TRAUMA THORAX

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Keperawatan UNEJ
HISTORY
ANGKA KEMATIAN TINGGI
ORGAN PENTING UNTUK OKSIGENISASI TUBUH
Trimodal Death Distribution
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
Mechanism of Injury

Penetrating injuries
 E.g. stab wounds etc.
 Primarily peripheral lung
 Haemothorax
 Pneumothorax
 Cardiac, great vessel or oesophageal injury
Blunt injuries
 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
 Chest wall injuries

 Rib fractures

 Flail chest

 Open pneumothorax
Rib fractures

 Most common thoracic injury

 Localised pain, tenderness, crepitus
 CXR to exclude other injuries
 Analgesia avoid taping
 Underestimation of effect
 Upper ribs, clavicle or scapula fracture:
suspect vascular injury
Flail chest

 Multiple rib fractures produce a mobile

fragment which moves paradoxically with
respiration
 Significant force required
 Usually diagnosed clinically
 Rx: ABC
Analgesia
Flail chest
Flail Chest - detail
 Open pneumothorax

 Defect in chest wall provides a direct

communication between the pleural space
and the environment
 Lung collapse and paroxysmal shifting of
mediastinum with each respiratory effort ±
tension pneumothorax
 “Sucking chest wound”
 Rx: ABCs…closure of wound…chest
drain
Lung injury

 Pulmonary contusion
 Pneumothorax
 Haemothorax
 Parenchymal injury
 Trachea and bronchial injuries
 Pneumomediastinum
Pneumothorax

 Air in the pleural cavity

 Blunt or penetrating injury that disrupts the
parietal or visceral pleura
 Unilateral signs: movement and breath
sounds, resonant to percussion
 Confirmed by CXR
 Rx: chest drain
Pneumothorax classification
By side:
 left or right
 in both side
By lung collapse degree:
 Partial (paracostal)
 Subtotal (smaller than 2/3 of lung volume)
 Total (more than 2/3 of lung volume)
By mechanism of formation:
- open
- closed
- tension
Pneumothorax
Tension pneumothorax

 Air enters pleural space and cannot escape

 P/C: chest pain, dyspnoea
 Dx: - respiratory distress
- tracheal deviation (away) -
absence of breath sounds -
distended neck veins -
hypotension
 Surgical emergency
 Rx: emergency decompression before CXR
 Either large bore cannula in 2nd ICS, MCL or
insert chest tube
 CXR to confirm site of insertion
Haemothorax

 Blunt or penetrating trauma

 Requires rapid decompression and fluid
resuscitation
 May require surgical intervention
 Clinically: hypovolaemia
absence of breath sounds dullness to percussion
 CXR may be confused with collapse
 Decompression always by chest catchment in 7
ICS on middle or posterior axillary line
Hemothorax classification
By side:
 left or right
 in both side
By blood lost volume :
 Small (< 10% of BCV, or <500 ml)
 Middle (10-20 % of BCV, or 500-1000ml)
 Big (10-20 % of BCV, or 1000-2000ml)
 Total ( > 40 % of BCV, or >2000ml)
Hemothorax classification

By bleeding presence:
- stopped (Reviloi – Gregoire test negative)
- continues (Reviloi – Gregoire test positive)
By clots presence:
- clotted
- unclotted
By infection complication presence:
- non-infected
- infected
Indication for urgent
thoracotomy
 In pneumothorax:
Absence of active air catchment during more than
2 days (presence of pneumothoraz on CXR)

 In hemothorax:
Evacuation of > 1000ml blood simultaneously or
bleeding continues during 4 hours with blood
loss > 200 ml per hour
 Cardiac Tamponade

 Blood in the pericardial sac

 Most frequently penetrating injuries
 Shock, JVP, PEA, pulsus paradoxus
 Classically, Beck’s triad: -
distended neck veins -
muffled heart sounds -
hypotension
 Rx: Volume resuscitation
Pericardiocentesis
Cardiac
tamponade
ILUSTRASI KASUS
LAKI 28 TAHUN SOPIR TRUK TERTUSUK BESI SETELAH TRUKNYA MENABRAK
PANCANG BESI DARI TRUK DIDEPANNYA YANG BERISI BESI BANGUNAN .
SADAR , NGOROK , NADI 120 X / MENIT , NAFAS 40 X/MENIT
TEKANAN DARAH 80/60 MMHG.
TRAUMA

KEMATIAN CEPAT

Trauma ORGAN central

OTAK
PEMBULUH DARAH BESAR
JANTUNG
TERANCAM KEMATIAN

A
B
C
D

Ini harus bisa ditolong !!!!!

GANGGUAN JALAN NAFAS ??
KORBAN GELISAH DAN TERIAK .
TOLONG SAYA CEPAT, DADAKU SAKIIT …

DIAM , DADA TAK BERGERAK

SUARA NAFAS NGOROK
BERNAFAS DENGAN OTOT LEHER TEGANG
 FIKSASI LEHER

 JAW THRUST
 CERVICAL COLLAR
LIHAT

Pupil ?
Test nafas !

Darah di mulut ?
Penekanan trakhea ?

Bersihkan
Intubasi
Crycothyroidotomi
Reposisi sternum
OKSIGEN 10 L / MENIT
NON REBREATHING MASK
MONITOR OXYMETRI / SAT OKSIGEN
 GANGGUAN
PENGEMBANGAN PARU ??

 LIHAT
 RABA
 KETOK
 DENGAR
TRAUMA DADA ?
SESAK / FREKWENSI NAFAS CEPAT
 CARI

 JEJAS
 LUKA TEMBUS
 BENTUK DINDING DADA TAK SIMETRIS
 KREPITASI
 PERKUSI HIPERSONOR ATAU REDUP
 SUARA NAFAS HILANG /JAUH
 BUNYI JANTUNG HILANG
 TUMPUL
 DADA SIMETRIS. VENA LEHER LEBAR
TRAKHEA TIDAK DITENGAH

SUARA NAFAS HILANG HIPERSONOR

TENSION
PNEUMOTORAK

PNEUMOTORAK

NEEDLE
TORAKOSENTESIS
WSD SELA IGA 2
SELA IGA 5
SUARA NAFAS REDUP HEMOTORAK
HILANG WSD

Infus 2 liter 1500 CC

Siapkan darah atau
tranfusi
3 CC / BB / JAM

STOP BLEEDING MASSIVE HEMOTORAK

( TORAKOTOMI )
DADA TAK SIMETRIS
(FLAIL CHEST )
PNEUMO / WSD
HEMOTORAK
???

OXYGEN
KONTUSIO PARU
BAGGING
OR VENTILATOR
EDEMA
 LUKA TEMBUS

SUCKING WOUND
TEST CAIRAN PNEUMOTORAK
WSD &
TUTUP LUKA
HEMATO ?
DARURAT
Jahit tiga sisii
LUKA TEMBUS DADA KIRI
SUARA JANTUNG HILANG

LIHAT !!!
VENA LEHER LEBAR

TAMPONADE JANTUNG
PERICARDIOSENTESIS
EMFISEMA SUBCUTAN
TRAUMATIK ASPIKSIA
44