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Thoracic trauma katec

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Thoracic trauma katec

  1. 1. น . พ . ธวัชชัย อิ่มพูล , พบ ., วว . ศัลยศาสตร์ทั่วไป หน่วยศัลยกรรมการบาดเจ็บและศัลยกรรมวิกฤตบำบัด (Trauma & Surgical Critical Care Unit) กลุ่มงานศัลยกรรม โรงพยาบาลขอนแก่น Thoracic Trauma
  2. 2. Objectives <ul><li>Identify and treat life-threatening injuries found during the primary survey </li></ul><ul><li>Identify and treat potentially life-threatening injuries found during the secondary survey </li></ul>
  3. 3. THORAX
  4. 4. Thoracic Trauma <ul><ul><li>Significant cause of mortality </li></ul></ul><ul><ul><li>Blunt: < 10% require operation </li></ul></ul><ul><ul><li>Penetrating: 15-30% require operation </li></ul></ul><ul><ul><li>Majority: Require simple procedures </li></ul></ul><ul><ul><li>Most life-threatening injuries are identified during the primary survey </li></ul></ul>
  5. 5. Thoracic Trauma <ul><ul><li>Laryngeotracheal injury / Airway obstruction </li></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Open pneumothorax </li></ul></ul><ul><ul><li>Flail chest and pulmonary contusion </li></ul></ul><ul><ul><li>Massive hemothorax </li></ul></ul><ul><ul><li>Cardiac tamponade </li></ul></ul>What are the immediately life-threatening chest injuries?
  6. 6. Thoracic Trauma <ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Hypoventilation </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul><ul><ul><ul><li>Respiratory </li></ul></ul></ul><ul><ul><ul><li>Metabolic </li></ul></ul></ul><ul><ul><li>Inadequate tissue perfusion </li></ul></ul>What are the pathophysiologic consequences of these chest injuries? Manage in the primary survey as identified
  7. 7. Laryngotracheal Injury Airway Obstruction <ul><ul><li>Rare </li></ul></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Subcutaneous emphysema </li></ul></ul><ul><ul><li>Manage in the primary survey as soon as possible </li></ul></ul><ul><ul><ul><li>Intubate cautiously </li></ul></ul></ul><ul><ul><ul><li>Tracheostomy </li></ul></ul></ul>
  8. 8. Tension Pneumothorax <ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Hypotension (Shock) </li></ul></ul><ul><ul><li>Distended neck veins </li></ul></ul><ul><ul><li>Unilateral decrease in breath sounds </li></ul></ul><ul><ul><li>Hyperresonance </li></ul></ul><ul><ul><li>Cyanosis (late sign) </li></ul></ul>
  9. 9. Tension Pneumothorax <ul><ul><li>Clinical diagnosis, not by x-ray </li></ul></ul><ul><ul><li>Immediate decompression </li></ul></ul><ul><ul><ul><li>Needle </li></ul></ul></ul><ul><ul><ul><li>Chest tube </li></ul></ul></ul>
  10. 10. Needle Thoracentesis
  11. 11. Open Pneumothorax
  12. 12. Open Pneumothorax <ul><ul><li>3-sided dressing cover over defect </li></ul></ul><ul><ul><li>Chest tube </li></ul></ul><ul><ul><li>Definitive operation </li></ul></ul>
  13. 13. Three Sides-Dressing
  14. 14. Flail Chest and Pulmonary Contusion
  15. 15. Paradoxical motion
  16. 16. Flail Chest and Pulmonary Contusion <ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Re-expand lung </li></ul></ul><ul><ul><li>Intubate as indicated </li></ul></ul><ul><ul><li>Judicious fluids </li></ul></ul><ul><ul><li>Analgesia </li></ul></ul>
  17. 17. Massive Hemothorax <ul><ul><li>Systemic / pulmonary vessel disruption </li></ul></ul><ul><ul><li>> 1500 mL blood loss </li></ul></ul><ul><ul><li>Flat vs. distended neck veins </li></ul></ul><ul><ul><li>Shock with no breath sounds and/or percussion dullness </li></ul></ul>
  18. 18. Massive Hemothorax <ul><ul><li>Rapid volume restoration </li></ul></ul><ul><ul><li>Chest decompression and x-ray </li></ul></ul><ul><ul><li>Autotransfusion </li></ul></ul><ul><ul><li>Operative intervention </li></ul></ul>
  19. 19. Cardiac Tamponade <ul><ul><li>Most ; penetrating injury </li></ul></ul><ul><ul><li>Decreased arterial pressure </li></ul></ul><ul><ul><li>Distended neck veins </li></ul></ul><ul><ul><li>Muffled heart sounds </li></ul></ul><ul><ul><li>Pulseless electrical activity (PEA) </li></ul></ul>Radio antenna
  20. 20. Cardiac Tamponade A Secure airway B Ventilate and oxygenate C Volume resuscitation FAST, operation
  21. 21. Subxiphoid Pericardial aspiration (Pericardiocentesis)
  22. 22. Resuscitative Thoracotomy When should I consider resuscitative thoracotomy?
  23. 23. Aim Resuscitative thoracotomy <ul><li>1. Remove pericardial blood in cardiac tamponade </li></ul><ul><li>2. Stop bleeding in chest </li></ul><ul><li>3. Open cardiac massage </li></ul><ul><li>4. cross-clamp descending aorta </li></ul>
  24. 24. Resuscitative Thoracotomy <ul><ul><li>Patients with penetrating thoracic injury arriving with PEA may be a candidate </li></ul></ul><ul><ul><li>When a surgeon with appropriate skills is present </li></ul></ul><ul><ul><li>ED thoracotomy not indicated in blunt trauma with PEA </li></ul></ul>When should I consider resuscitative thoracotomy?
  25. 25. Thoracic Trauma What are the potentially life-threatening chest injuries? How do I identify them? When and how do I correct the problem?
  26. 26. Thoracic Trauma <ul><ul><li>Tracheobronchial tree injury </li></ul></ul><ul><ul><li>Simple pneumothorax </li></ul></ul><ul><ul><li>Pulmonary contusion </li></ul></ul><ul><ul><li>Hemothorax </li></ul></ul>What are the potentially life-threatening chest injuries?
  27. 27. Thoracic Trauma <ul><ul><li>Blunt cardiac injury </li></ul></ul><ul><ul><li>Traumatic aortic disruption </li></ul></ul><ul><ul><li>Blunt esophageal rupture </li></ul></ul><ul><ul><li>Traumatic diaphragmatic injury </li></ul></ul>What are the potentially life-threatening chest injuries?
  28. 28. Thoracic Trauma <ul><ul><li>Physical examination </li></ul></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>Pulse oximetry </li></ul></ul><ul><ul><li>ABG </li></ul></ul><ul><ul><li>ECG </li></ul></ul>How do I identify potentially life-threatening thoracic injuries?
  29. 29. Tracheobronchial Tree Injury <ul><ul><li>Often missed </li></ul></ul><ul><ul><li>Blunt or penetrating </li></ul></ul><ul><ul><li>Persistent pneumothorax </li></ul></ul><ul><ul><li>Bronchoscopy </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Airway and ventilation </li></ul></ul></ul><ul><ul><ul><li>Tube thoracostomy </li></ul></ul></ul><ul><ul><ul><li>Operation </li></ul></ul></ul>
  30. 30. Simple Pneumothorax <ul><ul><li>Penetrating / blunt trauma </li></ul></ul><ul><ul><li>Most : Lung laceration </li></ul></ul><ul><ul><li>Ventilation / perfusion defect </li></ul></ul><ul><ul><li>Hyperresonance </li></ul></ul><ul><ul><li>Decreased breath sounds </li></ul></ul><ul><ul><li>Tube thoracostomy </li></ul></ul>
  31. 31. Pulmonary Contusion <ul><ul><li>Common </li></ul></ul><ul><ul><li>Oxygenate and ventilate </li></ul></ul><ul><ul><li>Delayed X-ray changes </li></ul></ul><ul><ul><li>Selective intubation </li></ul></ul><ul><ul><li>Normovolemia , Maintain lung volumes </li></ul></ul>
  32. 32. Hemothorax <ul><ul><li>Chest wall injury </li></ul></ul><ul><ul><li>Lung / vessel laceration </li></ul></ul><ul><ul><li>hypotension , decreased breath sounds and dullness to percussion </li></ul></ul><ul><ul><li>Tube thoracostomy </li></ul></ul>
  33. 33. Blunt Cardiac Injury <ul><ul><li>Rare </li></ul></ul><ul><ul><li>Injury spectrum (myocardial contusion , chamber rupture , coronary artery dissection / thrombosis , valvular disruption </li></ul></ul><ul><ul><li>Abnormal ECG / monitor changes </li></ul></ul><ul><ul><li>Echocardiography </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Dysrhythmias </li></ul></ul></ul><ul><ul><ul><li>Perfusion / Compromise blood pressure </li></ul></ul></ul><ul><ul><ul><li>Complications </li></ul></ul></ul>
  34. 34. Traumatic Aortic Disruption <ul><ul><li>Rapid acceleration / deceleration mechanism </li></ul></ul><ul><ul><li>X-ray signs </li></ul></ul><ul><ul><li>High index of suspicion </li></ul></ul><ul><ul><li>Surgical consult </li></ul></ul>
  35. 35. Traumatic Aortic Disruption <ul><ul><li>Diagnosis by Helical CT or Aortography </li></ul></ul>
  36. 36. Blunt Esophageal Rupture <ul><ul><li>Blunt vs. penetrating injury (more common) </li></ul></ul><ul><ul><li>Severe epigastric blow </li></ul></ul><ul><ul><li>Pain / shock out of proportion to injury </li></ul></ul><ul><ul><li>Left pneumothorax or hemothorax without rib fracture </li></ul></ul>
  37. 37. Esophageal Injury <ul><ul><li>Chest tube: Particulate matter </li></ul></ul><ul><ul><li>Mediastinal air </li></ul></ul><ul><ul><li>Contrast swallow, esophagoscopy </li></ul></ul><ul><ul><li>Operation </li></ul></ul>
  38. 38. Diaphragmatic Injury <ul><ul><li>Most diagnosed on left </li></ul></ul><ul><ul><li>Blunt: Large tears </li></ul></ul><ul><ul><li>Penetrating: Small perforations </li></ul></ul><ul><ul><li>Misinterpreted x-ray </li></ul></ul><ul><ul><li>Contrast radiography </li></ul></ul><ul><ul><li>Operation </li></ul></ul>
  39. 39. Traumatic Asphyxia <ul><ul><li>Acute, temporary compression SVC </li></ul></ul><ul><ul><li>Impaired venous return </li></ul></ul><ul><ul><li>Petechiae </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Cerebral edema </li></ul></ul>
  40. 40. Subcutaneous Emphysema <ul><ul><li>Airway injury </li></ul></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><ul><li>Blast injury </li></ul></ul><ul><ul><li>Iatrogenic </li></ul></ul>
  41. 41. Fractures and Associated Injuries <ul><ul><li>Ribs 1-3 </li></ul></ul><ul><ul><li>Severe force </li></ul></ul><ul><ul><li>Associated injuries have high mortality risk </li></ul></ul><ul><ul><li>Ribs 4-9 </li></ul></ul><ul><ul><li>Pulmonary contusion and pneumothorax </li></ul></ul><ul><ul><li>Ribs 10-12 </li></ul></ul><ul><ul><li>Suspect abdominal injury </li></ul></ul>Sternum, Scapular, and Rib
  42. 42. Pitfalls <ul><li>Simple pneumothorax converts to tension pneumothorax </li></ul><ul><li>Retained hemothorax </li></ul><ul><li>Diaphragmatic injury </li></ul><ul><li>Severity of rib fractures / pulmonary contusion </li></ul><ul><li>Extremes of age </li></ul>Pitfalls
  43. 43. Summary <ul><li>Common in multiply injured patients </li></ul><ul><li>Life-threatening injuries </li></ul><ul><li>Potentially-lethal injuries </li></ul><ul><li>Initial stabilization by simple techniques in the majority of cases </li></ul>Goal: Restore normal gas exchange and perfusion

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