THORACIC TRAUMA

Thoracic injuries
following both penetrating and blunt trauma, it has been estimated that chest injuries are responsible for ! to "# of all trauma deaths$ chest injuries are also common in multipl% injured patients$

Rib fractures
Most common injur% associated with blunt chest trauma
&'(! # of all trauma admission the true incidence in probabl% higher since up to "!# of rib fractures ma% be missed on initial C)R

Causes*
motor +ehicle crashes falls blows to the chest with blunt objects

Rib fractures
fractures of ribs , trought - . ma/imum fre0uenc% directl%
at the site of force

laterall%
significant antero'posterior compression of the chest

 the first rib is protected b% the shoulder girdle and cla+icle

fractures of the first rib indicate a significant amount of energ% transferred to the torso ha+e been associated with aortic injuries

posterior rib fractures are also associated with significant energ% transfer to the thora/$

Hemotorax & Fracturi costale multiple decubit dorsal

 Associated injuries*
!# incidence of splenic injur% is associated with fractures of ribs 1, (!, and (( on the left side similar for hepatic injuries "!# of patients with blunt cardiac injur% ha+e rib fractures$

Rib fractures ' diagnosis

The diagnosis of rib fractures is primaril% clinical 2ain
directl% antero'posterior compression,

Crepitus o+er the possible area of fracture 3ecreased breath sounds on the side of injur% 2ain*
subse0uent atelectasis underl%ing pulmonar% contusion restriction of +entilation$

Chest )R
radiologic confirmation of the diagnosis is not essential

Rib fractures
children
pulmonar% contusion is more common rib fractures 4 a sign of signi5cant energ% transfer$

elderl%
2atients older than 6" %ears with , or more rib fractures had a "'fold increased mortalit% rate and an almost &'fold increased incidence of pneumonia compared with %ounger patients

Treatment
Ade0uate pain relief and pulmonar% care are the primar% therapeutic goals pain
poor inspirator% effort ineffecti+e cough atelectasis pneumonia
Elderly patients, especiall% those with preexisting pulmonary disease, are particularl% prone to these complications$

Treatment
intra+enous narcotics patient'controlled analgesia continuous opioid infusion intercostal ner+e bloc7 epidural analgesia
Multiple fractures 8lderl% patients 2atients with underl%ing pulmonar% disease

 hospital admission*
histor% of smo7ing chronic obstructi+e pulmonar% disease ederl% patients with multiple fractures

Flail Chest

fracture of more than consecuti+e ribs in or more places this creating a free'floating segment of the chest wall a better de5nition ma% be 9an incompetent segment of chest wall large enough to impair the patient:s respiration$;

Flail Chest
respirator% failure after chest wall injur% is almost ne+er due to the mechanical +entilator% d%sfunction imposed b% the chest wall injur% itself in great measure, it is caused b% the underl%ing pulmonar% contusion ' almost uni+ersall% accompanies flail chest$ increasing age also is associated with an increasing ris7 of death with <ail chest, li7el% because of comorbid conditions and less abilit% to tolerate respirator% compromise$

 The parado/ical mo+ements of the flail segment are caused b% negati+e intrapleural pressure generated during inspiration Up to !# of patients with se+ere blunt chest injuries

 The majorit% of complications resulting from rib fractures are related to chest wall pain, which limits pulmonar% function The inabilit% of patients to clear secretions ade0uatel% and the de+elopment of atelectasis from chest wall splinting are ris7 factors for the de+elopment of pulmonar% infection$

=lail chest ' treatment

ade0uate pain control and aggressi+e respirator% care to optimi>e pulmonar% function 2roph%lactic intubation is not indicated$ if a patient re0uires mechanical +entilation because of an underl%ing contusion or other injuries, internal pneumatic stabili>ation ?mechanical +entilation@ is possible wean the patient as soon as possible, again b% using epidural or other aggressi+e pain control techni0ues if possible$

=lail chest ' treatment

The presence of a <ail segment itself is not an indication to continue mechanical +entilation, but pulmonar% d%sfunction and inabilit% to +entilate are indications$ Areat chest wall instabilit% . surgical rib fracture 5/ation seems to be an attracti+e alternati+e to long'term mechanical +entilation$ =lail chest is associated with signi5cant late morbidit%, in terms of chronic pain and the sensation of decreased +entilator% capacit%$

Volet costal tratament istoric

Zdrobire hemitorace drept Radiografie iniial

Dup entilaie cu !""! mare

#tabili$are intern a segmentelor celor mai instabile

!ost stabili$are

Volet costal mi%care paradoxal

!nemotorax &pleurostomie' Volet costal (ontu$ie pulmonar

BT8RCAD =RACTUR8B
"# of patients with se+ere chest injuries associated with an increased incidence of both cardiac and great +essel injur%$

 Isolated sternal fracture ma% result from shoulder belt use Most fractures are trans+erse, in+ol+e the sternal'manubrial junction or upper one third of the sternum,

 The diagnosis of sternal fracture is made b% palpation of the sternum A lateral chest radiograph can re+eal sternal fractures and the degree of posterior displacement

 The treatment of sternal fracture is primaril% ade0uate pain relief and pulmonar% care, as for rib fractures$ Onl% If se+ere displacement is present, operati+e reduction with fi/ation of the fracture ma% be re0uired$ Options include wires in a 5gure'of'fashion, plates, or both$

Fractur de stern

Simple Pneumothorax
2neumothora/, defined as air in the potential space between the +isceral and parietal pleurae$ The loss of negati+e intrapleural pressure allows the lung to collapse from elastic recoil$

 2neumothora/ ordinaril% results from *

ruptured al+eoli or from small lacerations in the pulmonar% parench%ma and is fre0uentl% associated with rib fractures lacerations through the chest wall
stab or gunshot wounds iatrogenic injuries ' as a complication of placement of a central +enous catheter

 The diagnosis of pneumothora/ is suggested on ph%sical e/amination*

3ecreased ipsilateral breath sounds 3ecreased e/pansion of the affected hemithora/ H%perresonance to percussion Crepitus Bubcutaneous emph%sema

The chest radiograph is usuall% diagnostic

 Traumatic pneumothora/ is treated b% placement of a tube thoracostom% A chest tube should be inserted to e+acuate the air A chest radiograph should be obtained after insertion of the chest tube to confirm that proper tube positioning and ree/pansion of the lung ha+e occurred

 2atients with small, as%mptomatic pneumothoraces who do not re0uire general endotracheal anesthesia or positi+e'pressure +entilation ma% be obser+ed carefull% without placement of a tube thoracostom%$ If the air lea7 from the lung has sealed, the air in the pleural ca+it% will be reabsorbed, with subse0uent complete ree/pansion of the lung$ Berial chest films should be obtained to ensure that the pneumothora/ is progressi+el% decreasing and that the lung is not collapsed

!neumotorax st)ng

!neumotorax drept

!neumotorax drept

!neumotorax medial

!neumotorax simplu

Detaliu

Detaliu

"mfi$em subcutanat masi posttraumatic

Rg toracic

(*

Tension Pneumothorax
A tension pneumothora/ occurs if the pressure of accumulated air in the pleural space e/ceeds the ambient pressure, resulting in a net positi+e intrathoracic pressure Tension pneumothora/ occurs when air enters the pleural space from lung injur% or through the chest wall without a means of e/it$ 2ressure de+elops within the pleural space, compressing the superior and inferior +ena ca+a, impairing +enous return, and decreasing cardiac output$

Tension Pneumothorax
Most common causes*
2enetrating injur% to the chest Elunt trauma with parench%mal lung injur% Mechanical +entilation with high airwa% pressure Bpontaneous pneumothora/ with blebs that failed to seal

Tension Pneumothorax
Tension pneumothora/ must be a clinical diagnosis*

Be+ere respirator% distress 3%spnea, tach%pnea H%potension Unilateral absence of breath sounds H%perresonance to percussion o+er affected hemithora/ Cec7 +ein distention ?can be absent in h%po+olemic patients@ Tracheal de+iation ?late finding ' not necessar% to confirm clinical diagnosis@

If the tension pneumothora/ has not been diagnosed on clinical findings ?which it should be@, C)R will usuall% show a pneumothora/ large enough to cause tension a collapsed lung a depressed ipsilateral hemidiaphragm widened intercostal spaces mediastinal shift awa%

Tension 2neumothora/ ' treatment

Immediatel% decompress b% inserting a ( ' or (&'gauge IF catheter into the second intercostal space in the midcla+icular line$ This con+erts the tension pneumothora/ into a simple open pneumothora/$
=ollow immediatel% with tube thoracostom%$

!neumotorax +n tensiune

Inspir ,erul intr +n ca itatea pleural prin plaga pulmonar sau bula de emfi$em rupt &oca$ional prin plaga toracic penetrant' (olabarea plm)nului ipsilateral %i deplasarea contralateral a mediastinului (omprimarea plm)nului contralateral cu alterarea capacitii entilatorii a acestuia

Expir (re%terea presiunii intrapleurale cu +nchiderea comunicrii tip al unisens ,ccentuarea deplasrii mediastinale %i pleurale- deprimarea diafragmului ,lterarea +ntoarcerii enoase prin cre%terea presiunii intratoracice %i distorsionarea enei ca e

!neumotorax +n tensiune .anifestri clinice %i mane re terapeutice

Dispnee (iano$ Durere toracic De iaie traheal Hipersonoritate !leurostomie torace anterior spaiul 012 intercostal cu drena3 4eclaire

/mpingerea pistonului seringii ume$ite de ctre presiunea intratoracic 5nserie ac de calibru mare pentru decompresiune de urgen a presiunii intratoracice

!neumotorax st)ng +n tensiune

!neumotorax bilateral +n tensiune

(* 1 !neumotorax +n tensiune

!neumotorax st)ng +n tensiune Rg post mortem

(* !neumotorax +n tensiune cu extensie sub ficat

(* !neumotorax +n tensiune cu extensie sub ficat

!neumotorax +n tensiune &sufocant'

*uburi de dren introduse prea mult +n ca itatea pleural

(* torace superior po$iia tuburilor de dren *ub +n fisura oblic blocat de esut pulmonar

!neumotorax drept +n tensiune (* torace inferior

*ub neintrodus suficient 6ltimul orificiu aproape ie%it din ca itate

Hemothorax.
accumulation of blood in the pleural space it occurs in "!# to G"# of patients with se+ere blunt or penetrating chest trauma relati+el% as%mptomatic fran7 h%po+olemic shoc7 at the time of presentation, d%spnea or shortness of breath

Treatment of hemothora/
begins with tube thoracostom% to e+acuate the blood and ree/pand the lung Bimple tube thoracostom% is ade0uate treatment for up to -"# of patients ?the pulmonar% parench%ma has a high concentration of tissue thromboplastin, which probabl% contributes to hemostasis and sealing of air lea7s @$ indication for thoracotom% for e+acuation of clot and control of bleeding*
hemod%namic instabilit% massi+e hemothora/ more than (,!!! ml persistent bleeding, at a rate greater than !! mDHh for & hours, or greater than (!! mDHh for - hours$

 2h%sical e/amination
decreased breath sounds dullness to percussion on the injured side

Bupine chest films usuall% show ha>iness of the affected lung field or, with massi+e hemothora/, complete opacification

Hemotorax 1 surse
!lm)n ,rtera toracoacromial & ia traiect plag' ,rtera toracic lateral & ia traiect plag' Vase mari mediastinale 5nim

,rtera toracic intern Vase intercostale #tructuri intraabdominale &ficat- splin' ia diafragm

Hemotorax (uantificare %i atitudine

Minim (<350 ml) De obicei s)ngele se resoarbe spontan sub tratament conser ator *oracocente$a este rareori necesar

Moderat (350 1500 ml) *oracocente$ %i pleurostomie cu drena3 4eclaire

Masiv (>1500 ml) !leurostomie dubl pentru a pre eni colmatarea cu cheaguri *oracotomia poate fi necesar pentru a opri s)ngerarea

Hemotorax 1 ortostatism

Hemotorax drept

Hemotorax decubit dorsal & Fracturi costale multiple

Hemotorax masi

Hemotorax bilateral

Hemo1pneumotorax

Detaliu

Hemotorax st)ng Rg iniial &fr tensiune'

(* Hemotorax +n tensiune

(* Hemotorax +n tensiune

!lag prin +n3unghiere hemitorace drept inferior 7e$iune diafragmatic %i hepatic Hemotorax decubit dorsal

(*

Pulmonary Contusion
2ulmonar% contusion in+ol+es e/tensi+e interstitial hemorrhage within the parench%ma, with al+eolar collapse and e/tra+asation of blood and plasma into the al+eoli$ 2ulmonar% contusion occurs in up to G!# of patients with se+ere blunt chest trauma

 As a result, a +entilation'perfusion mismatch de+elops, which leads to arterial h%po/emia The h%po/emia is usuall% refractor% to increases in inspired o/%gen concentration$ 2ulmonar% compliance decreases, and wor7 of breathing increases

Pulmonary Contusion
initial C)Rs ma% be normal 9bruising; of the lung
interstitial and al+eolar edema hemorrhage subse0uent al+eolar collapse

chest CT can 9grade; the degree of injur% more accuratel% and ma% lead to better predictions of the clinical course

2ulmonar% Contusion . treatment

Is primaril% supporti+e
Intra+enous +olume should be restricted if possible since the associated capillar% lea7 will lead to a worsening of pulmonar% edema 3iuresis is indicated in the presence of +olume o+erload

Cot re0uire intubation

arterial blood gases partial pressure of o/%gen I6! mm Hg with inspired o/%gen concentration of "!# a respirator% rate J & breathsHmin

 These patients should be carefull% monitored, and care should be ta7en to pro+ide ade0uate analgesia for rib fractures$ 2atients who cannot sustain ade0uate pulmonar% function re0uire mechanical +entilation 2ositi+e end'e/pirator% pressure ?2882@ has a protecti+e effect and preser+es functional reser+e capacit% proph%lactic antibiotics is not indicated

(ontu$ie pulmonar

,RD# dup contu$ie pulmonar dreapt

(ontu$ie pulmonar asociat cu plag prin +mpu%care trunchi brahiocefalic

Tracheobronchial Injuries.
=rom blunt trauma are relati+el% uncommon
J (# of patients with se+ere trauma blunt trauma ' high'speed motor +ehicle accidents crushing injuries

If significant anteroposterior compressi+e force is applied to the chest, it causes rapid lateral deformation of the thoracic ca+it% and results in traction injur% of the trachea or main'stem bronchi, usuall% within cm of the carina 2enetrating injuries in+ol+e the cer+ical trachea in more than -!# of cases$

Tracheobronchial Injuries
Most patients with se+ere airwa% injuries die at the scene of the accident as a result of airwa% obstruction Cervical tracheal injuries*
Usuall% present with upper airwa% obstruction and c%anosis unrelie+ed with O B%mptoms include local pain, d%sphagia, cough, and hemopt%sis Bubcutaneous emph%sema

Tracheobronchial Injuries.
Thoracic tracheal or bronchial injuries*
-!# occur within cm of carina$ Intrapleural laceration
persistent d%spnea massi+e air lea7 massi+e pneumothora/ that does not reexpand with chest tube drainage$

Tracheobronchial Injuries.
8/trapleural rupture into the mediastinum$
pneumomediastinum subcutaneous emph%sema$ partial bronchial disruptions, "# will go undetected for to & wee7s, but persistent atelectasis, recurrent pneumonia, and suppuration should prompt further in+estigation

Radiographic signs on C)R

An abnormal admission C)R will be seen in 1!# of cases 2neumothora/ 2leural effusion 2neumomediastinum Bubcutaneous emph%sema ?air in the soft tissues of the nec7 and chest wall@ Mediastinal hematoma

Specific findings 2eribronchial air 3eep cer+ical emph%semaK radiolucent line along pre+ertebral fascia ?earl% and reliable sign@ =allen lung ' in which the lung is seen to drop awa%

Tracheobronchial Injuries.
2lacement of a tube thoracostom% ma% result in a continued massi+e air lea7 from the chest tube with no e/pansion of the lung
If so, a second chest tube should be placed, and bronchoscop% should be underta7en to confirm the diagnosis$

Treatment
J (H, of the circumference of the bronchus and the lung can be ree/panded with chest tube placement, nonoperati+e management probabl% will be successful I(H, of the circumference of the airwa%
earl% surgical repair is indicated$

2ersistent large air lea7 and inabilit% to ree/pand the lung also ma% necessitate surgical repair of bronchial injuries$

 3efiniti+e treatment includes primar% repair with mucosa' to'mucosa closure using absorbable, interrupted sutures$ 8/posure for injuries Median sternotom% pro+ides access to the anterior or left lateral portion of the mediastinal trachea Right posterolateral thoracotom% pro+ides e/posure of the right lateral or posterior aspect of the trachea or right lung bronchi or parench%mal injur% Deft posterolateral thoracotom% pro+ides access to the left lung bronchi or parench%mal laceration Eronchoscopic stent placement also has been used successfull% in the repair of isolated bronchial injuries

!lag prin +n3unghiere cer ical st)ng penetrant Laceraie traheal

*oracotomie dreapt reparare prin sutur traheal cu fire separate

!lag prin tiere cer ical cu perforaie traheal (linic emfi$em subcutanat Radiologic pneumomediastin *ratament conser ator &monitori$arecontrol bronhoscopic'

Elunt cardiac injur%

Cardiac in+olment in nonpenetrating trauma probabl% ocuurs more ofthen than reali>ed$ It is most common unsuspected +isceral injur% responsible for death$

 Mechanisms*
Budden deceleration Compression between the sternum and +ertebral column 8/ternal blow, e+en without associated chest wall fractures =ragment of the fractured bon% chest wall is dri+en into the heart$

The clues to cardiac injuries

Eruise on sternum =ractured sternum Une/plained h%potension Recurrent hemothora/ 8CA e+idence of ischemia or m%ocardial infarction, conduction disturbances ' heart bloc7 Cew cardiac murmurs Muffed heart tones

M%ocardial contusion
Is the most common lesion encountered clinicall% in patients with nonpenetrating cardiac injur% Is the one of the most fre0uentl% missed diagnoses in patients with multiple injuries$

M%ocardial contusion
Cardiac contusion is recogni>ed as a dar7 red, hemorrhagic area =ull thic7ness of the m%ocardium
Rupture of the m%ocardium Aneur%sm formation

3amaged m%ocardium is predisposed to the de+elopment of cardiac arrh%thmias

M%ocardial contusion
3iagnosis*
B%mptom of cardiac contusion ma% be absent or mas7ed b% other se+ere injuries The most common s%mptom ? G!#@ is precordial pain The most common dela%ed s%mptoms are angina, palpitations and congesti+e heart failure The most fre0uentl% encounted ph%sical finding is tach%cardia

M%ocardial contusion
8CA
8CA should be performed an admission as a screening test for all patients suspected of ha+ing ECI
3%srh%thmia ? tach%cardia@ Atrial or +entricular ectop% B'T changes .ele+ation bundle branch bloc7 hemifascicular bloc7s

 If the 8CA is normal at admission and & hours later, the ris7 of de+eloping life' threatening arrh%thmias is essentiall% nil Creatinine phospho7inase ?C2L@ and troponin'I le+els ' correlate with the se+erit% of m%ocardial contusion

 8chocardiogram asses *
wall motion +al+ular competenc% global cardiac performance intramural hematomas, pericardial effusion ma% be the most sensiti+e test for the diagnosis of blunt cardiac injur% Transthoracic echocardiogram ?TT8@ is con+enient and nonin+asi+e T88 should be used when the TT8 is technicall% inade0uate

M%ocardial contusion' treatment

3%srh%thmias should be treated aggressi+el%
there are no data to support the use of proph%lactic antid%srh%thmics$

The treatment of arrh%thmias follows standard algorithms Dow cardiac output ma% re0uire support with an intra'aortic balloon pump ?IAE2@

Cardiac Tamponade
can occur from either blunt or penetrating trauma, although penetrating injuries are much more common G" to (!! mD of blood can produce tamponade

Cardiac Tamponade
Tamponade should be considered in patients with se+ere blunt chest trauma who remain h%potensi+e and ha+e no e+idence of e/ternal blood loss or hemorrhage into the thora/, abdomen, or pel+is

 Eec7Ms triad
muffled heart sounds decreased pulse pressure jugular +enous distention
occurs in a minorit% of patients ?&!#@ if the patient is h%po+olemic, jugular +enous distention ma% not de+elop until late in the presentation$

Cardiac Tamponade
2ulsus parado/us
decrease in s%stolic pressure of I(! mmHg during inspiration

LussmaulMs sign is a hard and true sign of tamponade

inspiration in a spontaneousl% breathing patient results in an increase of the jugular +enous distention

=ABT ultrasound e/amination should be performed to identif% pericardial fluid

A positi+e pericardial +iew on the =ABT in an unstable patient is an indication to proceed with median sternotom% or left anterolateral thoracotom% An e0ui+ocal pericardial +iew on the =ABT e/amination or a positi+e e/amination in a stable patient necessitates an operati+e pericardial window A negati+e =ABT in penetrating injur% can be falsel% negati+e secondar% to decompression of pericardial fluid into the pleural space$

Cardiac Tamponade
Chest radiograph%
2neumothora/ Hemothora/ Cegati+e$ The pericardium is not acutel% distensible, and an enlarged cardiac silhouette is not reliabl% seen in acute tamponade

 Central +enous catheter in the hemod%namicall% stable patient

A +er% high central +enous pressure ?I ! to " cm H O@ is probabl% diagnostic but depend on the patientMs +olume status$

Cardiac Tamponade ! treatment

intubation, o/%genate, and start +olume resuscitation$ 2ericardiocentesis can be used as a tempori>ing maneu+er to relie+e tamponade until definiti+e repair is possible$ this is often difficult to successfull% perform because of nature of the procedure and relati+el% small blood +olume in the sac$

Cardiac Tamponade ! treatment

hemod%namic instabilit% should undergo immediate left anterolateral thoracotom% with a wide, longitudinal opening of the pericardium$
Cardiac lacerations should be digitall% controlled until ade0uate blood +olume is restored and the patient is relati+el% stable$ The use of staples also has been ad+ocated to close cardiac lacerations rapidl% but temporaril% for immediate hemostasis$

 Bmall lacerations in the beating heart can be then repaired using nonabsorbable sutures Darger lacerations ma% re0uire cardiopulmonar% b%pass for ade0uate decompression and repair$ The left thoracotom% incision can be carried trans+ersel% across the sternum into the right chest to facilitate e/posure of the entire heart and great +essels if necessar%$

Hemopericard acut %i tamponad cardiac

!re$ena s)ngelui +n sacul pericardic inextensibil +mpiedic umplerea cardiac

8oc de se eritate ariabil

!resiune enoas crescut

Hipotensiune arterial !uls slab

Dinamica presiunii arteriale %i enoase +n tamponada cardiac

!ericardiocente$a

!uncie pericardic la ni elul unghiului costoxifoid Rol diagnostic %i decompresi

9rientarea superioar a acului pentru e itarea le$rii diafragmului %i ficatului

Aortic injuries
Traumatic rupture of the aorta is defined as a tear in the wall of the aorta that is contained b% the ad+entitia of arter% and the parietal pleura Techanism of injur% is rapid deceleration
falls from significant height high'speed motor +ehicle crashes ejected occupants$

 -!# of the +ictims die at the scene The remaining patients are at ris7 for dela%ed free rupture into the mediastinum or pleural space$

Aortic injuries
Docated
pro/imal aortic arch near the aortic +al+e just distal to the origin of the left subcla+ian arter% at the diaphragmatic hiatus

Bur+i+ors usuall% ha+e a contained hematoma held onl% b% an intact ad+entitial la%er$

Aortic injuries
sur+i+ors are initiall% h%potensi+e but respond to fluid resuscitation because free rupture of the transected aorta is rapidl% fatal, persistent or recurring h%potension usuall% results from a secondar% bleeding source, not the aortic injur%

Aortic injuries
Clinical signs*
As%mmetr% in upper e/tremit% blood pressures and upper e/tremit% h%pertension Nidened pulse pressure Chest wall contusion 2osterior scapular pain A careful neurologic e+aluation is important because patients ma% ha+e paraplegia or paraparesis from loss of blood flow through the intercostal arteries that suppl% the spinal cord

OOOOOne half of patients with great +essel injur% from blunt trauma ha+e no e/ternal signs of blunt chest injur%$

Aortic injuries
Bigns on C)R*
Nidened mediastinum ?I- cm@K this is the most consistent finding =racture of first three ribs, scapula, or sternum Obliteration of aortic 7nob 3e+iation of trachea to right 8le+ation and rightward shift of the right mainstem bronchus 3epression of the left mainstem bronchus 3e+iation of esophagus ?nasogastric tube@ to right Deft pleural effusion

 Co single sign reliabl% confirms or e/cludes aortic injur%$ Howe+er, a widened mediastinum is the most consistent finding on C)R and should prompt further e+aluation$

Aortic injuries
Chest computed tomograph% ?CT@
mediastinal hematomas are suggesti+e for aortic injur% Helical and new high'speed, high'resolution scanners can pro+ide definiti+e diagnosis of the aortic injur%, ri+aling angiograph% with respect to o+erall accurac%$

Mediastinal hematomas found on chest CT mandate aortogram for definiti+e diagnosis$

 3efiniti+e diagnostic aortic injuries found on helical scanners ma% also re0uire aortograph%, depending on the practices of the surgeon who will perform the repair$ mall intimal tears and dissections ma% be missed on CT scan$

Aortic injuries
Transesophageal echocardiogram ?T88@ A positi+e T88 will confirm the location of the injur% If the T88 is negati+e, an aortogram will be re0uired to reliabl% e/clude the injur%

T88 is an e/cellent alternati+e for unstable patients who*

Must be transported directl% to the OR for other ca+itar% bleeding Ha+e a +er% wide mediastinum and a high suspicion of thoracic aortic injur% e/ists 2atients in the ICU who are high ris7 for transport to radiolog%$

Aortic injuries . treatment

Control and pre+ent h%pertension
maneu+ers to decrease wall tension in the aorta preoperati+el% ma% decrease ris7 of rupture Eeta bloc7ade ? 8smolol, Dabetolol@ should be instituted onl% after significant hemorrhage from other injuries has been ruled out

 The goal for s%stolic blood pressure should be appro/imatel% (!! mmHHg Citroprusside can be added as a second agent if blood pressure is not controlled with beta bloc7ad
OOO increased wall shear stress because pulse pressure often increases as s%stolic blood pressure decreases OOOalso should be a+oided in patients with head injuries$

Aortic injuries
Most blunt injuries of the aorta re0uire immediate surgical repair Btable pseudoaneur%sms that ma% be safel% managed with dela%ed operation if necessar% in the presence of other life' threatening injuries$

Aortic injuries
Injuries of the ascending aorta often re0uire full cardiopulmonar% b%pass for repair, and median sternotom% pro+ides the best e/posure$ Injuries of the descending aorta accomplished through a left posterolateral thoracotom%$

 Relati+el% simple injures can be repaired primaril%$ The thoracic aorta has relati+el% limited mobilit%, and intercostal +essels should not be sacrificed to facilitate primar% repair owing to concerns about spinal cord perfusion$ More e/tensi+e injuries re0uire placement of a prosthetic graft$

.ediastin lrgit Ruptur de aort distal de subcla ia st)ng

!ont"#ie aortic !sudoane rism aortic cu mediastin lrgit

,specte tomografice

3iaphragmatic injur%
Elunt trauma$
3iaphragmatic injur% from blunt forces is classicall% large, radial, and located posterolaterall%$ The left hemidiaphragm is in+ol+ed in 6!# to -!# of cases$ 3iaphragmatic ruptures are mar7ers for se+ere intraabdominal injuries$

2enetrating trauma$
Nounds are smaller but tend to enlarge o+er time$ Deft'sided injuries still predominate$

 These injuries need operati+e repair when diagnosed because the% do not heal spontaneousl% and can produce herniation or strangulation of the intestine as late se0uelae

3iaphragmatic injur% ' diagnosis

3iagnosis can be difficult, therefore, ha+e a high inde/ of suspicion based on mechanism
Rapid deceleration or direct crush to the upper abdomen Be+ere chest trauma, lower rib fractures 2enetrating injuries to the chest and upper abdomen

C)R is diagnostic in onl% !# to "!# of cases of blunt trauma$

2ossible CR) findings include*

Hemidiaphragmatic ele+ation or lower lobe atelectasis Casogastric tube in left hemithora/ Btomach, colon, or small bowel in chest In penetrating trauma and small defects, the diaphragm appears normalOOOOO normal$ After e/tubation, herniation ma% become apparent on C)R Right hemidiaphragm tears are less li7el% to be diagnosed b% C)R because of the presence of the li+er in the defect$

3iaphragmatic injur% ' diagnosis

CT scan ma% miss diaphragmatic injur% in the absence of gross hollow +isceral herniation$ 3iagnostic peritoneal la+age ?32D@
If an ipsilateral chest tube is present, 32D fluid ma% be obser+ed e/iting the chest tube

direct +isuali>ation of the injur% b% laparotom%, laparoscop%, or thoracoscop% remains the gold standard for diagnosis$

3iaphragmatic injur% ' treatment

Most diaphragmatic tears re0uire repair$ Fiscera tend to herniate as a result of changes in intrathoracic pressure during respiration, with strangulation as a possible late complication$ Acute repair is accomplished +ia laparotom%, in most cases, with nonabsorbable, interrupted hori>ontal mattress sutures$

 Thoracotom% ma% be needed to reduce large defects in chronic herniation$ 2rosthetic material or flaps are often needed to close the defect$

A coiled nasogastric tube within the left hemithoracic ca+it% is pathognomonic for a rupture of the left hemidiaphragm$

,ccident de motociclet 1 Ruptur diafragmatic dreapt

,spect intraoperator

7aceraie diafragmatic st)ng cu hernierea stomacului +n torace

Ruptur diafragmatic dreapt cu herniere hepatic %i a colecistului

,spect intraoperator

#utur

$"pt"r dia%ra%matic st&n' c" herniere a stomac"l"i (i splinei ,spect radiologic

(* #tomac intratoracic & fractur costal

,spect intraoperator dup reducerea herniei

8anul de constricie de la ni elul stomacului

#utura diafragmului

Ruptur frenic "xamen radiologic digesti cu substan de contrast

7aceraie diafragmatic

)astrotorax st&n' ,spect radiologic

,specte tomografice

*ernie dia%ra'matic

+e%ect dia%ra'matic

*ernie dia%ra'matic

*ernie dia%ra'matic

TH8 38A3DP "#$%&

Proceduri

4loc ner os intercostal

7ocul optim de in3ectare unghiul coastei &cel mai u%or palpabil'

7ocuri pentru in3ecie :; 6nghiul coastei &preferat' 0; 7inia axilar posterioar 2; 7inia axilar anterioar <; #ediul fracturii =; !arasternal :; ,cul se introduce p)n atinge marginea inferioar a coastei 0; Retragere u%oar a acului- orientare inferioar- a ansare 2 mm pentru a aluneca sub coast %i a a3unge +n spaiul intercostal 2; ,spirare +naintea introducerii aneste$icului

+rena, ple"ral 7ocul introducerii

"xplorare digital

5nseria tubului

,ncorarea tubului la tegument

Drena3 sub ni el lichidian

*oracoscopia

M"nc de echip -