Keynote lecture of thoracic trauma in Faculty of Medicine Universitas Padjadjaran

1. Thoracic Trauma
Navy Laksmono
Cardiothoracic and Vascular Surgery
Dr. Hasan Sadikin General Hospital Bandung
Faculty of Medicine Universitas Padjadjaran

2. Blunt Trauma
• Deceleration (motor vehicle
accident), shearing, and
compression.
Types of Chest Trauma
Penetrating Trauma
• Gunshot and stabbing.

3. Chest Trauma
Lethal Six Hidden Six
• Airway obstruction
• Tension pneumothorax
• Cardiac tamponade
• Open pneumothorax
• Massive hemothorax
• Flail chest
• Aortic rupture
• Tracheobronchial rupture
• Blunt cardiac injury
• Diaphragmatic tear
• Esophageal perforation
• Pulmonary contusion
•

4. Respiration
Still remember?

5. How do you breathe?

6. In the setting of Trauma
What you should do?
GOAL : PATIENT STAY ALIVE
PRIMARY SURVEY
With simultaenous resuscitation

7. PRIMARY SURVEY | A-irway and Cervical Movement Restriction
CHECK AIRWAY STATUS : PATENCY
SECURE THE AIRWAY IMMEDIATELY IF NEEDED : INTUBATION
*CRICOTHYROIDECTOMY FOLLOWED BY TRACHEOSTOMY IF
UPPER AIWAY IS COMPROMISED !
ASSUME CERIVAL INJURY!
C-SPINE CONTROL :
UNTIL PROVEN OTHERWISE

8. PRIMARY SURVEY | B-REATHING AND VENTILATION
ASSESS THE BREATHING: RATE? SATURATION
INSPECTION : WOUND, BRUISES, CHEST WALL MOVEMENT,
DEFORMITY, VEIN NECK DISTENTION
AUSCULATION : BREATH SOUNDS?
PALPATION : CREPITATION?, DEFORMITIES?
PERCUSSION : SONOR? HYPERSONOR? DULLNESS?
• Airway obstruction
• Tension pneumothorax
• Cardiac tamponade
• Open pneumothorax
• Massive hemothorax
• Flail chest
AWARE OF :

9. PRIMARY SURVEY | C-IRCULATION AND HEMMORHAGE CONTROL
ASSESS TISSUE PERFUSION
BLOOD PRESSURE, Heart Rate, skin perfusion, level of consciousness,
urine output
SOURCE CONTROL OF BLEEDING!
EXTERNAL OR INTERNAL
INTERNAL SOURCE :
CHEST, ABDOMEN, RETROPERITONEUM, PELVIS, LONG BONES?
Aggressive and continued volume resuscitation
Is not a substitute
for definitive control of hemorrhage.

10. PRIMARY SURVEY | D-ISABILITY (NEUROLOGIC EVALUATION)
A decrease in a patient’s level of consciousness may indicate
decreased cerebral oxygenation and/or perfusion, or it may be
caused by direct cerebral injury.
Always REEVALUATE the patient’s oxygenation, ventilation, and
perfusion status
a patient’s level of consciousness can be altered by:
Hypoglycemia,
Alcohol
narcotics,
other drugs
Until proven otherwise, always presume that changes in level of
consciousness are a result of central nervous system injury

11. PRIMARY SURVEY | E-XPOSURE AND ENVIRONMENTAL CONTROL
Hypothermia is a potentially lethal complication in injured patients,
à prevent the loss of body heat and restore body temperature
Warm intravenous
fl
uids before infusing them, and maintain a warm
environment.
The temperature of the resuscitation area should be increased to
minimize the loss of body heat
A microwave can be used to warm crystalloid
fl
uids to 39°C, but it
should never be used to warm blood products.

12. ADJUNCT TO PRIMARY SURVEY
continuous electrocardiography,
pulse oximetry,
urinary catheters à urine output and assess for hematuria.
Gastric catheters à decompress distention and assess for evidence of blood.
x-ray examinations (e.g., chest and pelvis),
FAST, extended focused assessment with sonography for trauma (eFAST),
DPL.
arterial blood gas (ABG) measurement and blood lactate

13. Chest x-rays can show potentially life-
threatening injuries that require treatment or
further investigation,
These films can be taken in the resuscitation
area with a portable x-ray unit,
!!! but not interrupting the resuscitation
process !!!
Do not hesitate to obtain essential diagnostic
x-rays, even in pregnant patients.
X-RAY EXAMINATIONS AND DIAGNOSTIC STUDIES

14. FAST or now, eFAST are useful tools for quick
detection of intraabdominal blood, pneumothorax,
hemothorax, and cardiac tamponade.
Multiple studies have shown ultrasound to be more
sensitive than supine chest radiography for the
detection of pneumothorax.
Sensitivities 86% to 100%,
Speci
fi
cities 92% to 100%.
A study by Zhang et al. found :
the sensitivity of eFAST vs chest xray for
pneumothorax was 86% vs 27%
the average time to obtain eFAST vs chest xray was
2.3 vs 19.9 minutes
FAST : FOCUSED ASSESSMENT SONOGRAPHY IN TRAUMA

15. Right Upper Quadrant

16. Left Upper Quadrant

17. Suprapubic (Longitudinal)

18. Suprapubic (Transverse)

19. Lung
B-MODE
In the normal lung, the visceral and parietal pleura can be seen
to slide against each other, with a glistening or shimmering
appearance, as the patient breathes
In pneumothorax, the pleural line seen consists only of the
parietal layer, seen as a stationary line.

20. Lung
M-mode

22. Closed pneumothorax?
Open Pneumothorax?
Tension pneumothorax?

23. Open Pneumothorax
•Defek pada dinding dada dgn diameter > 2/3 trakhea shg
udara masuk melalui dinding dada lbh bsr d.p masuk
trakhea
••Tutup dgn pembalut steril 3 sisi -> LALU PASANG CTT

24. Tension Pneumothorax
•Chest pain
•Air hunger
• Tachypnea
•Respiratory distress
•Tachycardia
•Hypotension
•Tracheal deviation away from the side of the injury
•Unilateral absence of breath sounds
•Elevated hemithorax without respiratory movement
•Neck vein distention
•Cyanosis (late manifestation)

26. DECOMPRESSION
CHEST TUBE THORACOSTOMY
Make Tension to Simple
De
fi
nitve

27. When we can say it is massive?
• Initial production > 1000 ml
• in fresh trauma onset
• or:
• Continuous bleeding of 200 cc/
hr for 2 hrs
Hemothorax
Chest Tube Thoracostomy!

32. Cardiac Tamponade
Beck's Triad
• Hypotension
• Distended Neck Vein
• Mu
ffl
ed heart sounds
Pericardiocentesis
Subxyphoid
Pericardiostomy ?
Or

33. Management?
• Analgesia
• Respiratory status?
• Pneumonatic
fi
xation
(Mechanical Ventilation)
• Costa Internal Fixation
• Plate, clipping costae
Rib Fracture, Flail Chest
and Lung Contusion

35. •Its multiple rib fractures
that result in an unstable
chest wall.
•It occurs when a
segment of the thoracic
cage is separated from
the rest of the chest wall.
•more than two (>2)
segmental fractures on at
least two adjacent ribs.
Flail Chest

36. Aim to:
• Restore mechanical integrity
• Reduce the pain associated with
spontaneous ventilation
Resulting in:
• Reduced need for prolonged
mechanical ventilation &
tracheostomy
• Reduced incidence of complications
associated with
fl
ail chest injury
• Reduced length of stay: ICU,
hospital, rehabilitation
• Improved quality of life
• Health system cost savings

38. •Bruised lung, usually
caused by blunt force
trauma and may not
show up on chest x-ray
for a couple days.
Lung
Contusion

39. Diaphragmatic Rupture

40. Trachebronchial Injury

42. Aortic Rupture

44. TerimaKasih!