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Blunt Thoracic Injury Blunt Thoracic Injury
Chao-Wen ChenChao-Wen ChenAttending SurgeonAttending Surgeon
Trauma Service, KMUHTrauma Service, KMUH
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Preface Preface Preface Preface
2/3 of victims of major blunt trauma suffer from thoracic injury.
Thoracic injuries account for 20-25% of deaths due to trauma.
Major thoracic trauma is associated with multisystem injuries in 70% of cases.
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Common Injuries Develop Common Injuries Develop After Blunt Chest TraumaAfter Blunt Chest TraumaCommon Injuries Develop Common Injuries Develop After Blunt Chest TraumaAfter Blunt Chest Trauma
Thoracic cage fracturesLung contusion and tearsMyocardium contusionAortic rupture
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Initial SurveyInitial SurveyInitial SurveyInitial Survey
Assume the existence of C-spine injury ABCsGerneral evaluation: PE, PH, ECG, or ABG…Chest x-ray Administer oxygen
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處理原則處理原則處理原則處理原則謹記 ABC 順序與原則初級檢傷時,若遇以下危及生命之狀況,需立即診斷出並加以處理:
張力性氣胸 ( Tension Pneumothorax )連枷胸 ( flail chest )開放性胸壁傷口 ( open chest wound )大量血胸 ( massive hemothorax )心包填塞 ( cardiac tamponade )
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如何處理如何處理??如何處理如何處理??張力性氣胸連枷胸 開放性胸壁傷口大量血胸心包填塞
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如何處理如何處理??如何處理如何處理??張力性氣胸 Needle decompression/ Chest Tube
連枷胸 Pain control/ O2 / MV
開放性胸壁傷口 Wound coverage/Chest tube
大量血胸 Chest tube / Thoracotomy
心包填塞 Pericardial window
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Imaging SurveyImaging SurveyImaging SurveyImaging Survey
Chest x-rayChest x-ray : serve as a screening rather than a definite test repeat radiography should be ordered if suspicious
Computed tomographyComputed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest trauma
AngiogramAngiogram : for suspicious great vessel injuriesChest ultrasoundChest ultrasound : detect hemothorax, FAST
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處理原則處理原則處理原則處理原則二級檢傷時,若遇以下危及生命之狀況,需立即診斷出並加以處理:
主動脈破裂( contained aorta rupture )氣管或支氣管破裂( rupture of tracheobronchial tre
e )食道破裂( perforation of esophagus )橫膈破裂( rupture of diaphragm )心肌挫傷( myocardial contusion )肺部挫傷( pulmonary contusion )
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Contained aortic tearContained aortic tearContained aortic tearContained aortic tear
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PneumothoraxPneumothoraxPneumothoraxPneumothorax
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HemothoraxHemothoraxHemothoraxHemothorax
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Sternal fractureSternal fracture• More serious injuries may accompany• If suspected, a lateral CXR may be dia
gnostic• Operative reduction is usually unneces
sary • Hospitalization is not mandatory if the
ECG is normal and the patient’s vital sign is stable
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Flail chestFlail chest• Fracture of 2 or more consecutive ribs in at least
2 places each• About 30-40% of patients need mechanical
ventilation• ARDS is increased 20-30% in the presence of
flail chest
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Flail chestFlail chest• Close monitoring of respiratory performance• Adequate analgesic therapy• Provide oxygen therapy and ventilatory support• Aggressive pulmonary toilet
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Lung contusionLung contusion• CxR finding may range from minimal interstitial inf
iltrate to extensive lobar consolidation• Chest CT is accurate diagnostic tool but not alwa
ys mandatory• Tx : same as flail chestsame as flail chest, but pay attention to avoid
overhydration; use of steroid and prophylactic antibiotic are still controversial
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Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Blunt Cardiac Trauma - spectrumBlunt Cardiac Trauma - spectrum• Asymptomatic myocardiac contusion• Symptomatic myocardiac contusion• Free wall or septal wall rupture• Valvular tears• Coronary artery thrombosis
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Blunt Cardiac Trauma – risk factorsBlunt Cardiac Trauma – risk factors• Chest impact > 15 mph• Marked precordial tenderness, ecchymosis or contusion • PH of cardiac disease• Fractured sternum• Thoracic spine or ribs fractures• Hemodynamic instability, or multiple injuries• Age > 50
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Blunt Cardiac Trauma - assessmentBlunt Cardiac Trauma - assessment• Most are asymptomatic; severe cases die before
arrival• Common manifestation : arrhythmia, hemo-dyna
mic instability • Evaluation : CxR, ECG, cardiac enzymes, echo-c
ardigram, MUGA
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Blunt cardiac trauma - managementBlunt cardiac trauma - management• Most cases do not require Tx; Symptomatic arrhythmia
(2-5%) antiarrthythmics• Abnormal ECG and cardiac enzymes almost return to no
rmal within one week.• Patients with abnormal cardiac echo finding or MUGA
keep hospitalization till a repeat test show acceptable finding
• Cardiac rupture prompt surgical repair
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Troublesome InjuriesTroublesome InjuriesTroublesome InjuriesTroublesome Injuries
Blunt cardiac trauma - Guideline (USC+LAC)Blunt cardiac trauma - Guideline (USC+LAC)• Obtain admission ECG and CPK-MB/TnTTnT in patient with
suspect BCI• Repeat ECG 8-12 hours after admission• For unexplained hemodynamic instability, abnormal ECG,
and abnormal cardiac enzyme levels perform cardiac echogram
• If no suspect symptomatolgy, lab tests or ECG finding discharge after 12 hours
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胸部鈍傷處理流程 胸部鈍傷處理流程 胸部鈍傷處理流程 胸部鈍傷處理流程 PE Survey
理學檢查
氣胸Needle decompression/ Chest tube
Subxyphoid windowthoracotomy
Needle decompression/ Chest tube
張力性氣胸
血胸
心包填塞
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X-ray CXR 檢查
氣胸
Chest tube
Pain controlOxygen supplyAvoid fluid overloadResp. Distress(+)MV
NGTrepeat X-rayUGI seriesU/S or CT scan
血胸
橫膈?
連枷胸、肺挫傷
若出血 >1200ml 或 >200ml/hr ,考慮開胸術
縱膈積氣 氣胸 ( + ) Chest Tube氣胸 ( - ) 氣管支氣管鏡檢食道鏡檢或食道造影
縱膈腔變寬 Chest CTAortic Angiogram
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胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則
Admission OrderDay 1
□ Consider ICU admission for elderly patients, or if other complicating factors exist.
□ NPO□ Chest tube to suction, follow chest tube output□ Follow-up CXR□ Analgesia (□ oral □ epidural □ PCA)□ Pulmonary toilet□ OOB to chair
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胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則
Day 2□ Advance diet□ Chest tube to suction, follow chest tube output□ Morning CXR□ Analgesia (□ oral □ epidural □ PCA)□ Pulmonary toilet□ OOB to chair
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胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則
Day 3□ if no air leak, chest tube to water seal, otherwise to suction.
follow output□ Morning CXR□ Analgesia (□ oral □ epidural □ PCA)□ Pulmonary toilet□ Ambulate tid once chest tube is off suction
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胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則
Day 4□ Check CXR after 6-8 hours on water seal, if lung expanded
and output<150ml remove chest tube□ Recheck CXR 6 hours post removal, discharge if expanded.□ Change analgesia to orat□ Keep site dressing in place × 48 hrs
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胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則胸部鈍傷病患住院照護準則
無併發症病患預計留院時間 “ 4” 天 出院時應注意下列狀況:
病患呼吸狀況應符合生理基本需求,無窘迫情形 疼痛之適度處理 肺部擴展完全且血胸已順利引出 病患了解傷口後續照護原則
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