CEDERA THORAKS
Acute Indications for Thoracotomy
Acute hemodynamic deterioration and cardiac arrest in the trauma center 7
Patients with penetrating truncal trauma (resuscitative thoracotomy) 44
Cardiac tamponade
Ultrasound demonstration of hemopericardium 43
Vascular injury at the thoracic outlet 45
Massive air leak from the chest tube 46
Suspected cardiac herniation13
Endoscopic or radiographic demonstration of tracheal or bronchial injury 47,48
Radiographic evidence of great vessel injury 49,50
Significant missile embolism to the heart or pulmonary artery 51
Traumatic thoracotomy (loss of chest wall substance)
True mediastinal traverse with penetrating object
Transcardiac placement of inferior vena caval shunt for hepatic vascular wounds 52
Indikasi thorakotomi adalah produksi darah dari chest tube adalah 250 ml/ jam atau
mencapai jumlah 1500 cc.
Nonacute Indications for Thoracotomy
Nonevacuated clotted hemothorax 19
Chronic (or neglected) posttraumatic empyema
Chronic traumatic diaphragmatic hernia
Traumatic cardiac septal or valvular lesions21
Chronic traumatic thoracic aortic pseudoaneurysms 20
Nonclosing thoracic duct fistula
Missed tracheal or bronchial injury
Infected intrapulmonary hematoma (traumatic lung abscess)
Tracheoesophageal fistula
Innominate artery and tracheal fistula
Traumatic arterial venous fistula
CEDERA DIAFRAGMA
Cedera diafragma terutama disebabkan karena trauma tajam penetrating pada
daerah thorakoabdominal.
Area thorakoabdominal anterior yaitu:
Batas superior : nippel
Batas inferior : margin costa
Batas lateral : anterior axillary line
A coiled nasogastric tube within the left hemithoracic cavity is pathognomonic for a
rupture of the left hemidiaphrama
Barium enema reveals the left transverse and splenic flexure of the colon within the
left hemithoracic cavity following an old gunshot wound.
Adapted from American Association for the Surgery of Trauma-Organ Injury Scale for
Diaphragmatic Injuries
GRADEINJURY DESCRIPTION
I Contusion
II Laceration ≤2 cm
III Laceration 2-10 cm
IV Laceration >10 cm with tissue loss ≤25 cm2
V Laceration with tissue loss >25 cm2
Algorithm for treatment of diaphragm injury, acute vs. chronic.
DAMAGE CONTROL OPERATIONS
Definition
Damage control operations are performed in injured patients with profound
hemorrhagic shock and preoperative or intraoperative metabolic sequelae that are
known to adversely affect survival.
The widely accepted three stages of damage control are described as follows:
Limited operation for control of hemorrhage and contamination. Includes
control of hemorrhage from the heart or lung; conservative management of
injuries to solid organs; resection of major injuries to the gastrointestinal tract
without reanastomosis; control of hemorrhage from major arteries and veins in
the neck, trunk, or extremities; packing of organs or spaces to control the
inevitable coagulopathy; and use of an alternate closure of a cervical incision,
thoracotomy, laparotomy, or site of exploration of an extremity.
Resuscitation in the SICU. Includes vigorous rewarming of the hypothermic
patient; restoration of a normal cardiovascular state by the infusion of fluids and
blood and the use of inotropic and related drugs; correction of residual
coagulopathy after hypothermia is reversed; and supportive care for stunned
lungs and kidneys.
Reoperation. Completion of definitive repairs, search for missed injuries, and
formal closure of the incision, if possible.
Patients Likely To Need Damage Control Operations
Thoracic Trauma
Penetrating thoracic wound and systolic blood pressure <90 mmHg
Pericardial fluid on surgeon-performed ultrasound after blunt or penetrating
thoracic trauma
S/p emergency department thoracotomy for penetrating thoracic wound
Abdominal or Pelvic Trauma
Penetrating abdominal wound and systolic blood pressure <90 mmHg
Blunt abdominal trauma, systolic blood pressure <90 mmHg, and peritoneal fluid
on surgeon-performed ultrasound or gross blood on diagnostic peritoneal tap
Closed pelvic fracture, systolic blood pressure <90 mmHg, and peritoneal fluid
on surgeon-performed ultrasound or gross blood on diagnostic peritoneal tap
Open pelvic fracture
Trauma to an Extremity
Shotgun wound to femoral triangle of thigh
Mangled extremity from blunt trauma
General
Emergency laparotomy to be followed by emergent craniotomy for compressive
lesion, emergent thoracotomy for repair of ruptured descending thoracic aorta,
or therapeutic embolization of pelvic bleeder related to fracture
Clinical and Laboratory Manifestations of Increased Intra-abdominal Pressure
Abdominal
Body wall
Decreased blood flow
Gastrointestinal tract
Decreased mucosal blood flow and intramucosal pH
Possible bacterial translocation
Hepatic
Decreased portal blood flow and hepatocyte mitochondrial funtion
Renal
Increased renal vein pressure
Increased plasma renin and aldosterone
Decreased renal blood flow, glomerular filtration rate, and urine output
Thoracic
Lung
Increased intrathoracic pressure, peak airway pressure, peak inspiratory pressure, and
intrapulmonary shunt
Decreased dynamic compliance
Heart/cardiovascular
Decreased venous return and cardiac output
“False” increase of central venous pressure and pulmanary artery wedge pressure
Increased systemic and pulmonary vascular resistance
Central nervous system
Increased intracranial pressure secondary to decreased venous return
Decreased cerebral perfusion pressure
Grading of the Abdominal Compartment Syndrome
BLADDER PRESSUREGRADE (mmHg)RECOMMENDATION
I 10-15 Maintain normovolemia
II 16-25 Hypervolemic resuscitation
III 26-35 Decompression
IV >35 Decompression and reexploration
Indications for Emergent Return to the Operating Room after A Damage Control
Laparotomy
BLUNT TRAUMA PENETRATING TRAUMA
Normothermic but bleeding >2 U/h Bleeding >15 µ and hypothermia
Abdominal compartment syndrome with ongoing Normothermic but bleeding >2
blood loss U/h
Abdominal compartment syndrome with ongoing
blood loss
Guidelines for Elective Return to the Operating Room After A Damage Control
Laparotomy
Temperature >30°C [96.8°F]
Acid-base balance
Base deficit corrected to >-5 mmol/L if originally <-15 mmol/L
Serum lactate normal or correcting gradually
Coagulation
Prothrombin time <15 s
Partial thromboplastin time <35 s
Platelets >50,000/µL
Cardiovascular
Cardiac index >3 L/min/m2, with or without low-dose inotrope
Pulmonary
Fraction of inspired oxygen <0.50
O2 saturation >95%;
