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Blunt Thoracic Injury

Blunt Thoracic Injury. Chao-Wen Chen Attending Surgeon Trauma Service, KMUH. Preface. 2/3 of victims of major blunt trauma suffer from thoracic injury. Thoracic injuries account for 20-25% of deaths due to trauma.

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Blunt Thoracic Injury

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  1. Blunt Thoracic Injury Chao-Wen Chen Attending Surgeon Trauma Service, KMUH

  2. 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. Trauma Conference

  3. Common Injuries Develop After Blunt Chest Trauma • Thoracic cage fractures • Lung contusion and tears • Myocardium contusion • Aortic rupture Trauma Conference

  4. Initial Survey • Assume the existence of C-spine injury • ABCs • Gerneral evaluation: PE, PH, ECG, or ABG… • Chest x-ray • Administer oxygen Trauma Conference

  5. 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) Trauma Conference

  6. 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 Trauma Conference

  7. 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 Trauma Conference

  8. Imaging Survey • Chest x-ray : serve as a screening rather than a definite test  repeat radiography should be ordered if suspicious • Computed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest trauma • Angiogram : for suspicious great vessel injuries • Chest ultrasound : detect hemothorax, FAST Trauma Conference

  9. 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 tree) • 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) Trauma Conference

  10. Contained aortic tear Trauma Conference

  11. Pneumothorax Trauma Conference

  12. Hemothorax Trauma Conference

  13. Troublesome Injuries • Sternal fracture • More serious injuries may accompany • If suspected, a lateral CXR may be diagnostic • Operative reduction is usually unnecessary • Hospitalization is not mandatory if the ECG is normal and the patient’s vital sign is stable Trauma Conference

  14. Troublesome Injuries • Flail 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 Trauma Conference

  15. Troublesome Injuries • Flail chest • Close monitoring of respiratory performance • Adequate analgesic therapy • Provide oxygen therapy and ventilatory support • Aggressive pulmonary toilet Trauma Conference

  16. Troublesome Injuries • Lung contusion • CxR finding may range from minimal interstitial infiltrate to extensive lobar consolidation • Chest CT is accurate diagnostic tool but not always mandatory • Tx : same as flail chest, but pay attention to avoid overhydration; use of steroid and prophylactic antibiotic are still controversial Trauma Conference

  17. Pulmonary contusion Trauma Conference

  18. Troublesome Injuries • Blunt Cardiac Trauma - spectrum • Asymptomatic myocardiac contusion • Symptomatic myocardiac contusion • Free wall or septal wall rupture • Valvular tears • Coronary artery thrombosis Trauma Conference

  19. Troublesome Injuries • Blunt 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 Trauma Conference

  20. Troublesome Injuries • Blunt Cardiac Trauma - assessment • Most are asymptomatic; severe cases die before arrival • Common manifestation : arrhythmia, hemo-dynamic instability • Evaluation : CxR, ECG, cardiac enzymes, echo-cardigram, MUGA Trauma Conference

  21. Troublesome Injuries • Blunt cardiac trauma - management • Most cases do not require Tx; Symptomatic arrhythmia (2-5%)  antiarrthythmics • Abnormal ECG and cardiac enzymes almost return to normal 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 Trauma Conference

  22. Troublesome Injuries • Blunt cardiac trauma - Guideline (USC+LAC) • Obtain admission ECG and CPK-MB/TnT 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 Trauma Conference

  23. 氣胸 Needle decompression/ Chest tube 張力性氣胸 理學檢查 Needle decompression/ Chest tube 血胸 心包填塞 Subxyphoid window thoracotomy 胸部鈍傷處理流程 • PE Survey Trauma Conference

  24. 氣胸 若出血>1200ml 或>200ml/hr, 考慮開胸術 Chest tube 血胸 CXR檢查 NGTrepeat X-ray UGI series U/S or CT scan 橫膈? Pain control Oxygen supply Avoid fluid overload Resp. Distress(+)MV 連枷胸、肺挫傷 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 CT Aortic Angiogram • X-ray Trauma Conference

  25. 胸部鈍傷病患住院照護準則 • Admission Order • Day 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 Trauma Conference

  26. 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 Trauma Conference

  27. 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 Trauma Conference

  28. 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 Trauma Conference

  29. 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 Trauma Conference

  30. Thank you for your attention!

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