S1

THORACIC
TRAUMA

DR. AHMAT UMAR SPB, BTKV

BEDAH TORAK KARDIAK DAN VASKULER
BEDAH THORAX

• BEDAH JANTUNG
• BEDAH NON JANTUNG / PARU
Penetrating Thoracic Trauma
Penetrating Thoracic Trauma
 TRAUMA

ANAMNESA
PEMERIKSAAN FISIK
- INSPEKSI :
- PALPASI
- PERKUSI
- AUSKULTASI
PEMERIKSAN TAMBAHAN
: FOTO X RAY
 CARA PEMERIKSAAN FISIK PD TRAUMA TORAKS DAN
APA YANG DIEVALUASI?

• Inspeksi : gerak napas simetris? Gerakan paradoksal ? Retraksi? Pernapasan

cuping hidung? Adanya luka, bila ada luka terbuka lebih lebar dari ukuran trakea 
sucking wound . Evaluasi pula apakah ada jejas atau hematom pada regio toraks?
• Palpasi : nyeri tekan, vocal fremitus, krepitasi, ictus cordis
• Perkusi : sonor atau redup?
• Auskultasi : suara napas vesikuler meningkat atau menurun, bandingkan kanan
dan kiri. Bila pada pasien dgn ventilator mekanik, pastikan ETT terletak pada
tempatnya sebelum menilai suara napas kedua hemitoraks. Bisa saja terjadi
perbedaan suara napas karena letak ETT.
 THORACIC TRAUMA
A. IMMEDIATE LIFE THREATENING
INJURIES (THE LETHAL SIX)
• a. Airway Obstruction
• b. Tension Pneumothorax
• c. Pericardial Tamponade
• d. Open Pneumothorax (sucking
chest wound)
• e. Massive Hemathorax
• f. Flail Chest
B. POTENTIALLY LIFE THREATENING
INJURIES (THE HIDDEN SIX)
• a. Thoracic Aortic Disruption
• b. Tracheobronchial Injuries
• c. Blunt Myocardial Injury
• d. Diaphragmatic Injury
• e. Oesophageal Injury
• f. Pulmonary Contusion
THORACIC TRAUMA

• - 1 out of 4 death

• - blunt < 10 % require operation

• - penetrating 15%-30% require operation
• - majority require simple procedures
AIRWAY OBSTRUCTION
LARYNGEAL INJURY
• - rare occurrence
• - hoarseness
• - subcutaneous emphysema
• - treatment * intubation
* tracheostomy
BREATHING

TENSION PNEUMOTORAX :

Etiology
• Parenchymal and/or chest-wall injury.
• Air enters pleural space with no exit
• Positive pressure ventilation
- collapse of affected lung
- decrease venous return
- decrease ventilation of opposite lung.
BREATHING

Tension pneumothorax sign/symptoms

• Inspeksi ;
• o gelisah akibat hipoksia, keringat dingin  paling jelas.
• o gerak dada asimetris, dada sakit tertinggal & membesar, retraksi +,
• o tampak sianotik
• o distres napas berat, RR meningkat, seperti tercekik, susah bicara
• o distensi vena leher (JVP naik)
• o tekanan darah menurun akibat penurunan preload

• - Palpasi ; trakea terdorong ke kontralateral; takikardia

• - Perkusi ; hipersonor pada sisi yang sakit
• - Auskultasi ; suara napas menghilang
BREATHING
TENSION PNEUMOTHORAX

- needle decompression
- Clinical diagnosis, not by X ray
Therapy : Needle Thoracocentesis and chest
tube after it has been inserted
BREATHING

Open pneumothorax
- Cover defect
- Chest tube
- definitive operation
BREATHING

FLAIL CHEST /PULMONARY CONTUSION

• Reexpand lung
• Oxygen
• Judicous fluid management
• Intubation as indicated
• analgesia
FLAIL CHEST

• Terapi definitif  ditujukan pada pengembangan paru, oksigenasi, cairan

yang cukup serta analgesia
• Tekanan oksigen arterial dan kinerja pernafasan, penilaiannya menentukan
kapan diberi intubasi dan ventilasi
CIRCULATION

MASSIVE HEMOTHORAX :

• > 1500 ml blood loss

• Systemic/pulmonary vessel disruption
• Flat vs distended neck veins
• Shock with no breath sound and/or percussion dullness
CIRCULATION

Kapan hematotoraks dilakukan torakotomi?

• - Bila perdarahan lebih dari 800 cc

• - Perdarahan lebih dari 15cc/kgBB dalam 1 jam

• - Perdarahan 3-5 cc/kgBB/jam selama 3 jam

berturut turut
CIRCULATION

MASSIVE HEMOTHORAX

- rapid volume restoration

- chest decompression and X-ray

- autotransfusion

- operative intervention
CIRCULATION

CARDIAC TAMPONADE

- decrease arterial pressure

- distended neck veins
- muffled heart sound
- PEA
THERAPY – patent airway
- iv therapy
- pericardiocentesis
- pericardiostomy
SECONDARY SURVEY
POTENTIALLY LETHAL CHEST TRAUMA

1. SIMPLE PNEUMOTHORAX
2. HEMOTHORAX
3. PULMONARY CONTUSION
4. TRACHEOBRONCHIAL TREE INJURIES
5. BLUNT CARDIAC INJURY
6. TRAUMATIC AORTIC DISRUPTION
7. TRAUMATIC DIAPHRAGMATIC INJURY
8. MEDIASTINAL TRANSVERSING WOUNDS
1.SIMPLE PNEUMOTHORAX

- penetrating/blunt trauma
- hyperresonance
- decrease breath sounds
- tube thoracostomy
2.HEMOTHORAX

- chest wall injury

- lung/vessel laceration
- tube thoracostomy
3.PULMONARY CONTUSION

• Most common
• Oxygenate ventilate
• Selective intubation
4.TRACHEAL INJURY

• Frequently missed injury

• Blunt/penetrating trauma
• Partial vs complate
• Diagnostic aid endoscopy
• Treatment * airway ventilation
* operation
5.BLUNT CARDIAC INJURY

• Injury spectrum
• ECG changes: monitor change
• Echocardiography
6.AORTIC RUPTURE

• Rapid aceleration/deceleration
• Ligamentum arteriosum
• Salvage identify early
• Surgical consult
• X-ray: widened mediastinum,obliteration of the aortic
knob,depression of the left main stem bronchus,fractures of the
first or second rib or scapula
• Aortogram.
• Therapy  primer suture aorta / resection and grafting
7.DIAPHRAGMATIC RUPTURE

- most diagnosted on left

- blunt , large tears
- penetrating, small perforations
- misinterpreted x ray (elevated diaphragm,acute gastric dilatation,
aloculated pneumothorax)
- contras radiography
• Therapy  direct closure
8.MEDIASTINAL TRANSVERSING WOUND

HEMODINAMICALLY ABNORMAL
• exsanguinating thoracic hemorrhage
• tension pneumothorax
• Pericardial tamponade
• Esophageal or tracheobronchial injury
• Spinal cord injury

HEMODINAMICALLY NORMAL
- vascular: angiography
- tracheobronchial: bronchoscopy
- esophageal: esophagography,esophagoscopy
- Treatment  mandatory surgical consultation, repair identified injuries,
OTHERS TRAUMA

TRAUMATIC ASPHYXIA

 Ptechiae
 Swelling
 Plethora
 Cerebral edema
Terima kasih