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ACS

Thoracic Trauma
BY : dr. ADRIAN KHU,SpOT

ACS

Objectives

Indentify and treat injuries found during the


primary survey.
Indentify and treat injuries found during the
secondary survey.
Demonstrate the ability to perform life
saving chest management.
Indications
Contraindications

ACS

Thoracic Trauma

1 out of 4 deaths
Blunt : < 10% require operation
Penetrating : 15% - 30% require operation
Majority : require simple procedures

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Initial Assessment/ Management


Primary Survey

Identifies most life -threatening injuries


Resuscitation

Airway control

Ensure oxygenation/ventilation

Needle / tube thoracostomy

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Initial Assessment/Management
Secondary Survey

Identifies most
potentially lethal
injuries

Physical exam/
diagnostic tests

Definitive Care

Airway control
Ensure oxygenation
/ventilation
Tube thoracostomy
Hemodynamic
support
Operation

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Life threatening Chest Trauma


Primary Survey

Airway obstruction

Tension pneumothorax

Open pneumothorax

Flail chest

Massive hemothorax

Cardiac tamponade

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Airway Obstruction
Laryngeal injury

Rare occurrence

Hoarseness

Subcutaneous emphysema

Treatment
Intubation (caution)
Tracheostomy (by surgeon)

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Breathing
Tension pneumothorax: Etiology

Parenchymal and / or chest-wall injuries

Air enters pleural space with no exit

Positive pressure ventilation


Collapse of affected lung
Venous return
Ventilation of opposite lung

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Breathing
Tension Pneumothorax : Signs / Symptoms
Respiratory distress
Distended neck veins
Unilateral in breath sounds
Hyperresonance
Cyanosis, late

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Breathing
Tension
Pneumothorax

Immediate
decompression

Clinical diagnosis,
not by x-ray

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Breathing
Open Pneumothorax
Cover defect
Chest tube
Definitive operation

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Breathing
Flail chest

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Breathing
Flail Chest/pulmonary Contusion

Reexpand lung

Oxygen

Judicious fluid management

Intubation as indicated

Analgesia

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Circulation
Massive Hemothorax

1500 ml blood loss

Systemic / pulmonary vessel disruption

Flat vs distended neck veins

Shock with no breath sounds and /or


percussion dullness

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Circulation
Massive Hemothorax
Rapid volume restoration
Chest decompression and x-ray
Autotransfusion
Operative intervention

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Circulation
Cardiac Tamponade
Arterial pressure
Distended neck veins
Muffled heart sounds
PEA

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Circulation
Cardiac Tamponade

Patent airway

IV therapy

Pericardiocentesis

Pericardiotomy

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Resuscitative Thoracotomy
Qualified surgeon presnt on patients arrival
Indications
Penetrating thoracic injury
Pulseless with electrical activity
Contraindications
Blunt injury
Pulseless without electrical activity

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Potentially- Lethal Chest Trauma


Identified by :

In depth examination

Upright chest x-ray, if possible

ABGs

Pulse oximetry

ECG

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Potentially- Lethal Chest Trauma

Simple pneumothorax
Hemothorax
Pulmonary contusion
Tracheobronchial tree injury
Blunt cardiac injury
Traumatic aortic disruption
Traumatic diagpramatic injury
Mediastinal traversing wounds

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Secondary Survey
Pneumothorax
Penetrating /blunt
trauma
V / Q defect
Hyperresonance
Breath sounds
Tube thoracostomy

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Secondary Survey
Hemothorax

Chest wall injury


Lung /vessel
laceration
Tube thoracostomy

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Secondary Survey
Pulmonary Contusion

Most common

Oxygenate , ventilate

Selective intubation

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Secondary Survey
Tracheobronchial injury
Frequently missed
injury
Blunt / penetrating
trauma
Partial vs complete
Diagnostic aid : Endoscopy

Treatment
Airway
ventilation
Operation

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Secondary Survey
Blunt Cardiac Injury

Injury spectrum

Abnormal ECG : Monitor changes

Echocardiography

Treat : Dysrhythmias, Q, complications

Secondary Survey
Traumatic Aortic
Rupture
Rapid acceleration/
deceleration

Ligamentum
arteriosum

Salvage : identify early

Surgical consult

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ACS

Secondary Survey
Diaphragmatic Rupture

Most diagnosed on left

Blunt large tears

Penetrating small
perforations

Misinterpreted x ray

Contrast radiography

Operation

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Mediastinal Traversing wounds


Hemodynamically Abnormal

Exsanguinating thoracic hemorrhage

Tension pneumothorax

Pericardial tamponade

Esophageal / tracheobronchial injury

Spinal cord injury

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Mediastinal Traversing Wounds


Hemodynamically Abnormal

Treatment
Bilateral tube thoracostomies
Emergent surgical consultation

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Mediastinal Traversing Wounds


Hemodynamically Normal

Vascular : Angiography

Tracheobronchial : Bronchoscopy

Esophageal Esophagography,
esophagoscopy

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Mediastinal Traversing Wounds


Hemodynamically Normal

Treatment
Mandatory surgical consultation
Repair identified injuries

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Secondary Survey
Subcutaneous
Emphysema

Airway injury

Pneumothorax

Blast injury

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Secondary Survey
Traumatic Asphyxia

Petechiae
Swelling
Plethora
Cerebral edema

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Secondary Survey
Sternal, Scapular, and Rib Fracture:
Pathophysiology

Hemopneumothorax

Pain Splinting

Retained secretion

Associated injuries

Atelectasis pneumonia

Impaired ventilation

Pulmonary contusion

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Secondary Survey
Sternal, Scapular, and Rib Fractures
Ribs 1- 3

Severe force
Associated injuries High mortality risk

Ribs 4 9

Pulmonary contusion
Pneumohemothorax

Ribs 10 12 : Suspect abdominal injury

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Secondary Survey
Sternal, Scapular, and Rib Fractures :
Management

Chest x ray
Chest tube as
necessary
Selective
ventilation

Adequate pain
relief
Treat associated injuries
No constrictive devices

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Secondary Survey
Esophageal Trauma

Blunt vs penetrating

Severe epigastric blow

Pain, shock > injury

Pneumohemothorax without fracture

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Secondary Survey
Esophageal Trauma

Chest tube :
Particulate matter

Mediastinal air

Contrast swallow,
esophagoscopy

Operation

ACS

Secondary Survey
Other indication for Tube Thoracostomy

Suspected, severe lung injury


Air or ground transfer
General anesthesia
Positive pressure ventilation

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Pitfalls

Simple pneumothorax tension


pneumothorax
Retained hemothorax
Diaphragmatic injury
Delayed diagnosis of aortic injury
Severity of rib fractures pulmonary
contusion
Elderly

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Questions

ACS

Summary

Common in multiply injured


Life threatening injuries
Develop skills to treat
Monitoring