01. TRAUMA TORAKS (06-11-2012)

Thoracic traumaThoracic trauma

Dr. Subagjo, SpB, SpBTKVDr. Subagjo, SpB, SpBTKV

Dr. Artono Isharanto, SpB, SpBTKVDr. Artono Isharanto, SpB, SpBTKV

2.Thoracic trauma2.Thoracic trauma-1 out of 4 deaths1 out of 4 deaths

-blunt < 10% require blunt < 10% require

operation.operation.

- penetrating 15% - - penetrating 15% -

require operationrequire operation-majority require majority require

-Simple proceduresSimple procedures

S 1

Thoracic traumaThoracic trauma

- 1 out of 4 death- 1 out of 4 death - blunt < 10 % require operation- blunt < 10 % require operation - penetrating 15%-30% require operation- penetrating 15%-30% require operation - majority require simple procedures- majority require simple procedures

PRIMARY SURVEY/LIFE – PRIMARY SURVEY/LIFE – THREATENING INJURIESTHREATENING INJURIES

MAJOR PROBLEMS SHOULD BE MAJOR PROBLEMS SHOULD BE CORRECTED AS THEY ARE IDENTIFIEDCORRECTED AS THEY ARE IDENTIFIED- airway obstruction- airway obstruction- tension pneumothorax- tension pneumothorax- open pneumothorax- open pneumothorax- flail chest- flail chest- massive hemothorax- massive hemothorax- cardiac tamponade- cardiac tamponade

AIRWAY OBSTRUCTIONAIRWAY OBSTRUCTION laryngeal injury laryngeal injury

- rare occurrence- rare occurrence - hoarseness- hoarseness - subcutaneous emphysema- subcutaneous emphysema - treatment * intubation- treatment * intubation

* tracheostomy* tracheostomy

BREATHINGBREATHING

1.1. TENSION PNEUMOTORAX :TENSION PNEUMOTORAX : EtiologyEtiology Parenchymal and/or chest-wall injury.Parenchymal and/or chest-wall injury. Air enters pleural space with no exitAir enters pleural space with no exit Positive pressure ventilationPositive pressure ventilation - collapse of affected lung- collapse of affected lung - decrease venous return- decrease venous return - decrease ventilation of opposite lung.- decrease ventilation of opposite lung.

BREATHINGBREATHING

Tension pneumothorax sign/symptomsTension pneumothorax sign/symptoms- respiratory distressrespiratory distress- Distended neck veinsDistended neck veins- Unilateral decrease in breath soundsUnilateral decrease in breath sounds- HyperresonanceHyperresonance- Cyanosis, lateCyanosis, late

BREATHINGBREATHINGTENSION PNEUMOTHORAXTENSION PNEUMOTHORAX- immidiate decompressionimmidiate decompression- Clinical diagnosis, not by X rayClinical diagnosis, not by X ray

Therapy : nedlee decompression and chestTherapy : nedlee decompression and chest

tube after it has been insertedtube after it has been inserted

BREATHINGBREATHING

2.Open pneumothorax2.Open pneumothorax- cover defectcover defect- chest tubechest tube- definitive operationdefinitive operation

3. BREATHING3. BREATHING

FLAIL CHEST /PULMONARY CONTUSION FLAIL CHEST /PULMONARY CONTUSION Reexpand lungReexpand lung OxygenOxygen Judicious fluid managementJudicious fluid management Intubation as indicatedIntubation as indicated analgesia analgesia

4.CIRCULATION4.CIRCULATION

MASSIVE HEMOTHORAX :MASSIVE HEMOTHORAX : > 1500 ml blood loss> 1500 ml blood loss Systemic/pulmonary vessel disruptionSystemic/pulmonary vessel disruption Flat vs distended neck veinsFlat vs distended neck veins Shock with no breath sound and/or Shock with no breath sound and/or

percussion dullnesspercussion dullness

CIRCULATIONCIRCULATIONMASSIVE HEMOTHORAXMASSIVE HEMOTHORAX- rapid volume restorationrapid volume restoration- chest decompression and X-raychest decompression and X-ray- autotransfusionautotransfusion- operative interventionoperative intervention

::

CIRCULATIONCIRCULATION

CARDIAC TAMPONADECARDIAC TAMPONADE- decrease arterial pressuredecrease arterial pressure- distended neck veinsdistended neck veins- muffled heart soundmuffled heart sound- PEA PEA

THERAPY – patent airwayTHERAPY – patent airway

- iv therapy- iv therapy

- pericardiocentesis- pericardiocentesis

- pericardiotomy - pericardiotomy

SECONDARY SURVEYSECONDARY SURVEYPOTENTIALLY LETHAL CHEST POTENTIALLY LETHAL CHEST TRAUMATRAUMA

1.1. SIMPLE PNEUMOTHORAXSIMPLE PNEUMOTHORAX

2.2. HEMOTHORAXHEMOTHORAX

3.3. PULMONARY CONTUSIONPULMONARY CONTUSION

4.4. TRACHEOBRONCHIAL TREE INJURIESTRACHEOBRONCHIAL TREE INJURIES

5.5. BLUNT CARDIAC INJURYBLUNT CARDIAC INJURY

6.6. TRAUMATIC AORTIC DISRUPTIONTRAUMATIC AORTIC DISRUPTION

7.7. TRAUMATIC DIAPHRAGMATIC INJURYTRAUMATIC DIAPHRAGMATIC INJURY

8.8. MEDIASTINAL TRANSVERSING WOUNDS MEDIASTINAL TRANSVERSING WOUNDS

1.SIMPLE PNEUMOTHORAX1.SIMPLE PNEUMOTHORAX

- penetrating/blunt traumapenetrating/blunt trauma- hyperresonancehyperresonance- decrease breath soundsdecrease breath sounds- tube thoracostomytube thoracostomy

2.HEMOTHORAX2.HEMOTHORAX

- chest wall injurychest wall injury- lungvessel lacerationlungvessel laceration- tube thoracostomytube thoracostomy

3.PULMONARY CONTUSION3.PULMONARY CONTUSION Most commonMost common Oxygenate ventilateOxygenate ventilate Selective intubationSelective intubation

4.TRACHEAL INJURY4.TRACHEAL INJURY

Frequently missed injuryFrequently missed injury Blunt/penetrating traumaBlunt/penetrating trauma Partial vs complatePartial vs complate Diagnostic aid endoscopyDiagnostic aid endoscopy Treatment * airway ventilationTreatment * airway ventilation

* operation* operation

5.BLUNT CARDIAC INJURY5.BLUNT CARDIAC INJURY

Injury spectrumInjury spectrum ECG changes: monitor changeECG changes: monitor change EchocardiographyEchocardiography Tret dysrhytmia, Q complications Tret dysrhytmia, Q complications

6.AORTIC RUPTURE6.AORTIC RUPTURE Rapid aceleration/decelerationRapid aceleration/deceleration Ligamentum arteriosumLigamentum arteriosum Salvage identify earlySalvage identify early Surgical consultSurgical consult X-ray: widened mediastinum,obliteration of the aortic X-ray: widened mediastinum,obliteration of the aortic

knob,depression of the left main stem bronchus,fractures knob,depression of the left main stem bronchus,fractures of the first or second rib or scapulaof the first or second rib or scapula

Aortogram. Aortogram. Therapy Therapy primer suture aorta / resection and grafting primer suture aorta / resection and grafting

7.DIAPHRAGMATIC RUPTURE7.DIAPHRAGMATIC RUPTURE

- most diagnosted on left- most diagnosted on left

- blunt , large tears- blunt , large tears

- penetrating, small perforations- penetrating, small perforations

- miss interpreted x ray (elevated - miss interpreted x ray (elevated diaphragm,acute gastric delatation, a diaphragm,acute gastric delatation, a loculated pneumothoraxloculated pneumothorax

- contras radiography- contras radiography Therapy Therapy direct closure direct closure

8.MEDIASTINAL TRANSVERSING WOUND8.MEDIASTINAL TRANSVERSING WOUNDhemodinamically abnormalhemodinamically abnormal

exsanguinating thoracic hemorrhageexsanguinating thoracic hemorrhage tension pneumothoraxtension pneumothorax Pericardial tamponadePericardial tamponade Esophageal or tracheobronchial injuryEsophageal or tracheobronchial injury Spinal cord injurySpinal cord injury hemodinamicallyhemodinamically normalnormal- vascular: angiography- vascular: angiography- tracheobronchial: bronchoscopytracheobronchial: bronchoscopy- esophageal: esophagography,esophagoscopyesophageal: esophagography,esophagoscopy- Treatment Treatment mandatory surgical consultation, repair mandatory surgical consultation, repair

identified injuries, identified injuries,

OTHERS TRAUMAOTHERS TRAUMA

TRAUMATIC ASPHYXIATRAUMATIC ASPHYXIA PtechiaePtechiae SwellingSwelling PlethoraPlethora Cerebral edemaCerebral edema