trauma toraks
TRANSCRIPT
Trauma Toraks
Michael MulyonoOlivia Petrina
Adityo BaskoroDani Yudo
Classification
• Penetrating Trauma – <20-30% memerlukan torakotomi
• Blunt Trauma– <10% memerlukan torakotomi
Penetrating Trauma
• Pneumothorax– Open– Closed (Simple and Tension)
• Hematothorax• Hematopneumothorax• Vascular laceration• Tracheo-bronchial Rupture• Oesophagial Rupture• Cardiac penetrating wound• Tamponade• Diaphraghm Rupture
Blunt Trauma
• Rib Fracture– Multiple Rib – Flail Chest– Visceral Damage
• Pulmonary Contusion
• Pneumothorax
• Hematothorax
• Traumatic Asphyxia
Major Death Cause
• Airway Obstruction
• Hypovolemia
• Cardiac Tamponade
Tension Pneumothorax
• Develops when a one-way valve air leak occurs.
• Air forced into the thoracic cavity without means of escaping
• Will cause:– Collapse of affected lung– Displaced mediastinum reduce VR– Compressing opposite lung
Clinical Manifestation
• Dyspnea– Tachypnea at first
• Progressive ventilation/perfusion mismatch– Atelectasis on uninjured side
• Hypoxemia• Hyperinflation of injured side
of chest• Hyperresonance of injured
side of chest
• Diminished then absent breath sounds on injured side
• Cyanosis• Diaphoresis• JVD• Hypotension• Hypovolemia• Tracheal Shifting
– LATE SIGN
• Management – Immediate
decompression– needle thoracostomy at
2nd intercostal space, mid-clavicular line
– Definitive treatment: insertion of chest tube into fifth intercostal space, between the anterior and midaxillary line
Open Pneumothorax
• Sucking chest wound• Large defects of the
chest wall causing immediate equilibration between intrathoracic presure and atmospheric pressure
• Involve defects of more than two-thirds the diameter of trachea (Normal 1.0-1.5cm)
• Management:– Closing defect with sterile
occlusive dressing and taped on 3 sides
– Open end of the dressing allows air to escape
– A chest tube should be placed as soon as possible
– Definitive: surgical closure of defect
Hematothorax
– Accumulation of blood in the pleural space– Serious hemorrhage may accumulate 1,500
mL of blood• Mortality rate of 75%• Each side of thorax may hold up to 3,000 mL
– Blood loss in thorax causes a decrease in tidal volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax• Hemopneumothorax
Management :– High flow O2
– 2 large bore IV’s• Maintain SBP of 90-100• EVALUATE BREATH SOUNDS for fluid overload
– Chest Tube Insertion– Consider thoracotomy
Clinical Manifestation
• Shock– Dyspnea– Tachycardia– Tachypnea– Diaphoresis– Hypotension
• Dull to percussion over injured side
Flail Chest
• Occurs when a segment of the chest wall doesn’t have bony continuity with the rest of the thoracic cage
• Multiple rib fractures– Two or more ribs
fractured in two or more places
• Features:– Paradoxical motion of
chest wall– Pain– Restricted chest wall
movement– Hypoventilation– Worsening hypoxia
• CXR• ABG – respiratory
failure
• Definitive treatment– Reexpand the lung– Ensure oxygenation– Fixation
• Internal• External (Wide Plaster)
– Provide analgesia to improve ventilation
Pulmonary Contusion
– Soft tissue contusion of the lung– 30-75% of patients with significant blunt chest trauma– Frequently associated with rib fracture– Typical MOI
• Deceleration– Chest impact on steering wheel
• Bullet Cavitation– High velocity ammunition
– Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar tissue
• Progressive deterioration of ventilatory status
– Hemoptysis typically present
Pericardiac Tamponade
– Restriction to cardiac filling caused by blood or other fluid within the pericardium
– Occurs in <2% of all serious chest trauma• However, very high mortality
– Results from tear in the coronary artery or penetration of myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of cardiac contractions
– Removing as little as 20 ml can provide relief
Clinical Manifestation
• Dyspnea• Possible cyanosis• Beck’s Triad
– JVD– Distant heart tones– Hypotension or narrowing
pulse pressure
• Weak, thready pulse• Shock
• Kussmaul’s sign– Decrease or absence of
JVD during inspiration• Pulsus Paradoxus
– Drop in SBP >10 during inspiration
– Due to increase in CO2 during inspiration
• Electrical Alterans– P, QRS, & T amplitude
changes in every other cardiac cycle
• PEA
• Management :– High flow O2
– IV therapy– Consider pericardiocentesis; rapidly
deteriorating patient
Tracheobronchial Injury
– 50% of patients with injury die within 1 hr of injury– Disruption can occur anywhere in tracheobronchial
tree– Signs & Symptoms
• Dyspnea• Cyanosis• Hemoptysis• Massive subcutaneous emphysema• Suspect/Evaluate for other closed chest trauma
Management :– Support therapy
• Keep airway clear• Administer high flow O2
– Consider intubation if unable to maintain patient airway
• Observe for development of tension pneumothorax and SQ emphysema
Traumatic Asphyxia
– Results from severe compressive forces applied to the thorax
– Causes backwards flow of blood from right side of heart into superior vena cava and the upper extremities
– Signs & Symptoms• Head & Neck become engorged with blood
– Skin becomes deep red, purple, or blue– NOT RESPIRATORY RELATED
• JVD• Hypotension, Hypoxemia, Shock• Face and tongue swollen• Bulging eyes with conjunctival hemorrhage
– Support airway• Provide O2
• PPV with BVM to assure adequate ventilation
– 2 large bore IV’s– Evaluate and treat for concomitant injuries– If entrapment > 20 min with chest
compression• Consider 1mEq/kg of Sodium Bicarbonate
Thank You =)