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CHEST TRAUMA

(Basic Knowledge)

Soebandrijo MD, Darmawan Ismail MD


Sub 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: senapan

Blunt injuries
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= 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)
Airway dari hidung sampe alveolus.
Baca kontusio paru!

Tracheobronchial
tree lacerations
(rupture)
Esophageal
lacerations
Penetrating cardiac
injuries
Pericardial
tamponade
Spinal cord injuries
Diaphragm trauma
Intra-abdominal
trauma associated
organ injury

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 thrust
1.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 breathing
4.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, cricotiroidostomi
7.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
Pneumothorax

Breathing
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

Tension Pneumothorax

(simplify)

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
Dari anamnesis didapatkan sesak
nafas.

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

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.

Hemothorax
Blunt or penetrating
chest trauma
Shock

Dyspnea
Tachycardia
Tachypnea
Diaphoresis
Hypotension massive

Dull to percussion over


injured side
Treatment
Chest tube insertion &
consult
Bs dgn pulv pungsi. Kalo dr pulv
pungsi ada darah, dg pleural pungsi.

(simplify)

CXR Image

Trauma.org

Gambaran CT scan
Tension 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 segmental
2.2 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

Pas foto rontgen ada gambar lusen


di luar iga sering bersama tension

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.

Pericardial Tamponade
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

(simplify)

Kussmauls sign
Decrease or
absence of JVD
during inspiration
JVD
Pulsus Paradoxus
Distant heart tones
Drop in SBP >10
Hypotension or
during inspiration
narrowing pulse
Due to increase in
pressure
CO2 during
Weak, thready pulse
inspiration
Shock
Electrical Alterans
P, QRS, & T
amplitude changes
in every other
Cardiac tamponade sianosis, nadi kecil, penurunan kesadaran.
cycleterbendung,
Trias back tjd karena penekanan atrium kanancardiac
1venous return
Dyspnea
Possible cyanosis
Becks Triad

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 vaskuler
Syok 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 sbnrnya
Resusitasi 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

Laceration of vascular
structures
Internal bleeding consult
External bleeding

Buat hentikan perdarahan, tekan bagian proksimal dari perdarahan.


Bebat tekan itu tiap 30 menit dikendorin.