harry soedjatmikomarshal

Division Of Thoracic And Cardiovascular SurgeryDepartment Of Surgery

Faculty Of Medicine, University Of North Sumatera

American College of SurgeonsCommittee on Trauma Presents

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The Need

Trauma is leading cause of death in the first 4 decades of life.

3 patients permanently disabled per deathATLS provides common language

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ATLS Concept

ABCDE

Airway with c-spine protection

Breathing

Circulation

Disability / Neurologic status

Exposure / Environment

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Primary Survey Adult, children, pregnant women

Priorities are the same !

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Initial Assessment / Management

Transfer

Optimize patient

Status

Reevalution

Injury

Primary Survey Adjuncts

Resuscitation

Reevaluation Secondary Survey

Adjuncts

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Objectives

Indentify and treat injuries found during the primary survey.

Indentify and treat injuries found during the secondary survey.

Demonstrate the ability to perform

life saving chest management. Indications Contraindications

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Thoracic Trauma

1 out of 4 deaths Blunt : < 10% require operation Penetrating : 15% - 30% require

operation Majority : require simple

procedures

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Initial Assessment/ Management

Primary Survey Identifies most life -

threatening injuries

Resuscitation Airway control Ensure oxygenation/ventilation Needle / tube thoracostomy

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Secondary Survey

Identifies mostpotentially

lethal injuries Physical

exam/ diagnostic tests

Definitive Care Airway control Ensure

oxygenation /ventilation

Tube thoracostomy

Hemodynamic sup-port

Operation

Initial Assessment/ Management

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Life threatening Chest Trauma

Primary Survey Airway obstruction Tension pneumothorax Open pneumothorax Flail chest Massive hemothorax Cardiac tamponade

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Airway Obstruction

Laryngeal injury Rare occurrence Hoarseness Subcutaneous emphysema Treatment

• Intubation (caution)• Tracheostomy (by surgeon)

Intubasi orotrakeal

Intubation

Intubation

Trakeostomi

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Breathing

Tension pneumothorax,Etiology : Parenchymal and / or chest-wall

injuries Air enters pleural space with no exit Positive pressure ventilation

• Collapse of affected lung • ↓ Venous return• ↓ Ventilation of opposite lung

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Tension Pneumothorax :

Signs / Symptoms Respiratory distress Distended neck veins Unilateral ↓in breath sounds Hyperresonance Cyanosis, late

Breathing

Immediate decompression Clinical

diagnosis, not by x-ray

Breathing

Tension Pneumothorax

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Open Pneumothorax Cover defect Chest tube Definitive operation

Breathing

Plester 3 sisi

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Flail chest

Breathing

Flail chest complicates about 10% to 20% of patients with blunt chest trauma and is associated with a mortality rate ranging from 10% to 35%

Flail Chest

Davignon K, Kwo J, Bigatello LM. Pathophysiology and management of the flail chest. Minerva Anestesiol 2004;70:193-9.

This lesion is a clinical finding, and respiratory compromise in flail chest is more the result of underlying pulmonary contusion and ventilation perfusion mismatch than the actual structural defect to the chest wall.

Dorman T. Thoracic Trauma. Flail chest: pathophysiologic effects and pain control. Program and abstracts of the 31st International Educational and Scientific Symposium of the Society of Critical Care Medicine; January 26-30, 2002; San Diego, California.

Flail Chest

Flail chest exists when there are fractures of 3 or more ribs anteriorly and posteriorly, and paradoxic movement of a segment of chest wall results.

Dorman T. Thoracic Trauma. Flail chest: pathophysiologic effects and pain control. Program and abstracts of the 31st International Educational and Scientific Symposium of the Society of Critical Care Medicine; January 26-30, 2002; San Diego, California.

Flail Chest

segmental fracture of the ribsegmental fracture of the rib 1 rib1 rib

segmental fracture of the ribsegmental fracture of the rib 2 rib2 rib

segmental fracture of the ribsegmental fracture of the rib 3 rib3 rib

free floating rib

free floating rib

Flail Chest

CO2

CO2

PENDULLAR RESPIRATION

CO 2 narcosis

pathophysiology

Life threatening causes of asymmetrical chest

expansion

Right sided multiple rib fractures and flail chest Right pulmonary contusion

and subcutaneous emphysema

flail chest - detail

Segmental rib fractures

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Flail Chest/pulmonary Contusion

Reexpand lung Oxygen Judicious fluid management Intubation as indicated Analgesia

Breathing

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Circulation

Massive Hemothorax ≥ 1500 ml blood loss Systemic / pulmonary vessel

disruption Flat vs distended neck veinsShock with no breath sounds

and /or percussion dullness

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Massive Hemothorax Rapid volume restoration Chest decompression and

x-ray Autotransfusion Operative intervention

Circulation

restoration of

circulating volume

restoration of blood

oxygen-carrying capacity

normalizationof coagulation

status

Cardiac Tamponade

↓Arterial pressure Distended neck

veins Muffled heart

sounds Trias Beck’s

Circulation

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Cardiac Tamponade

Patent airway IV therapy Pericardiocentesis Pericardiotomy

Circulation

Pericardiocentesis should not be used

in setting of trauma to the

heartChest Surgery Clinics of Nort America, May 1997

pericardiocentesis

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Resuscitative Thoracotomy

Qualified surgeon present on patient’s arrival

Indications • Penetrating thoracic injury • Pulseless with electrical activity

Contraindications • Blunt injury • Pulseless without electrical activity

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Questions

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