TRAUMA THORAX

Arif Prasetyo SpBTKV

Trimodal Death Distribution:

(ACS,97)
.

Periode I : detik-menit cedera CNS, Cor, Aorta

Periode II : menit-jam kelainan multiple
(fr.iga, pneumotoraks, hemotoraks, dll.) + blood lost
Periode III : hari minggu sepsis atau MOF

Di Amerika (1990-an) : 180.000 kematian/ tahun karena

trauma: 25 % trauma toraks, 25 % trauma toraks + penyerta
10 % dari trauma tumpul dan 25 % dari trauma
tembus toraks torakotomi (ACS, 1997; Boffard, 2000).
Angka mortalitas trauma toraks adalah 10 %

Introduction to Thoracic Injury

Vital Structures
Heart, Great Vessels, Esophagus, Tracheobronchial Tree, &
Lungs
25% of MVC deaths are due to thoracic trauma
12,000 annually in US
Abdominal injuries are common with chest trauma.
Prevention Focus
Gun Control Legislation
Improved motor vehicle restraint systems
Passive Restraint Systems
Airbags

JENIS TRAUMA TORAKS

Blunt Trauma (Trauma Tumpul) :
Penetrating Trauma (Trauma

Tembus) :

Luka tembak
Luka tusuk
Terjatuh pada benda tajam

DEADLY DOZEN of THORACIC TRAUMA

Lethal Six

Airway Obstruction
Tension Pneumothorax
Cardiac Tamponade
Open Pneumothorax
Massive Hematothorax
Flail Chest

Hidden Six

Thoracic Aortic Disruption

Tracheobronchial Disruption
Myocardial Contusion
Traumatic Diaphragmatic Tear
Esophageal Disruption
Pulmonary Contusion

Perhatikan !
Terdapat perbedaan antara patofisiologi trauma tumpul
thorax dengan trauma tembus thorax, dengan demikian
ada perbedaan dalam algoritma tata laksana.
Mengetahui mekanisme dari cidera (mechanism of injury)
adalah penting !

Anatomy and Physiology of the Thorax

Thoracic Skeleton
12 Pair of C-shaped ribs
Ribs 1-7 : Join at sternum with cartilage end-points
Ribs 8-10 : Join sternum with combined cartilage at 7th rib
Ribs 11-12 : No anterior attachment

Sternum
Manubrium
Joins to clavicle and 1st rib
Jugular Notch

Body
Sternal angle (Angle of Louis)
Junction of the manubrium with the sternal body
Attachment of 2nd rib

Xiphoid process
Distal portion of sternum

Anatomy and Physiology of the

Thorax
Thoracic Skeleton
Topographical Thoracic Reference Lines

Midclavicular line
Anterior axillary line
Mid-axillary line
Posterior axillary line

Intercostal space
Artery, Vein and Nerve on inferior margin of each rib

Thoracic Inlet
Superior opening of the thorax
Curvature of 1st rib with associated structures

Thoracic Outlet
Inferior opening of the thorax
12th rib and associated structures & Xiphisternal joint

Anatomy and Physiology of the

Thorax
Diaphragm
Muscular, dome-like structure
Separates abdomen from the thoracic cavity
Affixed to the lower border of the rib cage
Central and superior margin extends to the level of the
4th rib anteriorly and 6th rib posteriorly
Major muscle of respiration

Draws downward during inspiration

Moves upward during exhalation

Anatomy and Physiology of the

Thorax
Associated Musculature

Shoulder girdle
Muscles of respiration
Diaphragm
Intercostal muscles
Contract to elevate the ribs and increase thoracic diameter
Increase depth of respiration

Sternocleidomastoid
Raise upper rib and sternum

Anatomy and Physiology of the Thorax

Physiology of Respiration
Changing pressure assists:
Venous return to heart
Pumping blood to systemic circulation

Inhalation
Diaphragm contracts and flattens
Intercostals contract expanding ribcage
Thorax volume increases
Less internal pressure than atmospheric
Air enters lungs

Exhalation
Musculature relaxes
Diaphragm & intercostals return to normal
Greater internal pressure than atmospheric
Air exits lungs

Anatomy and Physiology of the Thorax

Trachea, Bronchi & Lungs

Trachea
Hollow & cartilage supported structure

Bronchi
Right & left extend for 3 centimeters
Enters lungs at Pulmonary Hilum
Also where pulmonary arteries & veins enter
Further subdivide and terminate as alveoli
Basic unit of structure & function in the lungs
Single cell membrane
External versus Internal Respiration

Lungs
Right = 3 lobes
Left = 2 lobes

Anatomy and Physiology of the

Thorax
Trachea, Bronchi & Lungs
Pleura
Visceral Pleura
Cover lungs

Parietal Pleura
Lines inside of thoracic cavity

Pleural Space
POTENTIAL SPACE
Air in Space = PNEUMOTHORAX
Blood in Space = HEMOTHORAX
Serous (pleural) fluid within
Lubricates & permits ease of expansion

Anatomy and Physiology of the

Thorax
Mediastinum
Central space within thoracic cavity
Boundaries
Lateral: Lungs
Inferior: Diaphragm
Superior: Thoracic outlet

Structures

Heart
Great Vessels
Esophagus
Trachea
Nerves
Vagus
Phrenic

Thoracic Duct

Anatomy and Physiology of the

Thorax
Great Vessels
Aorta
Fixed at three sites
Annulus
Attaches to heart
Ligamentum Arteriosum
Near bifurcation of
pulmonary artery
Aortic hiatus
Passes through
diaphragm

Superior Vena Cava

Inferior Vena Cava
Pulmonary Arteries
Pulmonary Veins

Esophagus
Enters at thoracic inlet
Posterior to trachea
Exits at esophageal hiatus

PEMERIKSAAN FISIK

Inspeksi : Jejas ?

Auskultasi : Suara nafas ?

Palpasi : Nyeri Tekan ?

Perkusi : ?

DIAGNOSTIK TRAUMA TORAKS

1. Keadaan umum penderita:

Sesak; anemis, syok, pre-syok?; bagaimana nadi dan tensi penderita?
(akral?)
A. membebaskan airway (jalan nafas);
B. menjamin breathing (pernafasan);
C. memperbaiki circulation: infus (RL , atau darah); D; E
2. Status lokalis:
Inspeksi: jejas pada dinding toraks? Sisi mana?; gerakan nafas,
simetris,
terhambat?; arah dan lokalisasinya ?; flail chest?
Palpasi : krepitasi? (udara di bawah kulit, fraktur iga)
Perkusi : pneumotoraks?; hemotoraks? Sampai setinggi mana?
Auskultasi: suara nafas sisi mana yang kurang/hilang?; suara jantung?
3. Pemeriksaan tambahan:
a. Foto toraks AP; b. EKG; c. Echokardiografi; d. USG; e. Analisis gas darah, f.
Aortografi-angiografi; g.Esofagusgrafi/skopi; h.Torakoskopi; i. CT-scan

GANGGUAN JALAN
NAFAS ??
KORBAN GELISAH DAN TERIAK .
TOLONG SAYA CEPAT, DADAKU SAKIIT
COMMENT ?

DIAM , DADA TAK BERGERAK

SUARA NAFAS NGOROK
BERNAFAS DENGAN OTOT LEHER TEGANG

FIKSASI LEHER

JAW THRUST
CERVICAL COLLAR

LIHAT
Pupil ?
Test nafas !

Darah di mulut ?
Penekanan trakhea ?

Bersihkan
Intubasi
Crycothyroidotomi
Reposisi sternum

OKSIGEN 10 L / MENIT
NON REBREATHING MASK
MONITOR OXYMETRI / SAT OKSIGEN

GANGGUAN PENGEMBANGAN PARU ??

LIHAT
RABA
KETOK
DENGAR

Pathophysiology of Thoracic Trauma

Blunt Trauma
Results from kinetic energy forces
Subdivision Mechanisms
Blast

Pressure wave causes tissue disruption

Tear blood vessels & disrupt alveolar tissue
Disruption of tracheobronchial tree
Traumatic diaphragm rupture

Crush (Compression)
Body is compressed between an object and a hard surface
Direct injury of chest wall and internal structures

Deceleration
Body in motion strikes a fixed object
Blunt trauma to chest wall
Internal structures continue in motion
Ligamentum Arteriosum shears aorta

Age Factors
Pediatric Thorax : More cartilage = Absorbs forces
Geriatric Thorax : Calcification & osteoporosis = More fractures

Pathophysiology of Thoracic Trauma

Penetrating Trauma
Low Energy
Arrows, knives, handguns
Injury caused by direct contact
and cavitation

High Energy
Military, hunting rifles & high
powered hand guns
Extensive injury due to high
pressure cavitation

Trauma.org

Injuries Associated with Penetrating

Thoracic Trauma
Closed pneumothorax
Open pneumothorax
(including sucking chest
wound)
Tension pneumothorax
Pneumomediastinum
Hemothorax
Hemopneumothorax
Laceration of vascular
structures

Tracheobronchial tree
lacerations
Esophageal lacerations
Penetrating cardiac
injuries
Pericardial tamponade
Spinal cord injuries
Diaphragm trauma
Intra-abdominal
penetration with
associated organ injury

Pathophysiology of Thoracic Trauma

Chest Wall Injuries
Contusion
Most Common result of blunt injury
Signs & Symptoms

Erythema
Ecchymosis
DYSPNEA
PAIN on breathing
Limited breath sounds
HYPOVENTILATION
BIGGEST CONCERN = HURTS TO BREATHE

Crepitus
Paradoxical chest wall motion

Pathophysiology of Thoracic Trauma

Chest Wall Injuries
Rib Fractures
>50% of significant chest trauma cases due to blunt
trauma
Compressional forces flex and fracture ribs at weakest
points
Ribs 1-3 requires great force to fracture
Possible underlying lung injury

Ribs 4-9 are most commonly fractured

Ribs 9-12 less likely to be fractured
Transmit energy of trauma to internal organs
If fractured, suspect liver and spleen injury

Hypoventilation is COMMON due to PAIN

Pathophysiology of Thoracic Trauma

Chest Wall Injuries
Sternal Fracture & Dislocation
Associated with severe blunt anterior trauma
Typical MOI
Direct Blow (i.e. Steering wheel)

Incidence: 5-8%
Mortality: 25-45%

Myocardial contusion
Pericardial tamponade
Cardiac rupture
Pulmonary contusion

Dislocation uncommon but same MOI as fracture

Tracheal depression if posterior

Pathophysiology of Thoracic Trauma

Chest Wall Injuries
Flail Chest
Segment of the chest that becomes free to move with
the pressure changes of respiration
Three or more adjacent rib fracture in two or more
places
Serious chest wall injury with underlying pulmonary
injury
Reduces volume of respiration
Adds to increased mortality

Paradoxical flail segment movement

Positive pressure ventilation can restore tidal volume

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Simple Pneumothorax
AKA: Closed Pneumothorax
Progresses into Tension Pneumothorax

Occurs when lung tissue is disrupted and air leaks into the pleural
space

Progressive Pathology

Air accumulates in pleural space

Lung collapses
Alveoli collapse (atelectasis)
Reduced oxygen and carbon dioxide exchange

Ventilation/Perfusion Mismatch
Increased ventilation but no alveolar perfusion
Reduced respiratory efficiency results in HYPOXIA

Typical MOI: Paper Bag Syndrome

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Open Pneumothorax
Free passage of air between atmosphere and pleural
space
Air replaces lung tissue
Mediastinum shifts to uninjured side
Air will be drawn through wound if wound is 2/3
diameter of the trachea or larger
Signs & Symptoms

Penetrating chest trauma

Sucking chest wound
Frothy blood at wound site
Severe Dyspnea
Hypovolemia

Management of the Chest Injury Patient

Open Pneumothorax
High flow O2
Cover site with sterile occlusive
dressing taped on three sides
Progressive airway management
if indicated

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Tension Pneumothorax

Buildup of air under pressure in the thorax.

Excessive pressure reduces effectiveness of respiration
Air is unable to escape from inside the pleural space
Progression of Simple or Open Pneumothorax

Management of the Chest Injury Patient

Tension Pneumothorax
Confirmation
Auscultaton & Percussion

Pleural Decompression
2nd intercostal space in
mid-clavicular line
TOP OF RIB

Consider multiple
decompression sites if
patient remains
symptomatic
Large over the needle
catheter: 14ga
Create a one-way-valve:
Glove tip or Heimlich valve

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Tension Pneumothorax Signs & Symptoms
Dyspnea
Tachypnea at first
Progressive
ventilation/perfusion
mismatch
Atelectasis on
uninjured side
Hypoxemia
Hyperinflation of injured
side of chest
Hyperresonance of
injured side of chest

Diminished then absent

breath sounds on injured
side
Cyanosis
Diaphoresis
AMS
JVD
Hypotension
Hypovolemia
Tracheal Shifting
LATE SIGN

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Hemothorax
Accumulation of blood in the pleural space
Serious hemorrhage may accumulate 1,500 mL of
blood
Mortality rate of 75%
Each side of thorax may hold up to 3,000 mL

Blood loss in thorax causes a decrease in tidal volume

Ventilation/Perfusion Mismatch & Shock

Typically accompanies pneumothorax

Hemopneumothorax

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Hemothorax Signs & Symptoms
Blunt or penetrating chest trauma
Shock

Dyspnea
Tachycardia
Tachypnea
Diaphoresis
Hypotension

Dull to percussion over injured side

Pathophysiology of Thoracic Trauma

Pulmonary Injuries
Pulmonary Contusion

Soft tissue contusion of the lung

30-75% of patients with significant blunt chest trauma
Frequently associated with rib fracture
Typical MOI
Deceleration
Chest impact on steering wheel

Bullet Cavitation
High velocity ammunition

Microhemorrhage may account for 1- 1 L of blood loss in

alveolar tissue
Progressive deterioration of ventilatory status

Hemoptysis typically present

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Myocardial Contusion
Occurs in 76% of patients with severe blunt chest trauma
Right Atrium and Ventricle is commonly injured
Injury may reduce strength of cardiac contractions
Reduced cardiac output

Electrical Disturbances due to irritability of damaged myocardial cells

Progressive Problems
Hematoma
Hemoperitoneum
Myocardial necrosis
Dysrhythmias
CHF & or Cardiogenic shock

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Myocardial Contusion Signs & Symptoms

Bruising of chest wall

Tachycardia and/or irregular rhythm
Retrosternal pain similar to MI
Associated injuries
Rib/Sternal fractures

Chest pain unrelieved by oxygen

May be relieved with rest
THIS IS TRAUMA-RELATED PAIN
Similar signs and symptoms of medical chest pain

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Pericardial Tamponade
Restriction to cardiac filling caused by blood or other
fluid within the pericardium
Occurs in <2% of all serious chest trauma
However, very high mortality

Results from tear in the coronary artery or penetration

of myocardium
Blood seeps into pericardium and is unable to escape
200-300 ml of blood can restrict effectiveness of cardiac
contractions
Removing as little as 20 ml can provide relief

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Pericardial Tamponade Signs & Symptoms

Dyspnea
Possible cyanosis
Becks Triad
JVD
Distant heart tones
Hypotension or
narrowing pulse
pressure

Weak, thready pulse

Shock

Kussmauls sign
Decrease or absence of
JVD during inspiration
Pulsus Paradoxus
Drop in SBP >10 during
inspiration
Due to increase in CO2
during inspiration
Electrical Alterans
P, QRS, & T amplitude
changes in every other
cardiac cycle
PEA

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Myocardial Aneurysm or Rupture
Occurs almost exclusively with extreme blunt thoracic
trauma
Secondary due to necrosis resulting from MI
Signs & Symptoms
Severe rib or sternal fracture
Possible signs and symptoms of cardiac tamponade
If affects valves only
Signs & symptoms of right or left heart failure

Absence of vital signs

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Traumatic Aneurysm or Aortic Rupture
Aorta most commonly injured in severe blunt or penetrating
trauma
85-95% mortality

Typically patients will survive the initial injury insult

30% mortality in 6 hrs
50% mortality in 24 hrs
70% mortality in 1 week

Injury may be confined to areas of aorta attachment

Signs & Symptoms
Rapid and deterioration of vitals
Pulse deficit between right and left upper or lower extremities

Pathophysiology of Thoracic Trauma

Cardiovascular Injuries
Other Vascular Injuries
Rupture or laceration
Superior Vena Cava
Inferior Vena Cava
General Thoracic Vasculature

Blood Localizing in Mediastinum

Compression of:
Great vessels
Myocardium
Esophagus

General Signs & Symptoms

Penetrating Trauma
Hypovolemia & Shock
Hemothorax or hemomediastinum

Pathophysiology of Thoracic Trauma

Other Thoracic Injuries
Traumatic Esophageal Rupture
Rare complication of blunt thoracic trauma
30% mortality
Contents in esophagus/stomach may move into
mediastinum

Serious Infection occurs

Chemical irritation
Damage to mediastinal structures
Air enters mediastinum

Subcutaneous emphysema and penetrating trauma

present

Pathophysiology of Thoracic Trauma

Other Thoracic Injuries
Tracheobronchial Injury
MOI
Blunt trauma
Penetrating trauma

50% of patients with injury die within 1 hr of injury

Disruption can occur anywhere in tracheobronchial tree
Signs & Symptoms

Dyspnea
Cyanosis
Hemoptysis
Massive subcutaneous emphysema
Suspect/Evaluate for other closed chest trauma

Pathophysiology of Thoracic Trauma

Other Thoracic Injuries
Traumatic Asphyxia
Results from severe compressive forces applied to the
thorax
Causes backwards flow of blood from right side of
heart into superior vena cava and the upper extremities
Signs & Symptoms
Head & Neck become engorged with blood
Skin becomes deep red, purple, or blue
NOT RESPIRATORY RELATED

JVD
Hypotension, Hypoxemia, Shock
Face and tongue swollen
Bulging eyes with conjunctival hemorrhage

Assessment of the Thoracic Trauma

Patient
Scene Size-up
Initial Assessment
Rapid Trauma Assessment
Observe
JVD, SQ Emphysema, Expansion of chest
Question
Palpate
Auscultate
Percuss
Blunt Trauma Assessment
Penetrating Trauma Assessment

Ongoing Assessment

Management of the Chest Injury Patient

General Management
Ensure ABCs

High flow O2 via NRB

Intubate if indicated
Consider RSI
Consider overdrive ventilation
If tidal volume less than 6,000 mL
BVM at a rate of 12-16
May be beneficial for chest contusion and rib fractures
Promotes oxygen perfusion of alveoli and prevents atelectasis

Anticipate Myocardial Compromise

Shock Management
Consider PASG
Only in blunt chest trauma with SP <60 mm Hg

Fluid Bolus: 20 mL/kg

AUSCULTATE! AUSCULATE! AUSCULATE!

Management of the Chest Injury

Patient
Rib Fractures
Consider analgesics for pain and to improve chest excursion
Versed
Morphine Sulfate
CONTRAINDICATION
Nitrous Oxide
May migrate into pleural or mediastinal space and worsen
condition

Management of the Chest Injury

Patient
Sternoclavicular Dislocation
Supportive O2 therapy
Evaluate for concomitant injury
Flail Chest
Place patient on side of injury
ONLY if spinal injury is NOT suspected

Expose injury site

Dress with bulky bandage against flail segment
Stabilizes fracture site

High flow O2
Consider PPV or ET if decreasing respiratory status

DO NOT USE SANDBAGS TO STABILIZE FX

Management of the Chest Injury

Patient
Hemothorax
High flow O2
2 large bore IVs
Maintain SBP of 90-100
EVALUATE BREATH SOUNDS for fluid overload

Myocardial Contusion
Monitor ECG
Alert for dysrhythmias
IV if antidysrhythmics are needed

Management of the Chest Injury

Patient
Pericardial Tamponade
High flow O2
IV therapy
Consider pericardiocentesis; rapidly deteriorating
patient

Aortic Aneurysm
AVOID jarring or rough handling
Initiate IV therapy enroute
Mild hypotension may be protective
Rapid fluid bolus if aneurysm ruptures

Keep patient calm

Management of the Chest Injury

Patient
Tracheobronchial Injury
Support therapy
Keep airway clear
Administer high flow O2
Consider intubation if unable to maintain patient airway
Observe for development of tension pneumothorax and SQ
emphysema

Traumatic Asphyxia
Support airway
Provide O2
PPV with BVM to assure adequate ventilation

2 large bore IVs

Evaluate and treat for concomitant injuries
If entrapment > 20 min with chest compression
Consider 1mEq/kg of Sodium Bicarbonate

TERIMA KASIH