Management of chest injury

Essential items for the care of immediately life-threatening chest injuries have been addressed in section 5.2. These include capabilities for the emergency insertion of a chest tube, oxygenation and respiratory support. An extension of such issues is the ability to collect blood from chest tube output for autotransfusion. This is desirable at all hospital levels. The cost of the resources needed to provide this service in a sterile fashion prevents it from being considered essential.

Most chest injuries, whether blunt or penetrating, are managed without surgical operation. Major preventable complications are atelectasis and pneumonia. The prevention of these is contingent on adequate pulmonary toilet, which is in turn contingent on adequate pain control. These are all low-cost capabilities and should be essential at all hospital levels. Pain control implies an adequate supply of analgesics, which is addressed in section 5.12. In addition to the physical availability of the medications, adequate pain control implies the skills needed to understand the importance of pain control in a patient with a chest injury, the ability to assess a patient for such pain and its effect on their respiratory status, and the ability to assess adequate response to analgesia. Such skills are deemed essential at all hospital levels.

Useful adjuncts include regional anaesthesia, such as rib blocks (e.g. intercostal nerve blocks) and epidural analgesia. These would imply the availability of long-lasting local anaesthetics (e.g. bupivacaine). They also imply training to be able to perform the blocks satisfactorily and safely, and to recognize and treat potential complications. Capabilities for rib blocks are essential at specialist and tertiary level. They are possibly required at GP-level hospitals, if these are in more remote locations with limited capabilities for referral. Epidural analgesia would usually only be available where a fully trained physician anaesthetist is available. Due to this restriction and the cost of the special catheters needed, this capability is deemed desirable only for the upper two hospital levels.

Surgery for chest injuries can be classified as intermediate (including ligation of chest wall bleeding, pulmonary tractotomy and pulmonary resection) or advanced (including aortic repair with prosthetic graft). Intermediate thoraco-tomy capabilities are deemed desirable at the specialist level and essential at the tertiary level. Given the level of skill needed for such procedures, they would not be deemed desirable or even possibly required in GP-staffed hospitals, except under the most extreme circumstances. Performance of these procedures at specialist-level hospitals would imply the presence of a surgeon with the requisite skill, and adequate operative and postoperative facilities. The balance between these capabilities and the capability for rapid transfer to tertiary facilities needs to be determined on a local basis. Advanced thoracic surgical capabilities are deemed desirable at the tertiary care level, because of the high cost and hence low availability of more advanced materials, such as aortic grafts.

Any hospital performing thoracic surgical procedures should have basic quality improvement mechanisms in place to track the outcomes of such procedures.

TABLE 6 Chest injury

Facility level

TABLE 6 Chest injury

Facility level

Resources

Basic GP

Specialist

Tertiary

Autotransfusion from chest tubes

ID

D

D

Adequate pain control for chest injuries/rib fractures

DE

E

E

Respiratory therapy for chest injuries/rib fractures

IE

E

E

Rib block or intrapleural block

I PR

E

E

Epidural analgesia

II

D

D

Skills and equipment for intermediate thoracotomy

II

D

E

Skills and equipment for advanced thoracotomy

II

I

D

0 0

Post a comment