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1
Thoracic TraumaThoracic Trauma
Bisatyo MardjikoenBisatyo MardjikoenUniversitas Islam Negeri Syarif Universitas Islam Negeri Syarif
HidayatullahHidayatullahFakultas Kedokteran & Ilmu Fakultas Kedokteran & Ilmu
KesehatanKesehatanProgram Studi Ilmu KedokteranProgram Studi Ilmu Kedokteran
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Chest TraumaChest Trauma
Second leading cause of trauma Second leading cause of trauma deaths after head injurydeaths after head injury
About 20% of all trauma deathsAbout 20% of all trauma deaths
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AnatomyAnatomy
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Type of Chest InjuriesType of Chest Injuries
PenetratingPenetrating the forces are distributed over a small
area
Blunt Blunt the forces are distributed over a larger
area occur from compression or shearing occur from compression or shearing
forceforce
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Assessment Assessment
Signs and symptoms of chest trauma: Shortness of breath
Tachypnea
Chest pain
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Chest Injuries: Physical Examination
LOOK : bruises, lacerations, distended neck veins,tracheal deviation, open chest wounds, lack of symmetrical chest rise, paradoxical chest movement, cyanosis.
FEEL : tenderness, bony crepitus, subcutaneous emphysema and an unstable chest wall segment
LISTEN : presence or absence of breath sounds, and bilateral symmetry of air movement
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Chest TraumaChest Trauma
Initial exam directed toward:Initial exam directed toward: Open pneumothoraxOpen pneumothorax Flail chestFlail chest Tension pneumothoraxTension pneumothorax Massive hemothoraxMassive hemothorax Cardiac tamponadeCardiac tamponade
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Rib FractureRib Fracture
Most common chest injuryMost common chest injury More common in adults than More common in adults than
childrenchildren Especially common in elderlyEspecially common in elderly Ribs form ringsRibs form rings
Consider possibility of break in two Consider possibility of break in two placesplaces
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Rib FractureRib Fracture
Most commonly 5th to 9th ribsMost commonly 5th to 9th ribs Poor protectionPoor protection Associated injuries:
pulmonary contusion laceration of the intercostals artery
an/or vein with resulting hemothorax & pneumothorax
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Rib FractureRib Fracture
Fractures of 1st, 2nd ribs require high Fractures of 1st, 2nd ribs require high forceforce
Frequently have injury to aorta or bronchiFrequently have injury to aorta or bronchi 30% will die30% will die
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Rib FractureRib Fracture
Fractures of 8th to 12th ribs can damage Fractures of 8th to 12th ribs can damage underlying abdominal solid organs:underlying abdominal solid organs: LiverLiver SpleenSpleen KidneysKidneys
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Rib FractureRib Fracture
Signs and SymptomsSigns and Symptoms Localized pain, tendernessLocalized pain, tenderness Increases when patient:Increases when patient:
CoughsCoughs MovesMoves Breathes deeplyBreathes deeply
Chest wall instabilityChest wall instability Associated pneumo or hemothoraxAssociated pneumo or hemothorax
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Rib FractureRib Fracture
ManagementManagement Oxygenation, if necessaryOxygenation, if necessary Encourage patient to breath deeplyEncourage patient to breath deeply
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Flail ChestFlail Chest
Two or more adjacent ribs broken in Two or more adjacent ribs broken in two or more places two or more places
Produces free-floating chest wall Produces free-floating chest wall segmentsegment
Usually secondary to blunt traumaUsually secondary to blunt trauma More common in older patientsMore common in older patients
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Flail ChestFlail Chest
Signs and SymptomsSigns and Symptoms Paradoxical movementParadoxical movement
May May NOTNOT be present initially due to be present initially due to intercostal muscle spasmsintercostal muscle spasms
Be suspicious in any patient with Be suspicious in any patient with chest wall:chest wall:
TendernessTenderness CrepitusCrepitus
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Flail ChestFlail Chest
ConsequencesConsequences Pain, leading to decreased ventilationPain, leading to decreased ventilation Increased work of breathingIncreased work of breathing Contusion of lungContusion of lung
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Flail ChestFlail Chest
ManagementManagement Establish airwayEstablish airway Suspect spinal injuriesSuspect spinal injuries OxygenationOxygenation
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Simple PneumothoraxSimple Pneumothorax
Air in pleural space Air in pleural space Partial or complete lung Partial or complete lung
collapse occurscollapse occurs
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Simple PneumothoraxSimple Pneumothorax
CausesCauses Chest wall penetrationChest wall penetration Fractured rib lacerating lungFractured rib lacerating lung Paper bag effectPaper bag effect May occur spontaneously following:May occur spontaneously following:
ExertionExertion CoughingCoughing Air TravelAir Travel
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Simple PneumothoraxSimple Pneumothorax
Signs and SymptomsSigns and Symptoms Pain on inhalationPain on inhalation Difficulty breathingDifficulty breathing TachypneaTachypnea Decreased or absent breath soundsDecreased or absent breath sounds
Severity of symptoms depends on size of pneumothorax, speed of lung collapse,
and patient’s health status
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Simple PneumothoraxSimple Pneumothorax
ManagementManagement Establish airwayEstablish airway Suspect spinal injury based on Suspect spinal injury based on
mechanismmechanism High concentration OHigh concentration O22 Monitor for tension pneumothoraxMonitor for tension pneumothorax
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Open PneumothoraxOpen Pneumothorax
Hole in chest wall Hole in chest wall Allows air to enter pleural space Allows air to enter pleural space Larger hole = Greater chance air Larger hole = Greater chance air
will enter there than through will enter there than through trachea trachea
“Sucking Chest Wound”
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Sucking Chest Wound: First Aid
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Open PneumothoraxOpen Pneumothorax
ManagementManagement Close hole with occlusive dressingClose hole with occlusive dressing High concentration OHigh concentration O22
Assist ventilationsAssist ventilations Consider transport on injured sideConsider transport on injured side Monitor for tension pneumothoraxMonitor for tension pneumothorax
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Tension PneumothoraxTension Pneumothorax
One-way valve forms in lung or chest One-way valve forms in lung or chest wall wall
Air enters pleural space; cannot Air enters pleural space; cannot leaveleave
Air is trapped in pleural spaceAir is trapped in pleural space Pressure risesPressure rises Pressure collapses lungPressure collapses lung
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Tension PneumothoraxTension Pneumothorax
Trapped air pushes heart, lungs Trapped air pushes heart, lungs awayaway from injured sidefrom injured side
Vena cavae become kinkedVena cavae become kinked Blood cannot return to heartBlood cannot return to heart Cardiac output fallsCardiac output falls
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Tension PneumothoraxTension Pneumothorax
Signs and SymptomsSigns and Symptoms Extreme dyspneaExtreme dyspnea Restlessness, anxiety, Restlessness, anxiety,
agitationagitation Decreased breath Decreased breath
soundssounds Hyperresonance to Hyperresonance to
percussion percussion CyanosisCyanosis Subcutaneous Subcutaneous
emphysemaemphysema
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Tension PneumothoraxTension Pneumothorax
Signs and SymptomsSigns and Symptoms Rapid, weak pulseRapid, weak pulse Decreased BPDecreased BP Tracheal shift Tracheal shift awayaway from injured side from injured side Jugular vein distensionJugular vein distension
Early dyspnea/hypoxia - Late shock
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Tension PneumothoraxTension Pneumothorax
ManagementManagement Secure airwaySecure airway High concentration OHigh concentration O22 If available, request ALS intercept for If available, request ALS intercept for
pleural decompressionpleural decompression
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HemothoraxHemothorax
Blood in pleural spaceBlood in pleural space Most common result of major chest Most common result of major chest
wall traumawall trauma Present in 70 to 80% of penetrating, Present in 70 to 80% of penetrating,
major non-penetrating chest traumamajor non-penetrating chest trauma
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HemothoraxHemothorax
Signs and Signs and SymptomsSymptoms Rapid, weak pulseRapid, weak pulse Cool, clammy skinCool, clammy skin Restlessness, Restlessness,
anxietyanxiety ThirstThirst ChillsChills HypotensionHypotension Collapsed neck Collapsed neck
veinsveins
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HemothoraxHemothorax
Signs and SymptomsSigns and Symptoms Decreased breath soundsDecreased breath sounds Dullness to percussionDullness to percussion DyspneaDyspnea Ventilatory failureVentilatory failure
Shock precedes ventilatory failure
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HemothoraxHemothorax
ManagementManagement Secure airwaySecure airway Assist breathing with high Assist breathing with high
concentration Oconcentration O22
Rapid transportRapid transport
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Traumatic AsphyxiaTraumatic Asphyxia
Blunt force to chest causes Blunt force to chest causes Increased intrathoracic pressureIncreased intrathoracic pressure Backward flow of blood out of heart into Backward flow of blood out of heart into
vessels of upper chest, neck, headvessels of upper chest, neck, head
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Traumatic AsphyxiaTraumatic Asphyxia
Signs and SymptomsSigns and Symptoms Possible sternal fracture or central flail chestPossible sternal fracture or central flail chest ShockShock Purplish-red discoloration of:Purplish-red discoloration of:
HeadHead NeckNeck ShouldersShoulders
Blood shot, protruding eyesBlood shot, protruding eyes Swollen, cyanotic lipsSwollen, cyanotic lips
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Traumatic AsphyxiaTraumatic Asphyxia
Name given because patients looked Name given because patients looked like they had been strangled or hangedlike they had been strangled or hanged
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Traumatic AsphyxiaTraumatic Asphyxia
ManagementManagement Airway with C-spine controlAirway with C-spine control Assist ventilations with high Assist ventilations with high
concentration Oconcentration O22
Spinal stabilizationSpinal stabilization Rapid transportRapid transport
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Cardiovascular Cardiovascular TraumaTrauma
Any patient with significant blunt or Any patient with significant blunt or penetrating trauma to chest has penetrating trauma to chest has
heart/great vessel injury until proven heart/great vessel injury until proven otherwiseotherwise
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Myocardial ContusionMyocardial Contusion
Bruise of heart muscleBruise of heart muscle Most common blunt cardiac injuryMost common blunt cardiac injury Usually due to steering wheel Usually due to steering wheel
impactimpact
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Myocardial ContusionMyocardial Contusion
Behaves like acute MIBehaves like acute MI May produce arrhythmiasMay produce arrhythmias May cause cardiogenic shock, May cause cardiogenic shock,
hypotensionhypotension
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Myocardial ContusionMyocardial Contusion
Signs and SymptomsSigns and Symptoms Cardiac arrhythmias after blunt chest Cardiac arrhythmias after blunt chest
traumatrauma Angina-like pain unresponsive to Angina-like pain unresponsive to
nitroglycerinnitroglycerin Chest pain independent of respiratory Chest pain independent of respiratory
movementmovementSuspect in all blunt chest trauma
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Myocardial ContusionMyocardial Contusion
ManagementManagement High concentration OHigh concentration O2 2
TransportTransport Consider ALS interceptConsider ALS intercept
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Cardiac TamponadeCardiac Tamponade
Rapid accumulation of blood in Rapid accumulation of blood in space between heart, pericardiumspace between heart, pericardium
Heart compressed Heart compressed Blood entering heart decreasesBlood entering heart decreases Cardiac output fallsCardiac output falls
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Cardiac TamponadeCardiac Tamponade
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Cardiac TamponadeCardiac Tamponade
Signs and SymptomsSigns and Symptoms Hypotension unresponsive to Hypotension unresponsive to
treatmenttreatment Increased central venous pressure Increased central venous pressure
(distended neck/arm veins in (distended neck/arm veins in presence of decreased arterial BP)presence of decreased arterial BP)
Small quiet heart (decreased heart Small quiet heart (decreased heart sounds)sounds)
Beck’s Triad
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Cardiac TamponadeCardiac Tamponade
Signs and SymptomsSigns and Symptoms Narrowing pulse pressureNarrowing pulse pressure Pulsus paradoxicusPulsus paradoxicus
Radial pulse becomes weak or disappears Radial pulse becomes weak or disappears when patient inhaleswhen patient inhales
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Cardiac TamponadeCardiac Tamponade
ManagementManagement Secure airwaySecure airway High concentration OHigh concentration O22
Rapid transportRapid transport Definitive treatment is Definitive treatment is
pericardiocentesis followed by pericardiocentesis followed by surgerysurgery
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Traumatic Aortic Traumatic Aortic AneurysmAneurysm
Caused by sudden decelerations, Caused by sudden decelerations, massive blunt force:massive blunt force: Vehicle collisionsVehicle collisions Falls from heightsFalls from heights Crushing chest traumaCrushing chest trauma Blunt chest traumaBlunt chest trauma Animal kicksAnimal kicks
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Traumatic Aortic Traumatic Aortic AneurysmAneurysm
Rupture usually occurs just beyond Rupture usually occurs just beyond left subclavian arteryleft subclavian artery
Attachment of aorta to pulmonary Attachment of aorta to pulmonary artery at this point produces artery at this point produces shearing force on aortic archshearing force on aortic arch
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Traumatic Aortic Traumatic Aortic Aneurysm Aneurysm
Signs and SymptomsSigns and Symptoms Increased BP in arms in absence of head Increased BP in arms in absence of head
injuryinjury Decreased femoral pulses with full arm Decreased femoral pulses with full arm
pulsespulses Respiratory distressRespiratory distress Ache in chest, shoulders, lower back, Ache in chest, shoulders, lower back,
abdomen. (Only 25% of patients)abdomen. (Only 25% of patients)Detection requires high index of suspicion
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Traumatic Aortic Traumatic Aortic AneurysmAneurysm
ManagementManagement High concentration High concentration
oxygenoxygen Assist ventilationAssist ventilation Suspect spinal Suspect spinal
injuryinjury Rapid transportRapid transport
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Associated Abdominal Associated Abdominal TraumaTrauma
Diaphragm forms dome that extends Diaphragm forms dome that extends up into rib cageup into rib cage
Trauma to chest below 4th rib = Trauma to chest below 4th rib = Abdominal injury until proven Abdominal injury until proven otherwiseotherwise