S1

Thoracic trauma
Dr. Subagjo, SpB, SpBTKV
Dr. Artono Isharanto, SpB, SpBTKV

Thoracic trauma
- 1 out of 4 death
-

blunt < 10 % require operation

- penetrating 15%-30% require operation
- majority require simple procedures

PRIMARY SURVEY/LIFE
THREATENING INJURIES
MAJOR PROBLEMS SHOULD BE
CORRECTED AS THEY ARE IDENTIFIED
- airway obstruction
- tension pneumothorax
- open pneumothorax
- flail chest

AIRWAY OBSTRUCTION
laryngeal injury
- rare occurrence
- hoarseness
- subcutaneous emphysema
- treatment * intubation

* tracheostomy

BREATHING
1.

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

BREATHING
Tension pneumothorax sign/symptoms
- respiratory distress
- Distended neck veins
- Unilateral decrease in breath sounds
- Hyperresonance
- Cyanosis, late

BREATHING
TENSION PNEUMOTHORAX
- immidiate decompression
- Clinical diagnosis, not by X ray
Therapy : nedlee decompression and chest
tube after it has been inserted

BREATHING
2.Open pneumothorax
- cover defect
- chest tube
- definitive operation

3. BREATHING
FLAIL CHEST /PULMONARY CONTUSION
Reexpand lung
Oxygen
Judicious fluid management
Intubation as indicated
analgesia

4.CIRCULATION
MASSIVE HEMOTHORAX :
> 1500 ml blood loss
Systemic/pulmonary vessel disruption
Flat vs distended neck veins
Shock with no breath sound and/or
percussion dullness

CIRCULATION
MASSIVE HEMOTHORAX
- rapid volume restoration
- chest decompression and X-ray
- autotransfusion
- operative intervention

CIRCULATION
CARDIAC TAMPONADE
- decrease arterial pressure
- distended neck veins
- muffled heart sound
- PEA
THERAPY patent airway
- iv therapy
- pericardiocentesis
- pericardiotomy

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SECONDARY SURVEY
POTENTIALLY LETHAL CHEST
TRAUMA

SIMPLE PNEUMOTHORAX
HEMOTHORAX
PULMONARY CONTUSION
TRACHEOBRONCHIAL TREE INJURIES
BLUNT CARDIAC INJURY
TRAUMATIC AORTIC DISRUPTION
TRAUMATIC DIAPHRAGMATIC INJURY
MEDIASTINAL TRANSVERSING WOUNDS

1.SIMPLE PNEUMOTHORAX
penetrating/blunt trauma
- hyperresonance
- decrease breath sounds
- tube thoracostomy
-

2.HEMOTHORAX
chest wall injury
- lungvessel laceration
- tube thoracostomy
-

3.PULMONARY CONTUSION
Most common
Oxygenate ventilate
Selective intubation

4.TRACHEAL INJURY
Frequently missed injury
Blunt/penetrating trauma
Partial vs complate
Diagnostic aid endoscopy
Treatment * airway ventilation

* operation

5.BLUNT CARDIAC INJURY

Injury spectrum
ECG changes: monitor change
Echocardiography
Tret dysrhytmia, Q complications

6.AORTIC RUPTURE

Rapid aceleration/deceleration
Ligamentum arteriosum
Salvage identify early
Surgical consult
X-ray: widened mediastinum,obliteration of the aortic
knob,depression of the left main stem bronchus,fractures
of the first or second rib or scapula
Aortogram.
Therapy primer suture aorta / resection and grafting

7.DIAPHRAGMATIC RUPTURE
- most diagnosted on left
- blunt , large tears
- penetrating, small perforations
- miss interpreted x ray (elevated
diaphragm,acute gastric delatation, a
loculated pneumothorax
- contras radiography
Therapy direct closure

8.MEDIASTINAL TRANSVERSING
hemodinamically abnormal

WOUND

exsanguinating thoracic hemorrhage

tension pneumothorax
Pericardial tamponade
Esophageal or tracheobronchial injury
Spinal cord injury

hemodinamically normal
- vascular: angiography
- tracheobronchial: bronchoscopy
- esophageal: esophagography,esophagoscopy
- Treatment mandatory surgical consultation, repair
identified injuries,

OTHERS TRAUMA
TRAUMATIC ASPHYXIA
Ptechiae
Swelling
Plethora
Cerebral edema