chest trauma 1 dr. ber

7/15/2019 Chest Trauma 1 Dr. BER

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Thoracic Trauma

BERMANSYAH



Anatomi

• Jaringan Lunak dinding Torak

• Tulang

• Parenkim• Pembuluh Darah

• Jantung

• Mediastinum



Anatomy



Fisiologi Pernafasan

• Trakea

• Bronkus

• Bronkiolus• Alviolus

• Kapiler



Komponen Pernafasan

• Trakea

• Dinding Torak

• Parenkim Paru• Diafragma



Trauma Torak

• Trauma Tumpul

• Trauma Tajam

• Trauma Abdomen



CARDIOVASCULAR

SYSTEM

Anatomy & Physiology



THE HEART



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



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 )



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



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



Anatomy of the Heart

• Aorta

•

Coronary arteries• Arterioles

• Capillaries

•

Venules• Coronary sinus

• Right atrium

Coronary circulation



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



TRAUMA PADA DINDING DADA

• FRAKTUR CLAVICULA

• FRAKTUR STERNUM

• DISLOKASI SENDI STERNOCLAVICULA• FRAKTUR IGA

• “FLAIL CHEST”

• TRAUMA ASPIKSI



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.



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)



DISLOKASI SENDI

STERNOCLAVICULAR

– Kasus Jarang

• Anterior : Nyeri, nyeri tekan, sendi menonjol

kedepan

• Posterior : Sendi tertekan kedalam• Pengobatan : Reposisi



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



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



FRAKTUR IGA

Fraktur Iga + Hemotoraks / Pneumotoraks →

WSD

Fraktur Iga + contusio paru → perawatan ketat

→ ICU Fraktur Iga VI – XII → trauma Ginjal, Hati



FLAIL CHEST

– Segmen dinding dada yang bergerak

paradoksal pada Respirasi

– Fraktur Iga, Trauma langsung, 30% trauma

tumpul toraks – Kontusio paru faktor resiko terjadi ARDS



FLAIL CHEST

– Pengobatan :

• Internal stabilization (Pneumatik Stabilisasi)

– Intubasi Endotracheal

– Ventilasi Mekanik → Mereduksi Pnemonia

• Fiksasi Iga (Stabilisasi bedah)



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



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



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 (-)



PENGOBATAN

• WSDICS IV / ICS V linea aksilaris medialis –

- anterior

• Torakotomi

Kontrol kebocoran paru



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



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



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)



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



Klinis ruptur diafragma

• Riwayat trauma tumpul abdomen

• “Respiratory distress”

• Pendorongan mediastinum kontralateral

dan penekanan paru oleh organ viseral

• Venous return” menurun – CO menurun



TRAUMA ESPOHAGUS

• Trauma tumpul jarang dibandingkan truma

tusuk

• Diagnosis : pneumomediastim atau efusi

pleura

• Esophagography



TRAUMA TUMPUL JANTUNG

• Jarang terjadi

• Trauma langsung karena kecelakaan lalu

lintas

• “Myocardial Contusion”

• EKG



Penetrating injuries



Penanggulangan rongga Pleura

Tujuan

Mengembalikan kondisi fisiologis ronggapleura dengan cara :

1. Observasi

2. Pungsi pleura

3. WSD4. Continous suction ( I botol / 2 botol )



WSD



Indikasi Utama WSD

1. Robekan pleura visceral

2. Monitoring perdarahan untuk dapat

menentukan indikasi torakotomi yang

tidak berdasarkan kepada kondisi klinis

pasien



Pelaporan WSD

1. Initial

2. Undulasi

3. Expiratory bubble4. Produksi



Indikasi Continous Suction

1. Hematopneumotoraks agar darah segera

dapat dikeluar sebelum proses

pembekuan.

2. Robekan pleura visceral .



Definisi :

Pemasangan drain pada rongga pleura melalui

insisi pada sela iga

Tujuan :

Mengeluarkan cairan, darah, udara dari rongga

pleura.



I n d i k a s i

• Trauma toraks• Hematotoraks

• Pneumotoraks

• Chylotoraks

• Infeksi• Empiema

• Keganasan•

Efusi pleura / Fluidotoraks

• Pasca Torakotomi



Pneumotoraks



Hematotoraks



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.



Hematothorax

REMEMBER !!!

• < 3 cc/kgBB/jam Observasi

• 3 – 5 cc/kgBB/jam Hati-hati, Observasi ketat

• > 5 cc/kgBB/jam Operasi / Eksplorasi



Indikasi pencabutan drain

• Klinis

• Radiologis

• Kuantitas dan kualitas cairan



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



• Penderita harus dipasang infus

• Sebaiknya dilakukan di ruang operasi

• Jangan tinggalkan penderita setelah

pemasangan, perhatikan tanda-tanda vitalnya



Jenis WSD



Jenis WSD

Posisi yg WSD



Posisi yg WSD



T T l



Trauma Tumpul

• Dinding TorakJejas

Hematom

Laserasi

Fraktur iga

Fraktur clavicula

Cedera Vaskular



• M - MECHANISM OF INJURY

• I - INJURIES SUSTAINED

• S - SIGNS AND SYMPTOMS

• T - THERAPY



• TRAUMA TUMPUL

• TRAUMA TAJAM

• TRAUMA LEDAKAN

• BIOMEKANIK TRAUMA

• Semua harus dicari melalui anamnesayang teliti



Cidera yang didapat

• Kelainan dinding dada- Empisema kulit

- Fraktur iga respirasi paradoksal

• Kelainan rongga Pleura- Hematotoraks

- Pneumotoraks

- Hemato-Pneumotoraks- Chylothorax



• Kelainan Parenchym Paru

- Traumatic Wet Lung• Kelainan Mediastinum

- Cardiovascular

- Tracheobronchial- Esophagus

• Kelainan Abdominal

- Thoracoabdominal

Si d S t



Signs and Symptoms

• Dicari kemungkinan semua organ yang dapatdicederai sesuai dengan biomekanik trauma

dengan :

- Anamnesa- Inspeksi

- Palpasi

- Perkusi

- Auskultasi

- Pemeriksaan Penunjang lainnya

T i



Terapi

• Saluran nafas• Pernafasaan

• Sirkulasi

• Penanggulangan rongga Pleura• Stabilisasi dinding dada

• Menghilangkan rasa nyeri

• Torakoskopi• Torakotomi

St bili i Di di D d



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



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



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



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



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



and demonstrate the ability to perform the

following :

• Thoracic needle decompression

• Chest tube insertion

• pericardiocentesis

Mechanisms of injury in blunt chest trauma



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



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



• 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



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



Indikasi Torakotomi

Initial bubble (-) atelektasis bronkoskopi

• Pneumotorak WSD

spontan (+)chest fisio

Initial bubble (+) pengembangan paru terapi

( - )torakotomi

Indikasi Bronkoskopi



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



Trauma aspiksia



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



• Shunting paru right to left

saturasi vena pulmonalis menurun

• Shunting perifer left to right

darah kembali ke sentral tanpa melalui

kapiler

RUPTUR DIAFRAGMA



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



TRAUMA ESPOHAGUS

• Trauma tumpul jarang dibandingkan trumatusuk

• Selalu disertai trauma lainnya dari toraks

• Diagnosis : - Pneumomediastinum atau efusi

pleura

- Esophagography



Tension Pneumotoraks



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



Trauma Jantung



g

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



Ruptur Bronkhus

- Inspeksi

- Palpasi

- Perkusi

- Auskultasi

- Pemeriksaan tambahan



Ruptur diafragma

- Inspeksi

- Palpasi- Perkusi

- Auskultasi

- Pemeriksaan tambahan

Cardiac Tamponade



p

• 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



j y

• 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



Cervical/Neck TraumaIntroduction



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



Introduction

• Infrequent except C-spine

• Awareness is essential

• Can be devastating even fatal

• Signs often subtle or absent

• Often too late

Neck Zone



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?





CCH neck protocol


CCH k t l

• Zone I– Angio of arch and



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



• 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





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



Esophageal RuptureEsophageal Rupture



Complete Tracheal Rupture

Complete Tracheal Rupture



BLUNT NECK INJURY



• 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



• CT scan

• Laryngoscopy and Bronchoscopy

• Doppler Ultrasound• Angiography

• Contrast Esophagogram

• Flexible Esophagoscopy

Neck Injury : Conclusions




• 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





• 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



Thoracic Trauma

Introduction



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



Mechanism of Injury



• 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



Mechanism of Injury



Penetrating injuries • E.g. stab wounds etc.

• Primarily peripheral lung

• Haemothorax

• Pneumothorax

• Cardiac, great vessel ,trachea

or oesophageal injury

Penetrat ing in jur ies



Chest wall injuries

Chest wall injuries

Chest wall injuries



• Rib fractures

• Flail chest

• Open pneumothorax

Rib fractures



• 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



• 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



Open pneumothorax



• 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



Lung injury

Lung injury



• Pulmonary contusion

• Pneumothorax

• Haemothorax• Parenchymal injury

• Trachea and bronchial injuries

• Pneumomediastinum

Pulmonary contusion



• 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



Pulmonary contusion &

Left Lung Herniation



Pneumothorax



• 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



Tension pneumothorax



• 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



Haemothorax



• 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



Haemothorax



• 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



• Continuous bubble• Suggested by:

• Pneumothorax

• Pneumomediastinum

• Subcutaneous emphysema

• Hemoptysis• Airway obstruction

Tracheal and bronchial injuries



Trachea and bronchial injuries



• 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



Heart, Aorta & Diaphragm

Heart, Aorta & Diaphragm



• Blunt cardiac injury

- contusion

- ventricular, septal or valvular rupture

• Cardiac tamponade

• Ruptured thoracic aorta

• Diaphragmatic rupture

Blunt cardiac injury



• 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



Aortic rupture



• 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



Aortic rupture



• 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



Aortic rupture



Diaphragm Rupture



• 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



Left Gastrothorax



Chest trauma: summary

Chest trauma: summary• Common

Serio s



• 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



• NG tubes: -coiling-endobronchial placement

-pneumothorax

• Chest tubes: - subcutaneous- intraparenchymal

- intrafissural

• Central lines: - neck- coronary sinus

- pneumothorax

Line in jugular vein



Misplaced nasogastric tube

chest trauma 1 dr. ber

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