THORACIC TRAUMA 1 THORACIC TRAUMA 1 OUT

THORACIC TRAUMA 1

THORACIC TRAUMA 1 OUT OF 4 DEATHS 2

THORACIC INJURIES • BLUNT: < 10% REQUIRE OPERATION • PENETRATING: 15 -30% REQUIRE OPERATION • MAJORITY: SIMPLE PROCEDURES 3

PATHOPHISIOLOGY • HYPOXIA: PO 2 DECREASE • HYPERCARBIA: PCO 2 INCRESE • ACIDOSIS 4

LIFE-THREATENING CHEST TRAUMA • • • AIRWAY OBSTRUCTION TENSION PNEUMOTHORAX OPEN PNEUMOTHORAX MASSIVE HEMOTHORAX FLAIL CHEST CARDIAC TAMPONADE 5

TENSION PNEUMOTHORAX • AIR ENTERS PLEURAL SPACE - NO EXIT. • COLLAPSE OF AFFECTED LUNG • IMPAIRED VENOUS RETURN • IMPAIRED VENTILATION OF OPPOSITE LUNG 6

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TENSION PNEUMOTHORAX ETIOLOGY • POSITIVE PRESSURE VENTILATION (MOST COMMON) • PARENCHYMAL AND / OR CHESTWALL INJURIES 8

TRNSION PNEUMOTHORAX • TRACHEAL DEVIATION • RESPIRATORY DISTRESS • UNILATERAL ABSENCE OF BREATH SOUNDS • DISTENDED NECK VEINS • CYANOSIS - LATE 9

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TENSION PNEUMOTHORAX TREATMENT • IMMEDIATE DECOMPRESSION • CLINICAL DIAGNOSIS NOT RADIOLOGIC 11

OPEN PNEUMOTHORAX MANAGEMENT • COVER DEFECT IMMEDIATELY • CHEST TUBE • DEFINITIVE OPERATION 12

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MASSIVE HEMOTHORAX • > 1500 ml BLOOD LOSE • SYSTEMIC / PULMONARY VESSEL DISTENTION • FLAT vs DISTENDED NECK VEINS • SHOCK WITH NO BREATH SOUND AND/OR PERCUSSION DULNESS 14

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MASSIVE HEMOTHORAX • RAPID VOLUME RESTORE • CHEST DECOMPRESSION AND ROENTGENOGRAM • AUTO-TRANSFUSSION • OPERATIVE INTERVENTION 17

FLAIL CHEST / PULMONARY CONTUSION TREATMENT 18

FLAIL CHEST / PULMONARY CONTUSION TREATMENT • • • RE-EXPEND LUNG OXYGEN JUDICIOUS FLUID MANAGEMENT INTUBATION AS IDICATED ANALGESIA 19

FLAIL CHEST / PULMONARY CONTUSION TREATMENT 20

CARDIAC TAMPONADE 21

CARDIAC TAMPONADE • • • ARTERIAL PESSURE DECREASE NARROWED PULSE PRESSURE DISTENDED NECK VEINS MUFFLED HEART SOUNDS C. V. P INCREASED 22

CARDIAC TAMPONADE TREATMENT • • PATENT AIRWAY I. V THERAPY PERICARDIOCENTESIS PERICARDIOTOMY 23

CARDIAC TAMPONADE TREATMENT • PERICARDIOCENTESIS 24

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SECONDARY SURVEY • • IN-DEPTH PHYSICAL EXAM UPRIGHT CHEST FILM ABGs ECG 26

POTENTIALLY LETHAL CHEST TRAUMA • • PULMONARY CONTUSION MYOCARDIAL CONTUSION AORTIC DISRUPTION TRAUMATIC DIAPHRAGMATIC RUPTURE • TRACHEOBRONCHIAL DISRUPTION • ESOPHAGEAL DISRUPTION 27

PULMONARY CONTUSION • MOST COMMON • SELECTIVE INTUBATION • VENTILATE • MAINTAIN ADEQUATE VENTILATE 28

Pulmonary Contusion 29

MYOCARDIAL CONTUSION • • • BLUNT TRAUMA HISTORY ECG CHANGES 2 -D ECHO TRAET COMPLICATION 30

TRAUMATIC AORTIC RUPTURE • MOST COMMON CAUSE OF SUDDEN DEATH • AUTO CRASH • FALL FROM GREAT HEIGHT • SALVAGE POSSIBLE IF IDENTIFIED EARLY • COMMON SITE: LIGAMENTUM ARTERIOSUM 31

TRAUMATIC AORTIC RUPTURE 32

WIDENEND MEDIASTINUM ON ROENTGENOGRAM 33

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TRAUMATIC AORTIC RUPTURE TREATMENT • DIRECT REPAIR • RESECTION AND GRAFTING • TREATMENT BY QUALIFIED SURGEON 35

TRAUMATIC DIAPHRAGMATIC RUPTURE • DIAGNOSED ON LEFT SIDE • BLUNT => LARGE TEARS • PENETRATING => SMALL PERFORATIONS • MISINTERPRETED ROENTGENOGRAMS • CONTRAST RADIOGRAPHY • TREATMENT: OPERATION 36

TRACHEOBRONCHIAL INJURIES: LARYNX • RARE OCCURANCE • HOARSENESS, SUBCUTANEOUS EMPHYSEMA, PALPABLE FRACTURE • TREATMENT: ITUBATION • TRACHEOSTOMY 37

TRACHEOBRONCHIAL INJURIES: TRACHEA • PARTIAL vs COMPLETE OBSTRUCTION • ENDOSCOPY: DIAGNOSTIC AID • TREATMENT: OPERATION 38

TRACHEOBRONCHIAL INJURIES: BRONCHUS • • FREQUENTLY MISSED BLUNT TRAUMA ENDOSCOPY: DIAGNOSTIC AID TREATMENT: AIRWAY MAINTAINANCE • OPERATION 39

ESOPHAGEAL TRAUMA • CHEST TUBE-PARTICULATE MATTER • MEDIASTINAL AIR • CONTRAST SWALLOW / ESOPHAGOSCOPY • TREATMENT: OPERATION 40

ESOPHAGEAL TRAUMA • • BLUNT vs PENETRATING SEVER EPIGASTRIC BLOW SHOCK / PAIN > INJURY PNEUMOTHORAX WITHOUT FRACTURE 41

SUBCUTANEOUS EMPHYSEMA • AIRWAY INJURY • PNEUMOTHORAX • BLAST INJURY 42

SIMPLE PNEUMOTHORAX • • • BLUNT vs PENETRATING TRAUMA VENTILATION/PERFUSSION DEFECT HYPER-RESONANCE DECREASED BREATH SOUNDS TREATMENT: TUBE-THORACOTOMY 43

PNEUMOTHORAX • ETIOLOGY • LUNG/VESSEL LACERATION • TREATMENT: TUBE-THORACOTOMY 44

RIB FRACTURES • • PAIN/SPLINTING IMPAIRED VENTILATION INCREASED SECRETIONS ATHELECTASIS/PNEUMONIA 45

SCAPULAR AND RIB FRACTURES • SCAPULA AND RIBS 1 -3 • SEVERE FORCE • ASSOCIATED INJURIES HIGH MORTALITY RISK 46

RIB FRACTURES • RIBS 4 -9 • MAJORITY BLUNT TRAUMA • MIDSHAFT FRACTURE • INTRATHORACIC INJURY • RIBS 10 -12 • SUSPECT ABDOMINAL INJURY 47

RIB FRACTURES • CHEST FILM: EXCLUDE INTRATHORACIC INJURY • NO CONSTRICTIVE DEVICE • ADEQUATE PAIN RELIEF 48

OTHER INDICATION FOR TUBE THORACOSTOMY • • SUSPECTED SEVERE LUNG INJURY AIR OR GROUND TRANSFER GENERAL AESTHESIA POSITIVE PRESSURE VENTILATION 49

QUESTIONS ? ? ? 50