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7/15/2019 Chest Trauma 1 Dr. BER
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Thoracic Trauma
BERMANSYAH
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Anatomi
• Jaringan Lunak dinding Torak
• Tulang
• Parenkim• Pembuluh Darah
• Jantung
• Mediastinum
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Anatomy
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Fisiologi Pernafasan
• Trakea
• Bronkus
• Bronkiolus• Alviolus
• Kapiler
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Komponen Pernafasan
• Trakea
• Dinding Torak
• Parenkim Paru• Diafragma
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Trauma Torak
• Trauma Tumpul
• Trauma Tajam
• Trauma Abdomen
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CARDIOVASCULAR
SYSTEM
Anatomy & Physiology
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THE HEART
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Lokasi Jantung
• Di dalam Pericardium di rongga mediastinumdalam rongga Thorak
• Tepat di belakang tulang dada ( sternum )
• Kurang lebih 2/3 bagian terletak di sebelah kiri
dari garis tengah
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Fungsi dan Ukuran
•
Fungsi : sebagai pompa ganda agar terjadialiran dalam pembuluh darah yang
disebabkan adanya pergantian antara
kontraksi ( sistolik ) dan relaksasi
( diastolik )
• Ukuran : 250 – 350 gram
( kira-kira sebesar kepalan tangan )
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Perikardium
• Perikardium Fibrosa
Lapisan paling luar rongga Pericardium
Menjaga kedudukan jantung di rongga mediastinum
• Perikardium Serosa
– Lapisan parietalis
Lapisan bagian dalam dari rongga pericardial
– Lapisan visceralis / epicardium
• Rongga Perikardium
– Cairan pericardium
Mengurangi gesekan saat jantung bergerak
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Anatomy of the Heart
• Heart chambers :
– Left & right atria
– Left & right ventricles
• Heart valves :
– Atrioventricular valves :
• Right : Tricuspid
•
Left : Bicuspid/Mitral – Semilunar valves
• Right : Pulmonary valve
• Left : Aortic valve
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Anatomy of the Heart
• Aorta
•
Coronary arteries• Arterioles
• Capillaries
•
Venules• Coronary sinus
• Right atrium
Coronary circulation
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TRAUMA TUMPUL TORAKS
• TRAUMA PADA DINDING DADA
• TRAUMA PADA PARU DAN PLEURA
• TRAUMA PADA OSOFAGUS,DIAFRAGMA DAN DUKTUS TORASIKUS
• TRAUMA PADA JANTUNG DAN
PEMBULUH DARAH BESAR• TRAUMA TRAKHEOBRONKHIAL
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TRAUMA PADA DINDING DADA
• FRAKTUR CLAVICULA
• FRAKTUR STERNUM
• DISLOKASI SENDI STERNOCLAVICULA• FRAKTUR IGA
• “FLAIL CHEST”
• TRAUMA ASPIKSI
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FRAKTUR CLAVICULA
– Paling sering ditemukan (tunggal, disertai trauma
toraks, trauma pada sendi bahu ).
– Lokasi Fraktur pada bagian tengah.
– Deformitas, nyeri dan nyeri tekanan pada lokasi
trauma.
– Foto Rontgen tampak fraktur clavicula
– Konservatif : “Verband figure of eight” sekitar sendi
bahu.
– Komplikasi : “Malunion Fracture” akan menekan
pleksus Brakhialis dan pembuluh
darah subclavia.
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FRAKTUR STRENUM
– Trauma langsung pada Sternum
– Lokasi Fraktur bagian tengah atas Sternum
– Sering disertai Fraktur Iga
– Tidak perlu “Open Reduction”/fiksasi internal
– 61% perubahan EKG (Trauma Jantung)
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DISLOKASI SENDI
STERNOCLAVICULAR
– Kasus Jarang
• Anterior : Nyeri, nyeri tekan, sendi menonjol
kedepan
• Posterior : Sendi tertekan kedalam• Pengobatan : Reposisi
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FAKTUR IGA
– Trauma Langsung (Direct Injury)
– Lebih sering iga IV – IX
– Fraktur pada bagian lateral dada sulit dinilai
dengan x-Ray
– Diagnosis :
• Riwayat trauma dengan nyeri pleura yang
terlokalisir
• Nyeri tekan dan crepitasi dari fragmen
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FRAKTUR IGA
Akibat nyeri - diskontinuitas dinding dada -
pernafasan ↓ - atelektatis → pneumonia
Fungsi paru yang ↓→ mengancam jiwa
mortalitas pasien usia >80 thn→ 20% Pengobatan : Kontrol nyeri
• Analqetik sistemik
• Blok syaraf interkostal
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FRAKTUR IGA
Fraktur Iga + Hemotoraks / Pneumotoraks →
WSD
Fraktur Iga + contusio paru → perawatan ketat
→ ICU Fraktur Iga VI – XII → trauma Ginjal, Hati
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FLAIL CHEST
– Segmen dinding dada yang bergerak
paradoksal pada Respirasi
– Fraktur Iga, Trauma langsung, 30% trauma
tumpul toraks – Kontusio paru faktor resiko terjadi ARDS
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FLAIL CHEST
– Pengobatan :
• Internal stabilization (Pneumatik Stabilisasi)
– Intubasi Endotracheal
– Ventilasi Mekanik → Mereduksi Pnemonia
• Fiksasi Iga (Stabilisasi bedah)
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Indikasi Stabilisasi Bedah
1. Pasien perlu Torakotomi bila disertai komplikasi didalam rongga toraks → perdarahan.
2. Pasien yang mengalami gangguan pernafasanmeskipun telah dilakukan agresif bronkhoskopi,
ventilasi, analgetika, pada X Ray tidak ditemukankonstusio paru
3. Mereduksi lamanya pemakaian ventilasi bila pasiengagal “weaning ventilation”
4. Pasien dengan antero lateral “flail chest” , dislokasiyang progresif dari fraktur Iga, untuk mencegah terjadideformitas dinding dada di kemudian hari dengankonsekuensi terjadi kelainan restriksi
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Beberapa hal Penting pada Trauma Tumpul
Toraks
• Fraktur Claviula – Perhatikan cidera pada a.subclavia dan fleksus brakhialis
adanya kemunginan “ thoracic outlet syndrom” kemudian hari
• Kontusio jantung sering timbul pada trauma
sternum
• Perhatikan trauma pada trakhea, pembuluh
darah besar bila ada dislokasasi sendi “sterno
clavicular”ke medial • “Flail chest” umumnya dapat diobati dengan
intubasi dan ventilasi mekanik
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TRAUMA PADA PARU DAN PLEURA
PNEUMOTORAKS• Robekan langsung paru karena Fraktur Iga
• Tekanan yang meningkat pada saluran nafas
• Evaluasi• Sesak nafas
• Hipersonor
Bising nafas ↓
• “Tension Penumothorax”
• Sesak nafas• Gangguan Hemodinamik
• Pendorongan Trakhea
• Bising nafas (-)
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PENGOBATAN
• WSDICS IV / ICS V linea aksilaris medialis –
- anterior
• Torakotomi
Kontrol kebocoran paru
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HEMOTORAKS
• Laserasi paru, trauma pemb interkostal luka dinding
dada, trauma a.bronkhial, trauma pembulu darah
besar
• X Ray Toraks
• WSD untuk evakuasi• Torakotomi :
– Perdarahan > 1000 ml. Perdarahan masih berlangsung >
100 – 200 ml/jam
– Perdarahan < 1000 ml perdarahan masih berlangsung >100 -200 ml/jam untuk beberapa waktu
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HEMATOMA PARU
• Tidak menimbulkan gangguan “gas
exchange“ dan “shunting” pO2 nomal
• Hematoma pada jaringan paru, dapat
diidentifikasi pada “Xray toraks”
• Resiko infeksi dan Abses paru
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KONTUSIO PARU
• Trauma paru yang serius , terjadi infitrasidarah dan protein pada alveoli → “Intra
Pulmonary Shunting” → “Hypoxemia”
• X ray toraks timbul kelainan setelah 24-48 jam, ronkhi (+)
• Intubasi Endotrakheal + ventilasi
• Distres pernafasan (ARDS)
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RUPTUR DIAFRAGMA
• Peningkatan tekanan lntra Abdomnalmendadak
• Umumnya terjadi di sentral
• Sebelah kiri lebih sering dari sebelah kanan• Herniasi organ viseral abdomen ke toraks
• Dapat tenjadi ruptur intra perikardial
• Diagnosis : klinis, “ X Ray toraks, CT scantoraks
• Tx/ Torakotomi dan laparotomi
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Klinis ruptur diafragma
• Riwayat trauma tumpul abdomen
• “Respiratory distress”
• Pendorongan mediastinum kontralateral
dan penekanan paru oleh organ viseral
• Venous return” menurun – CO menurun
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TRAUMA ESPOHAGUS
• Trauma tumpul jarang dibandingkan truma
tusuk
• Diagnosis : pneumomediastim atau efusi
pleura
• Esophagography
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TRAUMA TUMPUL JANTUNG
• Jarang terjadi
• Trauma langsung karena kecelakaan lalu
lintas
• “Myocardial Contusion”
• EKG
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Penetrating injuries
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Penanggulangan rongga Pleura
Tujuan
Mengembalikan kondisi fisiologis ronggapleura dengan cara :
1. Observasi
2. Pungsi pleura
3. WSD4. Continous suction ( I botol / 2 botol )
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WSD
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Indikasi Utama WSD
1. Robekan pleura visceral
2. Monitoring perdarahan untuk dapat
menentukan indikasi torakotomi yang
tidak berdasarkan kepada kondisi klinis
pasien
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Pelaporan WSD
1. Initial
2. Undulasi
3. Expiratory bubble4. Produksi
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Indikasi Continous Suction
1. Hematopneumotoraks agar darah segera
dapat dikeluar sebelum proses
pembekuan.
2. Robekan pleura visceral .
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Definisi :
Pemasangan drain pada rongga pleura melalui
insisi pada sela iga
Tujuan :
Mengeluarkan cairan, darah, udara dari rongga
pleura.
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I n d i k a s i
• Trauma toraks• Hematotoraks
• Pneumotoraks
• Chylotoraks
• Infeksi• Empiema
• Keganasan•
Efusi pleura / Fluidotoraks
• Pasca Torakotomi
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Pneumotoraks
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Hematotoraks
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Cara perawatan
• Awasi tanda-tanda klinis pasien.• Posisi senyaman mungkin k/p setengah duduk.
• Seluruh sistim drainase dalam keadaan rapi, pipa dan botolharus transparan dan tidak ada kebocoran.
• Perawatan harus dilakukan secara aseptik.
• Drain harus terfiksasi dengan baik, baik pada tubuh ataupunpada sambungan.
• Patensi drain harus lancar & jangan tertekuk, bila tidak milking.
•
Botol drainase harus lebih rendah dari pasien.• Kuantitas & kualitas cairan harus dinilai minimal setiap 24 jam.
• Atasi nyeri & Fisio terapi nafas.
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Hematothorax
REMEMBER !!!
• < 3 cc/kgBB/jam Observasi
• 3 – 5 cc/kgBB/jam Hati-hati, Observasi ketat
• > 5 cc/kgBB/jam Operasi / Eksplorasi
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Indikasi pencabutan drain
• Klinis
• Radiologis
• Kuantitas dan kualitas cairan
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Teknik pencabutan
• Fiksasi plester dilepas, desinfeksi
• Benang dilepaskan, dipegang asisten
• Operator pegang drain, tangan kiri menjepit
luka
• Dengan satu komando, drain dicabut dgn satu
tarikan dan asisten mengikat benang dengan
simpul mati
• Kontrol foto toraks
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• Penderita harus dipasang infus
• Sebaiknya dilakukan di ruang operasi
• Jangan tinggalkan penderita setelah
pemasangan, perhatikan tanda-tanda vitalnya
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Jenis WSD
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Jenis WSD
Posisi yg WSD
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Posisi yg WSD
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T T l
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Trauma Tumpul
• Dinding TorakJejas
Hematom
Laserasi
Fraktur iga
Fraktur clavicula
Cedera Vaskular
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• M - MECHANISM OF INJURY
• I - INJURIES SUSTAINED
• S - SIGNS AND SYMPTOMS
• T - THERAPY
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• TRAUMA TUMPUL
• TRAUMA TAJAM
• TRAUMA LEDAKAN
• BIOMEKANIK TRAUMA
• Semua harus dicari melalui anamnesayang teliti
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Cidera yang didapat
• Kelainan dinding dada- Empisema kulit
- Fraktur iga respirasi paradoksal
• Kelainan rongga Pleura- Hematotoraks
- Pneumotoraks
- Hemato-Pneumotoraks- Chylothorax
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• Kelainan Parenchym Paru
- Traumatic Wet Lung• Kelainan Mediastinum
- Cardiovascular
- Tracheobronchial- Esophagus
• Kelainan Abdominal
- Thoracoabdominal
Si d S t
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Signs and Symptoms
• Dicari kemungkinan semua organ yang dapatdicederai sesuai dengan biomekanik trauma
dengan :
- Anamnesa- Inspeksi
- Palpasi
- Perkusi
- Auskultasi
- Pemeriksaan Penunjang lainnya
T i
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Terapi
• Saluran nafas• Pernafasaan
• Sirkulasi
• Penanggulangan rongga Pleura• Stabilisasi dinding dada
• Menghilangkan rasa nyeri
• Torakoskopi• Torakotomi
St bili i Di di D d
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Stabilisasi Dinding Dada
1. Flail chest
Ditanggulangi dengan respirator atau
fiksasi iga
2. Cara terapi dengan menekan atau
menarik ( traksi ) dari daerah dinding dada
yang bergerak “paradoksal” masih dapat
diterapkan kalau (1) tidak dapatdilaksanakan
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3. Menanggulangi rasa nyeri
1. Analgetik boleh dipakai asal tidak
mengganggu reflek batuk dan
pernafasan
2. Dianjurkan melakukan interkostal
blok anestesi dari nervusinterkostalis
I dik i T k t i
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Indikasi Torakotomi
1. Perdarahan selama monitoring melebihi 3 – 5 cc/ kg BB selama 3 jam
2. Paru tidak mengembang dan tetap ada
expiratory bubble setelah continous suction3. Kondisi pernafasan patient makin jelek pada
waktu pemasangan kontinous suction
4. Kalau perlu pada trauma torakoabdominal yang
ada indikasi laparatomi
Organs most commonly involved in severe
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O ga s ost co o y o ed se e e
blunt thoracic trauma
• Chest wall 70 %
• Lungs 20 - 25 %
• Heart 10 %
• Diaphragm 5 %• Aorta 3 - 4 %
Importance of obtaining a good clinical history in
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Importance of obtaining a good clinical history in
assessment of blunt chest trauma victims
• Patients involved in motor vehicle accident• Time of injury relative to arrival in hospital
• Type of impact ( head – on collision or side impact )
• Patient’s location within vehicle (front,back,driver)
• Approximate vehicle speed• Ejection from vehicle
• Death of another accupant of vehicle
• Was the trauma victim wearing a seat belt
• Patients involved in fall from a height• Height of fall
• Surface on which patient landed
Identify and initiate treatment of the following
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injuries during the primary survey
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest
• Massive hemothorax
• Cardiac tamponade
Identify and initiate treatment of the following
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injuries during the secondary survey
• Simple pneumothorax
• Hemothorax
• Pulmonary contusion
• Tracheobrochial distruption
• Blunt cardiac injury
• Traumatic diaphragmatic injury• Mediastinal traversing wounds
Recognize the indications for, complications of,
and demonstrate the ability to perform the
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and demonstrate the ability to perform the
following :
• Thoracic needle decompression
• Chest tube insertion
• pericardiocentesis
Mechanisms of injury in blunt chest trauma
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Mechanisms of injury in blunt chest trauma
• Direct impact over thorax ( rib fracture, flail chest, lungand cardiac contusion )
• Direct impact over hyperextended neck (laryngotracheal
injury )
• Direct impact with close glottis ( bronchial distruption )
• Rapid deceleration ( aortic or bronchial rupture)
• Vertical deceleration ( aortic rupture )
• Spinal flexion injuries ( rupture of thoracic duct )
• Suddenrise in intra-abdominal pressure ( diaphragmatic
rupture )
Importance of physical examination in
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p p y
assessment of blunt chest trauma victims
• Airway tachypnea, stridor airwayobstruction
or distruption.
inhalation of a
foreign body.
• Breathing abnormal chest wall flail chest .
movements ; severe lung
use of accessory muscles of contusion.
respiration ; respiratory
absence of breath failure.
sounds pneumothoraces,
hemothoraces
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• Circulation low blood pressure, significant hemorrhagetachycardia
. Cervical spine pain in back of neck fracture-dislocation
. Intracranial immobility or altered head injury
state of consciousness
Initial assessment and management
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Initial assessment and management
• Patient management must consist of @ primary survey
@ resuscitation of vital functions
@ detailed secondary survey
@ definitive care
• Hypoxia is the most serious feature of chest injury, earlyinterventions are designed to prevent or correct hypoxia
• Immediately life-threatening injuries are treated as quickly and as
simply as possible
• Most life-threatening thoracic injuries are treated by airway control or
an appropriately placed chest tube or needle
• The secondary survey is influenced by a history of the injury and a
high index of suspicion for specific injuries
Indikasi Torakotomi
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Indikasi Torakotomi
Initial bubble (-) atelektasis bronkoskopi
• Pneumotorak WSD
spontan (+)chest fisio
Initial bubble (+) pengembangan paru terapi
( - )torakotomi
Indikasi Bronkoskopi
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Indikasi Bronkoskopi
• Pada trauma toraks apabila dapatdibuktikan bahwa tekanan cavum pleura
negatif tetapi paru kollaps maka
persoalannya terdapat disaluran nafassehingga diperlukan tindakan untuk
membebaskan saluran nafas dengan
bronkoskopi
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Trauma aspiksia
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Trauma aspiksia
• Trauma tumpul paru yg menyebabkan tek.Intratoraks meningkat dan glottis tertutup.
• “Venous pressure” intratoraks meningkat
menyebabkan pemb.balik kepala danleher terbendung ---- odema & sianosiskepala dan leher,perdrhan subcojunctiva,tek. Intrakranial naik, kesadaran menurun,
buta• Monitor neurologi . Elevasi kepala
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• Shunting paru right to left
saturasi vena pulmonalis menurun
• Shunting perifer left to right
darah kembali ke sentral tanpa melalui
kapiler
RUPTUR DIAFRAGMA
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RUPTUR DIAFRAGMA
• Peningkatan tekanan lntra Abdomnalmendadak
• Umumnya terjadi di sentral
• Sebelah kiri lebih sering dari sebelah kanan• Herniasi organ viseral abdomen ke toraks
• Dapat tenjadi ruptur intra perikardial
• Diagnosis : klinis, “ X Ray toraks, CT scantoraks
• Tx/ laparotomi kalau perlu torakotomi
TRAUMA ESPOHAGUS
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TRAUMA ESPOHAGUS
• Trauma tumpul jarang dibandingkan trumatusuk
• Selalu disertai trauma lainnya dari toraks
• Diagnosis : - Pneumomediastinum atau efusi
pleura
- Esophagography
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Penetrating injuries
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Penetrating injuries
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Tension Pneumotoraks
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ension Pneumotoraks
1. Terjadi pada pneumotorak tertutup dengan mekanismeventil di robekan pleura visceral atau pada traumatajam dengan mekanisme ventil di dinding toraks
2. Setiap kasus dengan anamnesa sesak makin bertambah
dan pada perkusi adanya pneumotoraks suspecttension pneumotoraks tidak boleh dipastikan dengan x– ray harus langsung dilakukan fungsi pleura untukmenurunkan tekanan
3.Tidak selalu harus dilakukan torakotomi
4. Penaggulangan dapat dilaksanakan sesuai protokolpneumotoraks
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Trauma Jantung
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1. Setiap luka tusuk di daerah prekordial harus dianggapmengenai jantung sehingga harus segera torakotomi(kecuali kalau ada analisa yang menyatakan jantungtidak cedera)
2. Dapat dilakukan dulu perikardiosintesis atauperikardiostomi dengan catatan kalau ada perdarahanlangsung torakotomi
3. Darah dapat masuk kerongga perikardium karena ;– cedera perikard saja– Cedera mengenai epikardium (pembuluhdarah coroner– Cedera dapat menembus dinding jantung
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Ruptur Bronkhus
- Inspeksi
- Palpasi
- Perkusi
- Auskultasi
- Pemeriksaan tambahan
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Ruptur diafragma
- Inspeksi
- Palpasi- Perkusi
- Auskultasi
- Pemeriksaan tambahan
Cardiac Tamponade
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• Blood in the pericardial sac• Most frequently penetrating injuries
• Shock, JVP, PEA, pulsus paradoxus
• Classically, Beck’s triad: - distended neck veins
- muffled heart sounds
- hypotension• Rx: Volume resuscitation
Pericardiocentesis
Blunt cardiac injury
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• Myocardial contusion is the most commoninjury and is suspected with EKG changes and
serial enzyme elevations
• Coronary artery injury can result in thrombosis and myocardial infarction
• Atrial or ventricular rupture is usually fatal ,
although the pericardium may restrict bleeding enough to allow survival to the ER
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Cervical/Neck TraumaIntroduction
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Introduction
• 5-10% of all trauma
• Overall mortality rate as high as 11%
• Major vessel injury fatal in 65%, including
prehospital deaths
• Attending physician must have excellentknowledge of anatomy
Cervical/Neck TraumaIntroduction
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Introduction
• Infrequent except C-spine
• Awareness is essential
• Can be devastating even fatal
• Signs often subtle or absent
• Often too late
Neck Zone
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Penetrating Neck Trauma
Penetrating Neck Trauma
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Penetrating Neck Trauma
• Controversy regarding management of “soft” or no signs of injury
• Soft Signs – Hemoptysis/hematemesis
– Oropharygeal blood
– Dyspnea
– Dysphonia/dysphagia
– SubQ or mediastinal air
– Chest tube air leak
– Nonexpanding hematoma – Focal neuro deficits
• Issue of Mandatory versus Selective Exploration?
Penetrating Neck Trauma
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Penetrating Neck Trauma
CCH neck protocol
Penetrating Neck Trauma
CCH k t l
• Zone I– Angio of arch and
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CCH neck protocolCCH neck protocol Angio of arch and
great vessels
– CXR – Consider esophagus
and trachea
• Zone II
– Angiocarotid(s)/vertebral(s)
– Esophagram &endoscopy
– Consider bronchoscopy
• Zone III – Carotid angio
– Oropharyngeal exam
Radiographs
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• CXR - inspiratory/expiratory films toassess for phrenic nerve injury, look for
pneumothorax
• Cervical spine film to rule out fractures
• Soft tissue neck films AP and Lateral
• Arteriograms, contrast studies as
indicated
Penetrating Neck Trauma
Penetrating Neck Trauma
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Vascular inju ry
Subcutaneous emphysema
Airway obstruction
Sucking woundHemoptysis
Dyspnea
Stridor
Hoarseness or dysphonia
Laryngo tracheal in jury
Subcutaneous emphysema
HematemesisDysphagia or odynophagia
Pharynx/esophagus injury
Shock
HematomaHemorrhage
Pulse deficit
Neurologic deficit
Bruit or thrill in neck
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Esophageal RuptureEsophageal Rupture
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Complete Tracheal Rupture
Complete Tracheal Rupture
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BLUNT NECK INJURY
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• Lateral C spine X ray , CXR• Cervical immobilizations should continue untill
clinically and radiographycally cleared
• Pretracheal soft tissue > 0,5 mm is suggestive
C-spine fracture
• Subcutaneous empysema , retropharingeal air
Diagnostic modalities
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• CT scan
• Laryngoscopy and Bronchoscopy
• Doppler Ultrasound• Angiography
• Contrast Esophagogram
• Flexible Esophagoscopy
Neck Injury : Conclusions
Neck Injury : Conclusions
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• First priority is to secure the airway
• Not common but associated to high mortality and
morbidity• Neurologic deficit with normal brain CT needs
Angiographic Examination
• Be aware of subtle signs
Neck Injury : Conclusions
Neck Injury : Conclusions
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• Maintain respect for apparently minor neckwounds
• Careful history and complete physical exam
with appropriate ancillary studies• Arteriography for zone I and zone III injuries
• Vascular injuries most immediately life-
threatening
• Esophageal injury causes late mortality
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Thoracic Trauma
Introduction
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Introduction
• Chest trauma is often sudden and dramatic
• Accounts for 25% of all trauma deaths
• USA : 45.000 death
• Indonesia : ?
• 2/3 of deaths occur after reaching hospital
• Serious pathological consequnces:
-hypoxia, hypovolaemia, myocardial failure
Radiological Landmark
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Mechanism of Injury
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• Either:
- direct blow (e.g. rib fracture)
- deceleration injury or - compression injury
• Rib fracture is the most common sign of blunt
thoracic trauma
• Fracture of scapula, sternum, or first rib suggests
massive force of injury
Blunt injuries
B lun t in jur ies
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Mechanism of Injury
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Penetrating injuries • E.g. stab wounds etc.
• Primarily peripheral lung
• Haemothorax
• Pneumothorax
• Cardiac, great vessel ,trachea
or oesophageal injury
Penetrat ing in jur ies
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Chest wall injuries
Chest wall injuries
Chest wall injuries
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• Rib fractures
• Flail chest
• Open pneumothorax
Rib fractures
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• Most common thoracic injury• Localised pain, tenderness, crepitus
• CXR to exclude other injuries
• Analgesia
• Underestimation of effect
• Upper ribs, clavicle or scapula fracture: suspect
vascular injury
Flail chest
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• Multiple rib fractures produce a mobile fragmentwhich moves paradoxically with respiration
• Hypoxia is usually not present unless there is
underlying lung injury.• Usually diagnosed clinically
• Rx: ABC
AnalgesiaIntubation and ventilator support
Flail chest
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Open pneumothorax
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• Defect in chest wall provides a direct communicationbetween the pleural space and the environment
• Lung collapse and paroxysmal shifting of
mediastinum with each respiratory effort ± tensionpneumothorax
• “Sucking chest wound”
• Rx: ABCs…closure of wound…chest drain
Open pneumothorax
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Lung injury
Lung injury
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• Pulmonary contusion
• Pneumothorax
• Haemothorax• Parenchymal injury
• Trachea and bronchial injuries
• Pneumomediastinum
Pulmonary contusion
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• Occurs to a varying degree in allthoracic injuries
• Major component of flail chest
• Significant hypoventilation and
shunting
• Requires judicious fluid managementand ventilatory support
Pulmonary contusion
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Pulmonary contusion &
Left Lung Herniation
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Pneumothorax
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• Air in the pleural cavity• Blunt or penetrating injury that disrupts the parietal
or visceral pleura
• Unilateral signs: movement and breath sounds,resonant to percussion
• Confirmed by CXR
• Rx: chest drain
Pneumothorax
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Tension pneumothorax
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• Air enters pleural space and cannot escape• P/C: chest pain, dyspnoea
• Dx: - respiratory distress
- tracheal deviation (away)- absence of breath sounds
- distended neck veins
- hypotension
Tensionpneumothorax
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Haemothorax
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• Blunt or penetrating trauma• Requires rapid decompression and fluid
resuscitation
• Clinically: hypovolaemiaabsence of breath sounds
dullness to percussion
• CXR may be confused with collapse
Haemothorax
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Haemothorax
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• May require surgical intervention• Managed with early chest tube drainage
• Surgical exploration is recommended if initial
output is more than 1000 ml or chest tube
drainage is more than 200 ml/hr for 4 hours
• A clotted hemothorax should be evacuated
early by thoracotomy
Trachea and bronchial injuries
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• Continuous bubble• Suggested by:
• Pneumothorax
• Pneumomediastinum
• Subcutaneous emphysema
• Hemoptysis• Airway obstruction
Tracheal and bronchial injuries
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Trachea and bronchial injuries
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• Following intubation or a surgical airway, an anterior
collar incision is the best approach
• Median sternotomy may be required for associated
vascular injury or intrathoracic tracheal laceration
• Avoid tracheostomy if possible when a vascular
repair is in proximity
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Heart, Aorta & Diaphragm
Heart, Aorta & Diaphragm
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• Blunt cardiac injury
- contusion
- ventricular, septal or valvular rupture
• Cardiac tamponade
• Ruptured thoracic aorta
• Diaphragmatic rupture
Blunt cardiac injury
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• Should be monitored in the ICU• May require heparinization for coronary
thrombosis and anti-arrhythmic therapy
• Echocardiography and angiography areindicated for tamponade and post-injury
murmurs, which suggest valvular insufficiency
or septal defect
Cardiac tamponade
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Aortic rupture
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• Usually blunt trauma involving decelerationforces
• ~90% die within minutes, and who arrive at
the hospital, another 90% will die• Most common site near ligamentum
arteriosum
• Dx: clinical suspicion, CXR,aortography,contrast CT or TOE
Aortic rupture
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Aortic rupture
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• Weak leg pulses with hypertension in thearms, or a new murmur.
• 1st or 2nd rib fractures
• A widened upper mediastinum, deviation of
the trachea, a “pleural cap,”
• Rx: surgical…poor prognosis
Aortic rupture widening mediastinum
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Aortic rupture
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Aortic rupture
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Diaphragm Rupture
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• Most lacerations occur on the left hemidiaphragm
• Usually, the stomach herniates and undergoes
volvulus, massively dilates, and causes left lung
collapse and mediastinal shift to the right
• Gastric distension can also result in perforation and
should be prevented by NG tube placement
Diaphragm Rupture
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Left Gastrothorax
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Chest trauma: summary
Chest trauma: summary• Common
Serio s
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• Serious
• Primary goal is to provide oxygen to vital organs
• Remember Airway
BreathingCirculation
• Remember
Chest Wall Stability
Lung reExpansion• Be alert to change in clinical condition
Iatrogenic trauma
Iatrogenic trauma
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• NG tubes: -coiling-endobronchial placement
-pneumothorax
• Chest tubes: - subcutaneous- intraparenchymal
- intrafissural
• Central lines: - neck- coronary sinus
- pneumothorax
Line in jugular vein
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Misplaced nasogastric tube
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