KETENTUAN DALAM

MENGIKUTI PERKULIAHAN
SEBAIKNYA DATANG TEPAT WAKTU

BERPAKAIAN SOPAN DAN RAPI SEBAIKNYA

BUKAN BAJU KAOS

TIDAK DIPERKENANKAN MEMAKAI SENDAL
APAPUN JENISNYA, HARUS PAKAI SEPATU
MENGIKUTI KULIAH DENGAN SEBAIK2NYA,
KARENA KULIAH DIUSAHAKAN SISTIM
INTERAKTIF
MAHASISWA YG TERLAMBAT SEBAIKNYA
TDK USAH MASUK RUANGAN
SEMUA HP DALAM POSISI OFF

Chest Trauma
trauma toraks
Dr.Muhammad Nuralim Mallapasi.MD
BAGIAN BEDAH TORAKS KARDIOVASKULAR
FAK KEDOKTERAN UNHAS
RS DR.WAHIDIN SUDIROHUSODO
MAKASSAR.

Silent
epidemic

Complex disaster
Kerusuhan

Man-made disaster

Mass-casualties
disaster

Kecelakaan kereta api

small scale

Introduction
Blunt trauma to the chest can affect any
one or all components of the chest wall
and thoracic cavity
These include :

Ribs
- clavicles
Scapulae
- sternum
lungs and pleurae - tracheobronchial three
esophagus
- heart
great vessels

Anatomi dinding Toraks

Dasar Toraks

Rongga Toraks

Frequency

12 people per million population per day

33% requires hospital admission
Directly responsible for 20-25% of death attributed
to trauma

Etiology

MotorVehicleAccidents(MVA) 70-80% of these

trauma
Falls and violence
Blast injury

Pathophysiology
Derangements in the flow of air, blood, or
both in combination
Chest wall injures rib fractures
Direct lung injures lung contusions
Space-occupying lessions
pneumomothoraces, hemothoraces,
hemopneuomothoraces
Cardiac injures chamber rupture
Severe great vessels injures thoracic
aortic disruption

RAPIDLY LETHAL LESION

ie. Lesion that could kill the patient in a matter of minutes

a.airway obstruction
b. tension pneumothorax
c. open pneumothorax
d. massive haemothorax
e. flail chest
f. cardiac tamponade

Potensially lethal lesions,

.i.e. lesions that can kill the patient in matter of hours

a.pulmonary contusion
b. aortic rupture
c. tracheobronchial rupture
d. oesophageal rupture
e. diaphragmatic rupture
f. myocardial contusion

NON IMMEDIATELY LIFE

THREATENING LESIONS
a. haemothorax
b.simple pneumothorax
c.rib fractures
d.sternal fractures
e.soft tissue lesions
f.traumatic chylothorax
g.intrathoracic foreign bodies
h.subcutaneous emphysema
i.others.

8 Keadaan Trauma Toraks

1. Pneumotoraks (simple,open,
tension)
2. Hemotoraks
3. Kontusio Paru
4. Trauma cab tracheobronchial
5. Trauma Tumpul jantung
6. Trauma aorta
7. Trauma diafragma
8. Trauma mediastinum

Clinical Presentation
Varies widely from minor report to florish shock
Clinical history time of injury, mechanism,
velocity&deceleration, assosiated injury, silent
future
3 broad categories : (1) chest wall fracture,
dislocation, and barotrauma (including
diaphragmatic injury); (2) blunt injuries of the
plaurae,lungs, and aerodigestive tracts; and
(3) blunt injuries of the heart, great vessels

Diagnostic tests and procedures

Twelve-lead electrocardiogram

may found tachyarrhytmias and

conduction disturbances
Flexible or rigid esophagoscopy
the initial diagnostic procedure for
esophagela injury
Fiberoptic or rigid bronchoscopy
tracheobronchial injures

Indications

Most often treated with supportive measures and

simple interventional procedures chest tube
Chest wall fractures, dislocations, and barotrauma
(including diaphragmatic injures) indications for
immediate surgery :
(1) loss of chest wall integration
(2) (2)blunt diaphragmatic injures.
Relative immediate and long-term indication :
(1) delayed recognation of diaphragmatic injury and
(2) the development of a traumatic diaphragmatic
hernia.

Indications
Blunt injuries of the pleurae, lungs, and
aerodigestive tracts
Immediate surgery :
(1) massive air leak or high rate blood loss
from chest tube (1500mL or 200-300 mL/h);
(2) radiographically or endoscopically
tracheal, major bronchial, or esophageal
injury;
(3) recovery of gastrointestinal contents

 Relative immediate and long term surgery :

(1) chronic clotted hemofibrothorax, especially
when associated with a trapped or
nonexpanding lung;
(2) empyema;
(3) lung abscess;
(4) delayed recognations of tracheobronchial
or esophageal injuries;
(5) tracheoesophageal fiatula; and
(6) persistent thoracic duct fistula/chylothorax

Indications
Blunt injuries of the heart, great arteries,
veins, and lymphatics
immediate surgery :
(1) cardiac tamponade;
(2) radiographic confirmation of vessel
injury; (3) an embolism or missile into the
pulmonary artery or heart
Relative immediate and long-term
indication : late recognation of the injury
(development of traumatic pseudoaneurysm)

Rib Fractures
Most common blunt thoracic injuries, rib 4-

10 most frequently involved

Inspiratory chest pain, pain over the
fractures site
Tenderness and crepitus over the site of
fracture
Mostly do not need surgery, pain control
the goal of treatment
Early mobilization and aggressive pulmonary
toilet
Surgical Hemostasis if lacerates intercostal
artery

Flail Chest
>3 ribs fractures in >2 places free

floating and unstable chest wall or

Costochondral separation
Pain over fracture site, pain upon
inspiration, dyspnea.
Paradoxal inspiration (sucking chest)
chest wall move inward with inspiration
and outward with expiration
Labored respiration due to paradoxal
motion respiratory distress

Treatment : Flail Chest

Endotreacheal intubation and

positive pressure mechanical

ventilation
Stabilize chest wall internal
fixation

Clavicular fracture
Tenderness and tenderness over the site
Proximal segment displaced superiorly
action sternocleidomastoideus
Mostly can be managed without surgery
Immobilization figure eight, clavicle
strap, sling.
Oral analgesia

Sternal Fracture
Inspiratory pain, local tenderness, swelling,

ecchiymosis, crepitus
Associated injuries : rib fractures, long bone
fracture, close head injury
Blunt cardiac injury 20%
No therapy specifically analgesia and minimize
activities of pectoral and shoulder muscle
Most important exclude blunt myocardial injury
Open reduction & fixation badly displaced
wire suturing and placement of plates and screw

Scapular fracture
Uncommon
Associated injury : head, chest,

abdomen
Exclude major vascular injury
Shoulder immobilization sling or
shoulder harness
Early ROM exercise prevent shoulder
contracture

Blunt diaphragmatic injuries

Mostly left side
Must considered abdominal injury

with dyspnea and respiratory distress

Hypovolemic shock major splenic
or hepatic injury
Approached laparotomy suture
with polypropylene or dacron

Pneumothorax
Rib fracture or barotrauma
Dyspnea, decreased breath sound

and hyperresonance to percussion

Chest tube + suction sistem -20
cmH2O (pleur-evac) WSD if the
lung remains fully expanded chest
tube remove CXR

Tension pneumothorax
Ventile mechanism lungs collaps

respiratory distress
Diminished or absent of breath sound,
hemithorax hyperresonant to percussion,
trachea deviated
Immediate decompression with needle
thoracostomy (large bore nedle 14-16G)
Chest tube
Pain control

Open Pneumothorax
Caused by penetrating trauma

rarely due to blunt trauma

Respiratory distress lung collaps
Placing occlusive dressing over
wound chest tube

Hemothorax
Accumulation of blood within the

pleural space
Lacerations internal mammary
vessels or other major thoracic
vessels
Chest tube, massive (1500mL or 200300 mL/h) thorachotomy

Pulmonary contusion and other

parenchymal injures
Transmition of force to the lung parenchym
lung contusion with hemorrage into the lung
tissue
Clinical finding depent to the extent of the
injury
Pain control, pulmonary toilet, sumplemental
oxygen (intubation with mecanical
ventilation)
Surgical haemostatis laceration or avulsion

Blunt tracheal injury

Fracture, lacerations, and disruptions
Respiratory distress, cannot speak, stridor,

other sign associated w pneumothorax n

subcutaneous emphysema
Many die before can reach defenitive care
life trheatening require immediate surgical
repair to establishment of an adequate airway
Endotracheal intubation flexible
bronchoscope tube placed distal site of injury
Always prepared to perform emergency
trecheotomy
Surgical repair restoration of airway
continuity w primary end-to-end anstomosis

Blunt bronchial injuries

Laceration, tear, or disruption of a major
bronchus is life threatening many die
before treatment
Respiratory distress n physical sign
consistent w pneumothorax
Require surgical repair secure airway
Ipsilateral thoracotomy on the affected
side w single-lung ventilation
debridemant n end-to-end ansstomosis

Blunt esophageal injuries

Rare because protected location in

posterior mediastinum
Caused by a sudden increase
intraluminal pressure from a forceful
blow to the epigastrium
Spillage GI contents into the chest
Upper abdo & thoracic pain ass w
thypnea, tachycardia, subcutaneus
emphysema.

Treatment : Blunt esophageal

injuries
Fluid resuscitation n broad-spectrum iv

antibiotic n anaerob AB
Surgery debridemant w primary anatomosis
well-vascularized autologous tissue (parietal
pleura n intercostal muscle) Thal Patch
Poor general condition esophageal diversion
(a cervical esophagostomy), the distal
esophagus stapled, gastrostomy for
decompression, and wide mediatinal drainage
w chest tube.

Blunt cardial injuries

Cause by : MVA (most common), falls,

crush injuries, violent, sport injury, ect

Range varies from mild trauma ass w
arrythmias to severe rupture valve,
septum or myocardial
Clinical varies from chest pain to
cardiac tamponade to complete
cardivascular collaps
Treatment cardiosintesis to
cardiorrhapy w cardiopulmonar by pass

Blunt injuries of the thoracic

aorta and major thoracic
arteries
Mechanism injury: rapid deceleration

sharing force, direct compression

Many die before reaching defenitive
care
Treatment: endovascular stent grafts,
arteriorraphy w cardiopulmonary by
pass

Blunt injury of the superior

vena cava and major thoracic
veins
Rare, usually ass w injuries other

major thoracic vascular structures

Treatment : venorrhaphy w
cardiopulmonary by pass
Injured subclavian or azigous veins if
difficult to repair can be ligated

General preoperative details

ABCs establishment
Often Resuscitation effort must be

continue to the operating room

Diagnostic procedures completed if
the patients condition stabil
Blood drawn and sent for test and
crossmatching

General intraoperative
details
ABCs establishment, hemodinamic

monitoring, consider single-lung ventilation

techniques
Consider Cardiopulmonary bypass, patient
positioning and choice of incision
Median sternotomy access the heart,
intracardial portion of pulmonary vessels,
ascending aorta and aortic arch, venae
cavae, and the innominate artery
Extended median sternotomy subclavian
artery, branches of innominate artery

General intraoperative
details
Posterolateral left thoracotomy in the fourth

intercostal space approach the

descending thoracic aorta
Proximal of subclavian artery anterolateral
left thoracotomy in the third intercostal
sapce; distal supraclavicular incision
Distal esophagus left posterolateral
thoracotomy; more proximal require a right
thoracotomy
Lung or peripheal pulmonary vessels
posterolateral thoracotomy

General postoperative
details
ABCs care
Pain control to facilitates breathing to

prevent pulmonary complication such as

atelectasis and pneumonia
Chest physiotherapy, nebulizer, n
incentive spirometer encouragement
Chest tube + suction if the lung already
expanded n no evidence of air leak
chage to the water seal CXR

Workup
CBC routine laboratory test
ABG for objective measure of ventilation,

oxygenation, and acid-base status

therapuetics decisions
Electrolyte status
Coagulation profile
Serum troponin levels cardiac injures
Creatine kinase-MB levels myocardial injures
Serum lactate levels measure tissue
perfusion
Blood typ and crossmatch

Imaging studies
CXR should not wait CXR for diagnose

emergency measurement
Chest CT-scan should restricted to
undetected or occult injury is considered
Aortogram standard for diagnosis of
blunt aortic injures
Thoracic US pericardial effusions or
tamponade
Contrast Esophagogram for esophageal
injures

Complication
Wound
Infection and dehiscence

Cardiac

Myocardial infarction
Arrhytmias
Ventricular aneurysm formation
Septal defects
Valvular insufficiency

Complication
Pulmonary and
Bronchial

Atelectasis
Pneumonia
Pulmonary abscess
Clotted hemothorax
Fibrothorax
Bronchial repair
disruption

Vascular

Graft infection
Pseudoaneurysm
Graft thrombosis
Deep venous
thrombosis
Pulmonary
embolism

Complication
Neurological
Causalgia injuries
that involve the
brachial plexus
Paraplegia spinal
cord at risk during
repair of ruptured
thoracic aorta
Stroke

Esophageal

Leakage of repair
Mediastinitis
Esophageal fistula
Esophageal
stricture - late

Outcome and Prognosis

Mostly excellent 80% require

either ni invasive therapy or at most,

a tube thoracostomy
High mortality n morbidity cardiac
chamber rupture, injuries of
intrathoracic inferior n superior vena
cava, delayed recognition of
esophageal rupture.

TIPS2 EKSPERTISE FOTO

X RAY THORAKS
A: IRWAY
TRACHEA DAN BRONCHUS
B: REATHING
PLEURAL PACE
PARENCHYM PARU
C: IRCULATION
MEDIASTINUM
JANTUNG DAN PERICARD

D: DISABILITY
DIAFRGAMA

ELEVASI
DISRUPTION
EFFUSION

 E:EXPOSURE
BONY THORAX:
CLAVICULA
SCAPULA
COSTA
STERNUM
F: SOFT TISSUE
G: TUBES DAN LINES