4.

THORACIC TRAUMA

PRIMARY SURVEY : LIFE THREATENING INJURIES

AIRWAY OBSTRUCTION
Result from swelling, bleeding, or vomitus that is aspirated into the airway
In primary survey :
look for retractions, foreign body obstruction
listen air movement, stridor
feel crepitus over the anterior neck
Tracheobronchial tree injury
Patients typically present with hemoptysis, cervical subcutaneous emphysema, tension
pneumothorax, and/or cyanosis.
BREATHING PROBLEMS
Tension Pneumothorax
One way valve air leak occurs from the lung or through the chest wall.
The mediastinum displaced to the opposite side, decreasing venous return > shock,
compressing the opposite lung.
Sign and symptoms :
Chest pain, air hunger, tachpnea, respiratory distress, hypotension, tracheal deviation ,
unilateral absence of breath sounds, elevated hemithorax without respiratory movement, neck
vein distention, cyanosis
Tatalaksana : needle cecompresion, with 8 cm catheter > 90% reach pleural space
Open Pneumothorax
Large injury to the chest wall that remain open
Treatment : close the defect with a sterile dressing, tape securely only three side
Massive Hematothorax
Trearment : insert chest tube

CIRCULATION PROBLEMS
Massive Hematothorax
Result from the rapid accumulation of more than 1500 ml of blood or one third or more of the
patient;s blood volume in the chest cavity
Shock with absence of breath sounds or dullness to percussion on one side of the chest
Neck vein may be flat because hypovolemia or distended because tension pneumothorax
Treatment : large caliber iv line, infuse crystalloid, transfusion, chest tube (28-32 french at
the fifth ics, anterior midaxillary line
Thoracotomy required when there is continuing blood loss (200 ml/hr for 2 to 4 hours), or
penetrating anterior chest wound medial to the nipple line and posterior medial to the scapula
(the mediastinal box) >> potential damage of great vessel, hilar structures, and the heart
Cardiac Tamponade
Compression of the heart by an accumulation of fluid in the pericardial sac
Traumatic Circulatory Arrest

SECONDARY SURVEY
Potentially Life Threatening Injuries
Simple Pneumothorax
Treatment : chest tube in ics 5, anterior midaxillary line
Hemothorax
Flail chest
Pulmonary contusion
Blunt cardiac Injury
Traumatic aortic disruption
Widened mediastinum
Obliteration of the aortic knob
Deviation of the trachea to the right
Depression of the left mainstem bronchus
Elevation of the right mainstem bronkus
Obliteration of the space between the pulmonary artery and the aorta
Deviation of the esophagus to the right
Widened paratracheal stripe
Eidened paraspinal interfaces
Presence of a pleural or apical cap
Left hemothorax
Fractures of the first or second rib or scapula
Initial treatment :
Pain killer
Short acting beta blocker to a goal heart rate less than 80 bpm, if contraindicated can be
diganti ca chanel blocker / nikardipin ( jika tidak ada hipotensi)
Blood pressure control with goal MAP 60-70 mmHg
Traumatic Diaphragmatic injury
In x ray can be seen elevated diaphragm, the appearace of peritoneal lavage fluid in the chest
tube drainage
Blunt esophageal rupture

Other manifestations of chest injuries

Subcutaneous emphysema
Crushing injury to the chest
Rib, sternum, and scapular fractures