thoracic trauma katec

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หน�วัยศั�ลยกร์ร์มการ์บาดเจ็�บและศั�ลยกร์ร์มวักฤตบ#าบ�ด

(Trauma & Surgical Critical Care Unit)กล$�มงานศั�ลยกร์ร์ม โร์งพยาบาลขอิ่นแก�น

Thoracic Thoracic TraumaTrauma

ObjectivesObjectives

● Identify and treat life-threatening injuries found during the primary survey

● Identify and treat potentially life-threatening injuries found during the secondary survey

THORAXTHORAX

Thoracic TraumaThoracic Trauma

● Significant cause of mortality

● Blunt: < 10% require operation

● Penetrating: 15-30% require operation

● Majority: Require simple procedures

● Most life-threatening injuries are identified during the primary survey

Thoracic TraumaThoracic Trauma

● Laryngeotracheal injury / Airway obstruction

● Tension pneumothorax

● Open pneumothorax

● Flail chest and pulmonary contusion

● Massive hemothorax

● Cardiac tamponade

What are the immediately life-threatening chest injuries?

Thoracic TraumaThoracic Trauma

● Hypoxia

● Hypoventilation

● Acidosis● Respiratory

● Metabolic

● Inadequate tissue perfusion

What are the pathophysiologic consequences of these chest injuries?

Manage in the

primary survey as identified

Laryngotracheal InjuryLaryngotracheal Injury

Airway Obstruction

● Rare

● Hoarseness

● Subcutaneous emphysema

● Manage in the primary survey as soon as possible● Intubate cautiously

● Tracheostomy

Tension PneumothoraxTension Pneumothorax

● Respiratory distress

● Hypotension (Shock)

● Distended neck veins

● Unilateral decrease in breath sounds

● Hyperresonance

● Cyanosis (late sign)

Tension PneumothoraxTension Pneumothorax

● Clinical diagnosis, not by x-ray

● Immediate decompression● Needle

● Chest tube

Needle ThoracentesisNeedle Thoracentesis

Open PneumothoraxOpen Pneumothorax

Open PneumothoraxOpen Pneumothorax

● 3-sided dressing cover over defect

● Chest tube

● Definitive operation

Three Sides-Dressing

Flail Chest and Pulmonary Flail Chest and Pulmonary ContusionContusion

Paradoxical motionParadoxical motion

Flail Chest and Pulmonary Flail Chest and Pulmonary ContusionContusion

● Oxygen

● Re-expand lung

● Intubate as indicated

● Judicious fluids

● Analgesia

Massive HemothoraxMassive Hemothorax

● Systemic / pulmonary vessel disruption

● > 1500 mL blood loss

● Flat vs. distended neck veins

● Shock with no breath sounds and/or percussion dullness

Massive HemothoraxMassive Hemothorax

● Rapid volume restoration

● Chest decompression and x-ray

● Autotransfusion

● Operative intervention

Cardiac TamponadeCardiac Tamponade

● Most ; penetrating injury

● Decreased arterial pressure

● Distended neck veins

● Muffled heart sounds

● Pulseless electrical activity (PEA)

Radio antenna

Cardiac TamponadeCardiac Tamponade

A Secure airway

B Ventilate and

oxygenate

C Volume resuscitation

FAST, operation

Subxiphoid Pericardial aspirationSubxiphoid Pericardial aspiration(Pericardiocentesis)(Pericardiocentesis)

Resuscitative ThoracotomyResuscitative Thoracotomy

When should I consider resuscitative thoracotomy?

Aim Resuscitative thoracotomyAim Resuscitative thoracotomy

1. Remove pericardial blood in cardiac tamponade

2. Stop bleeding in chest 3. Open cardiac massage 4. cross-clamp descending aorta

Resuscitative ThoracotomyResuscitative Thoracotomy

● Patients with penetrating thoracic injury arriving with PEA may be a candidate

● When a surgeon with appropriate skills is present

● ED thoracotomy not indicated in blunt trauma with PEA

When should I consider resuscitative thoracotomy?

Thoracic TraumaThoracic Trauma

What are the potentially life-threatening chest injuries?

How do I identify them?

When and how do I correct the problem?

Thoracic TraumaThoracic Trauma

● Tracheobronchial tree injury

● Simple pneumothorax

● Pulmonary contusion

● Hemothorax

What are the potentially life-threatening chest injuries?

Thoracic TraumaThoracic Trauma

● Blunt cardiac injury

● Traumatic aortic disruption

● Blunt esophageal rupture

● Traumatic diaphragmatic injury

What are the potentially life-threatening chest injuries?

Thoracic TraumaThoracic Trauma

● Physical examination

● Chest x-ray

● Pulse oximetry

● ABG

● ECG

How do I identify potentially life-threatening thoracic injuries?

Tracheobronchial Tree InjuryTracheobronchial Tree Injury

● Often missed

● Blunt or penetrating

● Persistent pneumothorax

● Bronchoscopy

● Treatment● Airway and ventilation

● Tube thoracostomy

● Operation

Simple PneumothoraxSimple Pneumothorax

● Penetrating / blunt trauma

● Most : Lung laceration

● Ventilation / perfusion defect

● Hyperresonance

● Decreased breath sounds

● Tube thoracostomy

Pulmonary ContusionPulmonary Contusion

● Common

● Oxygenate and ventilate

● Delayed X-ray changes

● Selective intubation

● Normovolemia , Maintain lung volumes

HemothoraxHemothorax

● Chest wall injury

● Lung / vessel laceration

● hypotension , decreased breath sounds and dullness to percussion

● Tube thoracostomy

Blunt Cardiac InjuryBlunt Cardiac Injury

● Rare

● Injury spectrum (myocardial contusion , chamber rupture , coronary artery dissection / thrombosis , valvular disruption

● Abnormal ECG / monitor changes

● Echocardiography

● Treatment● Dysrhythmias

● Perfusion / Compromise blood pressure

● Complications

Traumatic Aortic DisruptionTraumatic Aortic Disruption

● Rapid acceleration / deceleration mechanism

● X-ray signs

● High index of suspicion

● Surgical consult

Traumatic Aortic DisruptionTraumatic Aortic Disruption

Diagnosis by Helical CT or Aortography

Blunt Esophageal RuptureBlunt Esophageal Rupture

● Blunt vs. penetrating injury (more common)

● Severe epigastric blow

● Pain / shock out of proportion to injury

● Left pneumothorax or hemothorax without rib fracture

Esophageal InjuryEsophageal Injury

● Chest tube: Particulate matter

● Mediastinal air

● Contrast swallow, esophagoscopy

● Operation

Diaphragmatic InjuryDiaphragmatic Injury

● Most diagnosed on left

● Blunt: Large tears

● Penetrating: Small perforations

● Misinterpreted x-ray

● Contrast radiography

● Operation

Traumatic AsphyxiaTraumatic Asphyxia

● Acute, temporary compression SVC

● Impaired venous return

● Petechiae

● Swelling

● Cerebral edema

Subcutaneous EmphysemaSubcutaneous Emphysema

● Airway injury

● Pneumothorax

● Blast injury

● Iatrogenic

Fractures and Associated InjuriesFractures and Associated Injuries

Ribs 1-3

● Severe force

● Associated injuries have high mortality risk

Ribs 4-9

● Pulmonary contusion and pneumothorax

Ribs 10-12

● Suspect abdominal injury

Sternum, Scapular, and Rib

Pitfalls

● Simple pneumothorax converts to tension pneumothorax

● Retained hemothorax

● Diaphragmatic injury

● Severity of rib fractures / pulmonary contusion

● Extremes of age

Pitfalls

SummarySummary

● Common in multiply injured patients

● Life-threatening injuries

● Potentially-lethal injuries

● Initial stabilization by simple techniques in the majority of cases

Goal: Restore normal gas exchange and perfusion

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