THORACIC TRAUMA胸 部 损 伤Key WordsChest WallPleuraThoracic CavityPleural SpaceIntrapleural PressureThoracic Cavity Pleural Space Thoracic injuries account for 20% to 25% of all trauma-related deaths, and complications of chest trauma contribute to another 25% of all deaths. Many of these deaths can be prevented with prompt diagnosis and correct management.ClassificationBlunt Trauma Penetrating TraumaThoraco-Abdominal TraumaMechanism of InjuryBlunt Trauma A direct blow to the chest - rib fracture Deceleration injury - pulmonary or cardiac contusion, aortic tear Compression injury - cardiac & diaphragm ruptureTraumatic AsphyxiaBlast Injury of LungTraumatic AsphyxiaMechanism of Injury Penetrating TraumaStab wounds, Gunshot wounds, Impalement on a foreign bodyStab woundsPenetratingPenetratingPathophysiology(1)Hypoxemia airway obstruction changes in intrathoracic pressure hypovolemia ventilation-perfusion mismatches flail chest , chest painPathophysiology (2)Hypercapnia inadequate ventilation a collapsed lung exogenous intoxication Pathophysiology (3)Acidosis hypoperfusion blood lossDiagnosisFocus on: mechanism of injury patient history symptoms & signsDiagnosisSupplement: chest radiograph transthoracic ultrasound pericardiocentesisInitial Treatment Top priorities: airway control adequate ventilation shock managementThoracostomy ExplorationCardiac arrest (resuscitative thoracotomy)Massive hemothorax (1500ml; 200-300ml/hr) Penetrating injuries of the anterior aspect of the chest with cardiac tamponade Large open wounds of the thoracic cage Major thoracic vascular injuries in the presence of hemodynamic instability Major tracheobronchial injuriesEvidence of esophageal perforation Emergency Room ThoracotomyRib FracturesRib FracturesFracture of the ribs is the most common thoracic injury.Most common on the 4-7th rib.Simple FractureSymptom -pain on inspirationConsequence -hemothorax, pneumothoraxSimple FractureDiagnosis: chest X-rayTreatment: pain relief, cough assistance, fixation (not always needed)Simple FractureFlail ChestTwo or more fractures in three or more consecutive ribsCostochondral separation Causes instability of the chest wallFlail ChestThoracic cage instability paradoxical respiratory motion hypoventilationFlail ChestFrench peasants threshing with flails around 1270. A flail is an agricultural tool used for threshing to separate grains from their husks.Flail ChestFlail ChestOn inspirationOn expirationFlail ChestClinical ManifestationsSevere chest pain, Dyspnea, Paradoxical respiratory motion,HypoxiaManagementExcellent pain reliefEndotracheal suction, intubationExternal fixationOpen reduction and internal fixationMechanical ventilation with PEEPPneumothoraxAn accumulation of gas in the pleural spacePneumothoraxResults from: lacerations of the chest wall or lung rupture of an alveoliCaused by: penetrating or blunt traumaClassificationClosed pneumothorax, Open pneumothorax Tension pneumothorax,Closed pneumothoraxthe most common type Closed pneumothoraxOpen pneumothoraxIntrapleural pressure risesLung collapse Mediastinal shift Open pneumothoraxOn inspirationOn expirationOpen pneumothoraxTension PneumothoraxA flap valve leak allows air to enter the pleural space but prevents its escapeTension pneumothoraxOn inspirationOn expirationTension pneumothoraxIntrapleural pressure risesLung collapseMediastinal shiftImpediment of venous returnImpairment of cardiac functionTension pneumothoraxManifestation Subcutaneous emphysema Absent breath sounds Mediastinal shift Acute respiratory distressSubcutaneous emphysemaInitial TreatmentPressure relief Large-bore needle insertion Chest tube insertionBlood in the pleural spaceHemothoraxHemothoraxHemorrhage into the pleural spaceSources: pulmonary tissue or vascular intercostal arteries heart or aorta ruptureHemothoraxManifestationsBlood loss, ShockCompression, Mediastinal shiftInfectionHemothoraxSubsequente Results: Clotted hemothorax Fibrothorax EmpyemaHemothoraxManagements: Thoracentesis Chest tube drainage ThoracostomyIndications for thoracostomy1.Unrelenting hemorrhage following either penetrating or blunt thoracic trauma2.An initial thoracic blood loss greater than 1500ml (30% blood volume)Indications for thoracostomy3. An ongoing loss of 250ml (5% blood volume) for 3 consecutive hours;4. Clinical situation and overall condition of the patients- P, BP, Hb,HCT, RBCThats all for today. Thanks!