12. thoracic trauma

8/13/2019 12. Thoracic Trauma

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Thoracic injuriesThoracic injuries

following both penetrating and blunttrauma,

it has been estimated that chest injuriesare responsible for ! to "# of all trauma

deaths$

chest injuries are also common in multipl%

injured patients$


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Rib fracturesRib fractures

Most common injur% associated with bluntchesttrauma

&'(! # of all trauma admission

the true incidence in probabl% higher since up to "!#of rib fractures ma% be missed on initial C)R

Causes* motor +ehicle crashes

falls blows to the chest with blunt objects


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fractures of ribs trought - . ma/imumfre0uenc%

directl% at the site of force

laterall%

significant antero'posterior compression ofthe chest


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the first rib is protected b% the shouldergirdle and cla+icle

fractures of the first rib indicate a significantamount of energ% transferred to the torso

ha+e been associated with aortic injuries

posterior rib fractures are also associatedwith significant energ% transfer to thethora/$


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Hemotorax & Fracturi costale multiple decubit dorsal


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Associated injuries* !# incidence of splenic injur% is associated

with fractures of ribs 1, (!, and (( on the left

side

similar for hepatic injuries "!# of patients with blunt cardiac injur% ha+e

rib fractures$


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Rib fractures ' diagnosisRib fractures ' diagnosis

The diagnosis of rib fractures is primaril% clinical 2ain

directl%

antero'posterior compression, Crepitus o+er the possible area of fracture 3ecreased breath sounds on the side of injur% 2ain*

subse0uent atelectasis underl%ing pulmonar% contusion restriction of +entilation$


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Chest )RChest )R

radiologic confirmation of the diagnosis isnot essential


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children pulmonar% contusion is more common rib fractures 4 a sign of signi5cant energ%

transfer$

elderl%

2atients older than 6" %ears with or morerib fractures had a "'fold increased mortalit%rate and an almost &'fold increased incidenceof pneumoniacompared with %ounger

patients


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TreatmentTreatment

intra+enous narcotics patient'controlledanalgesia

continuous opioid infusion

intercostal ner+e bloc7 epidural analgesia Multiple fractures 8lderl% patients

2atients with underl%ing pulmonar% disease


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hospital admission*

histor% of smo7ing chronic obstructi+e pulmonar% disease ederl% patients with multiple fractures


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Flail ChestFlail Chest

fracture of more than consecuti+e ribs in or more places

this creating a free'floating segment of thechest wall

a better de5nition ma% be 9an incompetentsegment of chest wall large enough toimpair the patient:s respiration$;


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Flail ChestFlail Chest

respirator% failure after chest wall injur% is almostne+er due to the mechanical +entilator%d%sfunction imposed b% the chest wall injur%

itself

in great measure, it is caused b% the underl%ingpulmonar% contusion ' almost uni+ersall%

accompanies flail chest$

increasing age also is associated with anincreasing ris7 of death with


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The parado/ical mo+ements of the flailsegment are caused b% negati+e

intrapleural pressure generated during

inspiration

Up to !# of patients with se+erebluntchest injuries


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The majorit% of complications resultingfrom rib fractures are related to chest wallpain, which limits pulmonar% function

The inabilit% of patients to clear secretionsade0uatel% and the de+elopment of

atelectasisfrom chest wall splinting areris7 factors for the de+elopment ofpulmonar% infection$


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=lail chest ' treatment=lail chest ' treatment

ade0uate pain control and aggressi+erespirator% care to optimi>e pulmonar% function

2roph%lactic intubation is not indicated$ if a patient re0uires mechanical +entilationbecause of an underl%ing contusion or otherinjuries, internal pneumatic stabili>ation?mechanical +entilation@is possible

wean the patient as soon as possible, againb% using epidural or other aggressi+e paincontrol techni0ues if possible$


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=lail chest ' treatment=lail chest ' treatment

The presence of a


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Volet costal tratament istoric

Zdrobire hemitorace drept


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Zdrobire hemitorace dreptRadiografie iniial

Dup entilaie cu !""! mare


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Dup entilaie cu !""! mare

#tabili$are intern a segmentelor celor mai instabile


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#tabili$are intern a segmentelor celor mai instabile

!ost stabili$are


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!ost stabili$are

Volet costal mi%care paradoxal
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Volet costal mi%care paradoxal

!nemotorax pleurostomie'
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!nemotorax pleurostomie'

Volet costal

(ontu$ie pulmonar


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BT8RAD =RACTUR8BBT8RAD =RACTUR8B

"# of patients with se+erechest injuries associated with an increased incidence of

both cardiac and great +essel injur%$


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Isolated sternal fracture ma% result fromshoulder belt use

Most fractures are trans+erse, in+ol+e thesternal'manubrial junction or upper one

third of the sternum,


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The diagnosis of sternal fracture is made b%palpation of the sternum

A lateral chest radiograph can re+eal sternalfractures and the degree of posteriordisplacement


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The treatment of sternal fracture isprimaril% ade0uate pain relief and

pulmonar% care, as for rib fractures$ Onl%

If se+ere displacement is present,operati+e reduction with fi/ation of the

fracture ma% be re0uired$

Options include wires in a 5gure'of'-fashion, plates, or both$

Fractur de stern


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Fractur de stern


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Simple PneumothoraxSimple Pneumothorax

2neumothora/, defined as air in thepotential space between the +isceral and

parietal pleurae$

The loss of negati+e intrapleural pressureallows the lung to collapse from elastic

recoil$


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2neumothora/ ordinaril% results from * ruptured al+eoli or from small lacerations in

the pulmonar% parench%ma and is fre0uentl%

associated with rib fractures lacerations through the chest wall

stab or gunshot wounds

iatrogenic injuries ' as a complication ofplacement of a central +enous catheter


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The diagnosis of pneumothora/ is suggested onph%sicale/amination*

3ecreased ipsilateral breath sounds

3ecreased e/pansion of the affected hemithora/ H%perresonance to percussion Crepitus Bubcutaneous emph%sema

The chest radiograph is usuall% diagnostic


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Traumatic pneumothora/ is treated b%placement of a tube thoracostom%

A chest tube should be inserted to e+acuate theair

A chest radiograph should be obtained afterinsertion of the chest tube to confirm that propertube positioning and ree/pansion of the lungha+e occurred


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2atients with small, as%mptomaticpneumothoraces who do not re0uire generalendotracheal anesthesia or positi+e'pressure+entilation ma% be obser+ed carefull% without

placement of a tube thoracostom%$

If the air lea7 from the lung has sealed, the air in

the pleural ca+it% will be reabsorbed, withsubse0uent complete ree/pansion of the lung$Berial chest films should be obtained to ensurethat the pneumothora/ is progressi+el%decreasing and that the lung is not collapsed

!neumotorax st)ng


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g

!neumotorax drept


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p

!neumotorax drept


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p

!neumotorax medial


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!neumotorax simplu


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Detaliu


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Detaliu


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"mfi$em subcutanat masi posttraumatic


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Rg toracic


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(*


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Tension PneumothoraxTension Pneumothorax

A tension pneumothora/ occurs if the pressure ofaccumulated air in the pleural space e/ceeds theambient pressure, resulting in a net positi+e intrathoracicpressure

Tension pneumothora/ occurs when air enters thepleural space from lung injur% or through the chest wall

without a means of e/it$

2ressure de+elops within the pleural space, compressingthe superior and inferior +ena ca+a, impairing +enousreturn, and decreasing cardiac output$


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Most common causes*

2enetrating injur% to the chest Elunt trauma with parench%mal lung injur% Mechanical +entilation with high airwa%

pressure

Bpontaneous pneumothora/ with blebs thatfailed to seal


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Tension pneumothora/ mustbe a clinical diagnosis*

Be+ere respirator% distress

3%spnea, tach%pnea H%potension Unilateral absence of breath sounds H%perresonance to percussion o+er affected

hemithora/ ec7 +ein distention ?can be absent in

h%po+olemic patients@

Tracheal de+iation ?late finding ' notnecessar% to confirm clinical diagnosis@


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If the tension pneumothora/ has not been diagnosed on clinicalfindings ?which it should be@, C)R will usuall% show a

pneumothora/ large enough to cause tension

a collapsed lung a depressed ipsilateral hemidiaphragm widened intercostal spaces

mediastinal shift awa%


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Tension 2neumothora/ ' treatmentTension 2neumothora/ ' treatment

Immediatel%decompress b% inserting a(' or (&'gauge IF catheter into the

second intercostal space in the

midcla+icular line$ This con+erts the tension pneumothora/

into a simple open pneumothora/$

=ollow immediatel%with tube thoracostom%$

!neumotorax +n tensiune


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Inspir,erul intr +n caitatea pleural prin plaga pulmonarsau bula de emfi$em rupt oca$ional prin plagatoracic penetrant'

(olabarea plm)nului ipsilateral %i deplasareacontralateral a mediastinului

(omprimarea plm)nului contralateral cu alterareacapacitii entilatorii a acestuia

Expir

(re%terea presiunii intrapleurale cu +nchiderea comunicrii tipal unisens

,ccentuarea deplasrii mediastinale %i pleurale- deprimareadiafragmului

,lterarea +ntoarcerii enoase prin cre%terea presiuniiintratoracice %i distorsionarea enei cae

!neumotorax +n tensiune


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.anifestri clinice %i manere terapeutice

Dispnee

(iano$

Durere toracic

Deiaie traheal

Hipersonoritate

/mpingerea pistonului seringii ume$itede ctre presiunea intratoracic

!leurostomie torace anteriorspaiul 012 intercostal cu drena34eclaire

5nserie ac de calibru mare pentrudecompresiune de urgen a presiuniiintratoracice

!neumotorax st)ng +n tensiune


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!neumotorax bilateral +n tensiune


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(* 1 !neumotorax +n tensiune


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!neumotorax st)ng +n tensiune


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gRg post mortem

(* !neumotorax +n tensiune cu extensie sub ficat


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(* !neumotorax +n tensiune cu extensie sub ficat


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!neumotorax +n tensiune sufocant'


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*uburi de dren introduse prea mult +n caitatea pleural


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(* torace superior po$iia tuburilor de dren*ub +n fisura oblic blocat de esut pulmonar


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*ub +n fisura oblic blocat de esut pulmonar

!neumotorax drept +n tensiune (* torace inferior


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*ub neintrodus suficient 6ltimul orificiu aproape ie%it din caitate


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Hemothorax.Hemothorax.

accumulation of blood in the pleural space

it occurs in "!# to G"# of patients with se+ere

blunt or penetrating chest trauma

relati+el% as%mptomatic

fran7 h%po+olemic shoc7 at the time ofpresentation, d%spnea or shortness of breath


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Treatment of hemothora/Treatment of hemothora/

begins with tube thoracostom% to e+acuate the blood and ree/pandthe lung

Bimple tube thoracostom% is ade0uate treatment for up to -"# ofpatients ?the pulmonar% parench%ma has a high concentration oftissue thromboplastin, which probabl% contributes to hemostasis and

sealing of air lea7s @$

indication for thoracotom%for e+acuation of clot and control ofbleeding* hemod%namic instabilit%

massi+e hemothora/ more than (,!!! ml persistent bleeding, at a rate greater than !! mDh for & hours, orgreater than (!! mDh for - hours$


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2h%sical e/amination decreased breath sounds dullness to percussion on the injured side

Bupine chest films usuall% show ha>inessof the affected lung field or, with massi+e

hemothora/, complete opacification

Hemotorax 1 surse


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!lm)n

,rtera toracoacromial ia traiect plag'

,rtera toracic lateral ia traiect plag'

,rtera toracic intern

Vase intercostale

#tructuri intraabdominale ficat- splin'ia diafragm

Vase mari mediastinale

5nim

Hemotorax

(uantificare %i atitudine


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(uantificare %i atitudine

Minim (1500 ml)

!leurostomie dubl pentru a preenicolmatarea cu cheaguri

*oracotomia poate fi necesar pentrua opri s)ngerarea

Hemotorax 1 ortostatism


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Hemotorax drept


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Hemotorax decubit dorsal & Fracturi costale multiple


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Hemotorax masi


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Hemotorax bilateral


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Hemo1pneumotorax


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Detaliu


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Hemotorax st)ng Rg iniial fr tensiune'


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(* Hemotorax +n tensiune


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(* Hemotorax +n tensiune


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!lag prin +n3unghiere hemitorace drept inferior7e$iune diafragmatic %i hepatic


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g % p

Hemotorax decubit dorsal

(*


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P l C iP l C t i


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Pulmonary ContusionPulmonary Contusion

2ulmonar% contusion in+ol+es e/tensi+einterstitial hemorrhage within the

parench%ma, with al+eolar collapse and

e/tra+asation of blood and plasma into theal+eoli$

2ulmonar% contusion occurs in up to G!#

of patients with se+ere blunt chest trauma


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As a result, a +entilation'perfusionmismatch de+elops, which leads to arterial

h%po/emia

The h%po/emia is usuall% refractor% toincreases in inspired o/%gen

concentration$

2ulmonar% compliance decreases, andwor7 of breathing increases

P l C t iP l C t i


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Pulmonary ContusionPulmonary Contusion

initial C)Rs ma% be normal

9bruising; of the lung interstitial and al+eolar edema hemorrhage subse0uent al+eolar collapse

chest CT can 9grade; the degree of injur% moreaccuratel% and ma% lead to better predictions ofthe clinical course

2 l C i2 l C t i t t t


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2ulmonar% Contusion . treatment2ulmonar% Contusion . treatment

Is primaril% supporti+e Intra+enous +olume should be restricted if possible

since the associated capillar% lea7 will lead to aworsening of pulmonar% edema

3iuresis is indicated in the presence of +olumeo+erload

ot re0uire intubation

arterial blood gases partial pressure of o/%gen 6!mm Hg with inspired o/%gen concentration of "!#

a respirator% rate J & breathsmin


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These patients should be carefull% monitored,and care should be ta7en to pro+ide ade0uateanalgesia for rib fractures$

2atients who cannot sustain ade0uatepulmonar% function re0uire mechanical+entilation

2ositi+e end'e/pirator% pressure ?2882@ has a

protecti+e effect and preser+es functionalreser+e capacit%

proph%lactic antibiotics is not indicated

(ontu$ie pulmonar


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,RD# dup contu$ie pulmonar dreapt


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(ontu$ie pulmonar asociat cu plag prin +mpu%care trunchi brahiocefalic


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T h b hi l I j iTracheobronchial Injuries


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Tracheobronchial Injuries.Tracheobronchial Injuries.

=rom blunt trauma are relati+el% uncommon J (# of patients with se+ere trauma blunt trauma ' high'speed motor +ehicle accidents crushing injuries

If significant anteroposterior compressi+e force is appliedto the chest, it causes rapid lateral deformation of thethoracic ca+it% and results in traction injur% of the tracheaor main'stem bronchi, usuall% within cm of the carina

2enetrating injuries in+ol+e the cer+ical trachea in morethan -!# of cases$

T h b hi l I j iTracheobronchial Injuries


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Tracheobronchial InjuriesTracheobronchial Injuries

Most patients with se+ere airwa% injuriesdie at the scene of the accident as a resultof airwa% obstruction

Cervical tracheal injuries* Usuall% present with upper airwa% obstruction

and c%anosis unrelie+ed with O

B%mptoms include local pain, d%sphagia,cough, and hemopt%sis Bubcutaneous emph%sema



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Thoracictracheal orbronchialinjuries* -!# occur within cm of carina$ Intrapleural laceration

persistent d%spnea massi+e air lea7 massi+e pneumothora/ that does not reexpandwith chest tube drainage$



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8/trapleural rupture into the mediastinum$ pneumomediastinum subcutaneous emph%sema$ partial bronchial disruptions, "# will go

undetected for to & wee7s, but persistent

atelectasis, recurrent pneumonia, and suppuration

should prompt further in+estigation

Radiographic signs on C)RRadiographic signs on C)R


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Radiographic signs on C)RRadiographic signs on C)R

An abnormal admission C)R will be seen in 1!# ofcases 2neumothora/ 2leural effusion 2neumomediastinum Bubcutaneous emph%sema ?air in the soft tissues of

the nec7 and chest wall@ Mediastinal hematoma

Specific findings 2eribronchial air 3eep cer+ical emph%semaK radiolucent line along

pre+ertebral fascia ?earl% and reliable sign@

=allen lun ' in which the lun is seen to dro awa



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2lacement of a tube thoracostom% ma%result in a continued massi+e air lea7 from

the chest tube with no e/pansion of the

lung If so, a second chest tube should be placed,

and bronchoscop% should be underta7en to

confirm the diagnosis$

TreatmentTreatment


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TreatmentTreatment

J ( of the circumferenceof the bronchus andthe lung can be ree/panded with chest tubeplacement, nonoperati+e managementprobabl%

will be successful

( of the circumferenceof the airwa% earl% surgical repair is indicated$

2ersistent large air lea7 and inabilit% to ree/pandthe lung also ma% necessitate surgical repair ofbronchial injuries$


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3efiniti+e treatment includes primar% repair with mucosa'to'mucosa closure using absorbable, interruptedsutures$

8/posure for injuries

Mediansternotom% pro+ides access to the anterior orleft lateral portion of the mediastinal trachea Right posterolateral thoracotom% pro+ides e/posure

of the right lateral or posterior aspect of the trachea orright lung bronchior parench%mal injur%

Deftposterolateral thoracotom% pro+ides access tothe left lung bronchior parench%mal laceration

Eronchoscopic stent placement also has been used

successfull% in the repair of isolated bronchial injuries

!lag prin +n3unghiere cerical st)ng penetrantLaceraie traheal


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*oracotomie dreapt reparare prin sutur traheal cu fire separate


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!lag prin tiere cerical cuperforaie traheal


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perforaie traheal(linic emfi$em subcutanat

Radiologic pneumomediastin*ratament conserator monitori$are-control bronhoscopic'

Elunt cardiac injur%Elunt cardiac injur%


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Elunt cardiac injur%Elunt cardiac injur%

Cardiac in+olment in nonpenetratingtrauma probabl% ocuurs more ofthen than

reali>ed$

It is most common unsuspected +isceralinjur% responsible for death$


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Mechanisms* Budden deceleration Compression between the sternum and

+ertebral column 8/ternal blow, e+en without associated chest

wall fractures

=ragment of the fractured bon% chest wall isdri+en into the heart$


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M%ocardial contusionM%ocardial contusion


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Is the most common lesion encounteredclinicall% in patients with nonpenetrating

cardiac injur%

Is the one of the most fre0uentl% misseddiagnoses in patients with multiple injuries$



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Cardiac contusion is recogni>ed as a dar7red, hemorrhagic area

=ull thic7ness of the m%ocardium

Rupture of the m%ocardium Aneur%sm formation

3amaged m%ocardium is predisposed tothe de+elopment of cardiac arrh%thmias



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3iagnosis* B%mptom of cardiac contusion ma% be absent

or mas7ed b% other se+ere injuries

The most common s%mptom ? G!#@ isprecordial pain

The most common dela%ed s%mptoms areangina, palpitations and congesti+e heart

failure

The most fre0uentl% encounted ph%sicalfinding is tach%cardia



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8C 8C should be performed an admission as a

screening test for all patients suspectedofha+ing ECI

3%srh%thmia ? tach%cardia@ Atrial or +entricular ectop% B'T changes .ele+ation bundle branch bloc7 hemifascicular bloc7s


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If the 8C is normal at admission and &hours later, the ris7 of de+eloping life'

threatening arrh%thmias is essentiall% nil

Creatinine phospho7inase ?C2L@ andtroponin'I le+els ' correlate with the

se+erit% of m%ocardial contusion


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8chocardiogram asses * wall motion +al+ular competenc% global cardiac performance

intramural hematomas, pericardial effusion ma% be the most sensiti+e test for the diagnosis of

blunt cardiac injur%

Transthoracic echocardiogram ?TT8@ is con+enientand nonin+asi+e

T88 should be used when the TT8 is technicall%inade0uate

M%ocardial contusion' treatmentM%ocardial contusion' treatment


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M%ocardial contusion' treatmentM%ocardial contusion treatment

3%srh%thmias should be treatedaggressi+el%

there are no data to support the use of

proph%lactic antid%srh%thmics$ The treatment of arrh%thmias follows

standard algorithms

Dow cardiac output ma% re0uire supportwith an intra'aortic balloon pump ?IAE2@

Cardiac TamponadeCardiac Tamponade


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can occur from either blunt or penetratingtrauma, although penetratinginjuries are

much more common

G" to (!! mD of blood can producetamponade



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Tamponade should be considered inpatients with se+ere blunt chest trauma

who remain h%potensi+e and ha+e no

e+idence of e/ternal blood loss orhemorrhage into the thora/, abdomen, or

pel+is


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2ulsus parado/us decrease in s%stolic pressure of (! mmHg

during inspiration

Lussmauls sign is a hard and true sign oftamponade

inspiration in a spontaneousl% breathing

patient results in an increase of the jugular+enous distention

=ABT ultrasound e/amination should be=ABT ultrasound e/amination should be

f d id if i di l fl idf d t id tif i di l fl id


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performed to identif% pericardial fluidperformed to identif% pericardial fluid

A positi+epericardial +iew on the =ABT in an unstablepatient is an indication to proceed with median

sternotom% or left anterolateral thoracotom%

An e0ui+ocalpericardial +iew on the =ABTe/amination or a positi+e e/amination in a stable

patient necessitates an operati+e pericardial window

A negati+e=ABT in penetrating injur% can be falsel%negati+e secondar% to decompression of pericardial

fluid into the pleural space$



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Chest radiograph% 2neumothora/ Hemothora/

egati+e$ The pericardium is not acutel% distensible,

and an enlarged cardiac silhouette is not

reliabl% seen in acute tamponade


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Central +enous catheter in thehemod%namicall% stable patient

A +er% high central +enous pressure ?! to" cm HO@ is probabl% diagnostic but depend

on the patients +olume status$

Cardiac TamponadeCardiac Tamponade! treatment! treatment


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pp

intubation, o/%genate, and start +olumeresuscitation$

2ericardiocentesiscan be used as a tempori>ing

maneu+er to relie+e tamponade until definiti+erepair is possible$ this is often difficult to successfull% perform

because of nature of the procedure andrelati+el% small blood +olume in the sac$

Cardiac TamponadeCardiac Tamponade!!


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treatmenttreatment

hemod%namic instabilit% should undergoimmediateleft anterolateral thoracotom%

with a wide, longitudinal opening of thepericardium$ Cardiac lacerations should be digitall%

controlled until ade0uate blood +olume isrestored and the patient is relati+el% stable$

The use of staples also has been ad+ocatedto close cardiac lacerations rapidl% buttemporaril% for immediate hemostasis$


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Bmall lacerations in the beating heart can bethen repaired using nonabsorbable sutures

Darger lacerations ma% re0uirecardiopulmonar% b%pass for ade0uate

decompression and repair$

The left thoracotom% incision can be carriedtrans+ersel% across the sternum into the right

chest to facilitate e/posure of the entire heartand great +essels if necessar%$

Hemopericard acut %i tamponad cardiac

!re$ena s)ngelui +n sacul pericardic inextensibil +mpiedicl di


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8oc de seeritate ariabil

Hipotensiune arterial

!uls slab

!resiune enoas crescut

umplerea cardiac

Dinamica presiunii arteriale %i enoase +n tamponada cardiac


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!ericardiocente$a


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!uncie pericardic la nielul unghiului costoxifoid

Rol diagnostic %i decompresi

9rientarea superioar a acului pentrueitarea le$rii diafragmului %i ficatului

Aortic injuriesAortic injuries


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Aortic injuriesj

Traumatic rupture of the aorta is definedas a tear in the wall of the aorta that is

contained b% the ad+entitia of arter% and

the parietal pleura Techanism of injur% is rapid deceleration

falls from significant height

high'speed motor +ehicle crashes ejected occupants$


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-!# of the +ictims die at the scene The remaining patients are at ris7 for

dela%ed free rupture into the mediastinum

or pleural space$



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Aortic injuriesj

Docated

pro/imal aortic arch near the aortic +al+e

just distal to the origin of the left subcla+ianarter%

at the diaphragmatic hiatus

Bur+i+ors usuall% ha+e a containedhematoma held onl% b% an intact

ad+entitial la%er$



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jj

sur+i+ors are initiall% h%potensi+e butrespond to fluid resuscitation

because free rupture of the transected

aorta is rapidl% fatal, persistent orrecurring h%potension usuall% results from

a secondar% bleeding source, not the

aortic injur%



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jj

Clinical signs* As%mmetr% in upper e/tremit% blood pressures and uppere/tremit% h%pertension

Nidened pulse pressure Chest wall contusion

2osterior scapular pain A careful neurologic e+aluation is important because patients

ma% ha+e paraplegia or paraparesis from loss of blood flowthrough the intercostal arteries that suppl% the spinal cord

One half of patients with great +essel injur% from blunttrauma ha+e no e/ternal signs of blunt chest injur%$



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jj

Bigns on C)R* Nidened mediastinum ?- cm@K this is the mostconsistent finding

=racture of first three ribs, scapula, or sternum

Obliteration of aortic 7nob 3e+iation of trachea to right 8le+ation and rightward shift of the right mainstem

bronchus

3epression of the left mainstem bronchus 3e+iation of esophagus ?nasogastric tube@ to right Deft pleural effusion


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o single sign reliabl% confirms ore/cludes aortic injur%$ Howe+er, a

widened mediastinum is the most

consistent finding on C)R and shouldprompt further e+aluation$



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jj

Chest computed tomograph%?CT@ mediastinal hematomas are suggesti+e for

aortic injur%

Helical and new high'speed, high'resolutionscanners can pro+ide definiti+e diagnosis ofthe aortic injur%, ri+aling angiograph%withrespect to o+erall accurac%$

Mediastinal hematomas found on chestCT mandate aortogramfor definiti+ediagnosis$


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3efiniti+e diagnostic aortic injuries foundon helical scanners ma% also re0uire

aortograph%,depending on the practices

of the surgeon who will perform the repair$

mall intimal tears and dissections ma% be

missed on CT scan$



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jj

Transesophageal echocardiogram ?T88@ A positi+e T88 will confirm the location of the injur% If the T88 is negati+e, an aortogram will be re0uired

to reliabl% e/clude the injur%

T88 is an e/cellent alternati+e for unstablepatients who* Must be transported directl% to the OR for other

ca+itar% bleeding Ha+e a +er% wide mediastinum and a high suspicion

of thoracic aortic injur% e/ists 2atients in the ICU who are high ris7 for transport to

radiolog%$

Aortic injuries . treatmentAortic injuries . treatment


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jj

Control and pre+ent h%pertension maneu+ers to decrease wall tension in the

aorta preoperati+el% ma% decrease ris7 of

rupture Eeta bloc7ade ? 8smolol, Dabetolol@ should beinstituted onl% after significant hemorrhage

from other injuries has been ruled out


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The goal for s%stolic blood pressure should beappro/imatel% (!! mmHg

itroprusside can be added as a secondagent if blood pressure is not controlled with

beta bloc7ad

increased wall shear stress because pulsepressure often increases as s%stolic blood

pressure decreases

also should be a+oided in patients with headinjuries$



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jj

Most blunt injuries of the aorta re0uireimmediatesurgical repair

Btable pseudoaneur%sms that ma% be

safel% managed with dela%ed operation ifnecessar% in the presence of other life'

threatening injuries$



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j

Injuries of the ascending aorta oftenre0uire full cardiopulmonar% b%pass for

repair, and median sternotom% pro+ides

the best e/posure$ Injuries of the descendingaorta

accomplished through a left posterolateral

thoracotom%$


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Relati+el% simple injures can be repairedprimaril%$

The thoracic aorta has relati+el% limited

mobilit%, and intercostal +essels shouldnot be sacrificed to facilitate primar% repair

owing to concerns about spinal cord

perfusion$ More e/tensi+e injuries re0uire placement

of a prosthetic graft$

.ediastin lrgitRuptur de aort distal de subclaia st)ng


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!ont"#ie aortic!sudoanerism aortic cu mediastin lrgit


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,specte tomografice

3iaphragmatic injur%3iaphragmatic injur%


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Elunt trauma$ 3iaphragmatic injur% from blunt forces is classicall%

large, radial, and located posterolaterall%$

The left hemidiaphragm is in+ol+ed in 6!# to -!#

of cases$ 3iaphragmatic ruptures are mar7ers for se+ere

intraabdominal injuries$

2enetrating trauma$ Nounds are smaller but tend to enlarge o+er time$ Deft'sided injuries still predominate$


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These injuries need operati+e repair whendiagnosed because the% do not heal

spontaneousl% and can produce herniation

or strangulation of the intestine as latese0uelae


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2ossible CR) findings include*2ossible CR) findings include*


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Hemidiaphragmatic ele+ation or lower lobe atelectasis asogastric tube in left hemithora/ Btomach, colon, or small bowel in chest In penetrating trauma and small defects, the

diaphragm appears normal normal$ After e/tubation, herniation ma% become

apparent on C)R

Right hemidiaphragm tears are less li7el% to be

diagnosed b% C)R because of the presence of theli+er in the defect$

3iaphragmatic injur% ' diagnosis3iaphragmatic injur% ' diagnosis


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CT scan ma% miss diaphragmatic injur% inthe absence of gross hollow +isceral

herniation$

3iagnostic peritoneal la+age ?32D@ If an ipsilateral chest tube is present, 32D

fluid ma% be obser+ed e/iting the chest tube

direct +isuali>ation of the injur% b%laparotom%, laparoscop%, or thoracoscop%remains the gold standard for diagnosis$

3iaphragmatic injur% ' treatment3iaphragmatic injur% ' treatment


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Most diaphragmatic tears re0uire repair$ Fiscera tend to herniate as a result of

changes in intrathoracic pressure duringrespiration, with strangulation as apossible late complication$

Acute repair is accomplished +ialaparotom%, in most cases, withnonabsorbable, interrupted hori>ontalmattress sutures$


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Thoracotom% ma% be needed to reducelarge defects in chronic herniation$

2rosthetic material or flaps are often

needed to close the defect$

A coiled nasogastric tube within the left hemithoracic ca+it%A coiled nasogastric tube within the left hemithoracic ca+it%

is pathognomonic for a rupture of the left hemidiaphragm$is pathognomonic for a rupture of the left hemidiaphragm$


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p g p p gp g p p g

,ccident de motociclet 1 Ruptur diafragmatic dreapt


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,spect intraoperator


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7aceraie diafragmatic st)ng cu hernierea stomacului +n torace


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Ruptur diafragmaticdreapt cu hernierehepatic %i acolecistului


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,spect intraoperator


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#utur


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$"pt"r dia%ra%matic st&n' c" herniere a stomac"l"i i splinei,spect radiologic


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(* #tomac intratoracic & fractur costal


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,spect intraoperator dup reducerea herniei


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8anul de constricie de la nielul stomacului


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#utura diafragmului


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Ruptur frenic

"xamen radiologic digesticu substan de contrast


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7aceraie diafragmatic


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astrotorax st&n',spect radiologic


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,specte tomografice

*ernie dia%ra'matic


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+e%ect dia%ra'matic


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*ernie dia%ra'matic


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*ernie dia%ra'matic


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TH8 38A3DPTH8 38A3DP "#$%&"#$%&


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ProceduriProceduri

4loc neros intercostal

7ocul optim de in3ectare unghiul coasteicel mai u%or palpabil'


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7ocuri pentru in3ecie:; 6nghiul coastei preferat'

0; 7inia axilar posterioar

2; 7inia axilar anterioar


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"xplorare digital


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5nseria tubului


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,ncorarea tubului la tegument


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Drena3 sub niel lichidian


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*oracoscopia


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M"nc de echip -


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