GENERAL EMERGENCY LIFE SUPPORT

TUJUAN
• Mengenal trauma toraks yang mengancam jiwa

• Mengetahui pertolongan pertama pada trauma

toraks dengan ancaman kematian, khususnya di
pelayanan gadar dan saat bencana

• Mengetahui komplikasi akibat trauma toraks

 INSIDEN

• 10% kematian terjadi pada pasien trauma toraks

• Terdapat 1 kematian (25%) akibat trauma toraks dari
4 kematian akibat trauma lainnya
• Mekanisme : tumpul dan tajam
• Hanya 10% trauma tumpul dan 15% trauma tajam
toraks yang memerlukan tindakan pembedahan
 Proses Bernafas
• Ventilasi (udara masuk paru2)

• Distribusi (udara keseluruh alveoli)

• Difusi (terjadi pertukaran gas O2-CO2)

• Perfusi (terjadi pertukaran di jaringan)

 Patofisiologi
• Trauma toraks menyebabkan nyeri, mengganggu
ventilasi, terjadi hipoksia jaringan

• Difusi O2-CO2 terganggu  penumpukkan CO2

dalam darah  hiperkarbia

• Akibat hal2 tsb  asidosis metabolik

 Trauma Toraks Dengan Ancaman Kematian

• Tension pneumotoraks

• Tamponade jantung

• Hematotoraks masif

• Flail chest
 Potensial Mengancam Jiwa
• Pneumotoraks

• Hematotoraks

• Trauma diafragma

• Trauma aorta

• Kontusio paru
 Major Thoracic Injury
“Lethal six” “Hidden six”

• Airway obstruction • Aortic rupture

• Tension pneumothorax • Tracheobronchial rupture
• Cardiac tamponade • Blunt cardiac injury
• Open pneumothorax • Diaphragmatic tear
• Massive hemothorax • Esophageal perforation
• Flail chest • Pulmonary contusion
 Tension Pneumotoraks
• Akibat trauma, udara bocor masuk rg pleura setiap inspirasi
dan tdk bisa keluar, sehingga tekanan intra pleura akan sangat
tinggi

• Paru2 kolaps, pembuluh drh balik (VCS,VCI) kolaps darah ke

jantung terhambat, isi jantung kurang tekanan darah
menurun. Mediastinum terdorong termasuk trakhea kearah
berlawanan

• Klinis sesak, tekanan darah turun, trakhea terdorong, lakukan

tindakan segera (needle thoracostomy), penegakkan diagnosa
 klinis bukan radiologis
 Needle Decompression
Insert hollow needle or catheter into After needle insertion, note audible
affected pleural space rush of air as pressure escapes

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Pneumothorax
 Tamponade Jantung
• Hemopericardium, krn perikard kaku maka terjadi gangguan
gerakan jantung.

• Terjadi bendungan vena (lihat v jugularis), bunyi jantung

menjauh, tekanan darah turun, ketiganya disebut TRIAS BECK.

• Tindakan perikardiostomi (tusuk dg jarum besar/abocath 14-

16F dgn spuit, pada ujung proc. Xiphoideus arah ujung
skapula kiri 45, hati2 bedakan darah intraperikard atau dari
dalam jantung, pasang EKG monitor)
Cardiac Tamponade
Pericardiocentesis
 Hematotoraks Masif
• Perdarahan dalam rg pleura

• Paru kolaps , hipoksia, tanda

syok hipovolemik, anemis.

• Pasang chest tube (WSD),

bila perdarahan > 200 cc/
jam (dalam 2-4 jam
pertama) indikasi
torakotomi penghentian
sumber perdarahan.
 Operative Intervention for Hemothorax

• As noted previously
• Hemothorax: massive =
initial drainage more than
1,000 cc or
• Continuous bleeding of
200 cc/hr for 2 hrs
 Open Pneumotoraks
• Defek pada dinding
dada dgn diameter >
2/3 trakhea shg
udara masuk melalui
dinding dada lbh bsr
d.p masuk trakhea

• Tutup dgn kasa steril

3 sisi
 Fraktur Kosta
• Perhatikan jumlah, lokasi, komplikasi

• # kosta 1-3 : curigai cedera kepala-leher, curigai kerusakan

pembuluh aorta, pleksus brakhialis
• # kosta 4-9 : paling sering, berakibat pneumotoraks,
hematotoraks, kontusio paru.
• # kosta 10-12: curigai trauma hepar – lien
• # kosta bagian belakang lebih stabil

• Terapi : pemberian O2, analgetika, observasi komplikasi

 Flail Chest
• Fraktur ≥ 2 tulang iga dan terdapat 2 atau lebih
garis fraktur (segmental)

• gerakan paradoksal, nafas cepat, nyeri, disertai

pneumotoraks, hematotoraks, kontusio paru. Sering
dgn distress pernafasan.

• Kenali klinis , penanganan kemungkinan intubasi dgn

ventilator, pemasangan chest tube, analgetika.
Flail Chest (lanjutan)
 Fraktur Sternum
• Sering akibat trauma langsung pd pengemudi
(tanpa safety belt/ air bag)

• Tampak deformitas

• Komplikasi yg dapat terjadi kontusio jantung,

tamponade jantung. Kenali tanda klinis
 Ruptur Diafragma
• Akibat trauma terjadi
mekanisme Paper bag effect
(efek kantung kertas), kiri lbh
sering

• Organ dalam abdomen bisa

masuk (gaster, kolon, ileum).
Klinis sesak. Bising usus di
rongga toraks, pasang NGT
buat X ray

• Koreksi dengan pembedahan

 Ruptura Trakhea - Bronkhus
• Ruptur trakhea,
bronkhus sering
didaerah karina (
percabangan), bila
ruptur total bisa fatal

• Klinis hemoptisis,
sianosis, empisema
subkutis, intubasi sulit
karena distorsi
trakhea.
Initial CXR of Concern
 Ruptur Aorta
• Sering bersifat fatal, bila partial/ kecil akan terdapat
hematom di mediastinum dapat menjadi sumbat
sementara

• Tampak jejas pada dada, tekanan darah tidak pernah

membaik, pada X ray terdapat gambaran pelebaran
mediastinum, curigai ruptur aorta

• Diagnostik aortografi, tindak pembedahan khusus

dengan fasilitas lengkap
 Indications for Angiography

• Widened
mediastinum (>8cm)
Complete Aortogram
 Ringkasan
• Trauma toraks dapat mengancam jiwa dengan
permasalahan  perlu prioritas setelah airway
problem teratasi

• Trauma toraks disertai trauma lain (trauma ganda)

meningkatkan kemungkinan kematian

• Penanganan pertama penting terutama Needle

thoracostomy, pericardiocentesis, pemasangan
thoracic tube/ drain
 Journal of Trauma-Injury Infection & Critical Care:
November 2010 - Volume 69 - Issue 5 - pp 1022-1029

The Pattern of Thoracic Trauma After Suicide Terrorist Bombing Attacks

Bala, Miklosh MD; Shussman, Noam MD; Rivkind, Avraham I. MD, FACS; Izhar, Uzi MD;
Almogy, Gidon MD

• Results:
Prospectively collected database of patients with chest injury who were admitted to
Hadassah Hospital Level I trauma centre, in Jerusalem, Israel, from October 2000 to
December 2005.
There were many female victims after suicide bombing attacks (49.1%) compared with
GSW (21.8%) and blunt trauma (24.6%; p = 0.009). The number of body regions injured
was significantly higher in the terror group compared with the GSW and blunt groups
(median, 4, 2, and 3, respectively, p < 0.0001). The pattern of chest injury after suicide
bombing attacks was caused by a unique combination of the effects of the blast wave
and penetrating shrapnel. More than half (52.7%) of the terror victims suffered from
lung contusion and 25 (45.5%) required tube thoracostomy. Five patients (9.1%)
underwent thoracotomy for lung lacerations (n = 3), injury to great vessels (n = 2),
cardiac lacerations (n = 1), and esophageal injury (n = 1). Penetrating shrapnel was the
mechanism of injury in all these cases.
 Radiology January 2010 254:285-291
Crush Thoracic Trauma in the Massive Sichuan Earthquake: Evaluation with
Multidetector CT of 215 Cases1
Zhi-Hui Dong, MD, Zhi-Gang Yang, MD, PhD, Tian-Wu Chen, MD, Yuan-Chun Feng, MD,
Zhi-Gang Chu, MD, Jian-Qun Yu, MD, Hong-Li Bai, MD and Qi-Ling Wang, MD

One hundred forty-three patients (66.5%; 95% confidence interval [CI]:

60.2%, 72.8%) had at least one rib fracture; the mean number of rib
fractures per patient was 11. Forty-five of these patients (31.5% of 143
patients; 95% CI: 23.9%, 39.1%) had flail chest, with a total of 288 ribs
fractured. There were 46 patients (21.4%; 95% CI: 15.9%, 26.9%) with
at least one vertebral fracture. There were 77 vertebral fractures total;
36 of these fractures were in T1 through T10. Twelve patients (5.6%;
95% CI: 2.5%, 8.7%) had sternal fractures, and 48 patients (22.3%; 95%
CI: 16.7%, 27.9%) had either scapular or clavicular fractures. There
were 117 patients (54.4%; 95% CI: 47.7%, 61.1%) with pulmonary
parenchymal injuries and 146 (67.9%; 95% CI: 61.7%, 74.1%) with
pleural injuries.
TERIMA KASIH