American College of Surgeons

Committee on Trauma Presents

harry soedjatmiko
marshal

Division Of Thoracic And Cardiovascular Surgery

Department Of Surgery 1
Faculty Of Medicine, University Of North Sumatera
The Need
 Trauma is leading cause of death in
the first 4 decades of life.
 3 patients permanently disabled per
death
ATLS provides common language

2
ATLS Concept
A Airway with c-spine protection
B Breathing
C Circulation
D Disability / Neurologic status
E Exposure / Environment

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Primary Survey
 Adult,
 children,

 pregnant women

Priorities are the same !

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 Initial Assessment /
Management
Injury
Transfer
Primary Survey
Optimize patient Adjuncts
Status
Resuscitation

Reevalution Reevaluation

Secondary Survey
Adjuncts 5
 Objectives
 Indentify and treat injuries found
during the primary survey.
 Indentify and treat injuries found
during the secondary survey.
 Demonstrate the ability to perform
life saving chest management.
 Indications
 Contraindications

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 Thoracic Trauma

1 out of 4 deaths
 Blunt : < 10% require operation
 Penetrating : 15% - 30% require
operation
 Majority : require simple procedures

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 Initial Assessment/
Management

Primary Survey
 Identifies most life -threatening
injuries
Resuscitation
 Airway control
 Ensure oxygenation/ventilation
 Needle / tube thoracostomy
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 Initial Assessment/
Management

Secondary Survey Definitive Care

 Identifies most  Airway control
potentially  Ensure oxygenation
lethal injuries /ventilation
 Physical exam/  Tube thoracostomy

diagnostic tests  Hemodynamic sup-

port
 Operation

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Life threatening Chest Trauma

Primary Survey
 Airway obstruction
 Tension pneumothorax
 Open pneumothorax
 Flail chest
 Massive hemothorax
 Cardiac tamponade
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 Airway Obstruction
Laryngeal injury
 Rare occurrence
 Hoarseness
 Subcutaneous emphysema
 Treatment
Intubation (caution)
Tracheostomy (by surgeon)

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 Intubation
Intubasi orotrakeal

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Trakeostomi

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 Breathing
Tension pneumothorax,
Etiology :
 Parenchymal and / or chest-wall injuries
 Air enters pleural space with no exit
 Positive pressure ventilation
Collapse of affected lung
↓ Venous return
↓ Ventilation of opposite lung

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 Breathing
Tension Pneumothorax :
Signs / Symptoms
 Respiratory distress
 Distended neck veins
 Unilateral ↓in breath sounds
 Hyperresonance
 Cyanosis, late

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 Breathing
Tension
Pneumothorax
 Immediate
decompression
 Clinical diagnosis,
not by x-ray

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 Breathing
Open Pneumothorax
 Cover defect
 Chest tube
 Definitive
operation

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Breathing
Flail chest
Plester 3 sisi

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 Flail Chest
 Flail chest
complicates about
10% to 20% of
patients with blunt
chest trauma and is
associated with a
mortality rate ranging
from 10% to 35%
Davignon K, Kwo J, Bigatello LM. Pathophysiology and management of 19
the flail chest. Minerva
Anestesiol 2004;70:193-9.
 Flail Chest
 This lesion is a clinical finding, and
respiratory compromise in flail
chest is more the result of
underlying pulmonary contusion
and ventilation perfusion
mismatch than the actual
structural defect to the chest wall.

Dorman T. Thoracic Trauma. Flail chest: pathophysiologic effects and pain control. Program and abstracts of the
31st International Educational and Scientific Symposium of the Society of Critical 20
Care Medicine; January 26-30,
2002; San Diego, California.
 Flail Chest
 Flail
chest exists when there
are fractures of 3 or more ribs
anteriorly and posteriorly, and
paradoxic movement of a
segment of chest wall results.

Dorman T. Thoracic Trauma. Flail chest: pathophysiologic effects and pain control. Program and
21 of the Society of Critical
abstracts of the 31st International Educational and Scientific Symposium
Care Medicine; January 26-30, 2002; San Diego, California.
segmental fracture
of the rib 11 rib
rib
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segmental fracture
of the rib 22 rib
rib
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free floating
rib

segmental fracture 33 rib

of the rib rib
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Flail Chest

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PENDULLAR RESPIRATION
pathophysiology

CO2 CO2

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CO 2 narcosis
 Life threatening causes of
asymmetrical chest expansion

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Right sided multiple rib fractures and flail
chest Right pulmonary contusion and
subcutaneous emphysema

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flail chest - detail

Segmental rib fractures

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 Breathing

Flail Chest/pulmonary Contusion

 Reexpand lung
 Oxygen
 Judicious fluid management
 Intubation as indicated
 Analgesia

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 Circulation
Massive Hemothorax
≥ 1500 ml blood loss
 Systemic / pulmonary vessel
disruption
 Flat vs distended neck veins
 Shock with no breath sounds
and /or percussion dullness

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 Circulation

Massive Hemothorax
 Rapid volume restoration
 Chest decompression and x-ray

 Autotransfusion

 Operative intervention

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restoration
of
circulating
volume

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 restoration
of blood
oxygen-carrying
capacity

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normalization
of coagulation
status

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 Circulation
Cardiac Tamponade
 ↓Arterial pressure
 Distended neck
veins
 Muffled heart
sounds
 Trias Beck’s

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 Circulation
Cardiac Tamponade
 Patent airway
 IV therapy

 Pericardiocentesis

 Pericardiotomy

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pericardiocentesis

Pericardiocentesis
should not be used
in setting of trauma
to the heart

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Chest Surgery Clinics of Nort America, May 1997
 Resuscitative Thoracotomy

 Qualified surgeon present on

patient’s arrival
 Indications
Penetrating thoracic injury
Pulseless with electrical activity
 Contraindications
Blunt injury
Pulseless without electrical activity

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Questions

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