This document provides an overview of thoracic trauma anatomy, physiology, and management. It describes the structures of the mediastinum and vasculature. Common thoracic injuries are classified and their pathophysiology, signs, and treatment are outlined. These include pneumothorax, hemothorax, flail chest, and cardiac tamponade. The primary and secondary surveys for evaluating thoracic trauma are reviewed, including inspection, palpation, percussion, and auscultation of the chest.

1. Thoracic Trauma

2. Anatomy

3. Anatomy

8. � Mediastinum
◦ The area between the
lungs
● Heart
● Trachea
● Vena cavae
● Pulmonary artery
● Aorta

9. � Arteries
◦ Aorta
◦ Carotid
◦ Subclavian
◦ Intercostal
� Veins
◦ Superior vena cava
◦ Inferior vena cava
◦ Subclavian
◦ Internal jugular
Vascular Anatomy

10. � Heart
◦ Ventricles
◦ Atria
◦ Valves
◦ Pericardium

11. � Physiology
◦ Ventilation—the
mechanical process of
moving air into and out
of the lungs
◦ Respiration—the
exchange of oxygen
and carbon dioxide
between the outside
atmosphere and the
cells of the body

12. � Blunt thoracic injuries
Classification
Mechanism of Injury

13. � Penetreating trauma

14. Rib fractur

15. � Two or more adjacent
ribs fractured in two
or more places
producing a free-
floating segment of
chest wall
Flail Chest
Pathophysiology

16. Pneumothorak

18. � To-and-from air motion out of the defect
� A defect in the chest wall
� A sucking sound on inhalation
� Tachycardia
� Tachypnea
� Respiratory distress
� Subcutaneous emphysema
� Decreased breath sounds on the affected side

19. radiology

21. � Nonpharmacological
◦ Occlude the open
wound—apply an
occlusive petroleum
gauze dressing
(covered with sterile
dressings) and secure
it with tape.
Open Pneumothorax
Management

22. � Associated Injuries
◦ A penetrating injury to
the chest
◦ Blunt trauma
◦ Penetration by a rib
fracture
◦ Many other
mechanisms of injury
Tension Pneumothorax

23. � Extreme anxiety
� Cyanosis
� Increasing dyspnea
� Difficult ventilations while being assisted
� Tracheal deviation (a late sign)
� Hypotension
� Tachycardia
Tension Pneumothorax
Assessment Findings

24. � Needle thoracostomy
Tension Pneumothorax
Management

25. � Accumulation of
blood in the pleural
space caused by
bleeding from
◦ Penetrating or blunt
lung injury
◦ Chest wall vessels
◦ Intercostal vessels
◦ Myocardium
Hemothorax

27. � Tachypnea
� Dyspnea
� Cyanosis
� Diminished or decreased breath sounds on the
affected side
Hemothorax
Assessment Finding

28. � Mengembalikan
tekanan rongga
pleura yang patologis
(positif) menjadi
fisiologis (negatif)
atau mendekati
fisiologis secepatnya
Terapi

31. � Increased
intrapericardial
pressure:
◦ Does not allow the heart
to expand and refill with
blood
◦ Results in a decrease in
stroke volume and
cardiac output
� Myocardial perfusion
decreases due to
pressure effects on the
walls of the heart and
decreased diastolic
pressures.
� Ischemic dysfunction
may result in infarction.
Pericardial Tamponade

32. � Tachycardia
� Respiratory distress
� Narrowed pulse pressure
� Cyanosis
� Beck’s triad
◦ Narrowing pulse pressure
◦ Neck vein distention
◦ Muffled heart sounds
Pericardial Tamponade
Assessment Findings

33. � Airway and ventilation
� Circulation—IV fluid challenge
� Nonpharmacological—pericardiocentesis (in-
hospital management)
Pericardial Tamponade
Management

34. � ABCs & MAJOR PROBLEMS SHOULD BE
CORRECTED AS THEY ARE IDENTIFIED
� Listen to air movement: nose, mouth, lung fields,
inspect the oropharynx
Primary Survey: Airway

35. � Chest & Neck completely exposed!
� Assess respiratory movement & quality of
respirations
� Cyanosis is a late sign of hypoxia
� Shallow respirations & respiratory rate may be the
only signs of impending respiratory distress
Primary Survey: Breathing

36. � These major thoracic injuries should be
recognized and addressed during the primary
survey
◦ Tension pneumo
◦ Open pneumo
◦ Flail chest
◦ Massive hemothorax

37. � One-way-valve/air leak occurs from the lung or
chest wall without any escape causing collapse of
the lung, mediastinum displacement, decreasing
venous return, & compressing the opposite lung
� THIS IS A CLINICAL DIAGNOSIS
◦ Chest pain, air hunger, respiratory distress, tachycardia,
hypotension, tracheal deviation, unilateral absence breath
sounds, distended neck veins, & cyanosis
◦ Difficult to differentiate from cardiac tamponade, but
hyperresonant percussion & absent breath sounds are
more likely with a pneumo
Tension Pneumothorax

38. � Open chest wall equilibrates intrathoracic and
atmospheric pressure if the opening is
approximately two-thirds the diameter of the
trachea
� Management: closing the defect with a sterile
occlusive dressing taped on 3 sides; chest tube
inserted placed on the same side at a remote
location to the wound
Open Pneumothorax

39. � Physical Exam:
◦ Pulse – quality, rate, regularity, peripheral pulses
◦ Blood pressure & pulse pressures
◦ Skin color & temperature
◦ Neck veins – may not be distended in hypotensive patients
with tamponade, tension pneumo, & diaphragmatic injury
� Major injuries that should be diagnosed in the
Primary Survey
◦ Massive hemothorax & Cardiac Tamponade
Primary Survey: Circulation

40. � Rapid accumulation of more than 1500mL of blood
or 1/3 the patients blood volume or >200 mL/hour
for 3 hours
� Associated with pneumo 25%
� Usually from penetrating chest trauma injuring
lung parenchymal vessels most common source
(self limiting); intercostal & internal mammary 2nd
most common, and rarely hilar vessels
� Shock, absent breath sounds, dullness to
percussion are signs
Massive Hemothorax

41. Massive Hemothorax
200-300 mL required to blunt costophrenic angles on upright
chest X-ray
Supine views can miss large collections of blood

42. � Blood should be removed as completely & rapidly
as possible
� 32-40 fr Chest tube inserted anterior axillary line &
directed posteriorly and laterally
Hemothorax Management

43. � Indications for Thoracotomy
◦ Initial drainage >20mL/kg
◦ Persistent bleeding >7mL/kg/hr
◦ Increasing hemothorax via x-rays
◦ Vital signs remain unstable without any other source of bleeding and
adequate resuscitation
� Indications for ED Thoracotomy
◦ Penetrating Traumatic Cardiac arrest with signs of life in the field; BP <50
after resuscitation; shock & signs of tamponade
◦ Blunt Trauma Cardiac arrest in the ED
◦ Suspected air embolus
◦ *ATLS Manual 7th Ed. “Thoracotomy is not indicated unless a surgeon,
qualified by training and experience, is present.
� Consider auto transfusion

44. � HEAD to Toe examination with adjuncts: upright
chest, CTs, ABGs, ECGs
Secondary Survey

45. � Inspect
� Palpate
� Percuss
� Auscultate
Thoraks exam

46. ◦ Shape and
configuration
◦ Anteroposterior
Diameter should be <
Transverse Diameter =
Ratio 1:2 to 5:7
◦ Note Position of Person
to breathe.
● ? orthopnea
◦ Skin Color & Condition,
nail color
inspeksi

48. Palpate
Symmetric Expansion- warmed hands –
thumbs @ T9-T10- pinch sm. Fold of skin

49. � Percuss start at the apices, across shoulders,
then interspaces side to side (5cm. Intervals)
Avoid scapulae & ribs
◦ Resonance predominates in healthy lung
◦ Hyperresonance – too much air, emphysema,
pneumothorax
◦ Dull = abnormal density, pneumonia, tumor, atelectasis
perkusi

51. auskultasi

52. Terima Kasih