Trauma pada dada blunt chest trauma.pptx

Trauma pada dada manusia

1. BLUNT CHEST TRAUMA Management Yan Fernandez Sembiring

2. Learning Objectives Participants will understand about the general principles of management in blunt chest trauma Participants will understand the management of immediately life-threatening injuries in blunt chest trauma Participants will understand the management of potentially life-threatening injuries in blunt chest trauma

3. Case A 26 year old male involved in a high speed, single vehicle MVC. He was extricated by rescue team who reported significant damage to the vehicle. Initial vital on scene were t 37.0, HR 130 bpm, BP 90/40, RR 38, SpO2 78% - 88% with a non rebreathing mask. GCS is 12. A bolus of crystalloid is started and the patient is brought to your ER. Primary survey reveals a patent airway without stridor or signs of blunt or penetrating injury. Patient is in a C-collar. There is significant ecchymosis of the chest bilaterally and subcutaneous emphysema on the left. Abdomen is soft without ecchymosis.

4. Epidemiology Chest trauma : blunt or penetrating Blunt chest trauma more common than penetrating chest trauma 25% of traumatic death associated with blunt chest trauma <10% blunt chest trauma need operative intervention (15-30% in penetrating chest trauma)

5. THORAX - ANATOMY CARDIAC BOX

6. General Principles ATLS approach High risk MOI : High speed motorvehicle collisions (40 kmh ) Falls from height (>6m) Direct blow Rapid deceleration injury Seatbelt non-use Steering wheel deformity Rarely isolated chest trauma alone

7. General Principles Secondary survey : head to toe, identify potentially life-threatening injuries Pulmonary Contusion Myocardial Contusion Aortic Disruption Traumatic diaphragmatic Rupture Tracheobronchial disruption Oesophageal disruption Primary survey : C-ABCDE , exclude or treat immediately life threatening injuries Airway obstruction Tension Penumothorax Open Pneumothorax Massive Haemothorax Flail Chest Cardiac Tamponade

8. General Principles Initial Imaging Bedside Chest X-Ray (CXR) and extended focused assessment with sonography for trauma (E-FAST) are essential initial investigations CXR provides valuable information for diagnosing pneumothorax and haemothorax >300 ml of blood in chest for visibility with CXR AP orientation can falsely suggest cardiomegaly E-FAST adds a thoracic component to the pericardial and abdominal survey Non-invasive, rapid, highly specific (99%) but required specific training and interoperator variability As a ‘rule-in’ test, and a negative study may require repeating in deteriorating patient or evaluate with CT CT imaging  definitive diagnostic tools Delay to surgical control Deterioration during transfer Potential radiation exposure

9. Immediately Life Threatening Injuries Tension Pneumothorax Massive Haemothorax Flail Chest Cardiac Tamponade

10. Tension Pneumothorax Air from an injured lung or airway is trapped within the pleural cavity and increased the normal negative intrapleural pressure Common complication of blunt trauma, often sustained from a fractured rib Sign and symptoms : Dyspnea/Tachypnea Pleuritic chest pain Hypoxia Hypotension Unilateral diminished/absent breath sounds Unilateral hyperresonance to percussion Jugular vein distension Tracheal shift Crepitus from subcutaneous emphysema

11. Each time we inhale, the lung collapses further. There is no place for the air to escape.. Heart is being compressed The trachea is pushed to The un affected side

12. Tension Pneumothorax Clinical diagnosis Management : Immediate needle decompression using large-bore needle into the 2 nd intercostal space in the mid- clavivular line of the affected hemithorax Followed by insertion of a chest tube through 5 th intercostal space in the anterior axillary line (safe triangle)

13. Massive Haemothorax Accumulation of blood in pleural space, often result from multiple rib fractures Source of bleeding Intercostal vessels Internal mammary vessel Pulmonary vessels Reduced or diminished breath sounds on auscultation and dullness to percussion Diagnostic : upright CXR (300 mL) and ultrasound (operator dependent)

14. Massive Haemothorax Appropriate resuscitation with iv fluids and blood Definitive treatment : Chest tube insertion in safe triangle for blood drainage Thoracotomy IF initial drainage ≥ 20 mL/kg (approximate 1500 mL) blood or ongoing output > 200 mL/hour for 2-4 hour

15. CHEST TUBE Complications of Chest Tube Bleeding Aspiration Damage to diaphragm Infections Subcutaneous emphysema Contraindications of chest tube Refractory coagulopathy Diaphragmatic hernia Adhesion in the pleural space

16. Flail Chest Unstable chest wall resulting from fractured of > 3 adjacent ribs in more than one location Paradoxical (seesaw) motion of chest wall Could lead to respiratory failure by combination of : Altered lung mechanics Pain with resulting hypoventilation Underlying pulmonary contusion

17. Flail Chest Management : Splint the segment (emergency) Breathing support via positive airway pressure : HFNO or NIV (CPAP) Effective analgesia : systemic or regional approaches Careful fluid management to prevent fluid overload Pulmonary toilet to prevent atelectasis and pneumonia

18. Cardiac Tamponade Fluid around the heart within pericardial sac causing compression of the heart Normal pericardial fluid 15-20 mL Acute phase > 100 cc of blood can lead to cardiac tamponade, chronic cases can accommodate up to 2 L fluid in pericardial sac without sign of tamponade effect Clinical presentation “ BECK’S Triad ” Dilated neck veins Muffled heart sounds Hypotension

19. Cardiac Tamponade Management : Rapid volume resuscitation to increase preload Immediate pericardiocentesis with ultrasound guidance Definitive sternotomy or left thoracotomy

20. Potentially Life Threatening Injuries Pulmonary Contusion Blunt Cardiac Injury Aortic Disruption Traumatic Diaphragmatic Rupture Tracheobronchial Disruption Oesophageal disruption

21. Pulmonary Contusion Injury to the lung parenchyma leading to edema and blood collection in the alveolar space Loss of normal lung structure and function Sign and symptoms : Chest pain and cough Dyspnea Hypoxemia Hemoptysis Excessive tracheobronchial secretion

22. CXR : non lobular patchy consolidation (noticeable after 4-6 hours after trauma) Management : Supporting oxygenation – prefer NIV / HFNO Fluid restriction – resuscitate to euvolemia Optimisation of analgesia Sitting upright > lying in bed Chest physiotherapy Common Complications : Pneumonia & ARDS

23. Blunt Cardiac injury MOI : direct myocardial compression between the sternum and spine, impaired cardiac conduction secondary to impact and avulsion of the great vessels Encompasses a range of presentation Myocardial contusion with regional or global cardiac dysfunction Conduction abnormalities from bundle branch block to commotio cordis Coronary artery injury Valvular injury Pericardial tears Cardiac rupture

24. Blunt Cardiac Injury Sign and symptoms : finding are not sensitive nor specific Associated with other major entities of chest trauma  high suspicion Screening tools : Troponin concentration and ECG, Echocardiography Management : conservatively  definitive intervention

25. Aortic Injury / Disruption 80% immediate death from aortic dissection Occur from high energy injuries to the thorax, often following rapid deceleration Most common site : ligamentum arteriosum, just distal to the left subclavian artery Signs and symptoms : no clinical signs with sufficient sensitivity or specificity to detect or rule out blunt aortic injury

26. Aortic Injury / Disruption CXR : Wide Mediastinum Gold standar : Aortography or CT Scan Management : Careful control of their blood pressure and heart rate to slow expansion of the injury Medical vs surgical management Immediate vs delay surgical

27. Traumatic Diaphragmatic Rupture Tear in the diaphragm that allows abdominal organ enter the chest cavity More common on the left side, radial tear beginning at the esophageal hiatus Sign and symptoms : Dyspneu Abdominal pain Referred shoulder pain Decreased breath sounds on the rupture side Bowel sounds heard in the cavity vomiting

28. Traumatic Diaphragmatic Rupture CXR : shows evidence of the stomachor colon in the chest Management : Supportive Laparatomy / thoracotomy repair

29. Tracheo -Bronchial Injury Frequently Fatal Severe subcutaneous emphysema with respiratory distress Hamman sign Diagnostic : Bronchoscopy Management : ABC, Surgical repair

30. CONCLUSION Blunt chest trauma is a common injury especially after high energy impacts, such as road trafiic collisions Energy transfer from the chest wall to the underlying lungs, heart and vascular and mediastinal structures can result in a number of immediately life-threatening conditions Understanding key injury patterns can aid in proper management for patient with blunt chest trauma

31. Reference Andari RE, Bozso SJ, et al. Blunt Cardiac Trauma: A Narrative Review. Mediastinum 2021; 5:28 Ludwig C, Koryllos A. Management of Chest Trauma. J Thorac Dis 2017; 9 (Suppl 3):S172-S177. Mistry RN, Moore JE. Management of blunt thoracic trauma. BJA Education 2022; 22:11. Shoar S, Hosseini FS, et al. Cardiac injury following blunt chest trauma: diagnosis, management and uncertainty. Int J Burn Trauma 2021; 11 (2): 80-89. Victor WL, Alejandra SG, et al. Chest Trauma : An Overview. J Anesth Crit Care Open Access 2015, 3 (1): 00082.

32. TERIMA KASIH