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Thoracic Trauma Thoracic Trauma
Bisatyo MardjikoenBisatyo MardjikoenUniversitas Islam Negeri Syarif HidayatullahUniversitas Islam Negeri Syarif Hidayatullah
Fakultas Kedokteran & Ilmu KesehatanFakultas Kedokteran & Ilmu KesehatanProgram Studi Ilmu KedokteranProgram Studi Ilmu Kedokteran
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Chest TraumaChest Trauma
Second leading cause of trauma deaths afterSecond leading cause of trauma deaths afterhead injury head injury
About 20% of all trauma deaths About 20% of all trauma deaths
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Anatomy Anatomy
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Type of Chest I njuries Type of Chest I njuries
Penetrating Penetrating the forces are distributed over a small area
BluntBluntthe forces are distributed over a larger area
occur from compression or shearing forceoccur from compression or shearing force
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A ssessme n t A ssessme n t
Signs and symptoms of chest trauma:Shortness of breath
Tachypnea
Chest pain
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Chest TraumaChest Trauma
Initial exam directed toward:Initial exam directed toward:O pen pneumothoraxO pen pneumothorax
Flail chestFlail chest Tension pneumothorax Tension pneumothoraxMassive hemothoraxMassive hemothorax
Cardiac tamponadeCardiac tamponade
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R ib FractureR ib Fracture
Most common chest injury Most common chest injury
More common in adults than childrenMore common in adults than childrenEspecially common in elderly Especially common in elderly Ribs form ringsRibs form rings
Consider possibility of break in two placesConsider possibility of break in two places
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R ib FractureR ib Fracture
Most commonly 5th to 9th ribsMost commonly 5th to 9th ribsPoor protectionPoor protection
Associated injuries:pulmonary contusion
laceration of the intercostals artery an/or vein withresulting hemothorax & pneumothorax
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R ib FractureR ib Fracture
Fractures of 1st, 2nd ribs require high forceFractures of 1st, 2nd ribs require high forceFrequently have injury to aorta or bronchiFrequently have injury to aorta or bronchi30% will die30% will die
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R ib FractureR ib Fracture
Fractures of 8th to 12th ribs can damage underlying Fractures of 8th to 12th ribs can damage underlying abdominal solid organs:abdominal solid organs:
L iverL iverSpleenSpleenKidneysKidneys
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R ib FractureR ib Fracture
Signs and SymptomsSigns and SymptomsL ocalized pain, tendernessL ocalized pain, tenderness
Increases when patient:Increases when patient:CoughsCoughsMovesMovesBreathes deeply Breathes deeply
Chest wall instability Chest wall instability Associated pneumo or hemothorax Associated pneumo or hemothorax
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R ib FractureR ib Fracture
ManagementManagementO xygenation, if necessary O xygenation, if necessary
Encourage patient to breath deeply Encourage patient to breath deeply
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Flail ChestFlail Chest
Two or more adjacent ribs broken in two or Two or more adjacent ribs broken in two ormore placesmore places
Produces freeProduces free--floating chest wall segmentfloating chest wall segmentUsually secondary to blunt traumaUsually secondary to blunt traumaMore common in older patientsMore common in older patients
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Flail ChestFlail Chest
Signs and SymptomsSigns and SymptomsParadoxical movementParadoxical movement
May May NO TNO T be present initially due to intercostalbe present initially due to intercostalmuscle spasmsmuscle spasmsBe suspicious in any patient with chest wall:Be suspicious in any patient with chest wall:
Tenderness TendernessCrepitusCrepitus
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Flail ChestFlail Chest
ConsequencesConsequencesPain, leading to decreased ventilationPain, leading to decreased ventilation
Increased work of breathing Increased work of breathing Contusion of lung Contusion of lung
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Flail ChestFlail Chest
ManagementManagementEstablish airway Establish airway
Suspect spinal injuriesSuspect spinal injuriesO xygenationO xygenation
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S imple P neumothoraxS imple P neumothorax
Air in pleural space Air in pleural spacePartial or complete lung collapse occursPartial or complete lung collapse occurs
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S imple P neumothoraxS imple P neumothorax
CausesCausesChest wall penetrationChest wall penetration
Fractured rib lacerating lung Fractured rib lacerating lung Paper bag effectPaper bag effectMay occur spontaneously following:May occur spontaneously following:
ExertionExertionCoughing Coughing Air Travel Air Travel
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S imple P neumothoraxS imple P neumothorax
Signs and SymptomsSigns and SymptomsPain on inhalationPain on inhalation
Difficulty breathing Difficulty breathing Tachypnea TachypneaDecreased or absent breath soundsDecreased or absent breath sounds
Severity of symptoms depends on size of pneumothorax, speed of lung collapse,
and patients health status
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O pe n PneumothoraxO pe n Pneumothorax
Hole in chest wallHole in chest wall Allows air to enter pleural space Allows air to enter pleural space
L arger hole = Greater chance air will enter thereL arger hole = Greater chance air will enter therethan through tracheathan through trachea
Sucking Chest Wound
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S ucki ng Chest Wou nd : First A id
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O pe n PneumothoraxO pe n Pneumothorax
ManagementManagementClose hole with occlusive dressing Close hole with occlusive dressing
High concentration OHigh concentration O 22 Assist ventilations Assist ventilationsConsider transport on injured sideConsider transport on injured side
Monitor for tension pneumothoraxMonitor for tension pneumothorax
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Te nsio n Pneumothorax Te nsio n Pneumothorax
O neO ne--way valve forms in lung or chest wall way valve forms in lung or chest wall Air enters pleural space; cannot leave Air enters pleural space; cannot leave Air is trapped in pleural space Air is trapped in pleural spacePressure risesPressure rises
Pressure collapses lung Pressure collapses lung
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Te nsio n Pneumothorax Te nsio n Pneumothorax
Trapped air pushes heart, lungs Trapped air pushes heart, lungs away away fromfrominjured sideinjured side
Vena cavae become kinked Vena cavae become kinkedBlood cannot return to heartBlood cannot return to heartCardiac output fallsCardiac output falls
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Te nsio n Pneumothorax Te nsio n Pneumothorax
Signs and SymptomsSigns and SymptomsExtreme dyspneaExtreme dyspneaRestlessness, anxiety,Restlessness, anxiety,
agitationagitationDecreased breath soundsDecreased breath soundsHyperresonance toHyperresonance topercussionpercussion
CyanosisCyanosisSubcutaneous emphysemaSubcutaneous emphysema
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Te nsio n Pneumothorax Te nsio n Pneumothorax
Signs and SymptomsSigns and SymptomsRapid, weak pulseRapid, weak pulse
Decreased BPDecreased BP Tracheal shift Tracheal shift away away from injured sidefrom injured side Jugular vein distension Jugular vein distension
E arly dyspnea/hypoxia - Late shock
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Te nsio n Pneumothorax Te nsio n Pneumothorax
ManagementManagementSecure airway Secure airway
High concentrationO
High concentrationO
22If available, request AL S intercept for pleuralIf available, request AL S intercept for pleuraldecompressiondecompression
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H emothoraxH emothorax
Blood in pleural spaceBlood in pleural spaceMost common result of major chest wall traumaMost common result of major chest wall trauma
Present in 70 to 80% of penetrating, major nonPresent in 70 to 80% of penetrating, major non--penetrating chest traumapenetrating chest trauma
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H emothoraxH emothorax
Signs and SymptomsSigns and SymptomsRapid, weak pulseRapid, weak pulseCool, clammy skinCool, clammy skin
Restlessness, anxiety Restlessness, anxiety Thirst ThirstChillsChillsHypotensionHypotensionCollapsed neck veinsCollapsed neck veins
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H emothoraxH emothorax
Signs and SymptomsSigns and SymptomsDecreased breath soundsDecreased breath sounds
Dullness to percussionDullness to percussionDyspneaDyspnea
Ventilatory failure Ventilatory failure
Shock precedes ventilatory failure
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H emothoraxH emothorax
ManagementManagementSecure airway Secure airway
Assist breathing with high concentrationO
Assist breathing with high concentrationO
22Rapid transportRapid transport
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Traumatic A sphyxia Traumatic A sphyxia
Blunt force to chest causesBlunt force to chest causesIncreased intrathoracic pressureIncreased intrathoracic pressureBackward flow of blood out of heart into vessels of Backward flow of blood out of heart into vessels of upper chest, neck, headupper chest, neck, head
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Traumatic A sphyxia Traumatic A sphyxia
Signs and SymptomsSigns and SymptomsPossible sternal fracture or central flail chestPossible sternal fracture or central flail chest
Shock Shock PurplishPurplish--red discoloration of:red discoloration of:HeadHeadNeck Neck
ShouldersShouldersBlood shot, protruding eyesBlood shot, protruding eyesSwollen, cyanotic lipsSwollen, cyanotic lips
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Traumatic A sphyxia Traumatic A sphyxia
Name given because patients lookedName given because patients lookedlike they had been strangled or hangedlike they had been strangled or hanged
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Traumatic A sphyxia Traumatic A sphyxia
ManagementManagement Airway with C Airway with C--spine controlspine control
Assist ventilations with high concentration O Assist ventilations with high concentration O 22Spinal stabilizationSpinal stabilizationRapid transportRapid transport
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Card iovascular TraumaCard iovascular Trauma Any patient with significant blunt or Any patient with significant blunt or
penetrating trauma to chest haspenetrating trauma to chest hasheart/great vessel injury until provenheart/great vessel injury until proven
otherwiseotherwise
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M yocar d ial Con tusio nM yocar d ial Con tusio n
Bruise of heart muscleBruise of heart muscleMost common blunt cardiac injury Most common blunt cardiac injury Usually due to steering wheel impactUsually due to steering wheel impact
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M yocar d ial Con tusio nM yocar d ial Con tusio n
Behaves like acute MIBehaves like acute MIMay produce arrhythmiasMay produce arrhythmiasMay cause cardiogenic shock, hypotensionMay cause cardiogenic shock, hypotension
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M yocar d ial Con tusio nM yocar d ial Con tusio n
Signs and SymptomsSigns and SymptomsCardiac arrhythmias after blunt chest traumaCardiac arrhythmias after blunt chest trauma
Angina Angina--like pain unresponsive to nitroglycerinlike pain unresponsive to nitroglycerinChest pain independent of respiratory movementChest pain independent of respiratory movement
Suspect in all blunt chest trauma
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M yocar d ial Con tusio nM yocar d ial Con tusio n
ManagementManagementHigh concentration OHigh concentration O 22
Transport TransportConsider AL S interceptConsider AL S intercept
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Card iac Tampo nadeCard iac Tampo nade
Rapid accumulation of blood in space betweenRapid accumulation of blood in space betweenheart, pericardiumheart, pericardium
Heart compressedHeart compressedBlood entering heart decreasesBlood entering heart decreasesCardiac output fallsCardiac output falls
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Card iac Tampo nadeCard iac Tampo nade
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Card iac Tampo nadeCard iac Tampo nade
Signs and SymptomsSigns and SymptomsHypotension unresponsive to treatmentHypotension unresponsive to treatmentIncreased central venous pressure (distendedIncreased central venous pressure (distendedneck/arm veins in presence of decreased arterialneck/arm veins in presence of decreased arterialBP)BP)Small quiet heart (decreased heart sounds)Small quiet heart (decreased heart sounds)
B ecks Triad
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Card iac Tampo nadeCard iac Tampo nade
Signs and SymptomsSigns and SymptomsNarrowing pulse pressureNarrowing pulse pressurePulsus paradoxicusPulsus paradoxicus
Radial pulse becomes weak or disappears when patientRadial pulse becomes weak or disappears when patientinhalesinhales
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Card iac Tampo nadeCard iac Tampo nade
ManagementManagementSecure airway Secure airway
High concentrationO
High concentrationO
22Rapid transportRapid transportDefinitive treatment is pericardiocentesisDefinitive treatment is pericardiocentesisfollowed by surgery followed by surgery
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Traumatic A ortic Aneurysm Traumatic A ortic Aneurysm
Caused by sudden decelerations, massive bluntCaused by sudden decelerations, massive bluntforce:force:
Vehicle collisions Vehicle collisionsFalls from heightsFalls from heightsCrushing chest traumaCrushing chest traumaBlunt chest traumaBlunt chest trauma
Animal kicks Animal kicks
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Traumatic A ortic Aneurysm Traumatic A ortic Aneurysm
Rupture usually occurs just beyond leftRupture usually occurs just beyond leftsubclavian artery subclavian artery
Attachment of aorta to pulmonary artery at this Attachment of aorta to pulmonary artery at thispoint produces shearing force on aortic archpoint produces shearing force on aortic arch
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Traumatic A ortic Aneurysm Traumatic A ortic Aneurysm
Signs and SymptomsSigns and SymptomsIncreased BP in arms in absence of head injury Increased BP in arms in absence of head injury
Decreased femoral pulses with full arm pulsesDecreased femoral pulses with full arm pulsesRespiratory distressRespiratory distress
Ache in chest, shoulders, lower back, abdomen. Ache in chest, shoulders, lower back, abdomen.( O nly 25% of patients)( O nly 25% of patients)
D etection requires high index of suspicion
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Traumatic A ortic Aneurysm Traumatic A ortic Aneurysm
ManagementManagementHigh concentrationHigh concentrationoxygenoxygen
Assist ventilation Assist ventilationSuspect spinal injury Suspect spinal injury Rapid transportRapid transport
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A ssociate d A bdomi nal Trauma A ssociate d A bdomi nal Trauma
Diaphragm forms dome that extends up into ribDiaphragm forms dome that extends up into ribcagecage
Trauma to chest below 4th rib = Abdominal Trauma to chest below 4th rib = Abdominalinjury until proven otherwiseinjury until proven otherwise
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