Thoracic Trauma

Pre test
Gambarkan anatomi thorax : dinding,
rongga, organ.
Gambarkan traktus respiratorius
Apa itu pneumothorax
Apa itu hematothorax
Apa itu cardiac tamponade
Apa itu flail chest
Overview
General Anatomy
Types of thoracic injuries
Exam findings
Treatment
Thoracic Anatomy

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 Thoracic Anatomy

http://info.med.yale.edu/intmed/cardio/echo_atlas/references/heart_anatomy.html
Thoracic Anatomy
 Thoracic Anatomy

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http://eng-sci.udmercy.edu/courses/bio123/Chapter43/lung%20anatomy.html
Thoracic Anatomy
Thoracic Anatomy
Thoracic Trauma
25% of nonmilitary trauma related deaths.
Mortality 5% for isolated chest trauma
Two or more organ systems 1/3 mortality
Nearly all penetrating injuries result in
pneumothorax with hemothorax in more than 75%
of cases.
Of penetrating trauma, 1/3 will be associated with
abdominal injuries.
Mechanisms of blunt trauma: compression, direct
trauma, and accel/decel forces.
Diagnosing Thoracic Injuries
Symptoms: Chest pain and SOB.
Physical Exam.
Look for six major conditions.
Think of mechanism of injury.
Dont forget about liver and spleen.
 Chest Wounds
Lethal six injuries:
Airway obstruction
Tension pneumothorax
Pericardial tamponade
Open pneumothorax
Massive hemothorax
Flail chest
The Box: bounded by nipples bilat, costal
margin inferiorly, and thoracic inlet superiorly
Have high suspicion of cardiac injury
Inspection
Chest Wall: look for signs of injury such
as contusions, flail chest, open chest
wounds.
Neck: Distended neck veins,
subcutaneous emphysema, swelling
and cyanosis
Abdomen: scaphoid abdomen
Physical Exam
Palpation: trachea position, tenderness,
or crepitus.
Percussion: dullness for hemothorax
and hyperresonance for pneumothorax
Auscultation: Equal breath sounds,
bowel sounds high in chest.
Pneumothorax
Can cause severe symptoms if:
Tensions pneumothorax
Occupies >40% of hemithorax
Pt in shock or preexisting cardiopulmonary
disease.
Occasionally can be delayed.
Can repeat film in 6hrs and.
Occult Pneumo: requires chest tube if patient
is going on a ventilator.
Pneumothorax
Traumatic injury
causes rupture of
lung parenchyma
and air enters the
pleural space
Negative pressure in
pleural space
facilitates air escape
Pneumothorax Types
Simple Pneumothorax air seen on
CXR with no vital sign derangements
and no mediastinal shift.
Tension Pneumothorax continued air
leakage into closed space causes
significant lung collapse, compression of
mediastinum, and compression of
opposite hemi-thorax
Pneumothorax Types
Open Pneumothorax from penetrating injury
If significant enough in size will cause Sucking
Chest Wound
Spontaneous Pneumothorax typically occurs
in tall, slender teenagers due to congenital
area of lung weakness.
Also seen asthma, COPD, restrictive lung dz
 Sucking Chest
Wound
A:Inspiration
B:Experation
Pneumothorax Exam
findings
Simple Tension Pneumothorax
Pneumothorax JVD
Diminished lung Tracheal shift
sounds Diminished SpO2
Tachycardia Absent breath sounds
Tachypnea Diminished breath
Dyspnea sounds on opposite side
Pleuritic chest pain Hypotension
Hyper-resonant to Narrowing pulse
percussion pressure
 Pneumothorax Radiographs

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 Pneumothorax Radiographs

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punksjon/pneumothorax.jpg http://www.ishikiriseiki.or.jp/new_sinryoka/geka/images/tension-pneumothorax1.jpg
Pneumothorax Radiographs

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 Pneumothorax Treatment
All types of pneumothorax
ABCs, supportive care, early notification
High flow oxygen
Rapid transport if unstable vitals
Open pneumothorax
Occlusive dressing placed
Consider securing only on three sides
Watch for signs of tension pneumothorax
Cover site with
sterile occlusive
dressing taped on
three sides
Pneumothorax Treatment
Tension Pneumothorax
Acute life threatening emergency
Needle decompression affected side
2nd intercostal space mid-clavicular line -OR-
4th or 5th intercostal space at mid-axillary line
Place above rib to avoid neurovascular bundle
All needle decompressions will need chest
tube upon arrival at hospital
Tension Pneumothorax
Clinical diagnosis
Dyspnea, hypoperfusion, distended neck
veins, diminished breath sounds,
hyperresonant percussion, tracheal deviation.
Decompress with 14 gauge catheter
2nd intercostal space midclavicular line
If no improvement then look for other cause (ie
Cardiac Tamponade)
Chest Tube
Needle Decompression
Subcutaneous Emphysema
Air from lung parenchyma
or the tracheobronchial
tree.
Interstitial lung injury
through hilum and
mediastinum.
If extensive then suspect
injury to pharynx, larynx, or
esophagus.
Should be assumed that pt
has ptx even if not visible
on chest x-ray.
 Ruptura trakhea - bronkhus
Ruptur trakhea,
bronkhus sering
didaerah Carina
( percabangan), bila
ruptur total bisa fatal

Klinis hemoptisis,
sianosis, empisema
subkutis, intubasi
sulit karena distorsi
trakhea.
 Next time..
Hemothorax
Most frequently from lung injury.
5-15% of pts admitted with chest
trauma require thorocotomy.
Upright film: 200-300 mL of blood.
Treatment: Chest tube.
Chest Tube
Site: anterior axillary line.
2-3cm incision 1-2cm below interspace.
Extend down to intercostal muscles.
24F or 28F tube for pnuemothorax.
32F or 40F tube form hemothorax.
Massive Hemothorax
Each hemithorax can hold 40-50% of
blood volume.
Defined: 1500 mL or more.
Cause: Injury to lung parenchyma,
intercostal artery or internal mammary
artery
Massive Hemothorax
Life threatening
Hypovolemia causing inadequate preload
Hypoxia
Compresses the vena cava.
Chest x-ray-Aerated lung surrounded
by fluid.
Treat: Chest tube operation
Cardiac Tamponade
Caused by blunt and penetrating
trauma.
Stab wounds to midchest most common
cause.
Pericardial sack has poor compliance.
150-200 mL can result in tamponade.
Cardiac Tamponade
Obstruction of venous return leading to
hypoperfusion and distended neck veins.
Becks Triad : JVD,hypotension, muffled hear
tones
Treat: Fluid bolus and Pericardiocentesis
As little as 5-10 mL can improve cardiac
performance
Cardiac Tamponade ECHO
Tamponade jantung
Chest Wall Injuries
Soft tissue with bleeding: control with
pressure. Explore in OR.
Open Chest Wounds
If exceeds 2/3 are of trachea then air will enter
through chest wall
Cover with air tight dressing but may cause
tension pneumothorax.
Do not insert chest tube through tract.
Tissue loss
Bony Injuries
Simple rib fractures: 50% will not appear on x-
ray. Look for complications:
Hemopneumothorax
Contusion
1st and 2nd rib fractures: requires significant
force. Look for other injuries.
Multiple: If 9,10,11 then think liver spleen injury.
Flail Chest: Segmental fx or 3 or more adjacent
ribs. Paradoxical movement. Hypoxemia from
underlying contusion.
Flail Chest
Free floating
segment of ribs.
3 or more rib
fractures broken in 2
places.
Look for paradoxical
chest wall motion
Inhaleinward
Exhaleoutward
Decreased air entry.
Flail Chest Treatment
Analgesia and intercostal nerve block.
Belts and adhesive tape inhibit
expansion.
Restrict IV fluids.
Ventilatory support: shock, 3 or more
injuries, head injury, pulmonary disease,
>65 yrs.
Consider Ventilatory Support
Respiratory failure from flail chest.
Shock
Multiple injuries
Comatose
Requiring multiple transfusions
Elderly
Preexisting pulmonary disease
RR >30-35
Po2 <50 on room air
Sternal Fractures

Incidence 3%.
Normal vitals and normal EKG. Repeat
EKG in 6 hrs
Injuries to Lung
Pulmonary Contusion
Significant source or morbidity and
mortality.
Hemorrhage and edema without laceration.
Caused by compression-decompression
injury.
Pulmonary Contusion

Pathological changes: capillary damage

causes interstitial and intraalveolar
extravasation of blood and edema.
First hemorrhage then edema.
Pt becomes hypoxic, hypercarbic, and
acidotic.
Diagnosis and Treatment
Chest x-ray: areas of opacification seen
within 6 hrs.
Maintain adequate ventilation.
Usually require support if more than
28% of lung volume.
Pneumomediastinum
Hamman sign: crunching, rasping sound,
synchronous with heartbeat
Suspect if subcutaneous emphysema in neck.
Traumatic pneumomediastinum is usually
asymptomatic.
Must look for injury to the larynx, trachea,
major bronchi, pharynx or esophagus.
Lung Injuries
Hematoma: parenchymal tears filled
with blood. Can form abscess.
Lacerations: major hemorrhage from
sharp ends of fractured ribs.
Air embolism: air from injured bronchus
forced into vessel.
Tracheobronchial Injury
Caused by rapid deceleration.
Expiration against closed glottis or
compression against vertebral column.
Signs and Symptom: dyspnea, hemoptysis,
Hamman sign, and sternal tenderness.
10% asymptomatic.
Injury occurs within 2cm of carina or at origin
of lobar bronchi.
Diaphragmatic Injury
Mostly penetrating trauma.
4-5% from blunt trauma.
80-90% on left in blunt trauma.
Often Intraop diagnosis in penetrating
trauma.
Penetrating Injury to Heart
Factors affecting survival: weapon
used, size of myocardial injury, artery
damage and presence of tamponade.
1/3 can be saved.
Signs of life in OR: 70% gunshot and
85% stab wound survival.
If no sign of life in field-do not
resuscitate.
Heart Injury Cont
Usually rapidly fatal from massive
hemorrhage.
<1/4 of patients reach hospital.

Becks triad: distended neck veins,

hypotension, muffled heart tones.
Other causes: tension pneumothorax,
myocardial dysfunction and systemic air
embolism.
Diagnosing
X-ray:most patients have normal
silhouettes. Pericardium is
noncompliant.
EKG: nonspecific
Echo: pericardial fluid
Pericardiocentesis
Paraxiphoid approach
Can direct needle toward left scapula or
right scapula (less likely to damage
ventricle).
Up and back at 45 degrees for 4-5 cm.
Aspirate every 1-2mm.
Removal of 5-10 mL can increase
stroke volume by 25-50%.
Pericardiocentesis
Pericardiocentesis
Indications For Thoracotomy/Median
Sternotomy
Hemodynamic instability with penetrating chest
wound
Massive hemothorax >1500cc
Persistent htx >200cc/hr x 4hrs or persistent large htx
despite chest tube
Persistent air leak/tracheobronchial fistula with
inability to ventilate patient
Cardiac tamponade
Esophageal injury
Great vessel injury
Thoracotomy Indicated for Cont
Bleeding In:
Pts losing more than 1500mL in first 4-
8hrs.
Chest tube drains 200-300mL per hour.
Chest continues to be more than half
full on x-ray with functioning chest tube.