Penetrating chest injury 2003


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Penetrating chest injury 2003

  1. 2. <ul><li>Stabbed with a knife at Lt chest ,2cm below the Lt nipple ,20min ago,40-yr old man was tranferrred to the hospital with consciousness. At arrival, his blood pressure 90/60 mmHg, pulse 100/min, RR 20 /min. After rapidly infuse 2000 cc of balanced salt solution intravenously, his blood pressure was 110/70 mmHg however, he complained more chest tightness. </li></ul>
  2. 4. 1.Cause of low BP at arrival? <ul><li>External hemorrhage from stab wound </li></ul><ul><li>Internal hemorrhage : </li></ul><ul><li>- blood in the pleural cavity 1, lung laceration bleeding. - vascular or thoracic intercostal broken blood vessel damage - damage to the heart and large blood vessels rupture </li></ul><ul><li>- Hemopericardium </li></ul>
  3. 6. 2.What cause of progressive chest tightness <ul><li>Continue bleeding </li></ul><ul><li>increase intrathoracic& intrapericardium pressure </li></ul><ul><li>Esophagus rupture </li></ul>
  4. 8. Assessment Massive hemothorax Tension pneumothorax Cardiac tamponade Hx Parenchymal : Blunt Another : penetrate M/c : Blunt M/c : Penetrate Pulse Rapid Rapid Rapid Blood pressure Low Low Low Pulsus paradoxus No Yes Possibly Heart sounds Audible Audible Muffled Neck vein Flat Distended Distended Percussion Dull Hyperresonance Normal Trachea Midline/deviated Deviated Midline Chest symmetry Normal/Asymmetry Asymmetrical Normal Breath sounds Absent/rhonchi/rales Absent Present Investigation Thoracentesis : if non massive should CXR Thoracentesis Fast
  5. 9. 3.Hemothorax , pneumothorax , hemopericarium ? <ul><li>Hemothorax </li></ul><ul><li>History : เจ็บแน่นหน้าอกชายโครง ลิ้นปี่ , หอบเหนื่อยหายใจไม่ออก </li></ul><ul><li>Physical : - Tachycardia </li></ul><ul><li> - decrease chest movement </li></ul><ul><ul><li> - flat neck vein </li></ul></ul><ul><li> - Dypnea </li></ul><ul><li> - Trachea & mediastinum shift to contralateral site </li></ul><ul><li>Absent and decrease unilateral breath sound </li></ul><ul><li>Dullness on percussion </li></ul><ul><li>  </li></ul><ul><li>Investigation : </li></ul><ul><li>  </li></ul><ul><li>CXR : Upright : Hyperdensity , </li></ul><ul><li>Supine : air-fulid level hyperdensity at posterior </li></ul><ul><li>Fast : positive </li></ul><ul><li>Serial HCT </li></ul><ul><li>Thoracocentesis : flesh blood </li></ul><ul><li>CT : location of fluid or clotted blood </li></ul>
  6. 10. <ul><li>Pneumothorax </li></ul><ul><li>History : เจ็บแน่นหน้าอกชายโครง ลิ้นปี่ , หอบเหนื่อยหายใจไม่ออก </li></ul><ul><li>Physical : </li></ul><ul><li>decrease chest movement </li></ul><ul><li>Dypnea </li></ul><ul><li>cyanosis </li></ul><ul><li>Trachea & mediastinum shift to contralateral site </li></ul><ul><li>Absent and decrease unilateral breath sound </li></ul><ul><li>hyperresonance on percussion </li></ul><ul><li>Investigation : </li></ul><ul><li>CXR : Hypodensity with no lung marking , lung collapse , flat diaphragm </li></ul><ul><li>Thoracocentesis : air </li></ul>
  7. 11. <ul><li>  </li></ul><ul><li>Hemopericardium </li></ul><ul><li>History : ไม่มีอาการ , ซึม , กระสับกระส่าย , หอบเหนื่อย , แน่นหน้าอก , ปัสสาวะลดลง , ความรู้สึกตัวลดลง กลืนลำบาก , สะอึก , คลื่นไส้แน่นท้อง </li></ul><ul><li>Physical : </li></ul><ul><li>Tachycardia </li></ul><ul><li>neck vein engorged </li></ul><ul><li>BP drop </li></ul><ul><li>Muffled heart sound </li></ul><ul><li>Paradoxical pulse </li></ul><ul><li>Kussmaul’s sign </li></ul><ul><li>Ewart’s sign </li></ul><ul><li>Investigation : </li></ul><ul><li>CXR : Enlarged heart shadow , Globular shaped heart from pericardium fluid </li></ul><ul><li>Echocardiogram : show fluid in pericardium sac </li></ul><ul><li>Central line : rising central venous pressure </li></ul><ul><li>EKG : low voltage QRS complex , decrease T wave, electrical alternans </li></ul><ul><li>Pericardiocentesis : fresh blood , no clotted blood </li></ul>
  8. 13. 4.If you have detected fresh blood from the left chest, what would your next action ? <ul><li>เบื้องต้นใส่ ICD ถ้าพบว่ามีเลือด ลม หรืออื่น ๆ อยู่ในช่องปอด </li></ul><ul><li>Suture at wound </li></ul><ul><li>Investigation ต่อ เช่น CXR, Fast เป็นต้น </li></ul>
  9. 15. 5. If you put in a chest tube in and fresh blood came out about 800 cc, what is your plan? <ul><li>Moderate(500 – 1000cc) </li></ul><ul><ul><li>Chest tube </li></ul></ul><ul><ul><ul><li>Bleeding stops </li></ul></ul></ul><ul><ul><ul><ul><li>Clearing and no further treatment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Persistent hemothorax requires thoracotomy </li></ul></ul></ul></ul><ul><ul><ul><li>Continued bleeding requires thoracotomy </li></ul></ul></ul>
  10. 17. 6. If you put in a chest tube in and fresh blood came out more than 2000cc and there was no detecable vital signs after that, what is your response to this situation? <ul><li>อันดับแรก clamp สาย ICD และส่ง emergency thoracotomy </li></ul>
  11. 18. Thoracotomy <ul><li>Penetrating trauma </li></ul><ul><li>Patients with a penetrating thoracotomy wound who have acute deterioration (vital signs remain or become unstable (severe shock SBP<50). If patient is in mild or moderate shock (SBP 50- </li></ul><ul><li>90mmHg) and shock persists or rapidly recurs after 2-3 liters of balanced electrolyte solution is </li></ul><ul><li>Infused in 10 mins, then er thoractomy is indicated </li></ul><ul><li>Patients with uncontrollable hemorrhage (initial chest tube output is higher than 20ml/kg(1500- </li></ul><ul><li>2000ml) or subsequent output is is >200ml/hr for 4 consecutive hours or longer </li></ul><ul><li>Cardiac tamponade </li></ul><ul><li>Patients experiencing cardiac arrest </li></ul>
  12. 19. Thoracotomy <ul><li>Patients with suspicion of a major thoracic vascular injury at the thoracic inlet with hemodynamic </li></ul><ul><li>instability </li></ul><ul><li>Traumatic thoracotomy (chest wall disruption) </li></ul><ul><li>Massive air leak from the chest tube </li></ul><ul><li>Patients with clinical evidence of an air embolism due to lung parenchymal or hilar injuries. </li></ul><ul><li>Impalement wounds to the chest </li></ul><ul><li>?Bullet embolism to heart or pulmonary artery </li></ul><ul><li>Radiographic evidence of great vessel injury </li></ul>