TRAUMA THORAX

Disusun oleh: Uray Ria Aprini

Pembimbing: dr. Rantapina, Sp.B

Kepaniteraan Klinik Ilmu Bedah

Rumah Sakit Abdul Azis
Singkawang
2019
Thoracic trauma: significat cause of mortality.
Less than 10% of blunct chest injuries require operative intervention. 15%-30% of penetrating
chest injuries require operative intervention
The physiologic consequences of thoracic trauma: hypoxia, hypervarbia, and acidosis.

As in all trauma patients, the primary survey of patients with thoracic injuries begins with:
Airway
Breathing
Circulation
 Airway Obstruction
Airway obstruction reluts from swelling, bleeding, or vomitus that is aspirated into the airway,
interfering with gas exchange. Eg: Laryngeal Injury

1. look for evidence of air hunger

2. Inspect the oropharynx
3. Listen for air movement at the patient’s nose, mouth, and lung fields
4. Listen for evidence of partial upper airway obstruction (stridor)
5. Feel for crepitus over the anterior neck.

Reduce a posterior
Suction
dislocation/fracture
 Tracheobronchial Tree Injury

- occur within 1 inch (2.54 cm) of the carina.

- Present with: hemoptysis, cervical subcutaneous emphysema, tension pneumothorax, cyanosis.

- Incomplete expansion of the lung and continued large air leak after placement of a chest tube suggests a T
racheobronchial injury, and placement of more than one chest tube may be necessary to overcome the significant
air leak.
Bronchoscopy confirms the diagnosis. If tracheobronchial injury is suspected, obtain immediate surgical
consultation.

Advanced airway skills:

selective intubation of the immediate operative intervention
Fiber-optically assisted
unaffected bronchus is indicated.
endotracheal tube placement
 Expose the patients's chest
Palpate to determine if there are
areas of tenderness, repitus, or
defectts Cyanosis is late sign of hypoxia in
Look at the chest wall to assess
trauma patients
movement and determine
wheter it's equal

Tension Pneumothorax
Assess te adequacy of
Open Pneumothorax
respirations.
Massive Hemothorax

Listen to the chest to evaluate for

equal breath spunds and identify
any extra sounds that may
indicate effysuin or contusion
 Tension Pneumothorax

• Etiology:
• Mechanical positive-pressure ventilation in patients with
visceral pleural injury.
• Tension pneumothorax also can complicate a simple
pneumothorax
• Tension pneumothorax is a clinical diagnosis reflectiong air
under pressure in the affected pleural space.
• Do not delay treatment to obtain radiologic confirmation
 Tension Pneumothorax

• Sign and Symptoms:

• Chest pain Immediate decompression:
Rapidly inserting a large-over-the
• AIr hunger
needle catheter into the pleural
• Tachypnea space.
• Respiratory distress
• Tachycardia Tube thoracostomy is mandatory after
• Hypotension needle or finger decompression of the
• Tracheal deviation away from the side of the injury chest
• Unilateral absence of breath sounds
• elevated hemithorax without respiratory movement
Finger thoracostomy is an alternative
• neck vein distention approach.
• cyanosis
 Open Pneumothorax

• Large injuries to the chest wall

that remain open --> an open
pneumothorax/sucking chest
wound.
• The clinical sign and symptoms:
pain, difficulty breathing,
tachypnea, decreased breath
sound on the affected side, and
noisy movement of air through
the chest wall injury
close the defect with a sterile dressing Treatment
large enough to overlap the wound’s
edges.

Tape it securely on only three sides to

provide a flutter-valve effect

As the patient breathes in, the

dressing occludes the wound,
preventing air from entering.

During exhalation, the open end of

the dressing allows air to escape from
the pleural space.

Place a chest tube remote from the

wound as soon as possible.
 CIRCULATION PROBLEMS Massive hemothorax

• Results from the rapid accumulation of more than 1500 mL of blood or one-
third or more of the patients's blood volume in the chest cavity.
• A massive hemothoraxis suggested when shock is associated with the
absence of breath sound or dullness to percussion on one side of the chest

Simultaneously restoring blood volume and decompressing the chest cavity.

When appropriate, blood from the chest tube can be collected in a device
suitable for autotransfusion.

The immediate return of 1500 mL or more of blood -> the need for urgent thoracotomy.
 CIRCULATION PROBLEMS Cardiac Tamponade

Compression of the heart by an accumulation of fluid in the pericardial sac

-> decreased cardiac output due to decreased inflow to the heart.

The classic clinical triad:

muffled heart sounds, hypotension, and distended veins is not uniformly
present with cardiac tamponade.

Focused assessment with sonography for trauma (FAST) is a rapid and accurate
method of imaging the heart and pericardium that can effectively identify
cardiac tamponade
 CIRCULATION PROBLEMS Traumatic Circulatory Arrest

Trauma patients who are unconscious and have no pulse, including PEA (as
observed in extreme hypovolemia), ventricular fibrillation, and asystole (true
cardiac arrest) are considered to be in circulatory arrest.

Start closed CPR simultaneously + ABC management

Secure a definitive airway with orotracheal intubation

Administer mechanical ventilation with 100% oxygen

perform bilateral finger or tube thoracostomies

Continuously monitor ECG + oxygen saturation + begin rapid fluid resuscitation
SECONDARY SURVEY
• Simple pneumothorax
• Hemothorax
• Flai Chest
• Pulmonary Cobtusion
• Blunt Cardiac Injury
• Traumatic aortic disruption
• Traumatic diaphragnaric Injury
• Blunt esophageal rupture
 Simple Pneumothorax

• results from air entering the potential space between the visceral and parietal pleura
• inspection for bruising, lacerations, and contusions.
• Assess movement of the chest wall and
• assess and compare breath sounds bilaterally.
• When a pneumothorax is present, breath sounds are often decreased on the affected side.
• Percussion : hipersonor
• Treatment: chest tube placed in the fifth intercostal space, just anterior to the midaxillary line.
a chest x-ray examination is done to confirm appropriate placement and reexpansion of the lung.

American Collage of Surgeons. Advance Trauma Life Support. United States of America, 9th Ed
 Hemothorax
• Type of pleural effusion in which blood (<1500 mL) accumulates in the pleural cavity.
• The primary cause of hemothorax is laceration of the lung, great vessels, an intercostal vessel, or an internal
mammary artery from penetrating or blunt trauma.
• Expose the chest and cervical areas, and observe the movement of the chest wall. Look for any penetrating chest
wall injuries, including the posteriorthorax. Assess and compare breath sounds in both hemithoraces. Typically,
dullness to percussion is heard on the affected side.
• Obtain a chest x-ray with the patient in the supine position. A small amount of blood will be identified as a
homogeneous opacity on the affected side

treated with a 28-32

French chest tube.

American Collage of Surgeons. Advance Trauma Life Support. United States of America, 9th Ed
Flail Chest dan Kontusio Paru
• A flail chest occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic
cage.

• A pulmonary contusion is a bruise of the lung, caused by thoracic trauma. Blood and other fluids accumulate in
the lung tissue, interfering with ventilation and potentially leading to hypoxia

• Observation of abnormal respiratory motion and palpation of crepitus from rib or cartilage fractures can aid the
diagnosis. A chest x-ray may suggest multiple rib fractures but may not show costochondral separation.

American Collage of Surgeons. Advance Trauma Life Support. United States of America, 9 th Ed
Flail Chest dan Kontusio Paru
initial treament: administration of humidified oxygen, adequate ventilation, and cautious fluid resuscitation.

Patients with significant hypoxia (i.e., PaO2 < 60 mm Hg [8.6 kPa] or SaO2 < 90%) on room air may require
intubation and entilation within the first hour after injury.

Definitive treatment of flail chest and pulmonary contusion involves ensuring adequate oxygenation, administering
fluids judiciously, and providing analgesia to improve ventilation.

American Collage of Surgeons. Advance Trauma Life Support. United States of America, 9th Ed
Blunt Cardiac Injury
• Trauma tumpul jantung dapat menyebabkan:
- Kontusio muskulorum miokardial
- Ruptur ruang kardiak
- Diseksi arteri coroner dan atau thrombosis

The true diagnosis of blunt myocardial injury can be established only by

direct inspection of the injured myocardium. Clinically significant
sequelae are hypotension, dysrhythmias, and/or wall-motion
abnormality on two-dimensional echocardiography.

American Collage of Surgeons. Advance Trauma Life Support. United States of America, 9th Ed
Disrupsi aorta traumatika
Traumatic aortic rupture is a common cause of sudden death after a vehicle collision or fall from a great height.

• Widened mediastinum • Deviation of the esophagus

• Obliteration of the aortic knob (nasogastric tube) to the right
• Deviation of the trachea to the right • Widened paratracheal stripe
• Depression of the left mainstem bronchus • Widened paraspinal interfaces
• Elevation of the right mainstem bronchus • Presence of a pleural or apical
• Obliteration of the space between the cap
pulmonary artery and the aorta (obscuration • Left hemothorax
of the aortopulmonary window) • Fractures of the first or second
rib or scapula
 Disrupsi aorta traumatika
Pain should first be conrolled with analgesics. If no contraindications exist, heart
rate control with a short-acting beta blocker. Goal: heart rate < 80 bpm and BP
control -> MAP of 60 to 70 mm Hg

Hypotension -> contraindication to these medications

Open repair involves resection + repair of the torn segment / infrequently,

primary repair

Endovascular repair is the most common option for managing aortic injury and
has excellent short-term outcomes.
 Ruptur diafragma traumatik
Traumatic diaphragmatic ruptures are more commonly diagnosed on the left
side, perhaps because the liver obliterates the defect or protects it on the
right side, whereas the appearance of displaced bowel, stomach, and/or
nasogastric (NG) tube is more easily detected in the left chest.

Blunt trauma produces large radial tears that lead to herniation, whereas
penetrating trauma produces small perforations that can remain symptomatic
for years.

Treatment is by direct repair. Care must be taken when placing a chest tube in
patients with suspected diaphragm injury, as tubes can inadvertently injure
the abdominal contents that have become displaced into the chest cavity.

American Collage of Surgeons. Advance Trauma Life Support. United States of America, 9th Ed
Blunt Esophageal Rupture
• Esophageal trauma most commonly results from penetrating injury.
Although rare, blunt esophageal trauma, caused by the forceful
expulsion of gastric contents into the esophagus from a severe blow
to the upper abdomen, can be lethal if unrecognized.

• Treatment of esophageal rupture consists of wide drainage of the

pleural space and mediastinum with direct repair of the injury.
Repairs performed within a few hours of injury improve the patient’s
prognosis.