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 =)