Beruflich Dokumente
Kultur Dokumente
Thoracic Trauma
BY : dr. ADRIAN KHU,SpOT
© ACS
Objectives
Indentify and treat injuries found during the
primary survey.
Indentify and treat injuries found during the
secondary survey.
Demonstrate the ability to perform life
saving chest management.
• Indications
• Contraindications
© ACS
Thoracic Trauma
1 out of 4 deaths
Blunt : < 10% require operation
Penetrating : 15% - 30% require operation
Majority : require simple procedures
© ACS
Resuscitation
Airway control
Ensure oxygenation/ventilation
Initial Assessment/Management
Secondary Survey Definitive Care
Identifies most Airway control
potentially lethal Ensure oxygenation
/ventilation
injuries
Tube thoracostomy
Physical exam/
Hemodynamic
diagnostic tests
support
Operation
© ACS
Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade
© ACS
Airway Obstruction
Laryngeal injury
Rare occurrence
Hoarseness
Subcutaneous emphysema
Treatment
• Intubation (caution)
• Tracheostomy (by surgeon)
© ACS
Breathing
Breathing
Tension Pneumothorax : Signs / Symptoms
• Respiratory distress
• Distended neck veins
• Unilateral ↓in breath sounds
• Hyperresonance
• Cyanosis, late
© ACS
Breathing
Tension
Pneumothorax
Immediate
decompression
Clinical diagnosis,
not by x-ray
© ACS
Breathing
Open Pneumothorax
• Cover defect
• Chest tube
• Definitive operation
© ACS
Breathing
Flail chest
© ACS
Breathing
Flail Chest/pulmonary Contusion
Reexpand lung
Oxygen
Intubation as indicated
Analgesia
© ACS
Circulation
Massive Hemothorax
≥ 1500 ml blood loss
percussion dullness
© ACS
Circulation
Massive Hemothorax
Rapid volume restoration
Autotransfusion
Operative intervention
© ACS
Circulation
Cardiac Tamponade
• ↓Arterial pressure
• Distended neck veins
• Muffled heart sounds
• PEA
© ACS
Circulation
Cardiac Tamponade
Patent airway
IV therapy
Pericardiocentesis
Pericardiotomy
© ACS
Resuscitative Thoracotomy
• Qualified surgeon presnt on patient’s arrival
Indications
• Blunt injury
• Pulseless without electrical activity
© ACS
ABGs
Pulse oximetry
ECG
© ACS
Secondary Survey
Pneumothorax
Penetrating /blunt
trauma
V / Q defect
Hyperresonance
↓ Breath sounds
Tube thoracostomy
© ACS
Secondary Survey
Hemothorax
Secondary Survey
Pulmonary Contusion
Most common
Oxygenate , ventilate
Selective intubation
© ACS
Secondary Survey
Tracheobronchial injury
Frequently missed
Treatment
injury
• Airway
Blunt / penetrating
trauma ventilation
Partial vs complete • Operation
Diagnostic aid : Endoscopy
© ACS
Secondary Survey
Blunt Cardiac Injury
Injury spectrum
Echocardiography
deceleration
Ligamentum
arteriosum
Salvage : identify early
Surgical consult
© ACS
Secondary Survey
Diaphragmatic Rupture
Most diagnosed on left
Penetrating → small
perforations
Misinterpreted x –ray
Contrast radiography
Operation
© ACS
Tension pneumothorax
Pericardial tamponade
Tracheobronchial : Bronchoscopy
Esophageal Esophagography,
esophagoscopy
© ACS
Secondary Survey
Subcutaneous
Emphysema
Airway injury
Pneumothorax
Blast injury
© ACS
Secondary Survey
Traumatic Asphyxia
Petechiae
Swelling
Plethora
Cerebral edema
© ACS
Secondary Survey
Sternal, Scapular, and Rib Fracture:
Pathophysiology
Hemopneumothorax
Pain Splinting
Retained secretion
Associated injuries
Atelectasis pneumonia
Impaired ventilation
Pulmonary contusion
© ACS
Secondary Survey
Sternal, Scapular, and Rib Fractures
Ribs 1- 3
• Severe force
• Associated injuries → High mortality risk
Ribs 4 – 9
• Pulmonary contusion
• Pneumohemothorax
Ribs 10 – 12 : Suspect abdominal injury
© ACS
Secondary Survey
Sternal, Scapular, and Rib Fractures :
Management
Secondary Survey
Esophageal Trauma
Blunt vs penetrating
Secondary Survey
Esophageal Trauma
Chest tube :
Particulate matter
Mediastinal air
Contrast swallow,
esophagoscopy
Operation
© ACS
Secondary Survey
Other indication for Tube Thoracostomy
Suspected, severe lung injury
Pitfalls
Simple pneumothorax → tension
pneumothorax
Retained hemothorax
Diaphragmatic injury
Delayed diagnosis of aortic injury
Severity of rib fractures pulmonary
contusion
Elderly
© ACS
Questions
© ACS
Summary
Common in multiply injured
Life – threatening injuries
Develop skills to treat
Monitoring