TRAUMA THORAX

TRAUMA THORAXM. Riyan Saputra

Pembimbing dr. Asep Hermana, Sp. BINITIAL EVALUATION AND RESUSCITATION OF THE INJURED PATIENTPrimary SurveyThe first step in patient management is performing the primary survey, the goal of which is to identify and treat conditions that constitute an immediate threat to life. The ATLS course refers to the primary survey as assessment of the "ABCs" (Airway with cervical spine protection, Breathing, and Circulation).AIRWAY MANAGEMENT WITH CERVICAL SPINE PROTECTIONEnsuring a patent airway is the first priority in the primary survey.All patients with blunt trauma require cervical spine immobilization until injury is excluded Patients who have an abnormal breathing sounds, tachypnea, or altered mental status require further airway evaluation. Blood, vomit, the tongue, foreign objects, and soft tissue swelling can cause airway obstruction;Continue....In the comatose patient, the tongue may fall backward and obstruct the hypopharynx; this may be relieved by either a chin lift or jaw thrust.Establishment of a definitive airway (i.e., endotracheal intubation) is indicated in Patients with apneaImpending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling, or aspiration

BREATHING AND VENTILATIONOnce a secure airway is obtained, adequate oxygenation and ventilation must be assured. All injured patients should receive supplemental oxygen.The following conditions constitute an immediate threat to life due to inadequate ventilation : Tension pneumothorax, Open pneumothorax, andFlail chest with underlying pulmonary contusion.Tension PneumothoraxThe diagnosis of tension pneumothorax is implied by respiratory distress and hypotension in combination with any of the following physical signs in patients with chest trauma: Tracheal deviation away from the affected side, Lack of or decreased breath sounds on the affected side, and Subcutaneous emphysema on the affected side.Distended neck veins.Continue...Although immediate needle thoracostomy decompression in the second intercostal space in the midclavicular line may be indicated in the field, tube thoracostomy should be performed immediately in the ED before a chest radiograph is obtained.

Tube thoracostomy is performed in the midaxillary line at the fourth or fifth intercostal space Heavy scissors are used to cut through the intercostal muscle into the pleural space.The incision is digitally explored to confirm intrathoracic location and identify pleural adhesions. A 36F chest tube is directed superiorly and posteriorly with the aid of a large clamp.Open PneumothoraxAn open pneumothorax or "sucking chest wound" occurs with full-thickness loss of the chest wall, permitting free communication between the pleural space and the atmosphere.Complete occlusion of the chest wall defect without a tube thoracostomy may convert an open pneumothorax to a tension pneumothorax.Continue....Temporary management of this injury with an occlusive dressing that is taped on three sides. This acts as a flutter valve, permitting effective ventilation on inspiration while allowing accumulated air to escape from the pleural space on the untaped side, so that a tension pneumothorax is prevented.

Full-thickness loss of the chest wall results in an open pneumothorax. The defect is temporarily managed with an occlusive dressing that is taped on three sides,which allows accumulated air to escape from the pleural space and thus prevents a tension pneumothorax. Repair of the chest wall defect and tube thoracostomy remotefrom the wound is definitive treatment.

Temporary management of open pneumothorax ( Three sided dressing)Flail ChestFlail chest is a clinical anatomic diagnosis noted in blunt trauma patients with paradoxical or reverse motion of a chest wall segment while spontaneously breathing.Flail chest is one of the worst subset of injury and is likely the most common serious injury to the thorax seen by clinician.

Flail ChestTreatment & Management in http://emedicine.medscape.com/article/433779-treatmentContinue....In a mid-1970s report, Trinkle et al, provided compelling evidence that many patients fared better with adequate pain control, this remains the standard todayFlail ChestTreatment & Management in http://emedicine.medscape.com/article/433779-treatment

Flail Chest (Paradoxical Movement)

Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result.CIRCULATION WITH HEMORRHAGE CONTROLAn initial approximation of the patient's cardiovascular status can be obtained by palpating peripheral pulses.Systolic blood pressure (SBP) must be60 mmHg for the carotid pulse to be palpable, 70 mmHg for the femoral pulse, and 80 mmHg for the radial pulse.

Continue...At this point in the patient's evaluation, any episode of hypotension (defined as a SBP 1500 mL of blood in the pleural space.After blunt trauma, a hemothorax usually is due to multiple rib fractures with severed intercostal arteries, but occasionally bleeding is from lacerated lung parenchyma.A massive hemothorax is an indication for operative intervention, but tube thoracostomy is critical to facilitate lung re-expansion.

More than 1500 mL of blood in the pleural space is a massive hemothorax. In the upright position, blood is visible dependently in the pleural space.Cardiac Tamponade