1. Thorax Trauma

Pathophysiology Derangements in the flow of air, blood, or both in combinationChest wall injures rib fracturesDirect lung injures lung contusionsSpace-occupying lessions pneumothoraces, hemothoraces, hemopneumothoracesCardiac injures chamber ruptureSevere great vessels injures thoracic aortic disruptionTRAUMA THORAX

RAPIDLY LETHAL LESIONie. Lesion that could kill the patient in a matter of minutesairway obstructiontension pneumothoraxopen pneumothoraxmassive haemothoraxflail chestcardiac tamponade

Potensially lethal lesions,.i.e. lesions that can kill the patient in matter of hourspulmonary contusionaortic rupturetracheobronchial ruptureoesophageal rupturediaphragmatic rupturemyocardial contusion

NON IMMEDIATELY LIFE THREATENING LESIONSHaemothoraxsimple pneumothoraxrib fracturessternal fracturessoft tissue lesionstraumatic chylothoraxintrathoracic foreign bodiessubcutaneous emphysemaothers.

Clinical PresentationVaries widely from minor report to florish shockClinical history time of injury, mechanism, velocity&deceleration, assosiated injury, silent future3 broad categories : (1) chest wall fracture, dislocation, and barotrauma (including diaphragmatic injury); (2) blunt injuries of the plaurae,lungs, and aerodigestive tracts; and (3) blunt injuries of the heart, great vessels

Imaging studiesCXR should not wait CXR for diagnose emergency measurementChest CT-scan should restricted to undetected or occult injury is consideredAortogram standard for diagnosis of blunt aortic injuresThoracic US pericardial effusions or tamponadeContrast Esophagogram for esophageal injures

Rib FracturesMost common blunt thoracic injuries, rib 4-10 most frequently involvedInspiratory chest pain, pain over the fractures siteTenderness and crepitus over the site of fractureMostly do not need surgery, pain control the goal of treatmentEarly mobilization and aggressive pulmonary toiletSurgical Hemostasis if lacerates intercostal artery

Flail Chest>3 ribs fractures in >2 places free floating and unstable chest wall or Costochondral separation Pain over fracture site, pain upon inspiration, dyspnea.Paradoxal inspiration (sucking chest) chest wall move inward with inspiration and outward with expirationLabored respiration due to paradoxal motion respiratory distress

Treatment : Flail ChestEndotreacheal intubation and positive pressure mechanical ventilationStabilize chest wall internal fixation

Clavicular fractureTenderness and tenderness over the siteProximal segment displaced superiorly action sternocleidomastoideusMostly can be managed without surgeryImmobilization figure eight, clavicle strap, sling.Oral analgesia

Sternal FractureInspiratory pain, local tenderness, swelling, ecchiymosis, crepitusAssociated injuries : rib fractures, long bone fracture, close head injuryBlunt cardiac injury 20%No therapy specifically analgesia and minimize activities of pectoral and shoulder muscleMost important exclude blunt myocardial injuryOpen reduction & fixation badly displaced wire suturing and placement of plates and screw

Scapular fractureUncommonAssociated injury : head, chest, abdomenExclude major vascular injuryShoulder immobilization sling or shoulder harnessEarly ROM exercise prevent shoulder contracture

Blunt diaphragmatic injuriesMostly left sideMust considered abdominal injury with dyspnea and respiratory distressHypovolemic shock major splenic or hepatic injuryApproached laparotomy suture with polypropylene or dacron

PneumothoraxRib fracture or barotraumaDyspnea, decreased breath sound and hyperresonance to percussionChest tube + suction sistem -20 cmH2O (pleur-evac) WSD if the lung remains fully expanded chest tube remove CXR

Tension pneumothoraxVentile mechanism lungs collaps respiratory distressDiminished or absent of breath sound, hemithorax hyperresonant to percussion, trachea deviatedImmediate decompression with needle thoracostomy (large bore nedle 14-16G) Chest tube Pain control

Open PneumothoraxCaused by penetrating trauma rarely due to blunt traumaRespiratory distress lung collapsPlacing occlusive dressing over wound chest tube

HemothoraxAccumulation of blood within the pleural spaceLacerations internal mammary vessels or other major thoracic vesselsChest tube, massive (1500mL or 200-300 mL/h) thorachotomy

Pulmonary contusion and other parenchymal injuresTransmition of force to the lung parenchym lung contusion with hemorrage into the lung tissueClinical finding depent to the extent of the injuryPain control, pulmonary toilet, sumplemental oxygen (intubation with mecanical ventilation)Surgical haemostatis laceration or avulsion

Blunt tracheal injuryFracture, lacerations, and disruptionsRespiratory distress, cannot speak, stridor, other sign associated w pneumothorax n subcutaneous emphysemaMany die before can reach defenitive care life trheatening require immediate surgical repair to establishment of an adequate airwayEndotracheal intubation flexible bronchoscope tube placed distal site of injuryAlways prepared to perform emergency trecheotomySurgical repair restoration of airway continuity w primary end-to-end anstomosis

Blunt bronchial injuriesLaceration, tear, or disruption of a major bronchus is life threatening many die before treatmentRespiratory distress n physical sign consistent w pneumothoraxRequire surgical repair secure airwayIpsilateral thoracotomy on the affected side w single-lung ventilation debridemant n end-to-end ansstomosis

Blunt esophageal injuriesRare because protected location in posterior mediastinumCaused by a sudden increase intraluminal pressure from a forceful blow to the epigastriumSpillage GI contents into the chestUpper abdo & thoracic pain ass w thypnea, tachycardia, subcutaneus emphysema.

Treatment : Blunt esophageal injuriesFluid resuscitation n broad-spectrum iv antibiotic n anaerob ABSurgery debridemant w primary anatomosis well-vascularized autologous tissue (parietal pleura n intercostal muscle) Thal PatchPoor general condition esophageal diversion (a cervical esophagostomy), the distal esophagus stapled, gastrostomy for decompression, and wide mediatinal drainage w chest tube.

Blunt cardial injuriesCause by : MVA (most common), falls, crush injuries, violent, sport injury, ectRange varies from mild trauma ass w arrythmias to severe rupture valve, septum or myocardialClinical varies from chest pain to cardiac tamponade to complete cardivascular collapsTreatment cardiosintesis to cardiorrhapy w cardiopulmonar by pass

Blunt injuries of the thoracic aorta and major thoracic arteriesMechanism injury: rapid deceleration sharing force, direct compressionMany die before reaching defenitive careTreatment: endovascular stent grafts, arteriorraphy w cardiopulmonary by pass

Blunt injury of the superior vena cava and major thoracic veinsRare, usually ass w injuries other major thoracic vascular structuresTreatment : venorrhaphy w cardiopulmonary by passInjured subclavian or azigous veins if difficult to repair can be ligated