外科胸部外伤课件

THORACIC INJURY General consideration (1) Physiological basis: * Pleural cavities are the closed spaces * Lung ventilation is accomplished by the generation of negative pressure * Negative pressure: During the quiet respiration, it varies from -6 to -12 cmH2O with inspiration to -3 to -5 cmH2O during expiration General consideration (2) Anatomy basis: * Pleura is divided into two portions: Parietal: internal lining of the chest wall Visceral: covering the entire surface of the lung General consideration (3) Normal situation: * The pleural cavities are to be closed space * There are a little fluid accumulated not being seen Abnormal situation: Increased capillary hydro-pressure or great negative intra-pleural pressure, tends to increase transudation into the cavity, loss of intra-pleural negative pressure (pneumo- thorax) diminished transudation General consideration (4) Pleural cavity in summary: The vital important space for circulation and respiratory systems Special anatomic and physiological situation * negative pressure in the pleural cavities * thoraco-abdominal injury * mild traumatic injury may salvaged by relative minor procedure The treatment : simple straightly maneuver General consideration (5) Mechanisms of thoracic injury * blunt trauma (combined injury) * penetrating (local injury) Common causes * Peaceful time: Automobile, industrial accidents, violent injury * Wartime: missiles, gun shot General consideration (6) The classification of thoracic injury Closed thoracic injury: * rib fracture * pneumo-thorax * hemo-thorax * traumatic asphysia, et al. Open thoracic injury: * blind wound: triangle knife, stabbing injury. * penetrating injury: gun shot, gun fire General consideration (7) Thoraco-abdominal injury: Chest injury below the 4th intercostal space, diaphragm, spleen, liver, colon and stomach may be wounded most often Multiple combined injury: Multiple system and more than three organs are involved in the trauma of chest General consideration (8) The principles of management for thoracic injury: EvacuationEvacuation to an appropriate facility to an appropriate facility ResuscitationResuscitation: restore the organs function: restore the organs function AirwayAirway: suction of mouth and pharynx, : suction of mouth and pharynx, introduction of oral airway suffice, introduction of oral airway suffice, intubationintubation with with hyperventilation (or hyperventilation (or cricothyroidotomycricothyroidotomy) ) Adequate Adequate circulationcirculation: blood and transfusion for : blood and transfusion for hypovolemiahypovolemia shock shock Management for returning Management for returning negative pressurenegative pressure in the in the pleural cavitiespleural cavities History and physical examination for any History and physical examination for any complicationcomplication General consideration (9) Indication for Indication for thoracotomythoracotomy Uncontrolled hemorrhageUncontrolled hemorrhage Massive and Massive and continuoscontinuos air leak air leak ThoracoThoraco-abdominal injury with ruptured -abdominal injury with ruptured diaphragmdiaphragm Cardiac or great vessels injuryCardiac or great vessels injury Foreign body remain Foreign body remain Rupture of esophagusRupture of esophagus Severe lung or air way lacerationSevere lung or air way laceration Rib fracture (1) Special anatomy and injury * The 1st to 3rd ribs are well protected by the scapulas and shoulder muscles * The 4th to 7th ribs are most commonly injury involved because their length and location * The 8th to 10th ribs are well elasticity for their cartilage connection with the sternum * The last two (pseudo ribs) are free from anterior connection Rib fracture (2) Clinical classification: * Single rib fracture (single rib, single place) most often * Single rib fractures (single rib, multiple places) * Multiple ribs fracture (multiple ribs, single place) * Multiple ribs fractures (multiple ribs and places) floating chest wall and local chest wall reversed breath movement Rib fracture (3) Pathology Without significant internal involvement The pleura and lung may be punctured or lacerated (pneumothorax, hemothorax, pulmonary or cardiac contusion, et al.) Flail chest wall (floating chest wall): * The chest wall instability, paradoxical respiratory motion (suck in, push out) * Arterial blood gas test: PO2 decreases and PCO2 increases Rib fracture (4) Treatment principles Relief of the chest pain Immobilization of the wounded chest wall Prevention and treatment of any complication: pulmonary infection, DRS, heart failure, hemothorax, pneumothorax, et al. Rib fracture (5) The management of the flail chest wall The main project is to against the paradoxical respiratory movement of the chest wall Methods: pad with bandage external traction appliance (3 to 5 Kg, 1 to 2 weeks) internal stabilization (positive pressure assisted ventilation after trachea intubation) PNEUMOTHORAX (1) The air leak from the organs within the pleural cavity: pneumo-thorax resulted Classification: 1. Open (sucking) pneumo-thorax Direct communication between the atmosphere and the pleural cavity, lung collapses, mediastinum shifts, obstruction of the blood return in the thoracic great vessels, severe cardio-respiratory dynamic disturbed PNEUMOTHORAX (2) 2. Tension pneumo-thorax A true surgical emergency situation * High pressure remains and increases gradually in pleural cavity (trapped air) * Fatal with improper treatment 3. Partial or silence pneumo-thorax * less than 30 % of lung collapse * temporary and once communication between the atmosphere and the pleural cavity HEMOTHORAX (1) Hemorrhage into the pleural cavity space in some quantity in almost every patients, bleeding may be from any intra-thoracic structure Hemorrhage always coexists with Pneumothorax Early closed pleural cavity tubing drainage would prevent clotted hemorrhage HEMOTHORAX (2) The criterion for thoracotomy * more than 1000 ml blood