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Thoracic Trauma Thoracic Trauma BERMANSYAH BERMANSYAH

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Page 1: Chest Trauma 1 Dr. BER

Thoracic TraumaThoracic TraumaThoracic TraumaThoracic Trauma

BERMANSYAHBERMANSYAH

Page 2: Chest Trauma 1 Dr. BER

Anatomi Anatomi

• Jaringan Lunak dinding Torak

• Tulang

• Parenkim

• Pembuluh Darah

• Jantung

• Mediastinum

Page 3: Chest Trauma 1 Dr. BER

Anatomy Anatomy

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Fisiologi PernafasanFisiologi Pernafasan

• Trakea

• Bronkus

• Bronkiolus

• Alviolus

• Kapiler

Page 11: Chest Trauma 1 Dr. BER

KompKompoonen Pernafasannen Pernafasan

• Trakea

• Dinding Torak

• Parenkim Paru

• Diafragma

Page 12: Chest Trauma 1 Dr. BER

Trauma TorakTrauma Torak

• Trauma Tumpul

• Trauma Tajam

• Trauma Abdomen

Page 13: Chest Trauma 1 Dr. BER

CARDIOVASCULACARDIOVASCULAR SYSTEMR SYSTEM

Anatomy & Physiology

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THE HEART

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Lokasi Jantung Lokasi Jantung

• Di dalam Pericardium di rongga mediastinum dalam rongga Thorak

• Tepat di belakang tulang dada ( sternum )

• Kurang lebih 2/3 bagian terletak di sebelah kiri dari garis tengah

Page 16: Chest Trauma 1 Dr. BER

Fungsi dan Ukuran

• Fungsi : sebagai pompa ganda agar terjadi aliran dalam pembuluh darah yang disebabkan adanya pergantian antara kontraksi ( sistolik ) dan relaksasi ( diastolik )

• Ukuran : 250 – 350 gram ( kira-kira sebesar kepalan tangan )

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PerikardiumPerikardium

• Perikardium Fibrosa Lapisan paling luar rongga Pericardium Menjaga kedudukan jantung di rongga

mediastinum

• Perikardium Serosa– Lapisan parietalis Lapisan bagian dalam dari rongga pericardial– Lapisan visceralis / epicardium

• Rongga Perikardium – Cairan pericardium Mengurangi gesekan saat jantung bergerak

Page 19: Chest Trauma 1 Dr. BER
Page 20: Chest Trauma 1 Dr. BER

Anatomy of the HeartAnatomy of the Heart

• Heart chambers :– Left & right atria– Left & right ventricles

• Heart valves :– Atrioventricular valves :

• Right : Tricuspid• Left : Bicuspid/Mitral

– Semilunar valves• Right : Pulmonary valve• Left : Aortic valve

Page 21: Chest Trauma 1 Dr. BER

Anatomy of the HeartAnatomy of the Heart

• Aorta• Coronary arteries• Arterioles• Capillaries• Venules• Coronary sinus• Right atrium

Coronary circulationCoronary circulation

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TRAUMA TUMPUL TORAKSTRAUMA TUMPUL TORAKS

• TRAUMA PADA DINDING DADA

• TRAUMA PADA PARU DAN PLEURA

• TRAUMA PADA OSOFAGUS, DIAFRAGMA DAN DUKTUS TORASIKUS

• TRAUMA PADA JANTUNG DAN PEMBULUH DARAH BESAR

• TRAUMA TRAKHEOBRONKHIAL

Page 23: Chest Trauma 1 Dr. BER
Page 24: Chest Trauma 1 Dr. BER

TRAUMA PADA DINDING DADATRAUMA PADA DINDING DADA

• FRAKTUR CLAVICULA

• FRAKTUR STERNUM

• DISLOKASI SENDI STERNOCLAVICULA

• FRAKTUR IGA

• “FLAIL CHEST”

• TRAUMA ASPIKSI

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FRAKTUR CLAVICULAFRAKTUR CLAVICULA

– Paling sering ditemukan (tunggal, disertai trauma toraks, trauma pada sendi bahu ).

– Lokasi Fraktur pada bagian tengah.– Deformitas, nyeri dan nyeri tekanan pada lokasi

trauma.– Foto Rontgen tampak fraktur clavicula– Konservatif : “Verband figure of eight” sekitar sendi

bahu.– Komplikasi : “Malunion Fracture” akan menekan

pleksus Brakhialis dan pembuluh darah subclavia.

Page 26: Chest Trauma 1 Dr. BER

FRAKTUR STRENUMFRAKTUR STRENUM

– Trauma langsung pada Sternum– Lokasi Fraktur bagian tengah atas Sternum– Sering disertai Fraktur Iga– Tidak perlu “Open Reduction”/fiksasi internal – 61% perubahan EKG (Trauma Jantung)

Page 27: Chest Trauma 1 Dr. BER

DISLOKASI SENDI DISLOKASI SENDI STERNOCLAVICULARSTERNOCLAVICULAR

– Kasus Jarang• Anterior : Nyeri, nyeri tekan, sendi menonjol

kedepan• Posterior : Sendi tertekan kedalam• Pengobatan : Reposisi

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FAKTUR IGAFAKTUR IGA

– Trauma Langsung (Direct Injury)– Lebih sering iga IV – IX– Fraktur pada bagian lateral dada sulit dinilai

dengan x-Ray– Diagnosis :

• Riwayat trauma dengan nyeri pleura yang terlokalisir

• Nyeri tekan dan crepitasi dari fragmen

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FRAKTUR IGAFRAKTUR IGA

Akibat nyeri - diskontinuitas dinding dada - pernafasan ↓ - atelektatis → pneumonia

Fungsi paru yang ↓→ mengancam jiwa mortalitas pasien usia >80 thn→ 20%

Pengobatan : Kontrol nyeri• Analqetik sistemik• Blok syaraf interkostal

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FRAKTUR IGAFRAKTUR IGA

Fraktur Iga + Hemotoraks / Pneumotoraks → WSD

Fraktur Iga + contusio paru → perawatan ketat → ICU

Fraktur Iga VI – XII → trauma Ginjal, Hati

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FLAIL CHESTFLAIL CHEST

– Segmen dinding dada yang bergerak paradoksal pada Respirasi

– Fraktur Iga, Trauma langsung, 30% trauma tumpul toraks

– Kontusio paru faktor resiko terjadi ARDS

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FLAIL CHESTFLAIL CHEST

– Pengobatan : • Internal stabilization (Pneumatik Stabilisasi)

– Intubasi Endotracheal– Ventilasi Mekanik → Mereduksi Pnemonia

• Fiksasi Iga (Stabilisasi bedah)

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Indikasi Stabilisasi BedahIndikasi Stabilisasi Bedah

1. Pasien perlu Torakotomi bila disertai komplikasi di dalam rongga toraks → perdarahan.

2. Pasien yang mengalami gangguan pernafasan meskipun telah dilakukan agresif bronkhoskopi, ventilasi, analgetika, pada X Ray tidak ditemukan konstusio paru

3. Mereduksi lamanya pemakaian ventilasi bila pasien gagal “weaning ventilation”

4. Pasien dengan antero lateral “flail chest” , dislokasi yang progresif dari fraktur Iga, untuk mencegah terjadi deformitas dinding dada di kemudian hari dengan konsekuensi terjadi kelainan restriksi

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Beberapa hal Penting pada Trauma Tumpul Beberapa hal Penting pada Trauma Tumpul ToraksToraks

• Fraktur Claviula– Perhatikan cidera pada a.subclavia dan fleksus brakhialis

adanya kemunginan “ thoracic outlet syndrom” kemudian hari

• Kontusio jantung sering timbul pada trauma sternum

• Perhatikan trauma pada trakhea, pembuluh darah besar bila ada dislokasasi sendi “sterno clavicular”ke medial

• “Flail chest” umumnya dapat diobati dengan intubasi dan ventilasi mekanik

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TRAUMA PADA PARU DAN PLEURATRAUMA PADA PARU DAN PLEURA

PNEUMOTORAKS• Robekan langsung paru karena Fraktur Iga• Tekanan yang meningkat pada saluran nafas• Evaluasi

• Sesak nafas• Hipersonor

Bising nafas ↓

• “Tension Penumothorax”• Sesak nafas• Gangguan Hemodinamik• Pendorongan Trakhea• Bising nafas (-)

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PENGOBATAN• WSD

ICS IV / ICS V linea aksilaris medialis –

- anterior

• Torakotomi

Kontrol kebocoran paru

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HEMOTORAKS• Laserasi paru, trauma pemb interkostal luka dinding

dada, trauma a.bronkhial, trauma pembulu darah besar

• X Ray Toraks

• WSD untuk evakuasi

• Torakotomi :– Perdarahan > 1000 ml. Perdarahan masih berlangsung >

100 – 200 ml/jam

– Perdarahan < 1000 ml perdarahan masih berlangsung > 100 -200 ml/jam untuk beberapa waktu

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HEMATOMA PARU

• Tidak menimbulkan gangguan “gas exchange“ dan “shunting” pO2 nomal

• Hematoma pada jaringan paru, dapat diidentifikasi pada “Xray toraks”

• Resiko infeksi dan Abses paru

Page 39: Chest Trauma 1 Dr. BER

KONTUSIO PARU

• Trauma paru yang serius , terjadi infitrasi darah dan protein pada alveoli → “Intra Pulmonary Shunting” → “Hypoxemia”

• X ray toraks timbul kelainan setelah 24-48 jam, ronkhi (+)

• Intubasi Endotrakheal + ventilasi

• Distres pernafasan (ARDS)

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RUPTUR DIAFRAGMARUPTUR DIAFRAGMA

• Peningkatan tekanan lntra Abdomnal mendadak

• Umumnya terjadi di sentral• Sebelah kiri lebih sering dari sebelah kanan• Herniasi organ viseral abdomen ke toraks• Dapat tenjadi ruptur intra perikardial• Diagnosis : klinis, “ X Ray toraks, CT scan

toraks• Tx/ Torakotomi dan laparotomi

Page 41: Chest Trauma 1 Dr. BER

Klinis ruptur diafragmaKlinis ruptur diafragma

• Riwayat trauma tumpul abdomen

• “Respiratory distress”

• Pendorongan mediastinum kontralateral

dan penekanan paru oleh organ viseral

• Venous return” menurun – CO menurun

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TRAUMA ESPOHAGUSTRAUMA ESPOHAGUS

• Trauma tumpul jarang dibandingkan truma tusuk

• Diagnosis : pneumomediastim atau efusi pleura

• Esophagography

Page 43: Chest Trauma 1 Dr. BER

TRAUMA TUMPUL JANTUNGTRAUMA TUMPUL JANTUNG

• Jarang terjadi

• Trauma langsung karena kecelakaan lalu lintas

• “Myocardial Contusion”

• EKG

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Penetrating injuriesPenetrating injuries

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Penanggulangan rongga PleuraPenanggulangan rongga Pleura

TujuanMengembalikan kondisi fisiologis rongga pleura dengan cara :

1. Observasi2. Pungsi pleura3. WSD4. Continous suction ( I botol / 2 botol )

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WSD

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Indikasi Utama WSDIndikasi Utama WSD

1. Robekan pleura visceral

2. Monitoring perdarahan untuk dapat menentukan indikasi torakotomi yang tidak berdasarkan kepada kondisi klinis pasien

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Pelaporan WSD

1. Initial

2. Undulasi

3. Expiratory bubble

4. Produksi

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Indikasi Continous SuctionIndikasi Continous Suction

1. Hematopneumotoraks agar darah segera dapat dikeluar sebelum proses pembekuan.

2. Robekan pleura visceral .

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Definisi :Definisi :Pemasangan drain pada rongga pleura melalui insisi pada sela iga

Tujuan :Tujuan :Mengeluarkan cairan, darah, udara dari rongga pleura.

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I n d i k a s iI n d i k a s i

• Trauma toraks • Hematotoraks• Pneumotoraks• Chylotoraks

• Infeksi • Empiema

• Keganasan • Efusi pleura / Fluidotoraks

• Pasca Torakotomi

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PneumotoraksPneumotoraks

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HematotoraksHematotoraks

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Cara perawatanCara perawatan

• Awasi tanda-tanda klinis pasien.Awasi tanda-tanda klinis pasien.• Posisi senyaman mungkin k/p setengah duduk.Posisi senyaman mungkin k/p setengah duduk.• Seluruh sistim drainase dalam keadaan rapi, pipa Seluruh sistim drainase dalam keadaan rapi, pipa

dan botol harus transparan dan tidak ada dan botol harus transparan dan tidak ada kebocoran.kebocoran.

• Perawatan harus dilakukan secara aseptik.Perawatan harus dilakukan secara aseptik.• Drain harus terfiksasi dengan baik, baik pada tubuh Drain harus terfiksasi dengan baik, baik pada tubuh

ataupun pada sambungan.ataupun pada sambungan.• Patensi drain harus lancar & jangan tertekuk, bila Patensi drain harus lancar & jangan tertekuk, bila

tidak tidak milking.milking.• Botol drainase harus lebih rendah dari pasien.Botol drainase harus lebih rendah dari pasien.• Kuantitas & kualitas cairan harus dinilai minimal

setiap 24 jam.• Atasi nyeri & Fisio terapi nafas.

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HematothoraxHematothorax

REMEMBER !!!REMEMBER !!!

• < 3 cc/kgBB/jam < 3 cc/kgBB/jam Observasi Observasi

• 3 – 5 cc/kgBB/jam 3 – 5 cc/kgBB/jam Hati-hati, Observasi ketat Hati-hati, Observasi ketat

• > 5 cc/kgBB/jam > 5 cc/kgBB/jam Operasi / Eksplorasi Operasi / Eksplorasi

Page 63: Chest Trauma 1 Dr. BER

Indikasi pencabutan drainIndikasi pencabutan drain

• KlinisKlinis• RadiologisRadiologis• Kuantitas dan kualitas cairanKuantitas dan kualitas cairan

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Teknik pencabutanTeknik pencabutan

• Fiksasi plester dilepas, desinfeksi• Benang dilepaskan, dipegang asisten• Operator pegang drain, tangan kiri

menjepit luka• Dengan satu komando, drain dicabut

dgn satu tarikan dan asisten mengikat benang dengan simpul mati

• Kontrol foto toraks

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• Penderita harus dipasang infusPenderita harus dipasang infus

• Sebaiknya dilakukan di ruang operasiSebaiknya dilakukan di ruang operasi

• Jangan tinggalkan penderita setelah Jangan tinggalkan penderita setelah pemasangan, perhatikan tanda-tanda vitalnyapemasangan, perhatikan tanda-tanda vitalnya

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Jenis WSD Jenis WSD

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Posisi yg WSD Posisi yg WSD

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Trauma TumpulTrauma Tumpul

• Dinding TorakJejasHematomLaserasiFraktur igaFraktur claviculaCedera Vaskular

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• M - MECHANISM OF INJURY

• I - INJURIES SUSTAINED

• S - SIGNS AND SYMPTOMS

• T - THERAPY

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• TRAUMA TUMPUL

• TRAUMA TAJAM

• TRAUMA LEDAKAN

• BIOMEKANIK TRAUMA

• Semua harus dicari melalui anamnesa yang teliti

Page 79: Chest Trauma 1 Dr. BER

Cidera yang didapat

• Kelainan dinding dada

- Empisema kulit - Fraktur iga respirasi paradoksal

• Kelainan rongga Pleura- Hematotoraks

- Pneumotoraks

- Hemato-Pneumotoraks

- Chylothorax

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• Kelainan Parenchym Paru

- Traumatic Wet Lung

• Kelainan Mediastinum

- Cardiovascular

- Tracheobronchial

- Esophagus

• Kelainan Abdominal

- Thoracoabdominal

Page 81: Chest Trauma 1 Dr. BER

Signs and SymptomsSigns and Symptoms

• Dicari kemungkinan semua organ yang dapat dicederai sesuai dengan biomekanik trauma dengan :

- Anamnesa

- Inspeksi

- Palpasi

- Perkusi

- Auskultasi

- Pemeriksaan Penunjang lainnya

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TerapiTerapi

• Saluran nafas• Pernafasaan• Sirkulasi• Penanggulangan rongga Pleura• Stabilisasi dinding dada• Menghilangkan rasa nyeri• Torakoskopi• Torakotomi

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Stabilisasi Dinding DadaStabilisasi Dinding Dada

1. Flail chest

Ditanggulangi dengan respirator atau fiksasi iga

2. Cara terapi dengan menekan atau menarik ( traksi ) dari daerah dinding dada yang bergerak “paradoksal” masih dapat diterapkan kalau (1) tidak dapat dilaksanakan

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3. Menanggulangi rasa nyeri

1. Analgetik boleh dipakai asal tidak mengganggu reflek batuk dan

pernafasan

2. Dianjurkan melakukan interkostal blok anestesi dari nervus interkostalis

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Indikasi TorakotomiIndikasi Torakotomi

1. Perdarahan selama monitoring melebihi 3 – 5 cc / kg BB selama 3 jam

2. Paru tidak mengembang dan tetap ada expiratory bubble setelah continous suction

3. Kondisi pernafasan patient makin jelek pada waktu pemasangan kontinous suction

4. Kalau perlu pada trauma torakoabdominal yang ada indikasi laparatomi

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Organs most commonly involved in severe Organs most commonly involved in severe blunt thoracic traumablunt thoracic trauma

• Chest wall 70 %• Lungs 20 - 25 %• Heart 10 %• Diaphragm 5 %• Aorta 3 - 4 %

Page 87: Chest Trauma 1 Dr. BER

Importance of obtaining a good clinical history in Importance of obtaining a good clinical history in assessment of blunt chest trauma victimsassessment of blunt chest trauma victims

• Patients involved in motor vehicle accident• Time of injury relative to arrival in hospital• Type of impact ( head – on collision or side impact )• Patient’s location within vehicle (front,back,driver)• Approximate vehicle speed• Ejection from vehicle• Death of another accupant of vehicle• Was the trauma victim wearing a seat belt• Patients involved in fall from a height• Height of fall• Surface on which patient landed

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Identify and initiate treatment of the following Identify and initiate treatment of the following injuries during the primary surveyinjuries during the primary survey

• Airway obstruction

• Tension pneumothorax

• Open pneumothorax

• Flail chest

• Massive hemothorax

• Cardiac tamponade

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Identify and initiate treatment of the following Identify and initiate treatment of the following injuries during the secondary surveyinjuries during the secondary survey

• Simple pneumothorax

• Hemothorax

• Pulmonary contusion

• Tracheobrochial distruption

• Blunt cardiac injury

• Traumatic diaphragmatic injury

• Mediastinal traversing wounds

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Recognize the indications for, complications of, Recognize the indications for, complications of, and demonstrate the ability to perform the and demonstrate the ability to perform the followingfollowing : :

• Thoracic needle decompression

• Chest tube insertion

• pericardiocentesis

Page 91: Chest Trauma 1 Dr. BER

Mechanisms of injury in blunt chest traumaMechanisms of injury in blunt chest trauma

• Direct impact over thorax ( rib fracture, flail chest, lung and cardiac contusion )

• Direct impact over hyperextended neck (laryngotracheal injury )

• Direct impact with close glottis ( bronchial distruption )• Rapid deceleration ( aortic or bronchial rupture)• Vertical deceleration ( aortic rupture )• Spinal flexion injuries ( rupture of thoracic duct )• Suddenrise in intra-abdominal pressure ( diaphragmatic

rupture )

Page 92: Chest Trauma 1 Dr. BER

Importance of physical examination in Importance of physical examination in assessment of blunt chest trauma victimsassessment of blunt chest trauma victims

• Airway tachypnea, stridor airwayobstructionor distruption.inhalation of aforeign body.

• Breathing abnormal chest wall flail chest .movements ; severe lung use of accessory muscles of contusion.respiration ; respiratoryabsence of breath failure.sounds

pneumothoraces,hemothoraces

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• Circulation low blood pressure, significant hemorrhage

tachycardia

. Cervical spine pain in back of neck fracture-dislocation

. Intracranial immobility or altered head injury

state of consciousness

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Initial assessment and managementInitial assessment and management

• Patient management must consist of

@ primary survey

@ resuscitation of vital functions

@ detailed secondary survey

@ definitive care

• Hypoxia is the most serious feature of chest injury, early interventions are designed to prevent or correct hypoxia

• Immediately life-threatening injuries are treated as quickly and as simply as possible

• Most life-threatening thoracic injuries are treated by airway control or an appropriately placed chest tube or needle

• The secondary survey is influenced by a history of the injury and a high index of suspicion for specific injuries

Page 95: Chest Trauma 1 Dr. BER

Indikasi TorakotomiIndikasi Torakotomi

Initial bubble (-) atelektasis bronkoskopi

• Pneumotorak WSD

spontan (+) chest fisioInitial bubble (+) pengembangan paru

terapi

( - )

torakotomi

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Indikasi BronkoskopiIndikasi Bronkoskopi

• Pada trauma toraks apabila dapat dibuktikan bahwa tekanan cavum pleura negatif tetapi paru kollaps maka persoalannya terdapat disaluran nafas sehingga diperlukan tindakan untuk membebaskan saluran nafas dengan bronkoskopi

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Trauma aspiksiaTrauma aspiksia

• Trauma tumpul paru yg menyebabkan tek. Intratoraks meningkat dan glottis tertutup.

• “Venous pressure” intratoraks meningkat menyebabkan pemb.balik kepala dan leher terbendung ---- odema & sianosis kepala dan leher,perdrhan subcojunctiva, tek. Intrakranial naik, kesadaran menurun, buta

• Monitor neurologi . Elevasi kepala

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• Shunting paru right to left

saturasi vena pulmonalis menurun

• Shunting perifer left to right

darah kembali ke sentral tanpa melalui kapiler

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RUPTUR DIAFRAGMARUPTUR DIAFRAGMA

• Peningkatan tekanan lntra Abdomnal mendadak

• Umumnya terjadi di sentral• Sebelah kiri lebih sering dari sebelah kanan• Herniasi organ viseral abdomen ke toraks• Dapat tenjadi ruptur intra perikardial• Diagnosis : klinis, “ X Ray toraks, CT scan

toraks• Tx/ laparotomi kalau perlu torakotomi

Page 107: Chest Trauma 1 Dr. BER

TRAUMA ESPOHAGUSTRAUMA ESPOHAGUS

• Trauma tumpul jarang dibandingkan truma tusuk

• Selalu disertai trauma lainnya dari toraks

• Diagnosis : - Pneumomediastinum atau efusi pleura

- Esophagography

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Penetrating injuriesPenetrating injuries

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Tension PneumotoraksTension Pneumotoraks

1. Terjadi pada pneumotorak tertutup dengan mekanisme ventil di robekan pleura visceral atau pada trauma tajam dengan mekanisme ventil di dinding toraks

2. Setiap kasus dengan anamnesa sesak makin bertambah dan pada perkusi adanya pneumotoraks suspect tension pneumotoraks tidak boleh dipastikan dengan x – ray harus langsung dilakukan fungsi pleura untuk menurunkan tekanan

3.Tidak selalu harus dilakukan torakotomi

4. Penaggulangan dapat dilaksanakan sesuai protokol pneumotoraks

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Trauma JantungTrauma Jantung

1. Setiap luka tusuk di daerah prekordial harus dianggap mengenai jantung sehingga harus segera torakotomi (kecuali kalau ada analisa yang menyatakan jantung tidak cedera)

2. Dapat dilakukan dulu perikardiosintesis atau perikardiostomi dengan catatan kalau ada perdarahan langsung torakotomi

3. Darah dapat masuk kerongga perikardium karena ;– cedera perikard saja – Cedera mengenai epikardium (pembuluhdarah coroner– Cedera dapat menembus dinding jantung

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Ruptur Bronkhus

- Inspeksi- Palpasi- Perkusi- Auskultasi- Pemeriksaan tambahan

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Ruptur diafragma

- Inspeksi- Palpasi- Perkusi- Auskultasi- Pemeriksaan tambahan

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Cardiac TamponadeCardiac Tamponade• Blood in the pericardial sac • Most frequently penetrating injuries• Shock, JVP, PEA, pulsus paradoxus• Classically, Beck’s triad:

- distended neck veins- muffled heart sounds- hypotension

• Rx: Volume resuscitation Pericardiocentesis

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Blunt cardiac injuryBlunt cardiac injury• Myocardial contusion is the most common

injury and is suspected with EKG changes and serial enzyme elevations

• Coronary artery injury can result in thrombosis and myocardial infarction

• Atrial or ventricular rupture is usually fatal, although the pericardium may restrict bleeding enough to allow survival to the ER

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Cervical/Neck TraumaCervical/Neck Trauma IntroductionIntroduction

• 5-10% of all trauma• Overall mortality rate as high as 11%• Major vessel injury fatal in 65%, including

prehospital deaths• Attending physician must have excellent

knowledge of anatomy

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Cervical/Neck TraumaCervical/Neck Trauma IntroductionIntroduction

Cervical/Neck TraumaCervical/Neck Trauma IntroductionIntroduction

• Infrequent except C-spine• Awareness is essential• Can be devastating even fatal• Signs often subtle or absent• Often too late

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Neck ZoneNeck Zone

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Penetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck Trauma

• Controversy regarding management of “soft” or no signs of injury• Soft Signs

– Hemoptysis/hematemesis– Oropharygeal blood– Dyspnea– Dysphonia/dysphagia– SubQ or mediastinal air– Chest tube air leak– Nonexpanding hematoma– Focal neuro deficits

• Issue of Mandatory versus Selective Exploration?

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Penetrating Neck TraumaPenetrating Neck Trauma

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Penetrating Neck TraumaPenetrating Neck TraumaCCH neck protocolCCH neck protocol

Penetrating Neck TraumaPenetrating Neck TraumaCCH neck protocolCCH neck protocol

• Zone I– Angio of arch and great

vessels– CXR– Consider esophagus and

trachea

• Zone II– Angio carotid(s)/vertebral(s)– Esophagram & endoscopy– Consider bronchoscopy

• Zone III– Carotid angio– Oropharyngeal exam

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RadiographsRadiographs

• CXR - inspiratory/expiratory films to assess for phrenic nerve injury, look for pneumothorax

• Cervical spine film to rule out fractures• Soft tissue neck films AP and Lateral• Arteriograms, contrast studies as indicated

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Penetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck TraumaPenetrating Neck Trauma

Vascular injury

Subcutaneous emphysemaAirway obstructionSucking woundHemoptysis Dyspnea Stridor Hoarseness or dysphonia

Laryngotracheal injury

Subcutaneous emphysemaHematemesisDysphagia or odynophagia

Pharynx/esophagus injury

ShockHematoma

Hemorrhage Pulse deficit Neurologic deficit Bruit or thrill in neck

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Esophageal RuptureEsophageal RuptureEsophageal RuptureEsophageal Rupture

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Complete Tracheal RuptureComplete Tracheal Rupture

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Complete Tracheal Rupture

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BLUNT NECK INJURYBLUNT NECK INJURYBLUNT NECK INJURYBLUNT NECK INJURY

• Lateral C spine X ray , CXR• Cervical immobilizations should continue untill

clinically and radiographycally cleared• Pretracheal soft tissue > 0,5 mm is suggestive

C-spine fracture• Subcutaneous empysema , retropharingeal air

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Diagnostic modalitiesDiagnostic modalities

• CT scan• Laryngoscopy and Bronchoscopy• Doppler Ultrasound• Angiography• Contrast Esophagogram• Flexible Esophagoscopy

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Neck Injury : ConclusionsNeck Injury : Conclusions

• First priority is to secure the airway• Not common but associated to high mortality and

morbidity• Neurologic deficit with normal brain CT needs

Angiographic Examination• Be aware of subtle signs

Neck Injury : ConclusionsNeck Injury : Conclusions

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• Maintain respect for apparently minor neck wounds

• Careful history and complete physical exam with appropriate ancillary studies

• Arteriography for zone I and zone III injuries• Vascular injuries most immediately life-

threatening• Esophageal injury causes late mortality

Neck Injury : ConclusionsNeck Injury : ConclusionsNeck Injury : ConclusionsNeck Injury : ConclusionsNeck Injury : ConclusionsNeck Injury : ConclusionsNeck Injury : ConclusionsNeck Injury : Conclusions

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Thoracic TraumaThoracic Trauma IntroductionIntroduction

• Chest trauma is often sudden and dramatic• Accounts for 25% of all trauma deaths• USA : 45.000 death• Indonesia : ?• 2/3 of deaths occur after reaching hospital• Serious pathological consequnces:

-hypoxia, hypovolaemia, myocardial failure

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Radiological LandmarkRadiological Landmark

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• Either: - direct blow (e.g. rib fracture) - deceleration injury or

- compression injury• Rib fracture is the most common sign of blunt

thoracic trauma• Fracture of scapula, sternum, or first rib suggests

massive force of injury

Blunt injuries

Mechanism of InjuryMechanism of Injury

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Blunt injuriesBlunt injuries

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Mechanism of InjuryMechanism of Injury

Penetrating injuries• E.g. stab wounds etc.• Primarily peripheral lung• Haemothorax• Pneumothorax• Cardiac, great vessel ,trachea

or oesophageal injury

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Penetrating injuriesPenetrating injuries

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Chest wall injuries Chest wall injuries

• Rib fractures

• Flail chest

• Open pneumothorax

Chest wall injuries Chest wall injuries Chest wall injuries Chest wall injuries

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Rib fracturesRib fractures• Most common thoracic injury• Localised pain, tenderness, crepitus• CXR to exclude other injuries• Analgesia• Underestimation of effect• Upper ribs, clavicle or scapula fracture: suspect

vascular injury

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Flail chestFlail chest• Multiple rib fractures produce a mobile fragment

which moves paradoxically with respiration• Hypoxia is usually not present unless there is

underlying lung injury.• Usually diagnosed clinically• Rx: ABC

AnalgesiaIntubation and ventilator support

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Flail chestFlail chest

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Open pneumothoraxOpen pneumothorax• Defect in chest wall provides a direct communication

between the pleural space and the environment• Lung collapse and paroxysmal shifting of

mediastinum with each respiratory effort ± tension pneumothorax

• “Sucking chest wound”• Rx: ABCs…closure of wound…chest drain

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Open pneumothoraxOpen pneumothorax

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Lung injuryLung injuryLung injuryLung injury• Pulmonary contusion• Pneumothorax • Haemothorax• Parenchymal injury• Trachea and bronchial injuries• Pneumomediastinum

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Pulmonary contusionPulmonary contusion

• Occurs to a varying degree in all thoracic injuries

• Major component of flail chest

• Significant hypoventilation and shunting

• Requires judicious fluid management and ventilatory support

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Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion

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Pulmonary contusion & Pulmonary contusion & Left Lung HerniationLeft Lung Herniation

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PneumothoraxPneumothorax• Air in the pleural cavity• Blunt or penetrating injury that disrupts the parietal

or visceral pleura• Unilateral signs: movement and breath sounds,

resonant to percussion• Confirmed by CXR• Rx: chest drain

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PneumothoraxPneumothorax

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Tension pneumothorax Tension pneumothorax • Air enters pleural space and cannot escape• P/C: chest pain, dyspnoea• Dx: - respiratory distress

- tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension

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Tension Tension pneumothoraxpneumothorax

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HaemothoraxHaemothorax• Blunt or penetrating trauma• Requires rapid decompression and fluid

resuscitation• Clinically: hypovolaemia

absence of breath sounds dullness to percussion

• CXR may be confused with collapse

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HaemothoraxHaemothorax

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• May require surgical intervention• Managed with early chest tube drainage • Surgical exploration is recommended if initial

output is more than 1000 ml or chest tube drainage is more than 200 ml/hr for 4 hours

• A clotted hemothorax should be evacuated early by thoracotomy

HaemothoraxHaemothorax

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Trachea and bronchial injuriesTrachea and bronchial injuries

• Continuous bubble• Suggested by:

• Pneumothorax • Pneumomediastinum • Subcutaneous emphysema • Hemoptysis• Airway obstruction

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Tracheal and bronchial injuriesTracheal and bronchial injuries

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• Following intubation or a surgical airway, an anterior collar incision is the best approach

• Median sternotomy may be required for associated vascular injury or intrathoracic tracheal laceration

• Avoid tracheostomy if possible when a vascular repair is in proximity

Trachea and bronchial injuriesTrachea and bronchial injuries

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Heart, Aorta & DiaphragmHeart, Aorta & DiaphragmHeart, Aorta & DiaphragmHeart, Aorta & Diaphragm

• Blunt cardiac injury- contusion- ventricular, septal or valvular rupture

• Cardiac tamponade • Ruptured thoracic aorta• Diaphragmatic rupture

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• Should be monitored in the ICU • May require heparinization for coronary

thrombosis and anti-arrhythmic therapy• Echocardiography and angiography are

indicated for tamponade and post-injury murmurs, which suggest valvular insufficiency or septal defect

Blunt cardiac injuryBlunt cardiac injury

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Cardiac Cardiac tamponadetamponade

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Aortic ruptureAortic rupture• Usually blunt trauma involving deceleration

forces• ~90% die within minutes, and who arrive at

the hospital, another 90% will die • Most common site near ligamentum

arteriosum• Dx: clinical suspicion, CXR,

aortography,contrast CT or TOE

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Aortic ruptureAortic rupture

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• Weak leg pulses with hypertension in the arms, or a new murmur.

• 1st or 2nd rib fractures • A widened upper mediastinum, deviation of

the trachea, a “pleural cap,” • Rx: surgical…poor prognosis

Aortic ruptureAortic rupture

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Aortic rupture Aortic rupture widening mediastinumwidening mediastinum

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Aortic ruptureAortic rupture

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Aortic ruptureAortic rupture

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Diaphragm RuptureDiaphragm Rupture

• Most lacerations occur on the left hemidiaphragm• Usually, the stomach herniates and undergoes

volvulus, massively dilates, and causes left lung collapse and mediastinal shift to the right

• Gastric distension can also result in perforation and should be prevented by NG tube placement

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Diaphragm RuptureDiaphragm Rupture

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Left GastrothoraxLeft Gastrothorax

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Chest trauma: summaryChest trauma: summaryChest trauma: summaryChest trauma: summary• Common• Serious• Primary goal is to provide oxygen to vital organs• Remember

AirwayBreathing

Circulation• Remember

Chest Wall Stability Lung reExpansion

• Be alert to change in clinical condition

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Iatrogenic traumaIatrogenic traumaIatrogenic traumaIatrogenic trauma• NG tubes: -coiling

-endobronchial placement -pneumothorax

• Chest tubes: - subcutaneous - intraparenchymal - intrafissural

• Central lines: - neck - coronary sinus - pneumothorax

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Line in jugular Line in jugular vein vein

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Misplaced nasogastric Misplaced nasogastric tubetube