Cardiac Thoracic & Vascular Trauma; Every Doctor should know

Soebandrijo, Darmawan Ismail Sub Bag Bedah Toraks Kardiak & Vaskuler SMF. Ilmu Bedah FK UNS RSUD Dr Moewardi Surakarta

Apa yang anda lakukan?

Apa yang anda lakukan?

Apa yang anda lakukan?

Airway-Breathing & Vaskuler

Airway Dada organ vital Vaskuler
Thorak & kardiak Abdomen Pelvis Femur & fraktur di tempat lain Perdarahan eksternal

Deadly cases
Airway obstruction Tension pneumothorax & sucking chest wound Massive hemothorax Tracheobronchial injury Flail chest Pericardial tamponade Laceration of vascular structure

How to diagnose?
1. Airway
L: gerakan dada, L: suara nafas & ST, F: hembusan nafas

2. Breathing
L: tanda2 sesak, DVJ, gerakan dada paradoksal & tertinggal L: SD, ST F: Perkusi !! (palpasi krepitasi)

3. Circulation
L: anemis, cyanosis, DVJ L: SJ, SJ menjauh F: akral dingin, CRT, nadi, tekanan darah

Airway obstruction
Clinical finding
Shortness of breath (dyspnea) Stridor Apnea

Management
Chin lift Jaw thrust Triple finger manuever Evacuate foreign body (cross finger) Hemlich manuver Cricothyroidostomy Tracheostomy ET insertion

Tension Pneumothorax
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 or Open Pneumothorax

Tension Pneumothorax (simplify)

Anx: Progressive shortness of breath PE :
Pneumothorax percusion: hypersonor Neck vein distension (severe case)

Treatment :
Needle thoracocentesis Consult : chest tube insertion

CXR image

Needle thoracocentesis

OPEN (SUCKING) CHEST WOUND

SUCKING CHEST WOUND

SUCKING CHEST WOUND

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

Hemothorax
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

Hemothorax (simplify)
Blunt or penetrating chest trauma Shock
Dyspnea Tachycardia Tachypnea Diaphoresis Hypotension

Dull to percussion over injured side Treatment

Chest tube insertion & consult

CXR Image

Trauma.org

FLAIL CHEST

PARADOXICAL RESPIRATIONS

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

Flail Chest

Tracheobronchial Injury
MOI
Blunt trauma Penetrating trauma

50% of patients with injury die within 1 hr of injury Disruption can occur anywhere in tracheobronchial tree Signs & Symptoms
Dyspnea Cyanosis Hemoptysis Massive subcutaneous emphysema Crepitation Suspect/Evaluate for other closed chest trauma

Tracheobronchial Injury

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

Pericardial Tamponade
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 or Cardiac tamponade

Pericardial Tamponade (simplify)

Dyspnea Possible cyanosis Becks Triad
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 P, QRS, & T amplitude changes in every other cardiac cycle PEA

DVJ Distant heart tones Hypotension or narrowing pulse pressure

Weak, thready pulse Shock

Pericardial Tamponade (ilustrations)

Laceration of vascular structures

General sign
Hypovolemia & shock Penetrating trauma (mostly)

External bleeding
Pemeriksaan teliti Balut tekan Torniquet Penjahitan

Laceration of vascular structures

External bleeding

Uncontrolled bleeding or Massive vascular trauma victims

Laceration of vascular structures

Internal bleeding Resusitasi cairan
Thoracic
Px . Pada B (Chest XR)

Abdominal
Px: Cairan bebas dari peritoneum, berupa distensi, pekak alih & undulasi FAST (USG) or CT

Pelvicum
Px: distraction test, culdocentesis, floating prostat USG

Femur
Px: Expanding hematoma, Iskemia distal (XRay)

ATLS & ACLS

Prinsip ABC Beda setting
Contoh:
saat berpidato atau main tenis tiba2 tak sadar, perawatan di RS tiba2 tak sadar

Bisa simultan
Contoh: pasien tua, trauma & mempunyai riw. Gangguan disritmia, kel: sesak nafas progresif dan kemudian cardiac arrest saat di UGD

Keterlambatan penangan akibat kurang waspada

Kasus trauma dengan gangguan kesadaran
Selalu ingat ABC, sblm D

Kasus fraktur
Selalu ingat NVD karena ada golden periode utk lesi vaskuler.

Always !!!
PREPARE
FOR THE

WORST

HOPE
FOR THE BEST