CHEST TRAUMA

Soebandrijo MD, Darmawan Ismail MD

Introduction
Chest trauma is often sudden and
dramatic
Accounts for 25% of all trauma deaths
2/3 of deaths occur after reaching hospital
Serious pathological consequnces:
hypoxia,
hypovolaemia,
myocardial failure
ketiganya
ini
sering
menyebabkan
kematian
Mechanism of Injury
Penetrating Trauma
Low Energy
Arrows, knives, handguns
Injury caused by direct contact
High Energy
Military, hunting rifles & high powered hand
guns
Extensive injury due to high pressure
Blunt injuries (Trauma Tumpul)

Either:
direct blow (e.g. rib fracture)
deceleration injury
compression injury

Rib fracture is the most common sign

of blunt thoracic trauma

Fracture of scapula, sternum, or first rib

suggests massive force of injury

Age Factors
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Pediatric
Thorax:
More
cartilage = Absorbs forces
Geriatric Thorax: Calcification
& osteoporosis = More fracture

Injuries Associated with

Cardio Thoracic
Vascular Trauma
Airway obstruction
Closed pneumothorax
Open
pneumothorax
(sucking
chest
wound)
Tension pneumothorax
Pneumomediastinum
Hemothorax (massive)
Hemopneumothorax
Rib fracture (flail chest)
Tracheobronchial tree lacerations (rupture)
Esophageal lacerations
Penetrating cardiac injuries
Pericardial tamponade
Spinal cord injuries
Diaphragm trauma
Intra-abdominal trauma associated organ
injury
Laceration of vascular structures (central
& peripheral)

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Basic management concept in traumatic

patient Is ABCDE
Airway obstruction
Clinical finding
Shortness of breath (dyspnea)
Stridor
Apnea
Management
Chin lift
Jaw thrust
Triple finger manuever
Evacuate foreign body
ET insertion
Cricothyroidostomy
Tracheostomy
Keluhan pertama: sesak nafas. Selain itu stidor,
gurgling (karena cairan), lbh berat lagi apneu.
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u/ cedera spinal paling aman pake jaw thrust

1.
Yg bs dilakuin u/ pertolongan pertama:
chin lift, jaw thrust dan crossing finger
manuver. Bisa juga triple finger manuver.
2.
Apapun yg kliatan dr cavum oris harus
diangkat (crossing finger manuver).
3.
Kalo pasien masih blm bs nafas initial
breathing
4.
Kalo udah niup (bagging) tp dada ga
ngembang mungkin jalan nafasny ada
sumbatan (obstruksi jalan nafas yg ga
kliatan).
5.
Pake heimlich manuver slanjutnya kalo
pasien sadar. Kalo ga sadar, pake abdominal
thrust.
6.
Kalo
masih
belum
bs
nafas,
cricotiroidostomi
7.
Kalo ditiup dada ngembang dan airway
baik tp krn hipoksia lama jadi apneu
dilakukan breathing support. Kalo ud
cricottiroidostomi tetep ga ngembang
sumbatan
ada
di
bawah
membrana
cricothyroidea endotrakeal tube u/ dorong
sumbatan
ke
kanan
dan
paru2
kiri
ngembang.
Tension Pneumothorax
Ventile phenomenon
Build up of air under pressure in the thorax.
Excessive pressure reduces effectiveness of
respiration
Air is unable to escape from inside the pleural
space
Progression of Simple (closed) or Open
Pneumothorax
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Kegawatan kalau tidak ditangi segera bisa

menyebakan kematian.

Breathing
Ventile phenomenon saat inspirasi udara bisa
masuk tetapi saat ekspirasi tidak bisa keluar
tekanan makin tinggi tension pneumothoraks.
Pada gambar tension pneumothoraks sebelah
kiri.
Kalau
udah
ada
diagnosis
tension
pneumothoraks, ga usah foto rontgen krn pas
nunggu hasil, pasien bs meninggal. Langsung
lakukan tindakan thorakosintesis masukan jarum
ke SIC 2 linea midclavicula.
CXR image

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Tension Pneumothorax (simplify)

Anx: Progressive shortness of breath
Physical Examination:
Respiratory distress
Tracheal deviation (away)
Absence
of
breath
sound
percusion: hypersonor
Jugular Vein Distend
Hypotension
Treatment :
Needle thoracocentesis
Consult : chest tube insertion
Needle thoracocentesis

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&

Needle thoracocentesis: pake infus kateter yg

paling besar.
OPEN (SUCKING) CHEST WOUND

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Upon exhaling, air in the chest escapes

through the flutter-type valve created by
taping 3 sides only
With inhaling, the patch should suck
against the skin, preventing air entry
tatalaksana: plester 3 sisi, yg dipake buat plester
sesuatu yg kedap udara (handscoon, plastik

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steril). Jadi supaya udara dari luar tidak bisa

masuk tetapi udara dari dalam bisa keluar.
Jadi kalo ada luka terbuka di dada jgn dijait,
cukup diplester 3 sisi. Kalo dijait malah jd
tension.
Hemothorax

Accumulation of blood in the

pleural space

Serious
hemorrhage
may
accumulate 1,500 mL of blood

Mortality rate of 75%

Each side of thorax may

hold up to 3,000 mL

MASSIVE (criteria)

Blood loss in thorax causes a

decrease in tidal volume

Ventilation/Perfusion
Mismatch & Shock

Typically
accompanies
pneumothorax

Hemopneumothorax
Perkusi jadi redup. Kalo pneumothoraks jd
hipersonor
Blunt or penetrating chest trauma
Shock
Dyspnea
Tachycardia
Tachypnea
Diaphoresis
Hypotension massive
Dull to percussion over injured side
Treatment
Chest tube insertion & consult

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Bs dgn pulv pungsi. Kalo dr pulv pungsi ada

darah, dg pleural pungsi.
CXR Image

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Gambaran CT scan
Tension udara radiolusen (lbh gelap)
Hemothorax
cairan
radioopak
(lbh
terang).
Flail chest
Multiple rib fractures produce a mobile
fragment which moves paradoxically
with respiration
Significant force required
Usually diagnosed clinically
Treatment
ABC
Analgesia
Fixation : internal &/ external
Khas: paradoxiscal movement/ respiratorik saat
inspirasi harusnya dada mengembang, jadi
kempis. Saat ekspirasi jadi mengembang.
Dx:
fraktur costa segmental
2 kosta/ lbh dan berurutan.
Menimbulkan nyeri hebat dibandingkan trauma
lainnya karena ga bs diimobilisasi parunya.
Ketika inspirasi, kasih kain sesuai kedalaman
terus diplester, pasien tarik nafas dan kasih
analgetik yg dalam. Plesternya paling maksimal
dari pertengahan dpn ke pertengahan belakang.
PARADOXICAL RESPIRATIONS

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Tracheobronchial Injury
MOI
Blunt trauma
Penetrating trauma
50% of patients with injury die within 1 hr of
injury
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Disruption
can
occur
anywhere
in
tracheobronchial tree
Signs & Symptoms

Dyspnea

Cyanosis

Hemoptysis

Massive
subcutaneous
emphysema

Suspect/Evaluate for other

closed chest trauma
Tanda khas: emfisema subkutis (jd
bengkak secara luas gitu), ada batuk
darah setelah kecelakaan.
Kalo dipalpasi, kayak ada tas kresek.
Begitu dipencet, pas dilepas jd ngembang
lg.
Tracheobronchial Injury
Observe for development of Subcutaneus
emphysema & tension pneumothorax
(deadly)
Treatment
Keep airway clear
Administer high flow O2
Consider intubation if unable to
maintain patient airway
If tension needle thoracocentesis
Consult
:
tracheal
repair
or
tracheostomy
Lakukan multiple insisi di tepi atas
clavicula, lalu darah keluar buka pake
tumpul sampai udara ada yg keluar. Tp ini
sudah ga dianjurkan.
Pericardial Tamponade

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Restriction to cardiac filling caused

by blood or other fluid within the
pericardium
Occurs in <2% of all serious chest
trauma
However, very high mortality
Results from tear in the coronary
artery or penetration of myocardium
Blood seeps into pericardium
and is unable to escape
200-300 ml of blood can
restrict
effectiveness
of
cardiac
contractions
Removing as little as
20 ml can provide relief

Pericardial Tamponade (simplify)

Dyspnea
Possible cyanosis
Becks Triad
JVD
Distant heart tones
Hypotension or narrowing pulse
pressure
Weak, thready pulse
Shock
Kussmauls sign
Decrease or absence of JVD during
inspiration
Pulsus Paradoxus
Drop in SBP >10 during inspiration
Due to increase in CO2 during
inspiration
Electrical Alterans

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P, QRS, & T amplitude changes in

every other cardiac cycle

PEA
Cardiac tamponade sianosis, nadi
kecil, penurunan kesadaran.
Trias back tjd karena penekanan
atrium
kanan
1venous
return
terbendung, 2...., 3hipotensi.

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Laceration of vascular structures

General sign
Shock Hypovolemia (co morbid
cardiogenic)
Penetrating trauma (mostly)
Internal bleeding
Thoracic Chest XR
Abdominal FAST or CT
Pelvicum CXR
Femur expanding hematoma +
XR
External
bleeding

thorough
examination & suturing
Laserasi pada vaskuler
Syok hipovolemia (tensi <70 mmHg), curiga
perdarahan.
Pelvic rupture bs jadi perdarahan bnyk jika
mengenai articulatio sacroiliaca.
3 tes:
- Destruksi tes
- Kompresi AP lateral
- Distraction tes (slh 1 memegang femur, 1
lagi di ala ossis ilii pas femur dorong ke
bawah, ala ikut ke bwh lepas dari sacrum
brarti).

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Laceration of vascular structures

Internal bleeding consult
External bleeding

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Buat hentikan perdarahan, tekan bagian

proksimal dari perdarahan.
Bebat tekan itu tiap 30 menit dikendorin.

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