chest trauma 1 dr. ber
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Thoracic TraumaThoracic TraumaThoracic TraumaThoracic Trauma
BERMANSYAHBERMANSYAH
Anatomi Anatomi
• Jaringan Lunak dinding Torak
• Tulang
• Parenkim
• Pembuluh Darah
• Jantung
• Mediastinum
Anatomy Anatomy
Fisiologi PernafasanFisiologi Pernafasan
• Trakea
• Bronkus
• Bronkiolus
• Alviolus
• Kapiler
KompKompoonen Pernafasannen Pernafasan
• Trakea
• Dinding Torak
• Parenkim Paru
• Diafragma
Trauma TorakTrauma Torak
• Trauma Tumpul
• Trauma Tajam
• Trauma Abdomen
CARDIOVASCULACARDIOVASCULAR SYSTEMR SYSTEM
Anatomy & Physiology
THE HEART
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
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 )
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
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
Anatomy of the HeartAnatomy of the Heart
• Aorta• Coronary arteries• Arterioles• Capillaries• Venules• Coronary sinus• Right atrium
Coronary circulationCoronary circulation
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
TRAUMA PADA DINDING DADATRAUMA PADA DINDING DADA
• FRAKTUR CLAVICULA
• FRAKTUR STERNUM
• DISLOKASI SENDI STERNOCLAVICULA
• FRAKTUR IGA
• “FLAIL CHEST”
• TRAUMA ASPIKSI
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.
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)
DISLOKASI SENDI DISLOKASI SENDI STERNOCLAVICULARSTERNOCLAVICULAR
– Kasus Jarang• Anterior : Nyeri, nyeri tekan, sendi menonjol
kedepan• Posterior : Sendi tertekan kedalam• Pengobatan : Reposisi
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
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
FRAKTUR IGAFRAKTUR IGA
Fraktur Iga + Hemotoraks / Pneumotoraks → WSD
Fraktur Iga + contusio paru → perawatan ketat → ICU
Fraktur Iga VI – XII → trauma Ginjal, Hati
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
FLAIL CHESTFLAIL CHEST
– Pengobatan : • Internal stabilization (Pneumatik Stabilisasi)
– Intubasi Endotracheal– Ventilasi Mekanik → Mereduksi Pnemonia
• Fiksasi Iga (Stabilisasi bedah)
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
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
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 (-)
PENGOBATAN• WSD
ICS IV / ICS V linea aksilaris medialis –
- anterior
• Torakotomi
Kontrol kebocoran paru
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
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
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)
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
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
TRAUMA ESPOHAGUSTRAUMA ESPOHAGUS
• Trauma tumpul jarang dibandingkan truma tusuk
• Diagnosis : pneumomediastim atau efusi pleura
• Esophagography
TRAUMA TUMPUL JANTUNGTRAUMA TUMPUL JANTUNG
• Jarang terjadi
• Trauma langsung karena kecelakaan lalu lintas
• “Myocardial Contusion”
• EKG
Penetrating injuriesPenetrating injuries
Penanggulangan rongga PleuraPenanggulangan rongga Pleura
TujuanMengembalikan kondisi fisiologis rongga pleura dengan cara :
1. Observasi2. Pungsi pleura3. WSD4. Continous suction ( I botol / 2 botol )
WSD
Indikasi Utama WSDIndikasi Utama WSD
1. Robekan pleura visceral
2. Monitoring perdarahan untuk dapat menentukan indikasi torakotomi yang tidak berdasarkan kepada kondisi klinis pasien
Pelaporan WSD
1. Initial
2. Undulasi
3. Expiratory bubble
4. Produksi
Indikasi Continous SuctionIndikasi Continous Suction
1. Hematopneumotoraks agar darah segera dapat dikeluar sebelum proses pembekuan.
2. Robekan pleura visceral .
Definisi :Definisi :Pemasangan drain pada rongga pleura melalui insisi pada sela iga
Tujuan :Tujuan :Mengeluarkan cairan, darah, udara dari rongga pleura.
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
PneumotoraksPneumotoraks
HematotoraksHematotoraks
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.
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
Indikasi pencabutan drainIndikasi pencabutan drain
• KlinisKlinis• RadiologisRadiologis• Kuantitas dan kualitas cairanKuantitas dan kualitas cairan
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
• 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
Jenis WSD Jenis WSD
Posisi yg WSD Posisi yg WSD
Trauma TumpulTrauma Tumpul
• Dinding TorakJejasHematomLaserasiFraktur igaFraktur claviculaCedera Vaskular
• M - MECHANISM OF INJURY
• I - INJURIES SUSTAINED
• S - SIGNS AND SYMPTOMS
• T - THERAPY
• TRAUMA TUMPUL
• TRAUMA TAJAM
• TRAUMA LEDAKAN
• BIOMEKANIK TRAUMA
• Semua harus dicari melalui anamnesa yang teliti
Cidera yang didapat
• Kelainan dinding dada
- Empisema kulit - Fraktur iga respirasi paradoksal
• Kelainan rongga Pleura- Hematotoraks
- Pneumotoraks
- Hemato-Pneumotoraks
- Chylothorax
• Kelainan Parenchym Paru
- Traumatic Wet Lung
• Kelainan Mediastinum
- Cardiovascular
- Tracheobronchial
- Esophagus
• Kelainan Abdominal
- Thoracoabdominal
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
TerapiTerapi
• Saluran nafas• Pernafasaan• Sirkulasi• Penanggulangan rongga Pleura• Stabilisasi dinding dada• Menghilangkan rasa nyeri• Torakoskopi• Torakotomi
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
3. Menanggulangi rasa nyeri
1. Analgetik boleh dipakai asal tidak mengganggu reflek batuk dan
pernafasan
2. Dianjurkan melakukan interkostal blok anestesi dari nervus interkostalis
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
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 %
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
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
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
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
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 )
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
• 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
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
Indikasi TorakotomiIndikasi Torakotomi
Initial bubble (-) atelektasis bronkoskopi
• Pneumotorak WSD
spontan (+) chest fisioInitial bubble (+) pengembangan paru
terapi
( - )
torakotomi
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
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
• Shunting paru right to left
saturasi vena pulmonalis menurun
• Shunting perifer left to right
darah kembali ke sentral tanpa melalui kapiler
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
TRAUMA ESPOHAGUSTRAUMA ESPOHAGUS
• Trauma tumpul jarang dibandingkan truma tusuk
• Selalu disertai trauma lainnya dari toraks
• Diagnosis : - Pneumomediastinum atau efusi pleura
- Esophagography
Penetrating injuriesPenetrating injuries
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
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
Ruptur Bronkhus
- Inspeksi- Palpasi- Perkusi- Auskultasi- Pemeriksaan tambahan
Ruptur diafragma
- Inspeksi- Palpasi- Perkusi- Auskultasi- Pemeriksaan tambahan
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
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
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
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
Neck ZoneNeck Zone
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?
Penetrating Neck TraumaPenetrating Neck Trauma
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
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
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
Esophageal RuptureEsophageal RuptureEsophageal RuptureEsophageal Rupture
Complete Tracheal RuptureComplete Tracheal Rupture
Complete Tracheal Rupture
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
Diagnostic modalitiesDiagnostic modalities
• CT scan• Laryngoscopy and Bronchoscopy• Doppler Ultrasound• Angiography• Contrast Esophagogram• Flexible Esophagoscopy
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
• 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
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
Radiological LandmarkRadiological Landmark
• 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
Blunt injuriesBlunt injuries
Mechanism of InjuryMechanism of Injury
Penetrating injuries• E.g. stab wounds etc.• Primarily peripheral lung• Haemothorax• Pneumothorax• Cardiac, great vessel ,trachea
or oesophageal injury
Penetrating injuriesPenetrating injuries
Chest wall injuries Chest wall injuries
• Rib fractures
• Flail chest
• Open pneumothorax
Chest wall injuries Chest wall injuries Chest wall injuries Chest wall injuries
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
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
Flail chestFlail chest
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
Open pneumothoraxOpen pneumothorax
Lung injuryLung injuryLung injuryLung injury• Pulmonary contusion• Pneumothorax • Haemothorax• Parenchymal injury• Trachea and bronchial injuries• Pneumomediastinum
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
Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion
Pulmonary contusion & Pulmonary contusion & Left Lung HerniationLeft Lung Herniation
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
PneumothoraxPneumothorax
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
Tension Tension pneumothoraxpneumothorax
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
HaemothoraxHaemothorax
• 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
Trachea and bronchial injuriesTrachea and bronchial injuries
• Continuous bubble• Suggested by:
• Pneumothorax • Pneumomediastinum • Subcutaneous emphysema • Hemoptysis• Airway obstruction
Tracheal and bronchial injuriesTracheal and bronchial injuries
• 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
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
• 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
Cardiac Cardiac tamponadetamponade
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
Aortic ruptureAortic rupture
• 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
Aortic rupture Aortic rupture widening mediastinumwidening mediastinum
Aortic ruptureAortic rupture
Aortic ruptureAortic rupture
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
Diaphragm RuptureDiaphragm Rupture
Left GastrothoraxLeft Gastrothorax
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
Iatrogenic traumaIatrogenic traumaIatrogenic traumaIatrogenic trauma• NG tubes: -coiling
-endobronchial placement -pneumothorax
• Chest tubes: - subcutaneous - intraparenchymal - intrafissural
• Central lines: - neck - coronary sinus - pneumothorax
Line in jugular Line in jugular vein vein
Misplaced nasogastric Misplaced nasogastric tubetube