1 blunt thoracic injury chao-wen chen attending surgeon trauma service, kmuh

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Blunt Thoracic Injury Blunt Thoracic Injury

Chao-Wen ChenChao-Wen ChenAttending SurgeonAttending Surgeon

Trauma Service, KMUHTrauma Service, KMUH

2004-July Trauma Conference 2

Preface Preface Preface Preface

2/3 of victims of major blunt trauma suffer from thoracic injury.

Thoracic injuries account for 20-25% of deaths due to trauma.

Major thoracic trauma is associated with multisystem injuries in 70% of cases.


Common Injuries Develop Common Injuries Develop After Blunt Chest TraumaAfter Blunt Chest TraumaCommon Injuries Develop Common Injuries Develop After Blunt Chest TraumaAfter Blunt Chest Trauma

Thoracic cage fracturesLung contusion and tearsMyocardium contusionAortic rupture


Initial SurveyInitial SurveyInitial SurveyInitial Survey

Assume the existence of C-spine injury ABCsGerneral evaluation: PE, PH, ECG, or ABG…Chest x-ray Administer oxygen


處理原則處理原則處理原則處理原則謹記 ABC 順序與原則初級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理：

張力性氣胸（ Tension Pneumothorax ）連枷胸（ flail chest ）開放性胸壁傷口（ open chest wound ）大量血胸（ massive hemothorax ）心包填塞（ cardiac tamponade ）


如何處理如何處理？？如何處理如何處理？？張力性氣胸連枷胸開放性胸壁傷口大量血胸心包填塞


如何處理如何處理？？如何處理如何處理？？張力性氣胸 Needle decompression/ Chest Tube

連枷胸 Pain control/ O2 / MV

開放性胸壁傷口 Wound coverage/Chest tube

大量血胸 Chest tube / Thoracotomy

心包填塞 Pericardial window


Imaging SurveyImaging SurveyImaging SurveyImaging Survey

Chest x-rayChest x-ray : serve as a screening rather than a definite test repeat radiography should be ordered if suspicious

Computed tomographyComputed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest trauma

AngiogramAngiogram : for suspicious great vessel injuriesChest ultrasoundChest ultrasound : detect hemothorax, FAST


處理原則處理原則處理原則處理原則二級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理：

主動脈破裂（ contained aorta rupture ）氣管或支氣管破裂（ rupture of tracheobronchial tre

e ）食道破裂（ perforation of esophagus ）橫膈破裂（ rupture of diaphragm ）心肌挫傷（ myocardial contusion ）肺部挫傷（ pulmonary contusion ）


Contained aortic tearContained aortic tearContained aortic tearContained aortic tear


PneumothoraxPneumothoraxPneumothoraxPneumothorax


HemothoraxHemothoraxHemothoraxHemothorax


Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries

Sternal fractureSternal fracture• More serious injuries may accompany• If suspected, a lateral CXR may be dia

gnostic• Operative reduction is usually unneces

sary • Hospitalization is not mandatory if the

ECG is normal and the patient’s vital sign is stable



Flail chestFlail chest• Fracture of 2 or more consecutive ribs in at least

2 places each• About 30-40% of patients need mechanical

ventilation• ARDS is increased 20-30% in the presence of

flail chest



Flail chestFlail chest• Close monitoring of respiratory performance• Adequate analgesic therapy• Provide oxygen therapy and ventilatory support• Aggressive pulmonary toilet



Lung contusionLung contusion• CxR finding may range from minimal interstitial inf

iltrate to extensive lobar consolidation• Chest CT is accurate diagnostic tool but not alwa

ys mandatory• Tx : same as flail chestsame as flail chest, but pay attention to avoid

overhydration; use of steroid and prophylactic antibiotic are still controversial


Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion



Blunt Cardiac Trauma - spectrumBlunt Cardiac Trauma - spectrum• Asymptomatic myocardiac contusion• Symptomatic myocardiac contusion• Free wall or septal wall rupture• Valvular tears• Coronary artery thrombosis



Blunt Cardiac Trauma – risk factorsBlunt Cardiac Trauma – risk factors• Chest impact > 15 mph• Marked precordial tenderness, ecchymosis or contusion • PH of cardiac disease• Fractured sternum• Thoracic spine or ribs fractures• Hemodynamic instability, or multiple injuries• Age > 50



Blunt Cardiac Trauma - assessmentBlunt Cardiac Trauma - assessment• Most are asymptomatic; severe cases die before

arrival• Common manifestation : arrhythmia, hemo-dyna

mic instability • Evaluation : CxR, ECG, cardiac enzymes, echo-c

ardigram, MUGA



Blunt cardiac trauma - managementBlunt cardiac trauma - management• Most cases do not require Tx; Symptomatic arrhythmia

(2-5%) antiarrthythmics• Abnormal ECG and cardiac enzymes almost return to no

rmal within one week.• Patients with abnormal cardiac echo finding or MUGA

keep hospitalization till a repeat test show acceptable finding

• Cardiac rupture prompt surgical repair



Blunt cardiac trauma - Guideline (USC+LAC)Blunt cardiac trauma - Guideline (USC+LAC)• Obtain admission ECG and CPK-MB/TnTTnT in patient with

suspect BCI• Repeat ECG 8-12 hours after admission• For unexplained hemodynamic instability, abnormal ECG,

and abnormal cardiac enzyme levels perform cardiac echogram

• If no suspect symptomatolgy, lab tests or ECG finding discharge after 12 hours


胸部鈍傷處理流程胸部鈍傷處理流程胸部鈍傷處理流程胸部鈍傷處理流程 PE Survey

理學檢查

氣胸Needle decompression/ Chest tube

Subxyphoid windowthoracotomy

Needle decompression/ Chest tube

張力性氣胸

血胸

心包填塞


X-ray CXR 檢查

氣胸

Chest tube

Pain controlOxygen supplyAvoid fluid overloadResp. Distress(+)MV

NGTrepeat X-rayUGI seriesU/S or CT scan

血胸

橫膈？

連枷胸、肺挫傷

若出血 >1200ml 或 >200ml/hr ，考慮開胸術

縱膈積氣氣胸 ( ＋ ) Chest Tube氣胸 ( － ) 氣管支氣管鏡檢食道鏡檢或食道造影

縱膈腔變寬 Chest CTAortic Angiogram


胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則

Admission OrderDay 1

□ Consider ICU admission for elderly patients, or if other complicating factors exist.

□ NPO□ Chest tube to suction, follow chest tube output□ Follow-up CXR□ Analgesia (□ oral □ epidural □ PCA)□ Pulmonary toilet□ OOB to chair



Day 2□ Advance diet□ Chest tube to suction, follow chest tube output□ Morning CXR□ Analgesia (□ oral □ epidural □ PCA)□ Pulmonary toilet□ OOB to chair



Day 3□ if no air leak, chest tube to water seal, otherwise to suction.

follow output□ Morning CXR□ Analgesia (□ oral □ epidural □ PCA)□ Pulmonary toilet□ Ambulate tid once chest tube is off suction



Day 4□ Check CXR after 6-8 hours on water seal, if lung expanded

and output<150ml remove chest tube□ Recheck CXR 6 hours post removal, discharge if expanded.□ Change analgesia to orat□ Keep site dressing in place × 48 hrs



無併發症病患預計留院時間 “ 4” 天出院時應注意下列狀況：

病患呼吸狀況應符合生理基本需求，無窘迫情形疼痛之適度處理肺部擴展完全且血胸已順利引出病患了解傷口後續照護原則

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Thank you for your Thank you for your attention!attention!

1 blunt thoracic injury chao-wen chen attending surgeon trauma service, kmuh

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