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thoracic and abd.trauma.pptx
- 1. SEMINAR 3 SAWLA GENERALHOSPITAL THORACIC AND ABDOMINAL TRAUMA
- 2.
- 3. Introduction • Trauma isone of the leading causes of mortality, morbidity and disability worldwide. • trauma mostly affects people in their productive years of life • Deaths due to trauma tend to occur In three patterns • - Immediate death (50%) - Early deaths (30%) - Late deaths (20%)
- 4. Definition and types ✔Traumais tissue damage, which occurs due to transfer of different forms of energy either intentionally or unintentionally. ✔Trauma can be classified according to the Mechanism - Blunt Injury: Caused by acceleration, Deceleration,rotational or shearing force - Penetrating Injury: Caused by a direct breach by penetrating object.e.g Bullet injury, stab injury
- 5. Early management oftrauma • Management is depend on ATLS protocol • It generally consists of a primary survey and resuscitation followed by a secondary survey and definitive Managements. I- The primary survey and resuscitation. • During this time, life-threatening injuries are identified and simultaneously resuscitation is begun
- 6. A- Airway maintenance -It is assess of airway patency by inspect foreign body and communication ability - If the airway is compromised, use suctioning, jaw trust positioning, oropharyngeal tube or endotracheal tube to open it and taking care of cervical spine B- Breathing and ventilation - it is assessing of breathing adequacy - examined by inspection, palpation, percussion and auscultation -The aim is to identify and manage life-threatening thoracic conditions
- 7. Man..... Interventions:Needle decompression Chest tubes Occlusivedressing C- Circulation with bleeding control -assessment of hemodynamic status by measuring blood pressure and pulse rate, and inspecting skin color Intervention -Establish IV -stop external hemorrhage by pressure, bandaging or tourniquet - take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate. - if suspect cardiac tamponade -Cardiac tamponade decompression Is done
- 8. Man..... D- Disability/Neurologic assessment -neurologicexamination is done to assess consciousness. The Glasgow Coma Scale is a quick method to determine the level of consciousness E-Exposure patient should be completely undressed Used for examination not to miss serious injuries
- 9. Man...... II- Secondary surveyand definitive Management It include: - history - examination of all body system - investigations - specific treatment
- 10. THORACIC INJURY • 25%of all trauma deaths are a result of chest injuries alone. • Secondar cause of trauma death after head injury • It involve: The chest wall ,Lung ,Mediastinal structures, Diaphragm
- 11. Classification Based on Mechanism Blunt:85%of all chest injury result from MVA(75%),fall and crush of injury Penetrating: 15% Stab and gunshot wounds are common cause It results in hemothorax and pneumothora.
- 12. Class.... Based on severity Immediatelylife threatening -Airway obstruction -Tension pneumothorax - Pericardial tamponade -Open pneumothorax -Massive haemothorax -Flail chest
- 13. Class... • Potentially lifethreateningcontusion -Aortic injuries -Tracheobronchial injuries -Myocardial contusion -Rupture of diaphragm -Oesophageal injuries -Pulmonary contusion
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- 16. Tension Pneumothorax Pathophysiology ofPneumothorax • Normally, the pressure within the pleural space is • negative in comparison to alveolar and atmospheric pressure. • If there is an opening made into the pleural space, air rapidly rushes in due to the negative pressure. • As pressure rises, lung tissue collapses. • The amount of collapse is dependent on the • size of the pneumothorax. E.g. if < 25% • asymptomatic
- 18. Ten...... • It isa life-threatening condition caused by the continuous entrance and entrapment of air into the pleural space • Air flows in one way only which means only entering • It compressing the lungs, heart, blood vessels, and other structures in the chest.
- 20. Clinical presentation - Tachypnea -Dyspnea - Distended neck veins - Tracheal deviation - Hyperresonance and - Absent breath sounds
- 21. Diagnosis • Based onclinical • CXR shouldn't be needed to identify because of it delay therapeutic intervention and cause lethal delay Treatment • Rapid insertion of Large bore needle in to the 2ndICS atMCL/mid clvicular line • Follwed by Chest tube insertion
- 22. Open pneumothorax • Occursdue to a large defect in thorax (>3cm) • It leading to immediate equilibration between intrathoracic and atmospheric pressure • When wound is >2/3 of tracheal diameter - inspiration pulls airs through wound into pleural space - air doesn't flow through the trachea in to the lungs
- 24. Clinical presentation • RespiratoryDistress • Tachypnea and Dyspnea • Asymmetrical chest expansion • Hyper-resonant to percussion • Diminished or absent breath sounds on affected side • Air movement through the wound; noticed as • “bubbling” of blood at the wound site
- 25.
- 26. Management • Closing defectwith sterile occlusive plastic dressing taped on 3 sides to form a 1 • way valve • chest tube inserted in a site remote • from injury site. • Definitive Rx may warrant debridement and closure in the OR and Early referral
- 27. Haemothorax • Hemothorax isa collection of bloody fluid in the pleural space • Following blunt or penetrating wound to the chest • Sources:-Chestwallvessels, • -Lungparenchyma • -MajorThoracicvessels • ClinicalPresentation-respiratory distress and shock. • Dull percussion • Absent breath sounds • Tachycardia • Hypotension due to blood loss.
- 28. Diagnosis • Clinical Examfindings • CXR (> 250ml on lateral, > 500ml)
- 29. Management • correct theshock • Insert IC drain • Intubation (in some cases) • Thoracotomy • Indications • - Drainage of 1500ml of blood or ongoing hemorrhage of >200ml/hr over 3-4hrs
- 30. Cardiac Tamponade • Iscompression of the heart by • an accumulation of fluid in the pericardial sac. • It decrease cardiac output • Most commonly the result of penetrating trauma Clinical Presentation: • it has Similar clinical presentation as tension pneumothorax • Their difference is presence of hyperresonance on percussion indicates tension pneumothorax, whereas the presence of bilateral breath sounds indicates cardiac tamponade.
- 31. Investigation CXR --enlarged heartshadow Echocardiograpy --fluid in pericardial sac Management Needle pericardiocentesis -for stabilization until definitive management,but there may be high risk of iatrogenic injury to the heart Definitive management -Operative (sternetomy or left thoracotomy & repair of the heart)
- 32. Flail chest • 3or more ribs fractured in 2 or more places. Diagnosis: -Paradoxical chest wall movement -Poor air movement -Hypoxia Therapy: Pain control Pulmonary & physical therapy Intubation and ventilator support if needed Fluid restriction if possible
- 33.
- 34. Classification of injury •Bluntinjury(BAT) - mostcommon. - RTA(75%),Industrial,sporting • Penetrating injury (PAT) • •Lowenergy–Stab Wound • •Highenergy-GSW mortality is high
- 35. Class.. • Based onhemodynamic stability - hemodynamically ‘normal - hemodynamically ‘stable - hemodynamically ‘unstable’-immediate Surgery is required • A trauma laparotomy is the final step in the pathway to delineate intra-abdominal injury
- 36. Management • ATLS principles •Base line labs Hematocrit Leukocyte count Pancreatic enzyme ( serum amylase and lipase ) Liver function test Urinanalysis
- 37. Imaging • FAST-ultrasound • Diagnosticperitoneal lavage • Abdominal, Pelvic CTscan • Local wound exploration • Angiography • Plan and. X-ray
- 38. Focused Assessment with sonographyof trauma (FAST) • To diagnosis free intraperitonial fluid • Area of assessment Pericardium Perihepatic and hepatorenal Presplenic Pelvis
- 39. Limitations of FAST •Injury to solid parenchyma, the retroperitoneum, • or the diaphragm is not well seen •Uncooperative patients, obesity, bowel gas, and subcutaneous air interfere with image quality •Less sensitive than peritoneal lavage for hemoperitoneum (< 500ml) •Blood cannot be distinguished from ascites or urine •Subcapsular injuries cannot be detected
- 40. CT imaging • Accuratefor viisceral lesion and intraperitonal hemorrhage • Disadvantages Insensitive for injury of the pancreas,diaphragm,small bowel and mesentry Diagnostic Peritoneal Lavage Determine presences blood in peritoneum
- 41. Algorithm for theevaluation of penetrating abdominal injurys
- 42. Algorithm for theinitial evaluation of a patient with suspected BAT
- 43.
- 44. Splenic Injuries • Mostcommonly injured organ • •~25% of blunt abdominal trauma • •~7%penetrating abdominal trauma Signs & Symptoms • Feature of shock (pallor, tachycardia, restlessness, tachypnea, anxiety, hypotension and decreased pulse pressure • Tenderness and abdominal rigidity in LUQ • Abdominal distension • Kehr's sign (pain after lying down and foot elevation • Ballance's sign (fixed dullness to percussion on left and shifting dullness on the right
- 45.
- 46. Treatment • Non operativemanagement Indication ~ hemodynamically stable ~ Lack of guarding and rigidity ~ Minimal evidence of blood loss ~ Children • Operative management -Splenorraphy -Splenectomy
- 47. Hepatic Injuries • Secondmost commonly injured intra-abdominal organ • Associated with Rt 8-12 rib fractures • Blunt trauma (15-20%) • Penetrating trauma~37% Signs & Symptoms • RUQ penetrating or blunt trauma(hx) • RUQ pain, Rt chest wall & shoulder pain • Rigidity or guarding • Reboundtenderness • Signs of hemorrhage or shock
- 48. Mgt of HepaticInjuries • The management of liver injuries can be • summarized as ‘thefourPs’: • 1.Push; • 2.Pringle (performed with avascular clamp occludes the hepatic pedicle containing the portal vein, hepatic artery, and common bileduct) 3.Plug; 4.Pack.
- 49. Abdominal Hollow OrganInjuries • Small bowel is the most frequently injured Blunt trauma -Seat belt injuries and crush are most common cause - it has high risk of infection Penetrating trauma: –GSW, stab wound
- 50. Gastric & BowelTreatment •Follow ATLS principles • Surgical repair • Diversion of the injured bowel with re anastomosis at a later time