33 - Chest Trauma

8/17/2019 33 - Chest Trauma

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KETENTUAN DALAMKETENTUAN DALAM

MENGIKUTI PERKULIAHANMENGIKUTI PERKULIAHAN

• SEBAIKNYA DATANG TEPAT WAKTUSEBAIKNYA DATANG TEPAT WAKTU• BERPAKAIAN SOPAN DAN RAPI SEBAIKNYABERPAKAIAN SOPAN DAN RAPI SEBAIKNYA

BUKAN BAJU KAOSBUKAN BAJU KAOS

• TIDAK DIPERKENANKAN MEMAKAI SENDALTIDAK DIPERKENANKAN MEMAKAI SENDAL APAPUN JENISNYA, HARUS PAKAI SEPATU APAPUN JENISNYA, HARUS PAKAI SEPATU

• MENGIKUTI KULIAH DENGAN SEBAIK2NYA,MENGIKUTI KULIAH DENGAN SEBAIK2NYA,KARENA KULIAH DIUSAHAKAN SISTIMKARENA KULIAH DIUSAHAKAN SISTIM

INTERAKTIFINTERAKTIF• MAHASISWA YG TERLAMBAT SEBAIKNYAMAHASISWA YG TERLAMBAT SEBAIKNYA

TDK USAH MASUK RUANGANTDK USAH MASUK RUANGAN

• SEMUA HP DALAM POSISI “OFF”SEMUA HP DALAM POSISI “OFF”


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Chest TraumaChest Traumatrauma torakstrauma toraks

Dr.Muhammad Nuralim Mallapasi.MDDr.Muhammad Nuralim Mallapasi.MD

BAGIAN BEDAH TORAKS KARDIOASK!"ARBAGIAN BEDAH TORAKS KARDIOASK!"AR

#AK KEDOKTERAN !NHAS#AK KEDOKTERAN !NHAS

RS DR.$AHIDIN S!DIROH!SODORS DR.$AHIDIN S!DIROH!SODO

MAKASSAR.MAKASSAR.


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SilentSilent

epidemicepidemic


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Complex disaster Kerusuhan


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Mass-casualties small scaleMass-casualties small scale

disasterdisaster

Kecelakaan kereta apiMan-made disasterMan-made disaster


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IntroductionIntroduction

• Blunt trauma to the chest can afect anyBlunt trauma to the chest can afect anyone or all components o the chest wallone or all components o the chest wall

and thoracic cavityand thoracic cavity• These include : These include : !i"s!i"s - clavicles- clavicles

ScapulaeScapulae - sternum- sternum

lun#s and pleuraelun#s and pleurae - tracheo"ronchial three- tracheo"ronchial three

esopha#usesopha#us - heart- heart

#reat vessels#reat vessels


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A%atomi di%di%& ToraksA%atomi di%di%& Toraks


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Dasar ToraksDasar Toraks


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Ro%&&a ToraksRo%&&a Toraks


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$re%uency$re%uency

• &' people per million population per day&' people per million population per day• (() re%uires hospital admission(() re%uires hospital admission• *irectly responsi"le or '+-',) o death attri"uted*irectly responsi"le or '+-',) o death attri"uted

to traumato trauma

tiolo#ytiolo#y

• Motor.ehicle/ccidents0M./1Motor.ehicle/ccidents0M./1

2+-3+) o these2+-3+) o thesetraumatrauma

• $alls and violence$alls and violence• Blast in4uryBlast in4ury


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5athophysiolo#y5athophysiolo#y

• *eran#ements in the 6ow o air7 "lood7 or*eran#ements in the 6ow o air7 "lood7 or"oth in com"ination"oth in com"ination

• 8hest wall in4ures8hest wall in4ures ri" racturesri" ractures• *irect lun# in4ures*irect lun# in4ures lun# contusionslun# contusions• Space-occupyin# lessionsSpace-occupyin# lessions

pneumomothoraces7 hemothoraces7pneumomothoraces7 hemothoraces7hemopneuomothoraceshemopneuomothoraces

• 8ardiac in4ures8ardiac in4ures cham"er rupturecham"er rupture• Severe #reat vessels in4uresSevere #reat vessels in4ures thoracicthoracic

aortic disruptionaortic disruption


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!/5I*9 9T;/9 9SI


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NON IMMEDIATELY LIFENON IMMEDIATELY LIFE

T!EATENIN" LE#ION#T!EATENIN" LE#ION#

• a. haemothora'a. haemothora'• (.simple p%eumothora'(.simple p%eumothora'

• ).ri( *ra)tures).ri( *ra)tures• d.ster%al *ra)turesd.ster%al *ra)tures• e.so*t tissue lesio%se.so*t tissue lesio%s• *.traumati) )h+lothora'*.traumati) )h+lothora'

• &.i%trathora)i) *orei&% (odies&.i%trathora)i) *orei&% (odies• h.su()uta%eous emph+semah.su()uta%eous emph+sema• i.others.i.others.


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, Keadaa% Trauma Toraks, Keadaa% Trauma Toraks

-. %eumotoraks /simple0ope%0-. %eumotoraks /simple0ope%0

te%sio%1te%sio%1

2. Hemotoraks2. Hemotoraks

3. Ko%tusio aru3. Ko%tusio aru

4. Trauma )a( tra)heo(ro%)hial4. Trauma )a( tra)heo(ro%)hial

5. Trauma Tumpul 6a%tu%&5. Trauma Tumpul 6a%tu%&

7. Trauma aorta7. Trauma aorta8. Trauma dia*ra&ma8. Trauma dia*ra&ma

,. Trauma mediasti%um,. Trauma mediasti%um


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8linical 5resentation8linical 5resentation

• .aries widely rom minor report to 6orish shock.aries widely rom minor report to 6orish shock

• 8linical history8linical history time o in4ury7 mechanism7time o in4ury7 mechanism7velocity>deceleration7 assosiated in4ury7 silentvelocity>deceleration7 assosiated in4ury7 silent

utureuture

• ( "road cate#ories : 0&1 chest wall racture7( "road cate#ories : 0&1 chest wall racture7dislocation7 and "arotrauma 0includin#dislocation7 and "arotrauma 0includin#

diaphra#matic in4ury1? 0'1 "lunt in4uries o thediaphra#matic in4ury1? 0'1 "lunt in4uries o the

plaurae7lun#s7 and aerodi#estive tracts? andplaurae7lun#s7 and aerodi#estive tracts? and

0(1 "lunt in4uries o the heart7 #reat vessels0(1 "lunt in4uries o the heart7 #reat vessels


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*ia#nostic tests and procedures*ia#nostic tests and procedures

• Twelve-lead electrocardio#ram Twelve-lead electrocardio#ram may ound tachyarrhytmias andmay ound tachyarrhytmias and

conduction distur"ancesconduction distur"ances• $le@i"le or ri#id esopha#oscopy$le@i"le or ri#id esopha#oscopy the initial dia#nostic procedure orthe initial dia#nostic procedure oresopha#ela in4uryesopha#ela in4ury

• $i"eroptic or ri#id "ronchoscopy$i"eroptic or ri#id "ronchoscopy tracheo"ronchial in4urestracheo"ronchial in4ures


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IndicationsIndications

• Most oten treated with supportive measures andMost oten treated with supportive measures andsimple interventional proceduressimple interventional procedures chest tu"echest tu"e

8hest wall ractures7 dislocations7 and "arotrauma8hest wall ractures7 dislocations7 and "arotrauma0includin# diaphra#matic in4ures10includin# diaphra#matic in4ures1 indications orindications or

immediate sur#eryimmediate sur#ery ::0&10&1 loss o chest wall inte#rationloss o chest wall inte#ration0'10'1 0'1"lunt diaphra#matic in4uresA0'1"lunt diaphra#matic in4uresA

!elative immediate and lon#-term indication!elative immediate and lon#-term indication ::0&10&1 delayed reco#nation o diaphra#matic in4ury anddelayed reco#nation o diaphra#matic in4ury and0'10'1 the development o a traumatic diaphra#maticthe development o a traumatic diaphra#matic

herniaAherniaA


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Blunt in4uries o the pleurae7 lun#s7 andBlunt in4uries o the pleurae7 lun#s7 and

aerodi#estive tractsaerodi#estive tracts

• Immediate sur#eryImmediate sur#ery

::

• 0&1 massive air leak or hi#h rate "lood loss0&1 massive air leak or hi#h rate "lood lossrom chest tu"e 0&,++m9 or '++-(++ m9h1?rom chest tu"e 0&,++m9 or '++-(++ m9h1?

• 0'1 radio#raphically or endoscopically0'1 radio#raphically or endoscopically

tracheal7 ma4or "ronchial7 or esopha#ealtracheal7 ma4or "ronchial7 or esopha#ealin4ury?in4ury?

• 0(1 recovery o #astrointestinal contents0(1 recovery o #astrointestinal contents


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• !elative immediate and lon# term sur#ery!elative immediate and lon# term sur#ery :: • 0&1 chronic clotted hemoC"rothora@7 especially0&1 chronic clotted hemoC"rothora@7 especially

when associated with a trapped orwhen associated with a trapped or

none@pandin# lun#?none@pandin# lun#?• 0'1 empyema?0'1 empyema?• 0(1 lun# a"scess?0(1 lun# a"scess?• 0D1 delayed reco#nations o tracheo"ronchial0D1 delayed reco#nations o tracheo"ronchial

or esopha#eal in4uries?or esopha#eal in4uries?• 0,1 tracheoesopha#eal Catula? and0,1 tracheoesopha#eal Catula? and• 0E1 persistent thoracic duct Cstulachylothora@0E1 persistent thoracic duct Cstulachylothora@


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Blunt in4uries o the heart7 #reat arteries7Blunt in4uries o the heart7 #reat arteries7veins7 and lymphaticsveins7 and lymphatics

• immediate sur#ery :immediate sur#ery :

• 0&1 cardiac tamponade?0&1 cardiac tamponade?• 0'1 radio#raphic conCrmation o vessel0'1 radio#raphic conCrmation o vessel

in4ury? 0(1 an em"olism or missile into thein4ury? 0(1 an em"olism or missile into thepulmonary artery or heartpulmonary artery or heart

• !elative immediate and lon#-term!elative immediate and lon#-termindication :indication : late reco#nation o the in4urylate reco#nation o the in4ury0development o traumatic pseudoaneurysm10development o traumatic pseudoaneurysm1


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Treatment : $lail 8hest Treatment : $lail 8hest

• ndotreacheal intu"ation andndotreacheal intu"ation andpositive pressure mechanicalpositive pressure mechanical

ventilationventilation• Sta"iliFe chest wallSta"iliFe chest wall internalinternal

C@ationC@ation


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8lavicular racture8lavicular racture

• Tenderness and tenderness over the site Tenderness and tenderness over the site

• 5ro@imal se#ment displaced superiorly5ro@imal se#ment displaced superiorly

action sternocleidomastoideusaction sternocleidomastoideus• Mostly can "e mana#ed without sur#eryMostly can "e mana#ed without sur#ery

• Immo"iliFationImmo"iliFation C#ure ei#ht7 clavicleC#ure ei#ht7 claviclestrap7 slin#Astrap7 slin#A

•


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Sternal $ractureSternal $racture

• Inspiratory pain7 local tenderness7 swellin#7Inspiratory pain7 local tenderness7 swellin#7ecchiymosis7 crepitusecchiymosis7 crepitus

• /ssociated in4uries : ri" ractures7 lon# "one/ssociated in4uries : ri" ractures7 lon# "one

racture7 close head in4uryracture7 close head in4ury• Blunt cardiac in4uryBlunt cardiac in4ury '+)'+)• =o therapy speciCcally=o therapy speciCcally anal#esia and minimiFeanal#esia and minimiFe

activities o pectoral and shoulder muscleactivities o pectoral and shoulder muscle

• Most importantMost important e@clude "lunt myocardial in4urye@clude "lunt myocardial in4ury• C@ation C@ation "adly displaced"adly displaced wire suturin# and placement o plates and screwwire suturin# and placement o plates and screw


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Scapular ractureScapular racture

• HncommonHncommon

• /ssociated in4ury : head7 chest7/ssociated in4ury : head7 chest7

a"domena"domen• @clude ma4or vascular in4ury@clude ma4or vascular in4ury

• Shoulder immo"iliFationShoulder immo"iliFation slin# orslin# or

shoulder harnessshoulder harness• arly !


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Blunt diaphra#matic in4uriesBlunt diaphra#matic in4uries

• Mostly let sideMostly let side

• Must consideredMust considered a"dominal in4urya"dominal in4ury

with dyspnea and respiratory distresswith dyspnea and respiratory distress• ;ypovolemic shock;ypovolemic shock ma4or splenicma4or splenic

or hepatic in4uryor hepatic in4ury

• /pproached laparotomy/pproached laparotomy suturesuturewith polypropylene or dacronwith polypropylene or dacron


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5neumothora@5neumothora@

• !i" racture or "arotrauma!i" racture or "arotrauma

• *yspnea7 decreased "reath sound*yspnea7 decreased "reath soundand hyperresonance to percussionand hyperresonance to percussion

• 8hest tu"e suction sistem -'+8hest tu"e suction sistem -'+cm;'< 0pleur-evac1cm;'< 0pleur-evac1 JS*JS* i thei the

lun# remains ully e@pandedlun# remains ully e@panded chestchest

tu"e removetu"e remove 8!8!


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;emothora@;emothora@

• /ccumulation o "lood within the/ccumulation o "lood within thepleural spacepleural space

• 9acerations internal mammary9acerations internal mammaryvessels or other ma4or thoracicvessels or other ma4or thoracic

vesselsvessels

• 8hest tu"e7 massive 0&,++m9 or '++-8hest tu"e7 massive 0&,++m9 or '++-(++ m9h1(++ m9h1 thorachotomythorachotomy


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5ulmonary contusion and other5ulmonary contusion and other

parenchymal in4uresparenchymal in4ures

• Transmition o orce to the lun# parenchym Transmition o orce to the lun# parenchym lun# contusion with hemorra#e into the lun#lun# contusion with hemorra#e into the lun#

tissuetissue

• 8linical Cndin#8linical Cndin# depent to the e@tent o thedepent to the e@tent o thein4uryin4ury

• 5ain control7 pulmonary toilet7 sumplemental5ain control7 pulmonary toilet7 sumplemental

o@y#en 0intu"ation with mecanicalo@y#en 0intu"ation with mecanicalventilation1ventilation1

• Sur#ical haemostatisSur#ical haemostatis laceration or avulsionlaceration or avulsion


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Blunt tracheal in4uryBlunt tracheal in4ury• $racture7 lacerations7 and disruptions$racture7 lacerations7 and disruptions• !espiratory distress7 cannot speak7 stridor7!espiratory distress7 cannot speak7 stridor7

other si#n associated w pneumothora@ nother si#n associated w pneumothora@ nsu"cutaneous emphysemasu"cutaneous emphysema

• Many die "eore can reach deenitive careMany die "eore can reach deenitive care

lie trheatenin#lie trheatenin#

re%uire immediate sur#icalre%uire immediate sur#icalrepair to esta"lishment o an ade%uate airwayrepair to esta"lishment o an ade%uate airway

• ndotracheal intu"ationndotracheal intu"ation 6e@i"le6e@i"le"ronchoscope"ronchoscope tu"e placed distal site o in4urytu"e placed distal site o in4ury

• /lways prepared to perorm emer#ency/lways prepared to perorm emer#encytrecheotomytrecheotomy

• Sur#ical repairSur#ical repair restoration o airwayrestoration o airwaycontinuity w primary end-to-end anstomosiscontinuity w primary end-to-end anstomosis


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Blunt esopha#eal in4uriesBlunt esopha#eal in4uries

• !are "ecause protected location in!are "ecause protected location inposterior mediastinumposterior mediastinum

• 8aused "y a sudden increase8aused "y a sudden increaseintraluminal pressure rom a orceulintraluminal pressure rom a orceul"low to the epi#astrium"low to the epi#astrium

• Spilla#e LI contents into the chestSpilla#e LI contents into the chest• Hpper a"do > thoracic pain ass wHpper a"do > thoracic pain ass w

thypnea7 tachycardia7 su"cutaneusthypnea7 tachycardia7 su"cutaneusemphysemaAemphysemaA


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Treatment : Blunt esopha#eal Treatment : Blunt esopha#eal

in4uriesin4uries

• $luid resuscitation n "road-spectrum iv$luid resuscitation n "road-spectrum ivanti"iotic n anaero" /Banti"iotic n anaero" /B

• Sur#erySur#ery de"ridemant w primary anatomosisde"ridemant w primary anatomosis well-vasculariFed autolo#ous tissue 0parietalwell-vasculariFed autolo#ous tissue 0parietalpleura n intercostal muscle1pleura n intercostal muscle1 Thal PatchThal Patch

• 5oor #eneral condition5oor #eneral condition esopha#eal diversionesopha#eal diversion0a cervical esopha#ostomy17 the distal0a cervical esopha#ostomy17 the distal

esopha#us stapled7 #astrostomy oresopha#us stapled7 #astrostomy ordecompression7 and wide mediatinal draina#edecompression7 and wide mediatinal draina#ew chest tu"eAw chest tu"eA


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Blunt cardial in4uriesBlunt cardial in4uries

• 8ause "y : M./ 0most common17 alls78ause "y : M./ 0most common17 alls7crush in4uries7 violent7 sport in4ury7 ectcrush in4uries7 violent7 sport in4ury7 ect

• !an#e varies rom mild trauma ass w!an#e varies rom mild trauma ass warrythmias to severe rupture valve7arrythmias to severe rupture valve7septum or myocardialseptum or myocardial

• 8linical varies rom chest pain to8linical varies rom chest pain to

cardiac tamponade to completecardiac tamponade to completecardivascular collapscardivascular collaps

• Treatment Treatment cardiosintesis tocardiosintesis tocardiorrhapy w cardiopulmonar "y passcardiorrhapy w cardiopulmonar "y pass


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Blunt in4uries o the thoracicBlunt in4uries o the thoracic

aorta and ma4or thoracicaorta and ma4or thoracic

arteriesarteries• Mechanism in4ury: rapid decelerationMechanism in4ury: rapid deceleration sharin# orce7 direct compressionsharin# orce7 direct compression

• Many die "eore reachin# deenitiveMany die "eore reachin# deenitivecarecare

• Treatment: endovascular stent #rats7 Treatment: endovascular stent #rats7

arteriorraphy w cardiopulmonary "yarteriorraphy w cardiopulmonary "ypasspass


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Blunt in4ury o the superiorBlunt in4ury o the superior

vena cava and ma4or thoracicvena cava and ma4or thoracic

veinsveins• !are7 usually ass w in4uries other!are7 usually ass w in4uries other

ma4or thoracic vascular structuresma4or thoracic vascular structures

• Treatment : venorrhaphy w Treatment : venorrhaphy wcardiopulmonary "y passcardiopulmonary "y pass

• In4ured su"clavian or aFi#ous veins iIn4ured su"clavian or aFi#ous veins i

dicult to repair can "e li#ateddicult to repair can "e li#ated


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Leneral preoperative detailsLeneral preoperative details

• /B8s esta"lishment/B8s esta"lishment

•


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Leneral intraoperativeLeneral intraoperative

detailsdetails

• /B8s esta"lishment7 hemodinamic/B8s esta"lishment7 hemodinamicmonitorin#7 consider sin#le-lun# ventilationmonitorin#7 consider sin#le-lun# ventilationtechni%uestechni%ues

• 8onsider 8ardiopulmonary "ypass7 patient8onsider 8ardiopulmonary "ypass7 patientpositionin# and choice o incisionpositionin# and choice o incision• Median sternotomyMedian sternotomy access the heart7access the heart7

intracardial portion o pulmonary vessels7intracardial portion o pulmonary vessels7ascendin# aorta and aortic arch7 venaeascendin# aorta and aortic arch7 venaecavae7 and the innominate arterycavae7 and the innominate artery

• @tended median sternotomy@tended median sternotomy su"claviansu"clavianartery7 "ranches o innominate arteryartery7 "ranches o innominate artery


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Leneral intraoperativeLeneral intraoperative

detailsdetails

• 5osterolateral let thoracotomy in the ourth5osterolateral let thoracotomy in the ourthintercostal spaceintercostal space approach theapproach thedescendin# thoracic aortadescendin# thoracic aorta

• 5ro@imal o su"clavian artery5ro@imal o su"clavian artery anterolateralanterolaterallet thoracotomy in the third intercostallet thoracotomy in the third intercostalsapce? distalsapce? distal supraclavicular incisionsupraclavicular incision

• *istal esopha#us*istal esopha#us let posterolaterallet posterolateralthoracotomy? more pro@imal re%uire a ri#htthoracotomy? more pro@imal re%uire a ri#ht

thoracotomythoracotomy• 9un# or peripheal pulmonary vessels9un# or peripheal pulmonary vessels

posterolateral thoracotomyposterolateral thoracotomy


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Leneral postoperativeLeneral postoperative

detailsdetails

• /B8s care/B8s care• 5ain control5ain control to acilitates "reathin# toto acilitates "reathin# to

prevent pulmonary complication such asprevent pulmonary complication such asatelectasis and pneumoniaatelectasis and pneumonia

• 8hest physiotherapy7 ne"uliFer7 n8hest physiotherapy7 ne"uliFer7 nincentive spirometer encoura#ementincentive spirometer encoura#ement

• 8hest tu"e suction8hest tu"e suction

i the lun# alreadyi the lun# alreadye@panded n no evidence o air leake@panded n no evidence o air leak cha#e to the water sealcha#e to the water seal 8!8!


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JorkupJorkup

• 8B88B8 routine la"oratory testroutine la"oratory test• /BL/BL or o"4ective measure o ventilation7or o"4ective measure o ventilation7

o@y#enation7 and acid-"ase statuso@y#enation7 and acid-"ase status

therapuetics decisionstherapuetics decisions• lectrolyte statuslectrolyte status• 8oa#ulation proCle8oa#ulation proCle• Serum troponin levelsSerum troponin levels cardiac in4urescardiac in4ures• 8reatine kinase-MB levels8reatine kinase-MB levels myocardial in4uresmyocardial in4ures• Serum lactate levelsSerum lactate levels measure tissuemeasure tissue

perusionperusion

• Blood typ and crossmatchBlood typ and crossmatch


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Ima#in# studiesIma#in# studies

• 8!8! should not wait 8! or dia#noseshould not wait 8! or dia#noseemer#ency measurementemer#ency measurement

• 8hest 8T-scan8hest 8T-scan should restricted toshould restricted toundetected or occult in4ury is consideredundetected or occult in4ury is considered

• /orto#ram/orto#ram standard or dia#nosis ostandard or dia#nosis o"lunt aortic in4ures"lunt aortic in4ures

• Thoracic HS Thoracic HS pericardial efusions orpericardial efusions or

tamponadetamponade• 8ontrast sopha#o#ram8ontrast sopha#o#ram or esopha#ealor esopha#eal

in4uresin4ures


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8omplication8omplication

JoundJound Inection and dehiscenceInection and dehiscence

8ardiac8ardiac Myocardial inarctionMyocardial inarction

/rrhytmias/rrhytmias

.entricular aneurysm ormation.entricular aneurysm ormation

Septal deectsSeptal deects

.alvular insuciency.alvular insuciency


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• 5ulmonary and5ulmonary andBronchialBronchial

/telectasis/telectasis

5neumonia5neumonia

5ulmonary a"scess5ulmonary a"scess

8lotted hemothora@8lotted hemothora@

$i"rothora@$i"rothora@ Bronchial repairBronchial repair

disruptiondisruption

• .ascular.ascular Lrat inectionLrat inection

5seudoaneurysm5seudoaneurysm

Lrat throm"osisLrat throm"osis

*eep venous*eep venous

throm"osisthrom"osis

5ulmonary5ulmonaryem"olismem"olism


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• =eurolo#ical=eurolo#ical 8ausal#ia in4uries8ausal#ia in4uries

that involve thethat involve the

"rachial ple@us"rachial ple@us

5araple#ia spinal5araple#ia spinal

cord at risk durin#cord at risk durin#

repair o rupturedrepair o ruptured

thoracic aortathoracic aorta StrokeStroke

• sopha#ealsopha#eal 9eaka#e o repair9eaka#e o repair

MediastinitisMediastinitis

sopha#eal Cstulasopha#eal Cstula

sopha#ealsopha#eal

stricture - latestricture - late


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??


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TI5S' KS5!TIS $


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•*: *IS/BI9IT*: *IS/BI9IT

*I/$!L/M/*I/$!L/M/•9./SI9./SI

•*IS!H5TI


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• E9E:OS!REE9E:OS!RE BON; THORA:9BON; THORA:9

C"AIC!"AC"AIC!"ASCA!"ASCA!"A

COSTACOSTA

STERN!MSTERN!M

#9 SO#T TISS!E#9 SO#T TISS!E

G9 T!BES DAN "INESG9 T!BES DAN "INES


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33 - Chest Trauma