CHEST TRAUMA(Basic Knowledge)

Soebandrijo MD, Darmawan Ismail MDSub Department of CARDIO THORACIC & VASCULAR SURGERY

UNS Medical Faculty – Dr Moewardi Hospital Surakarta

Introduction

• Chest trauma is often sudden and dramatic• Accounts for 25% of all trauma deaths• 2/3 of deaths occur after reaching hospital• Serious pathological consequnces:– hypoxia, – hypovolaemia, – myocardial failure

Mechanism of Injury

Penetrating Trauma– Low Energy• Arrows, knives, handguns• Injury caused by direct contact

– High Energy• Military, hunting rifles & high powered hand guns• Extensive injury due to high pressure

Trauma tusuk sering pada daerah2 konflik.

Rifles: senapanExtensive: luas

• Either:– direct blow (e.g. rib fracture)– deceleration injury – compression injury

• Rib fracture is the most common sign of blunt thoracic trauma

• Fracture of scapula, sternum, or first rib suggests massive force of injury

• Age Factors• Pediatric Thorax: More cartilage = Absorbs forces• Geriatric Thorax: Calcification & osteoporosis = More fracture

Blunt injuries

Blunt injuries= trauma tumpul.Pada pediatri, bnyk kartilago shg mengikuti bentuk trauma shg ga mudah patah tp tekanannya sampai ke organ.Geriatri tulang lbh kuat tp elastisitasnya berkurang shg mudah patah.

Blow:pukulan

Injuries Associated with Cardio Thoracic Vascular Trauma

• Airway obstruction• Closed pneumothorax• Open pneumothorax

(sucking chest wound)• Tension pneumothorax• Pneumomediastinum• Hemothorax (massive)• Hemopneumothorax• Rib fracture (flail chest)

• Tracheobronchial tree lacerations (rupture)

• Esophageal lacerations• Penetrating cardiac injuries• Pericardial tamponade• Spinal cord injuries• Diaphragm trauma• Intra-abdominal trauma

associated organ injury• Laceration of vascular

structures (central & peripheral)

Airway dari hidung sampe alveolus.Baca kontusio paru!

Basic management concept in traumatic patient

Is

ABCDE

Sub Department of Cardio Thoracic & Vascular Surgery responsible in ABC

Airway obstruction• Clinical finding– Shortness of breath (dyspnea)– Stridor – Apnea

• Management – Chin lift– Jaw thrust– Triple finger manuever– Evacuate foreign body– ET insertion– Cricothyroidostomy– Tracheostomy

Keluhan pertama: sesak nafas. Slain itu stidor, gurgling (karena cairan), lbh berat lg apneu.u/ cedera spinal paling aman pake jaw thrust1. Yg bs dilakuin u/ pertolongan pertama: chin lift, jaw thrust dan crossing finger manuver. Bs jg

triple finger manuver.2. Apapun yg kliatan dr cavum oris harus diangkat (crossing finger manuver).3. Kalo pasien masih blm bs nafas initial breathing4. Kalo udah niup (bagging) tp dada ga ngembang mungkin jalan nafasny ada sumbatan

(obstruksi jalan nafas yg ga kliatan).5. Pake heimlich manuver slanjutnya kalo pasien sadar. Kalo ga sadar, pake abdominal thrust.6. Kalo masih belum bs nafas, cricotiroidostomi7. Kalo ditiup dada ngembang dan airway baik tp krn hipoksia lama jadi apneu dilakukan

breathing support. Kalo ud cricottiroidostomi tetep ga ngembang sumbatan ada di bawah membrana cricothyroidea endotrakeal tube u/ dorong sumbatan ke kanan dan paru2 kiri ngembang.

Tension Pneumothorax

– Ventile phenomenon– Build up of air under

pressure in the thorax.– Excessive pressure

reduces effectiveness of respiration

– Air is unable to escape from inside the pleural space

– Progression of Simple (closed) or Open PneumothoraxBreathing

Ventile phenomenon pas inspirasi udara bs masuk tp pas ekspirasi ga bs kluar tekanan makin tinggi neken jantung tension pneumothoraks.Kalo uda ada diagnosis tension pneumothoraks, ga usah foto rontgen krn pas nunggu hasil, pasien bs meninggal.

CXR image

• Anx: Progressive shortness of breath• PE : – Respiratory distress – Tracheal deviation (away)– Absence of breath sound & percusion: hypersonor – Jugular Vein Distend– Hypotension

• Treatment : – Needle thoracocentesis– Consult : chest tube insertion

Tension Pneumothorax (simplify)

Dari anamnesis didapatkan sesak nafas.PE= physical examination.

Needle thoracocentesis

Needle thpracocentesis: pake infus kateter yg paling besar.

OPEN (SUCKING) CHEST WOUND

Suara seperti nyedot udara terdengar di dada. Hrs ada luka terbuka di dada (2/3 diameter trakea lukanya)

SUCKING CHEST WOUND

SUCKING CHEST WOUND

• Upon exhaling, air in the chest escapes

through the flutter-type valve created by taping

3 sides only• With inhaling, the patch

should suck against the skin, preventing air

entry

tatalaksana: plester 3 sisi, yg dipake buat plester sesuatu yg kedap udara (handscoon, plastik steril).Jadi kalo ada luka terbuka di dada jgn dijait, cukup diplester 3 sisi. Kalo dijait malah jd tension.

Hemothorax

• Hemothorax– Accumulation of blood in the pleural space– Serious hemorrhage may accumulate 1,500 mL of blood

• Mortality rate of 75%• Each side of thorax may hold up to 3,000 mL• MASSIVE (criteria)

– Blood loss in thorax causes a decrease in tidal volume• Ventilation/Perfusion Mismatch & Shock

– Typically accompanies pneumothorax• Hemopneumothorax

Perkusi jadi redup. Kalo pneumothoraks jd hipersonor.

• Blunt or penetrating chest trauma

• Shock– Dyspnea– Tachycardia– Tachypnea– Diaphoresis– Hypotension massive

• Dull to percussion over injured side

• Treatment Chest tube insertion & consult

Hemothorax (simplify)

Bs dgn pulv pungsi. Kalo dr pulv pungsi ada darah, dg pleural pungsi.

Trauma.org

CXR Image

Gambaran CT scanTension udara radiolusen (lbh gelap)Hemothorax cairan radioopak (lbh terang).

Flail chest

• Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration

• Significant force required• Usually diagnosed clinically• Treatment – ABC– Analgesia– Fixation : internal &/ external

Khas: paradoxiscal movement/ respiratorik pas inspirasi hrsnya dada ngembang, jd kempis. Pas ekspirasi jd ngembang.Dx:1. fraktur costa segmental2. 2 kosta/ lbh dan berurutan.Menimbulkan nyeri hebat dibandingkan trauma lainnya karena ga bs diimobilisasi parunya.Ketika inspirasi, kasih kain sesuai kedalaman terus diplester, pasien tarik nafas dan kasih

analgetik yg dalam. Plesternya paling maksimal dari pertengahan dpn ke pertengahan belakang.

PARADOXICAL RESPIRATIONS

Flail Chest - detail

Tracheobronchial Injury– MOI

• Blunt trauma• Penetrating trauma

– 50% of patients with injury die within 1 hr of injury– Disruption can occur anywhere in tracheobronchial tree– Signs & Symptoms

• Dyspnea• Cyanosis• Hemoptysis• Massive subcutaneous emphysema• Suspect/Evaluate for other closed chest trauma

Tanda khas: emfisema yg luas disubkutan (jd bengkak secara luas gitu), ada batuk darah stelah kecelakaan.Kalo dipalpasi, kayak ada ‘tas kresek’. Begitu dipencet, pas dilepas jd ngembang lg.

Pas foto rontgen ada gambar lusen di luar iga sering bersama tension pneumothorax

Tracheobronchial Injury

• Observe for development of Subcutaneus emphysema & tension pneumothorax (deadly)

• Treatment • Keep airway clear• Administer high flow O2

• Consider intubation if unable to maintain patient airway

• If tension needle thoracocentesis• Consult : tracheal repair or

tracheostomy

Lakukan multiple insisi di tepi atas clavicula, lalu darah keluar buka pake tumpul sampai udara ada yg keluar. Tp ini sudah ga dianjurkan.

– Restriction to cardiac filling caused by blood or other fluid within the pericardium

– Occurs in <2% of all serious chest trauma• However, very high mortality

– Results from tear in the coronary artery or penetration of myocardium• Blood seeps into pericardium and is unable to escape• 200-300 ml of blood can restrict effectiveness of cardiac

contractions– Removing as little as 20 ml can provide relief

Pericardial Tamponade

• Dyspnea• Possible cyanosis• Beck’s Triad– JVD– Distant heart tones– Hypotension or

narrowing pulse pressure

• Weak, thready pulse• Shock

Pericardial Tamponade (simplify)

• Kussmaul’s sign– Decrease or absence of

JVD during inspiration• Pulsus Paradoxus– Drop in SBP >10 during

inspiration– Due to increase in CO2

during inspiration• Electrical Alterans– P, QRS, & T amplitude

changes in every other cardiac cycle

• PEA

Cardiac tamponade sianosis, nadi kecil, penurunan kesadaran.Trias back tjd karena penekanan atrium kanan 1venous return terbendung, 2...., 3hipotensi.

Pericardial or Cardiac tamponade

Pericardial Tamponade (ilustrations)

Laceration of vascular structures• General sign

– Shock Hypovolemia (co morbid cardiogenic) – Penetrating trauma (mostly)

• Internal bleeding– Thoracic Chest XR– Abdominal FAST or CT– Pelvicum CXR– Femur expanding hematoma + XR

• External bleeding thorough examination & suturing

Laserasi pada vaskulerSyok hipovolemia (tensi <70 mmHg), curiga perdarahan.

Pelvic rupture bs jadi perdarahan bnyk jika mengenai articulatio sacroiliaca.3 tes:-Destruksi tes-Kompresi AP lateral-Distraction tes (slh 1 memegang femur, 1 lagi di ala ossis ilii pas femur dorong ke bawah, ala ikut ke bwh lepas dari sacrum brarti).

Flow chart:Syok hipovolemia

External bleeding internal(selesaikan lbh dl)

Penyebab, liat:Dijait diperban+ - fraktur tulang

plester panjang femur (bs(pake ini dl) sampai 1,5 L)

- thorax sbnrnyaResusitasi cairan di breathing ini(pasang infus) mriksanya. Tp

tensi belum naik lakuin perkusi lg.Tangani internal bleeding - abdominal tes

undulasi dan pekak beralih. Tp sensitivitasnya rendah, >300 cc baru +- pelvis rumit krn ada os pubisnya. c/ pd kehamilan ektopik terganggu

Laceration of vascular structures

• Internal bleeding consult• External bleeding

Buat hentikan perdarahan, tekan bagian proksimal dari perdarahan.Bebat tekan itu tiap 30 menit dikendorin.