pharmacology of opioids, metoclopramide, ondansetron, domperidone and scopolamine
Clinical and Communication Skills 
   - History from a trauma patient and/or witness including managing patient and family/whānau distress
   - Perform a primary survey in a trauma patient
   - Perform a secondary survey
   - Perform an assessment of the airway, breathing and circulation, cervical spine integrity, recognise signs of life
   - Perform an assessment of the level of consciousness using the Glasgow Coma Scale (GCS) and Alert, Voice, Pain, Unresponsive (AVPU) Scale
   - Classify hypovolaemic shock according to severity based on clinical signs
   - Indications for trauma series X-rays, further imaging, Focused Assessment with Sonography for Trauma (FAST) scanning
   - Interpret full blood count, arterial blood gas, chest X-ray, abdominal X-ray, limb plain film X-ray and pelvic X-ray
   - Management of severe hypotension, pneumothorax, cardiac tamponade
   - Complications and prognosis of penetrating chest trauma
   - Role of the haematologist/transfusion medicine specialist in the treatment of massive haemorrhage
   - Obtaining consent when the patient is unconscious
   - Assessment of pelvic/abdominal injury
   - Indications for splenectomy; long term management post splenectomy including vaccinations, travel and antibiotic advice
Personal and Professional Skills 
   - Ethics of life and death decision-making
   - Being able to manage own identification with the patient
   - Being aware of your own skills and calling for senior assistance as required
   - Self-care: coping with distressing presentations and maintaining your ability to carry out your tasks (see resources below)
   - Hospital transfer: when and how
   - Role of the police and coroner in trauma patients
   - Role of the Accident Compensation Corporation
Hauora Māori 
   - Rates of severe injuries by ethnicity
   - Ethnic disparities in the long-term management of traumatic injury in New Zealand
   - Differential ACC claims and rehabilitation for Māori vs non-Māori
   - Differential impact of injuries on employment/income for Māori (i.e. more likely to be employed in 'manual' jobs)
   - Consideration of access to cultural/spiritual support for patient and whānau
Population Health 
   - Provision of rescue helicopter services across New Zealand
   - Epidemiology of road traffic crashes including alcohol and drugs; strategies for prevention
Conditions to be considered relating to this scenario
simple pneumothorax, haemothorax, haemopneumothorax, rib fracture, sternal fracture, pulmonary contusion, skin laceration and contusion
Less common but 'important not to miss'
flail chest, tension pneumothorax, cardiac tamponade, splenic rupture, pulmonary laceration, great vessel injury, direct cardiac trauma, intracranial haemorrhage, diffuse axonal injury, spinal cord trauma
surgical emphysema

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