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น.พ. ธวั�ชช�ย อิ่�มพ ล , พบ.,วัวั.ศั�ลยศัาสตร์�ทั่��วัไป
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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