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Chest trauma

Hendy Buana Vijaya


Pendahuluan

• Trauma thoraks teradi pada sekitar 60% kasus multiple trauma.


• Cedera yang paling umum dari trauma thoraks baik trauma tumpul dan
tembus adalah hemotoraks dan pneumotoraks. Lebih dari 85% pasien dapat
diobati secara definitif dengan chest tube.
• Kurang dari 10 % dari trauma tumpul thoraks dan hanya 15% - 30% dari
trauma thoraks dengan penetrasi diperlukan intervensi berupa pembedahan.
Anatomi
Definisi
Trauma thoraks adalah luka atau cedera mengenai rongga thoraks yang dapat
menyebabkan kerusakan pada dinding thoraks ataupun isi dari cavum thoraks
yang disebabkan oleh benda tajam atau benda tumpul dan dapat menyebabkan
kondisi kegawatdarutan.
Etiologi

Trauma tembus (tajam)


• Pada trauma tembus terjadi diskontinuitas dinding toraks (laserasi) langsung akibat
penyebab trauma, terutama akibat tusukan benda tajam (pisau, kaca, peluru, dsb).

Trauma tumpul
• Pada trauma tumpul tidak terjadi diskontinuitas dinding toraks. Penyebabnya antara lain
kecelakaan lalu lintas, terjatuh, cedera olahraga, dsb. Kelainan tersering akibat trauma
tumpul toraks adalah kontusio paru.
Contoh kasus
Patomekanisme
Akselerasi
• Gaya perusak berbanding lurus dengan masa dan
percepatan (Hukum Newton II). Kerusakan yang terjadi
bergantung juga pada luas jaringan tubuh yang menerima
gaya perusak dari trauma tersebut.
Deselerasi
• Kerusakan yang terjadi oleh karena pada saat trauma
organ-organ dalam keadaan masih bergerak dan gaya
yang merusak terjadi akibat tumbukan pada dinding
thoraks dan/atau organ tubuh lainnya atau karena
tarikan dari jaringan pengikat organ tersebut
Patomekanisme
Torsio dan rotasi
• Gaya torsi dan rotasi yang terjadi umumnya diakibatkan oleh
adanya deselerasi organ-organ dalam yang sebagian strukturnya
memiliki jaringan pengikat/terfiksasi.
Blast injury
• Kerusakan jaringan terjadi tanpa adanya kontak langsung dengan
penyebab trauma, sebagai contoh ledakan kendaraan saat terjadi
kecelakaan lalu lintas. Gaya merusak diterima oleh tubuh melalui
penghantaran gelombang energi.
Patofisiologi

Kematian sel

Hipoksia
Hiperkarbia
Asidosis

Kegagalan ventilasi
Kegagalan pertukaran gas
Kegagalan sirkulasi
Kelainan akibat trauma thoraks
• Trauma pada dinding thoraks dan paru
• Trauma pada aorta dan jantung
Trauma pada dinding thoraks dan paru
a. Fraktur iga
b. Flail chest
c. Ruptur Diafragma
d. Kontusio paru
e. Pneumothoraks
f. Open pneumothoraks
g. Tension pneumothoraks
h. Hemothoraks
i. Hematothoraks massif
j. Cedera trakea dan bronkus
Trauma pada aorta dan jantung
• Temponade jantung
• Kontusio miokard
• Diseksi aorta
Penatalaksanaan
• Management  principles of general trauma management
(primary survey - secondary survey)
• Management of chest trauma can be divided into three distinct levels of
care;
a. pre-hospital trauma life support
b. in-hospital or emergency room trauma life support
c. surgical trauma life support
Prehospital trauma life
support
• Assessment of breathing and clinical examination of the thorax (respiratory
movements and quality of respiration) are necessary to recognize major thoracic
injuries such as tension pneumothorax, open pneumothorax, flail chest, pulmonary
contusion and massive haemothorax.
• Inspection, palpation, percussion and especially auscultation (sensitivity
90%, specificity 98%) will provide information as to whether a tension
pneumothorax is present.
• Clinical diagnosis of tension pneumothorax, may require immediate intervention, by
initial needle decompression of the pleura space.
Emergency room trauma life support
• Repetition of clinical examination in primary survey together with anamnestic information
on the mechanism of thoracic trauma will provide information on potential severity of
thoracic injury.
• When the extent of trauma cannot be defined it is recommend to perform
contrast-enhanced CT scan. As the sensitivity of a chest X-ray in the emergency room is
only 58.3%.
• Thoracic ultrasound examination is valid when CT scan is not necessary, in comparison with
chest X-ray it shows equivalent sensitivity and specificity for diagnosis of pneumothorax.
Ultrasonography in the emergency room is also a reliable method to exclude
pleural/pericardial effusion.
Primary survey
• As in all trauma patients, the primary survey of patients with thoracic injuries
begins with the airway, followed by breathing and then circulation.
• AIRWAY PROBLEMS
• BREATHING PROBLEMS
• CIRCULATION PROBLEMS
Airway
Primary • Airway obstruction
Survey • Tracheobranchial tree injury

Breathing
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax

Circulation
• Massive hemothorax
• Cardiac tamponade
Primary survey immediately life threatening injuries should be exclude or treated such as :
• Airway obstruction
Airway obstruction results from swelling, bleeding, or vomitus that is aspirated into the airway,
interfering with gas exchange.

• Tension pneumothorax
Tension pneumothorax develops when a “one-way valve” air leak occurs from the lung or
through the chest wall
Tension pneumothorax

Tension pneumothorax develops when a “one-way


valve” air leak occurs from the lung or through the chest
wall
Tension pneumothorax
• Chest pain
• Air hunger
• Tachypnea
• Respiratory distress
• Tachycardia
• Hypotension
• Tracheal deviation away from the side of
the injury
• Unilateral absence of breath sounds
• Elevated hemithorax without respiratory
movement
• Neck vein distention
• Cyanosis (late manifestation)
Open pneumothorax
Large injuries to the chest wall that remain
open can result in an open pneumothorax,
also known as a “sucking chest wound”
Open pneumothorax

• Pain
• Difculty breathing
• Tachypnea
• Decreased breath sounds on the
affected side
• Noisy movement of air through the
chest wall injury
Massive hematothorax
• Massive hemothorax results from the rapid
accumulation of more than 1500 mL of
blood or one third or more of the patient’s
blood volume in the chest
cavity
• Based on the rate of continuing blood loss
(200mL/hr for 2 to 4 haours)
Massive hematothorax
Massive hemothorax is initially managed by :

• Simultaneously restoring blood volume


• Decompressing the chest cavity.
• Establish largecaliber intravenous lines, infuse crystalloid
• Begin transfusion of uncrossmatched or type-specifc
blood
as soon as possible.
• When appropriate, blood from the chest tube can be
collected in a device suitable for autotransfusion
Tension pneumothorax VS Massive
hematothorax
Cardiac Tamponade
Cardiac tamponade is compression of the
heart by an accumulation of fluid in the
pericardial sac.
The classic clinical triad of muffled :
• Heart sounds
• Hypotension
• Distended
vein
Cardiac Tamponade
• Kussmaul’s sign (i.e., a rise in venous
pressure with inspiration when breathing
spontaneously) is a true paradoxical
venous pressure abnormality
• Focused assessment with sonography for
trauma (FAST) is a rapid and accurate
method of imaging the
heart and pericardium
• Over the needle catheter or the Saldinger
technique for insertion
Cardiac Tamponade
• Kussmaul’s sign (i.e., a rise in venous
pressure with inspiration when breathing
spontaneously) is a true paradoxical
venous pressure abnormality
• Focused assessment with sonography for
trauma (FAST) is a rapid and accurate
method of imaging the
heart and pericardium
• Over the needle catheter or the Saldinger
technique for insertion
Cardiac Tamponade

Secondary survey will provide information on potentially life-threatening injuries :
• Pulmonary contusion
• Myocardial contusion
• Aortic disruption
• Traumatic diaphargma rupture
• Tracheobronchial disruption
• Oesophagial disruption
Algorithm
Penetrating
Chest
Trauma
Algorithm
Penetrating
Chest
Trauma
Algorithm
Blunt
Chest
Trauma
Indication for immediate thoracic surgical
intervention are :
• Blood loss > 1,500 mL initially />200 mL / hour over 2-4 hours
• Endobronchial blood loss; massive contusion with significant imparment of
mechanical ventilation
• Tracheobronchial tree injury (air leakage/hemothorax)
• Injury of the hearth or large vessel (blood loss/pericardial tamponade)
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