CHEST TRAUMA

(Basic Knowledge)

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
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
Basic management concept
in traumatic patient
Is
ABCDE

Sub Department of Cardio Thoracic & Vascular Surgery

responsible in ABC
 Injuries Associated with
Cardio Thoracic Vascular Trauma
• Airway obstruction • Tracheobronchial tree
• Closed pneumothorax lacerations (rupture)
• Open pneumothorax • Esophageal lacerations
(sucking chest wound) • Penetrating cardiac injuries
• Tension pneumothorax • Pericardial tamponade
• Spinal cord injuries
• Pneumomediastinum
• Diaphragm trauma
• Hemothorax (massive)
• Intra-abdominal trauma
• Hemopneumothorax associated organ injury
• Rib fracture (flail chest) • Laceration of vascular
structures (central &
peripheral)
 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
 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
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
Needle thoracocentesis
OPEN (SUCKING) CHEST WOUND
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
 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
 Hemothorax (simplify)
• Blunt or penetrating chest
trauma
• Shock
– Dyspnea
– Tachycardia
– Tachypnea
– Diaphoresis
– Hypotension  massive
• Dull to percussion over injured
side
• Treatment
Chest tube insertion & consult
CXR Image

Trauma.org
 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
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
 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
 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)
• Dyspnea • Kussmaul’s sign
• Possible cyanosis – Decrease or absence of
• Beck’s Triad JVD during inspiration
• Pulsus Paradoxus
– JVD
– Drop in SBP >10 during
– Distant heart tones inspiration
– Hypotension or – Due to increase in CO2
narrowing pulse during inspiration
pressure • Electrical Alterans
• Weak, thready pulse – P, QRS, & T amplitude
• Shock changes in every other
cardiac cycle
• PEA
Pericardial or Cardiac tamponade
Pericardial Tamponade (ilustrations)
SIMPLIFY DIAGNOSIS OF LUNG
CONTUSION

• Complains :
no symptom, shortness of breath
• Physical examination:
tachycardia, tachypnoea, haemoptysis, rales, hypotension, confusion,
increased work of breathing
• Lab Finding:
Hypoxemia  Hypoxemia ratio  ALI / ARDS
hypercabnia
• Chest XR
Increase opacity (inhomogen)  traumatic site
• Chest CT Scan
percentage volume which appears to correlate with physiological dysfunction
TERIMAKASIH
5. Airway definitif harus dipasang pada
apnoe

6. Pengelolaan airway  penilaian

7. Pemilihan orotracheal, nasotracheal 

intubasi pengalaman & ketrampilan dokter

8. Airway surgikal indikasi untuk gagal

intubasi & diperlukan airway