胸部外伤课件_13

Chest Trauma Grinne Murphy Final Med April 2002 Introduction nChest trauma is often sudden and dramatic nAccounts for 25% of all trauma deaths n2/3 of deaths occur after reaching hospital nSerious pathological consequnces: -hypoxia, hypovolaemia, myocardial failure Mechanism of Injury Penetrating injuries nE.g. stab wounds etc. nPrimarily peripheral lung nHaemothorax nPneumothorax nCardiac, great vessel or oesophageal injury nEither: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury nRib fracture is the most common sign of blunt thoracic trauma nFracture of scapula, sternum, or first rib suggests massive force of injury Blunt injuriesBlunt injuries Chest wall injuries nRib fractures nFlail chest nOpen pneumothorax Rib fractures nMost common thoracic injury nLocalised pain, tenderness, crepitus nCXR to exclude other injuries nAnalgesiaavoid taping nUnderestimation of effect nUpper ribs, clavicle or scapula fracture: suspect vascular injury Flail chest nMultiple rib fractures produce a mobile fragment which moves paradoxically with respiration nSignificant force required nUsually diagnosed clinically nRx: ABC Analgesia Flail chestFlail chest Flail Chest - detail Open pneumothorax nDefect in chest wall provides a direct communication between the pleural space and the environment nLung collapse and paroxysmal shifting of mediastinum with each respiratory effort tension pneumothorax n“Sucking chest wound” nRx: ABCsclosure of woundchest drain Lung injury nPulmonary contusion nPneumothorax nHaemothorax nParenchymal injury nTrachea and bronchial injuries nPneumomediastinum Pneumothorax nAir in the pleural cavity nBlunt or penetrating injury that disrupts the parietal or visceral pleura nUnilateral signs: movement and breath sounds, resonant to percussion nConfirmed by CXR nRx: chest drain PneumothoraxPneumothorax Tension pneumothorax nAir enters pleural space and cannot escape nP/C: chest pain, dyspnoea nDx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension nSurgical emergency nRx: emergency decompression before CXR nEither large bore cannula in 2nd ICS, MCL or insert chest tube nCXR to confirm site of insertion Haemothorax nBlunt or penetrating trauma nRequires rapid decompression and fluid resuscitation nMay require surgical intervention nClinically: hypovolaemia absence of breath sounds dullness to percussion nCXR may be confused with collapse Heart, Aorta especially RTAs n90% die within minutes nMost common site near ligamentum arteriosum nDx: clinical suspicion, CXR, aortography, contrast CT or TOE nRx: surgicalpoor prognosis Aortic ruptureAortic rupture Iatrogenic trauma nNG tubes: -coiling -endobronchial placement -pneumothorax nChest tubes: - subcutaneous - intraparenchymal - intrafissural nCentral lines: - neck - coronary sinus - pneumothorax Line in jugular vein Line in jugular vein Misplaced Misplaced nasogastric nasogastric tubetube Chest trauma: