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• following both penetrating and blunt trauma, • it has been estimated that chest injuries are responsible for ! to "# of all trauma deaths$ • chest injuries are also common in multipl% injured patients$
• Most common injur% associated with blunt chest trauma
– &'(! # of all trauma admission – the true incidence in probabl% higher since up to "!# of rib fractures ma% be missed on initial C)R
– motor +ehicle crashes – falls – blows to the chest with blunt objects
Rib fractures • fractures of ribs . trought .. ma/imum fre0uenc% • directl% – at the site of force • laterall% – significant antero'posterior compression of the chest .
• the first rib is protected b% the shoulder girdle and cla+icle
– fractures of the first rib indicate a significant amount of energ% transferred to the torso – ha+e been associated with aortic injuries
• posterior rib fractures are also associated with significant energ% transfer to the thora/$
Hemotorax & Fracturi costale multiple – decubit dorsal
• Associated injuries*
– !# incidence of splenic injur% is associated with fractures of ribs 1, (!, and (( on the left side – similar for hepatic injuries – "!# of patients with blunt cardiac injur% ha+e rib fractures$
• Crepitus o+er the possible area of fracture • 3ecreased breath sounds on the side of injur% • 2ain* – subse0uent atelectasis – underl%ing pulmonar% contusion – restriction of +entilation$ .Rib fractures ' diagnosis • The diagnosis of rib fractures is primaril% clinical • 2ain – directl% – antero'posterior compression.
Chest )R • radiologic confirmation of the diagnosis is not essential .
Rib fractures • children – pulmonar% contusion is more common – rib fractures 4 a sign of signi5cant energ% transfer$ • elderl% – 2atients older than 6" %ears with . or more rib fractures had a "'fold increased mortalit% rate and an almost &'fold increased incidence of pneumonia compared with %ounger patients .
are particularl% prone to these complications$ . especiall% those with preexisting pulmonary disease.Treatment • Ade0uate pain relief and pulmonar% care are the primar% therapeutic goals • pain – poor inspirator% effort – ineffecti+e cough – atelectasis – pneumonia • Elderly patients.
Treatment • intra+enous narcotics patient'controlled analgesia • continuous opioid infusion • intercostal ner+e bloc7 • epidural analgesia – Multiple fractures – 8lderl% patients – 2atients with underl%ing pulmonar% disease .
• hospital admission* – histor% of smo7ing – chronic obstructi+e pulmonar% disease – ederl% patients with multiple fractures .
.Flail Chest • fracture of more than consecuti+e ribs in or more places • this creating a free'floating segment of the chest wall • a better de5nition ma% be 9an incompetent segment of chest wall large enough to impair the patient:s respiration$.
li7el% because of comorbid conditions and less abilit% to tolerate respirator% compromise$ .Flail Chest • respirator% failure after chest wall injur% is almost ne+er due to the mechanical +entilator% d%sfunction imposed b% the chest wall injur% itself • in great measure. it is caused b% the underl%ing pulmonar% contusion ' almost uni+ersall% accompanies flail chest$ • increasing age also is associated with an increasing ris7 of death with <ail chest.
• The parado/ical mo+ements of the flail segment are caused b% negati+e intrapleural pressure generated during inspiration • Up to !# of patients with se+ere blunt chest injuries .
which limits pulmonar% function • The inabilit% of patients to clear secretions ade0uatel% and the de+elopment of atelectasis from chest wall splinting are ris7 factors for the de+elopment of pulmonar% infection$ .• The majorit% of complications resulting from rib fractures are related to chest wall pain.
=lail chest ' treatment • ade0uate pain control and aggressi+e respirator% care to optimi>e pulmonar% function • 2roph%lactic intubation is not indicated$ – if a patient re0uires mechanical +entilation because of an underl%ing contusion or other injuries. again b% using epidural or other aggressi+e pain control techni0ues if possible$ . internal pneumatic stabili>ation ?mechanical +entilation@ is possible – wean the patient as soon as possible.
but pulmonar% d%sfunction and inabilit% to +entilate are indications$ • Areat chest wall instabilit% . in terms of chronic pain and the sensation of decreased +entilator% capacit%$ . surgical rib fracture 5/ation seems to be an attracti+e alternati+e to long'term mechanical +entilation$ • =lail chest is associated with signi5cant late morbidit%.=lail chest ' treatment • The presence of a <ail segment itself is not an indication to continue mechanical +entilation.
Volet costal – tratament istoric .
Zdrobire hemitorace drept Radiografie iniţială .
După entilaţie cu !""! mare .
#tabili$are internă a segmentelor celor mai instabile .
!ost stabili$are .
Volet costal – mi%care paradoxală .
!nemotorax &pleurostomie' Volet costal (ontu$ie pulmonară .
BT8RCAD =RACTUR8B • "# of patients with se+ere chest injuries • associated with an increased incidence of both cardiac and great +essel injur%$ .
• Isolated sternal fracture ma% result from shoulder belt use • Most fractures are trans+erse. . in+ol+e the sternal'manubrial junction or upper one third of the sternum.
• The diagnosis of sternal fracture is made b% palpation of the sternum • A lateral chest radiograph can re+eal sternal fractures and the degree of posterior displacement .
operati+e reduction with fi/ation of the fracture ma% be re0uired$ • Options include wires in a 5gure'of'fashion. plates. as for rib fractures$ Onl% If se+ere displacement is present.• The treatment of sternal fracture is primaril% ade0uate pain relief and pulmonar% care. or both$ .
Fractură de stern .
Simple Pneumothorax • 2neumothora/. defined as air in the potential space between the +isceral and parietal pleurae$ • The loss of negati+e intrapleural pressure allows the lung to collapse from elastic recoil$ .
• 2neumothora/ ordinaril% results from * – ruptured al+eoli or from small lacerations in the pulmonar% parench%ma and is fre0uentl% associated with rib fractures – lacerations through the chest wall • stab or gunshot wounds • iatrogenic injuries ' as a complication of placement of a central +enous catheter .
• The diagnosis of pneumothora/ is suggested on ph%sical e/amination* – – – – – 3ecreased ipsilateral breath sounds 3ecreased e/pansion of the affected hemithora/ H%perresonance to percussion Crepitus Bubcutaneous emph%sema • The chest radiograph is usuall% diagnostic .
• Traumatic pneumothora/ is treated b% placement of a tube thoracostom% • A chest tube should be inserted to e+acuate the air • A chest radiograph should be obtained after insertion of the chest tube to confirm that proper tube positioning and ree/pansion of the lung ha+e occurred .
as%mptomatic pneumothoraces who do not re0uire general endotracheal anesthesia or positi+e'pressure +entilation ma% be obser+ed carefull% without placement of a tube thoracostom%$ • If the air lea7 from the lung has sealed.• 2atients with small. with subse0uent complete ree/pansion of the lung$ Berial chest films should be obtained to ensure that the pneumothora/ is progressi+el% decreasing and that the lung is not collapsed . the air in the pleural ca+it% will be reabsorbed.
!neumotorax st)ng .
!neumotorax drept .
!neumotorax drept .
!neumotorax medial .
!neumotorax simplu .
"mfi$em subcutanat masi posttraumatic .
Rg toracică .
resulting in a net positi+e intrathoracic pressure • Tension pneumothora/ occurs when air enters the pleural space from lung injur% or through the chest wall without a means of e/it$ • 2ressure de+elops within the pleural space. impairing +enous return.Tension Pneumothorax • A tension pneumothora/ occurs if the pressure of accumulated air in the pleural space e/ceeds the ambient pressure. compressing the superior and inferior +ena ca+a. and decreasing cardiac output$ .
Tension Pneumothorax • Most common causes* – 2enetrating injur% to the chest – Elunt trauma with parench%mal lung injur% – Mechanical +entilation with high airwa% pressure – Bpontaneous pneumothora/ with blebs that failed to seal .
Tension Pneumothorax • Tension pneumothora/ must be a clinical diagnosis* – Be+ere respirator% distress – 3%spnea. tach%pnea – H%potension – Unilateral absence of breath sounds – H%perresonance to percussion o+er affected hemithora/ – Cec7 +ein distention ?can be absent in h%po+olemic patients@ – Tracheal de+iation ?late finding ' not necessar% to confirm clinical diagnosis@ .
• If the tension pneumothora/ has not been diagnosed on clinical findings ?which it should be@. C)R will usuall% show a pneumothora/ large enough to cause tension – a collapsed lung – a depressed ipsilateral hemidiaphragm – widened intercostal spaces – mediastinal shift awa% .
Tension 2neumothora/ ' treatment • Immediatel% decompress b% inserting a ( ' or (&'gauge IF catheter into the second intercostal space in the midcla+icular line$ • This con+erts the tension pneumothora/ into a simple open pneumothora/$ • =ollow immediatel% with tube thoracostom%$ .
!neumotorax +n tensiune Inspir .ccentuarea deplasării mediastinale %i pleurale.deprimarea diafragmului .erul intră +n ca itatea pleurală prin plaga pulmonară sau bula de emfi$em ruptă &oca$ional prin plaga toracică penetrantă' (olabarea plăm)nului ipsilateral %i deplasarea contralaterală a mediastinului (omprimarea plăm)nului contralateral cu alterarea capacităţii entilatorii a acestuia Expir (re%terea presiunii intrapleurale cu +nchiderea comunicării tip al ă unisens .lterarea +ntoarcerii enoase prin cre%terea presiunii intratoracice %i distorsionarea enei ca e .
!neumotorax +n tensiune .anifestări clinice %i mane re terapeutice Dispnee (iano$ă Durere toracică De iaţie traheală Hipersonoritate !leurostomie torace anterior spaţiul 012 intercostal cu drena3 4eclaire /mpingerea pistonului seringii ume$ite de către presiunea intratoracică 5nserţie ac de calibru mare pentru decompresiune de urgenţă a presiunii intratoracice .
!neumotorax st)ng +n tensiune .
!neumotorax bilateral +n tensiune .
(* 1 !neumotorax +n tensiune .
!neumotorax st)ng +n tensiune Rg post mortem .
(* – !neumotorax +n tensiune cu extensie sub ficat
(* – !neumotorax +n tensiune cu extensie sub ficat
!neumotorax +n tensiune &sufocant'
*uburi de dren introduse prea mult +n ca itatea pleurală .
(* torace superior – po$iţia tuburilor de dren *ub +n fisura oblică blocată de ţesut pulmonar .
!neumotorax drept +n tensiune – (* torace inferior .
*ub neintrodus suficient – 6ltimul orificiu aproape ie%it din ca itate .
• d%spnea or shortness of breath .Hemothorax. • accumulation of blood in the pleural space • it occurs in "!# to G"# of patients with se+ere blunt or penetrating chest trauma • relati+el% as%mptomatic • fran7 h%po+olemic shoc7 at the time of presentation.
!!! ml – persistent bleeding. at a rate greater than !! mDHh for & hours. or greater than (!! mDHh for .Treatment of hemothora/ • • begins with tube thoracostom% to e+acuate the blood and ree/pand the lung Bimple tube thoracostom% is ade0uate treatment for up to -"# of patients ?the pulmonar% parench%ma has a high concentration of tissue thromboplastin. which probabl% contributes to hemostasis and sealing of air lea7s @$ indication for thoracotom% for e+acuation of clot and control of bleeding* – hemod%namic instabilit% – massi+e hemothora/ more than (.hours$ • .
complete opacification . with massi+e hemothora/.• 2h%sical e/amination – decreased breath sounds – dullness to percussion on the injured side • Bupine chest films usuall% show ha>iness of the affected lung field or.
Hemotorax 1 surse !lăm)n .rtera toracoacromială & ia traiect plagă' .rtera toracică laterală & ia traiect plagă' Vase mari mediastinale 5nimă .splină' ia diafragm .rtera toracică internă Vase intercostale #tructuri intraabdominale &ficat.
Hemotorax (uantificare %i atitudine Minim (<350 ml) De obicei s)ngele se resoarbe spontan sub tratament conser ator *oracocente$a este rareori necesară Moderat (350 – 1500 ml) *oracocente$ă %i pleurostomie cu drena3 4eclaire Masiv (>1500 ml) !leurostomie dublă pentru a pre eni colmatarea cu cheaguri *oracotomia poate fi necesară pentru a opri s)ngerarea .
Hemotorax 1 ortostatism .
Hemotorax drept .
Hemotorax decubit dorsal & Fracturi costale multiple .
Hemotorax masi .
Hemotorax bilateral .
Hemotorax st)ng – Rg iniţială &fără tensiune' .
(* – Hemotorax +n tensiune .
(* – Hemotorax +n tensiune .
!lagă prin +n3unghiere hemitorace drept inferior 7e$iune diafragmatică %i hepatică Hemotorax – decubit dorsal .
with al+eolar collapse and e/tra+asation of blood and plasma into the al+eoli$ • 2ulmonar% contusion occurs in up to G!# of patients with se+ere blunt chest trauma .Pulmonary Contusion • 2ulmonar% contusion in+ol+es e/tensi+e interstitial hemorrhage within the parench%ma.
which leads to arterial h%po/emia • The h%po/emia is usuall% refractor% to increases in inspired o/%gen concentration$ • 2ulmonar% compliance decreases. a +entilation'perfusion mismatch de+elops. and wor7 of breathing increases .• As a result.
Pulmonary Contusion • initial C)Rs ma% be normal • 9bruising. of the lung – interstitial and al+eolar edema – hemorrhage – subse0uent al+eolar collapse • chest CT can 9grade. the degree of injur% more accuratel% and ma% lead to better predictions of the clinical course .
treatment • Is primaril% supporti+e – Intra+enous +olume should be restricted if possible since the associated capillar% lea7 will lead to a worsening of pulmonar% edema – 3iuresis is indicated in the presence of +olume o+erload • Cot re0uire intubation – arterial blood gases partial pressure of o/%gen I6! mm Hg with inspired o/%gen concentration of "!# – a respirator% rate J & breathsHmin .2ulmonar% Contusion .
and care should be ta7en to pro+ide ade0uate analgesia for rib fractures$ • 2atients who cannot sustain ade0uate pulmonar% function re0uire mechanical +entilation • 2ositi+e end'e/pirator% pressure ?2882@ has a protecti+e effect and preser+es functional reser+e capacit% • proph%lactic antibiotics is not indicated .• These patients should be carefull% monitored.
(ontu$ie pulmonară .
RD# după contu$ie pulmonară dreaptă ..
(ontu$ie pulmonară asociată cu plagă prin +mpu%care trunchi brahiocefalic .
Tracheobronchial Injuries. • =rom blunt trauma are relati+el% uncommon – J (# of patients with se+ere trauma – blunt trauma ' high'speed motor +ehicle accidents – crushing injuries • If significant anteroposterior compressi+e force is applied to the chest. it causes rapid lateral deformation of the thoracic ca+it% and results in traction injur% of the trachea or main'stem bronchi. usuall% within cm of the carina • 2enetrating injuries in+ol+e the cer+ical trachea in more than -!# of cases$ .
and hemopt%sis – Bubcutaneous emph%sema . cough. d%sphagia.Tracheobronchial Injuries • Most patients with se+ere airwa% injuries die at the scene of the accident as a result of airwa% obstruction • Cervical tracheal injuries* – Usuall% present with upper airwa% obstruction and c%anosis unrelie+ed with O – B%mptoms include local pain.
• Thoracic tracheal or bronchial injuries* – -!# occur within cm of carina$ – Intrapleural laceration • persistent d%spnea • massi+e air lea7 • massi+e pneumothora/ that does not reexpand with chest tube drainage$ .Tracheobronchial Injuries.
but persistent atelectasis. recurrent pneumonia. "# will go undetected for to & wee7s. and suppuration should prompt further in+estigation .Tracheobronchial Injuries. – 8/trapleural rupture into the mediastinum$ • pneumomediastinum • subcutaneous emph%sema$ • partial bronchial disruptions.
Radiographic signs on C)R • An abnormal admission C)R will be seen in 1!# of cases – 2neumothora/ – 2leural effusion – 2neumomediastinum – Bubcutaneous emph%sema ?air in the soft tissues of the nec7 and chest wall@ – Mediastinal hematoma • Specific findings – 2eribronchial air – 3eep cer+ical emph%semaK radiolucent line along pre+ertebral fascia ?earl% and reliable sign@ – =allen lung ' in which the lung is seen to drop awa% .
Tracheobronchial Injuries. a second chest tube should be placed. • 2lacement of a tube thoracostom% ma% result in a continued massi+e air lea7 from the chest tube with no e/pansion of the lung – If so. and bronchoscop% should be underta7en to confirm the diagnosis$ .
of the circumference of the bronchus and the lung can be ree/panded with chest tube placement. of the circumference of the airwa% – earl% surgical repair is indicated$ • 2ersistent large air lea7 and inabilit% to ree/pand the lung also ma% necessitate surgical repair of bronchial injuries$ .Treatment • J (H. nonoperati+e management probabl% will be successful • I(H.
interrupted sutures$ • 8/posure for injuries – Median sternotom% pro+ides access to the anterior or left lateral portion of the mediastinal trachea – Right posterolateral thoracotom% pro+ides e/posure of the right lateral or posterior aspect of the trachea or right lung bronchi or parench%mal injur% – Deft posterolateral thoracotom% pro+ides access to the left lung bronchi or parench%mal laceration • Eronchoscopic stent placement also has been used successfull% in the repair of isolated bronchial injuries .• 3efiniti+e treatment includes primar% repair with mucosa' to'mucosa closure using absorbable.
!lagă prin +n3unghiere cer icală st)ngă penetrantă Laceraţie traheal .
*oracotomie dreaptă – reparare prin sutură traheală cu fire separate .
!lagă prin tăiere cer icală cu perforaţie traheală (linic – emfi$em subcutanat Radiologic – pneumomediastin *ratament conser ator &monitori$arecontrol bronhoscopic' .
Elunt cardiac injur% • Cardiac in+olment in nonpenetrating trauma probabl% ocuurs more ofthen than reali>ed$ • It is most common unsuspected +isceral injur% responsible for death$ .
• Mechanisms* – Budden deceleration – Compression between the sternum and +ertebral column – 8/ternal blow. e+en without associated chest wall fractures – =ragment of the fractured bon% chest wall is dri+en into the heart$ .
The clues to cardiac injuries
• • • • • Eruise on sternum =ractured sternum Une/plained h%potension Recurrent hemothora/ 8CA e+idence of ischemia or m%ocardial infarction, conduction disturbances ' heart bloc7 • Cew cardiac murmurs • Muffed heart tones
• Is the most common lesion encountered clinicall% in patients with nonpenetrating cardiac injur% • Is the one of the most fre0uentl% missed diagnoses in patients with multiple injuries$
• Cardiac contusion is recogni>ed as a dar7 red, hemorrhagic area • =ull thic7ness of the m%ocardium
– Rupture of the m%ocardium – Aneur%sm formation
• 3amaged m%ocardium is predisposed to the de+elopment of cardiac arrh%thmias
– B%mptom of cardiac contusion ma% be absent or mas7ed b% other se+ere injuries – The most common s%mptom ? G!#@ is precordial pain – The most common dela%ed s%mptoms are angina, palpitations and congesti+e heart failure – The most fre0uentl% encounted ph%sical finding is tach%cardia
ele+ation bundle branch bloc7 hemifascicular bloc7s .M%ocardial contusion • 8CA – 8CA should be performed an admission as a screening test for all patients suspected of ha+ing ECI • • • • • 3%srh%thmia ? tach%cardia@ Atrial or +entricular ectop% B'T changes .
the ris7 of de+eloping life' threatening arrh%thmias is essentiall% nil • Creatinine phospho7inase ?C2L@ and troponin'I le+els ' correlate with the se+erit% of m%ocardial contusion .• If the 8CA is normal at admission and & hours later.
• 8chocardiogram asses * – – – – – – wall motion +al+ular competenc% global cardiac performance intramural hematomas. pericardial effusion ma% be the most sensiti+e test for the diagnosis of blunt cardiac injur% – Transthoracic echocardiogram ?TT8@ is con+enient and nonin+asi+e – T88 should be used when the TT8 is technicall% inade0uate .
M%ocardial contusion' treatment • 3%srh%thmias should be treated aggressi+el% – there are no data to support the use of proph%lactic antid%srh%thmics$ • The treatment of arrh%thmias follows standard algorithms • Dow cardiac output ma% re0uire support with an intra'aortic balloon pump ?IAE2@ .
although penetrating injuries are much more common • G" to (!! mD of blood can produce tamponade .Cardiac Tamponade • can occur from either blunt or penetrating trauma.
or pel+is .Cardiac Tamponade • Tamponade should be considered in patients with se+ere blunt chest trauma who remain h%potensi+e and ha+e no e+idence of e/ternal blood loss or hemorrhage into the thora/. abdomen.
• Eec7Ms triad – muffled heart sounds – decreased pulse pressure – jugular +enous distention • occurs in a minorit% of patients ?&!#@ • if the patient is h%po+olemic. jugular +enous distention ma% not de+elop until late in the presentation$ .
Cardiac Tamponade • 2ulsus parado/us – decrease in s%stolic pressure of I(! mmHg during inspiration • LussmaulMs sign is a hard and true sign of tamponade – inspiration in a spontaneousl% breathing patient results in an increase of the jugular +enous distention .
=ABT ultrasound e/amination should be performed to identif% pericardial fluid – A positi+e pericardial +iew on the =ABT in an unstable patient is an indication to proceed with median sternotom% or left anterolateral thoracotom% – An e0ui+ocal pericardial +iew on the =ABT e/amination or a positi+e e/amination in a stable patient necessitates an operati+e pericardial window – A negati+e =ABT in penetrating injur% can be falsel% negati+e secondar% to decompression of pericardial fluid into the pleural space$ .
and an enlarged cardiac silhouette is not reliabl% seen in acute tamponade .Cardiac Tamponade • Chest radiograph% – 2neumothora/ – Hemothora/ – Cegati+e$ – The pericardium is not acutel% distensible.
• Central +enous catheter in the hemod%namicall% stable patient – A +er% high central +enous pressure ?I ! to " cm H O@ is probabl% diagnostic but depend on the patientMs +olume status$ .
Cardiac Tamponade ! treatment • intubation. o/%genate. and start +olume resuscitation$ • 2ericardiocentesis can be used as a tempori>ing maneu+er to relie+e tamponade until definiti+e repair is possible$ – this is often difficult to successfull% perform because of nature of the procedure and relati+el% small blood +olume in the sac$ .
longitudinal opening of the pericardium$ – Cardiac lacerations should be digitall% controlled until ade0uate blood +olume is restored and the patient is relati+el% stable$ – The use of staples also has been ad+ocated to close cardiac lacerations rapidl% but temporaril% for immediate hemostasis$ .Cardiac Tamponade ! treatment • hemod%namic instabilit% should undergo immediate left anterolateral thoracotom% with a wide.
– Bmall lacerations in the beating heart can be then repaired using nonabsorbable sutures – Darger lacerations ma% re0uire cardiopulmonar% b%pass for ade0uate decompression and repair$ – The left thoracotom% incision can be carried trans+ersel% across the sternum into the right chest to facilitate e/posure of the entire heart and great +essels if necessar%$ .
Hemopericard acut %i tamponadă cardiacă !re$enţa s)ngelui +n sacul pericardic inextensibil +mpiedică umplerea cardiacă 8oc de se eritate ariabilă !resiune enoasă crescută Hipotensiune arterială !uls slab .
Dinamica presiunii arteriale %i enoase +n tamponada cardiacă .
!ericardiocente$a !uncţie pericardică la ni elul unghiului costoxifoid Rol diagnostic %i decompresi 9rientarea superioară a acului pentru e itarea le$ării diafragmului %i ficatului .
Aortic injuries • Traumatic rupture of the aorta is defined as a tear in the wall of the aorta that is contained b% the ad+entitia of arter% and the parietal pleura • Techanism of injur% is rapid deceleration – falls from significant height – high'speed motor +ehicle crashes – ejected occupants$ .
• -!# of the +ictims die at the scene • The remaining patients are at ris7 for dela%ed free rupture into the mediastinum or pleural space$ .
Aortic injuries • Docated – pro/imal aortic arch near the aortic +al+e – just distal to the origin of the left subcla+ian arter% – at the diaphragmatic hiatus • Bur+i+ors usuall% ha+e a contained hematoma held onl% b% an intact ad+entitial la%er$ .
not the aortic injur% . persistent or recurring h%potension usuall% results from a secondar% bleeding source.Aortic injuries • sur+i+ors are initiall% h%potensi+e but respond to fluid resuscitation • because free rupture of the transected aorta is rapidl% fatal.
Aortic injuries • Clinical signs* – As%mmetr% in upper e/tremit% blood pressures and upper e/tremit% h%pertension – Nidened pulse pressure – Chest wall contusion – 2osterior scapular pain – A careful neurologic e+aluation is important because patients ma% ha+e paraplegia or paraparesis from loss of blood flow through the intercostal arteries that suppl% the spinal cord • OOOOOne half of patients with great +essel injur% from blunt trauma ha+e no e/ternal signs of blunt chest injur%$ .
cm@K this is the most consistent finding – =racture of first three ribs.Aortic injuries • Bigns on C)R* – Nidened mediastinum ?I. or sternum – Obliteration of aortic 7nob – 3e+iation of trachea to right – 8le+ation and rightward shift of the right mainstem bronchus – 3epression of the left mainstem bronchus – 3e+iation of esophagus ?nasogastric tube@ to right – Deft pleural effusion . scapula.
• Co single sign reliabl% confirms or e/cludes aortic injur%$ Howe+er. a widened mediastinum is the most consistent finding on C)R and should prompt further e+aluation$ .
Aortic injuries • Chest computed tomograph% ?CT@ – mediastinal hematomas are suggesti+e for aortic injur% – Helical and new high'speed. ri+aling angiograph% with respect to o+erall accurac%$ • Mediastinal hematomas found on chest CT mandate aortogram for definiti+e diagnosis$ . high'resolution scanners can pro+ide definiti+e diagnosis of the aortic injur%.
• 3efiniti+e diagnostic aortic injuries found on helical scanners ma% also re0uire aortograph%. depending on the practices of the surgeon who will perform the repair$ • mall intimal tears and dissections ma% be missed on CT scan$ .
an aortogram will be re0uired to reliabl% e/clude the injur% • T88 is an e/cellent alternati+e for unstable patients who* – Must be transported directl% to the OR for other ca+itar% bleeding – Ha+e a +er% wide mediastinum and a high suspicion of thoracic aortic injur% e/ists – 2atients in the ICU who are high ris7 for transport to radiolog%$ .Aortic injuries • Transesophageal echocardiogram ?T88@ – A positi+e T88 will confirm the location of the injur% – If the T88 is negati+e.
Dabetolol@ should be instituted onl% after significant hemorrhage from other injuries has been ruled out – .Aortic injuries . treatment • Control and pre+ent h%pertension – maneu+ers to decrease wall tension in the aorta preoperati+el% ma% decrease ris7 of rupture – Eeta bloc7ade ? 8smolol.
– The goal for s%stolic blood pressure should be appro/imatel% (!! mmHHg – Citroprusside can be added as a second agent if blood pressure is not controlled with beta bloc7ad • OOO increased wall shear stress because pulse pressure often increases as s%stolic blood pressure decreases • OOOalso should be a+oided in patients with head injuries$ .
Aortic injuries • Most blunt injuries of the aorta re0uire immediate surgical repair • Btable pseudoaneur%sms that ma% be safel% managed with dela%ed operation if necessar% in the presence of other life' threatening injuries$ .
Aortic injuries • Injuries of the ascending aorta often re0uire full cardiopulmonar% b%pass for repair. and median sternotom% pro+ides the best e/posure$ • Injuries of the descending aorta accomplished through a left posterolateral thoracotom%$ .
and intercostal +essels should not be sacrificed to facilitate primar% repair owing to concerns about spinal cord perfusion$ • More e/tensi+e injuries re0uire placement of a prosthetic graft$ .• Relati+el% simple injures can be repaired primaril%$ • The thoracic aorta has relati+el% limited mobilit%.
.ediastin lărgit Ruptură de aortă distal de subcla ia st)ngă .
!ont"#ie aortic !sudoane rism aortic cu mediastin lărgit .
.specte tomografice .
3iaphragmatic injur% – Elunt trauma$ • 3iaphragmatic injur% from blunt forces is classicall% large. and located posterolaterall%$ • The left hemidiaphragm is in+ol+ed in 6!# to -!# of cases$ • 3iaphragmatic ruptures are mar7ers for se+ere intraabdominal injuries$ – 2enetrating trauma$ • Nounds are smaller but tend to enlarge o+er time$ • Deft'sided injuries still predominate$ . radial.
• These injuries need operati+e repair when diagnosed because the% do not heal spontaneousl% and can produce herniation or strangulation of the intestine as late se0uelae .
3iaphragmatic injur% ' diagnosis • 3iagnosis can be difficult. lower rib fractures – 2enetrating injuries to the chest and upper abdomen • C)R is diagnostic in onl% !# to "!# of cases of blunt trauma$ . ha+e a high inde/ of suspicion based on mechanism – Rapid deceleration or direct crush to the upper abdomen – Be+ere chest trauma. therefore.
or small bowel in chest In penetrating trauma and small defects. colon. herniation ma% become apparent on C)R – Right hemidiaphragm tears are less li7el% to be diagnosed b% C)R because of the presence of the li+er in the defect$ . the diaphragm appears normalOOOOO – normal$ After e/tubation.2ossible CR) findings include* – – – – Hemidiaphragmatic ele+ation or lower lobe atelectasis Casogastric tube in left hemithora/ Btomach.
32D fluid ma% be obser+ed e/iting the chest tube • direct +isuali>ation of the injur% b% laparotom%. laparoscop%.3iaphragmatic injur% ' diagnosis • CT scan ma% miss diaphragmatic injur% in the absence of gross hollow +isceral herniation$ • 3iagnostic peritoneal la+age ?32D@ – If an ipsilateral chest tube is present. or thoracoscop% remains the gold standard for diagnosis$ .
in most cases. interrupted hori>ontal mattress sutures$ . with strangulation as a possible late complication$ • Acute repair is accomplished +ia laparotom%. with nonabsorbable.3iaphragmatic injur% ' treatment • Most diaphragmatic tears re0uire repair$ • Fiscera tend to herniate as a result of changes in intrathoracic pressure during respiration.
• Thoracotom% ma% be needed to reduce large defects in chronic herniation$ • 2rosthetic material or flaps are often needed to close the defect$ .
A coiled nasogastric tube within the left hemithoracic ca+it% is pathognomonic for a rupture of the left hemidiaphragm$ .
ccident de motocicletă 1 Ruptură diafragmatică dreaptă ..
.spect intraoperator .
7aceraţie diafragmatică st)ngă cu hernierea stomacului +n torace .
Ruptură diafragmatică dreaptă cu herniere hepatică %i a colecistului .
.spect intraoperator .
$"pt"r dia%ra%matic st&n' c" herniere a stomac"l"i (i splinei .spect radiologic .
(* – #tomac intratoracic & fractură costală .
.spect intraoperator – după reducerea herniei .
8anţul de constricţie de la ni elul stomacului .
#utura diafragmului .
Ruptură frenică "xamen radiologic digesti cu substanţă de contrast .
7aceraţie diafragmatică .
)astrotorax st&n' .spect radiologic .
specte tomografice ..
*ernie dia%ra'matic .
+e%ect dia%ra'matic .
*ernie dia%ra'matic .
*ernie dia%ra'matic .
TH8 38A3DP "#$%& .
. 6nghiul coastei &preferat' 0. #ediul fracturii =.cul se introduce p)nă atinge marginea inferioară a coastei 0.orientare inferioară. !arasternal :.a ansare 2 mm pentru a aluneca sub coastă %i a a3unge +n spaţiul intercostal 2.spirare +naintea introducerii aneste$icului . Retragere u%oară a acului.4loc ner os intercostal 7ocul optim de in3ectare – unghiul coastei &cel mai u%or palpabil' 7ocuri pentru in3ecţie :. . 7inia axilară posterioară 2. 7inia axilară anterioară <.
ple"ral 7ocul introducerii .+rena.
"xplorare digitală .
5nserţia tubului .
.ncorarea tubului la tegument .
Drena3 sub ni el lichidian .
M"nc de echip - .
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