management of thoracic trauma
INTRODUCTION
Thoracic cavity is a cavity filled by a variety of vital organs, diantarannya: heart, lungs, large blood vessels.
Thoracic cavity formed by a framework of cone-shaped breasts that are composed of strong bones and muscles strong, but with a flexible construction and the foundation of a sheet of strong connective tissue called the diaphragm. Construction framework of the above strongly support the chest flexibility functions, including: functional protection against trauma and respiratory function.
Only a sharp trauma and blunt trauma with a large enough force that it is capable of causing injury to the appliance / vital organ in the above.
Pathophysiology
Trauma to the thoracic trauma consisted of sharp and blunt trauma.
In sharp trauma, there are wounds on kutis and subcutis tissue, muscle tissue may be more to reach more deeply or to injure the parietal pleura or parietal pericardium. Can also penetrate deeper, so that damage lung tissue, penetrate the wall of the heart or major blood vessels of the mediastinum.
Sharp trauma that penetrates the parietal pleura will cause a collapsed lung, due to the entry of outside atmospheric air into the lung cavity. When pleural viseralispun impregnable, the possibility of sharp trauma to the lung tissue is very large, so in addition to decreased ventilation due to short circuit bronkho - outside air through sharp cuts, probably also occurred Hemoptoe massif with the result - a result.
Sharp trauma that wounded the parietal pericardium can cause cardiac tamponade with tertimbunya blood in the pericardium cavity, which will be able to reduce activity of diastolic heart failure. Tembusnya Eksanguinasi result of heart or blood vessel walls in mediasternum large, capable of causing cardiac arrest within 2-5 minutes, depending on the degree of bleeding.
One other type of sharp trauma, the trauma of a bullet pierced. Fatality due to a bullet injury was greater than any other type of sharp trauma, because of greater tissue damage caused by high-speed rotation of the pleura, resulting in penetrating wounds of relatively higher exit from penetrating entrance wound.
Blunt thoracic trauma, when the power of trauma is not big enough, will only lead to pressure on the chest frame, which is due to the flexing will take shape when the pressure is lost. Blunt trauma such, are visible from the outside might not give an illustration of physical abnormalities, but can cause muscle skeleton kontusi against his chest, which can cause bleeding in situ and the formation of inter-or intra-muscular haematomas, which are sometimes quite large, resulting in pain on respiration and the patient looks like experiencing dyspnea.
Blunt trauma with a large enough force, capable of causing broken ribs, maybe just one rib, can also be some ribs at the same time, it can be only one location on each rib fractures, multiple fractures can also occur, may only involve unilateral rib side, may also result in bilateral .
Blunt trauma rarely cause any damage to heart tissue, except in case of trauma with a large enough force from the front, for example: due to drive a car steering wheel or pressing the chest caused by a sudden cessation of high-speed car crashes into vehicle or building front. Pressure steering wheel is capable of causing cardiac tamponade, hemorrhage or hematoma cavity pericardium heart wall that will reduce systolic and diastolic motion.
Encouragement or a blunt blow to the chest wall so strong framework, thus exceeding the power of flexibility ribs, rib fractures can cause the fracture fragments and the tip can damage the parietal pleura, or even the visceral pleura and lung tissue. After the trauma of missing a fragment of rib fractures will be returned to the original position due to the flexing, and due to the curvature of the ribs form a bulge toward the outside frame, and the binding between the ribs by muscles inter-oseus/otot intekostalis.
Circumstances mentioned above, although only in the morphologically simple and can be closed fractures of the ribs in a good position, but capable of causing hematotoraks or pneumothorax, not even a possibility of happening "Tension Pneumotorax", due to the circumstances in which the alveoli open, with a visceral pleural injury functioning "nipple" and the parietal pleura that covers injuries caused by the increased air pressure in the pleural cavity. Tension pneumothorax will urge further unilateral lung, resulting in decrease in ventilation between 15-20%.
If the pressure continues, there is mediastinal shift toward the contralateral and will push even further resulting in the contralateral lung was reduced ventilation capacity.
Lung tissue damage with terbukannya alveoli, allowing the emfisem subcutis, due to the spread of air discharged from the alveoli and interstitial tissue infiltrated into the lung to the mediastinum, and subsequently spread through the media subcutis. Emphysema subcutis in general can be spread throughout the body surface and is very noticeable with the "markup" scrotum or labiya majus.
ENFORCEMENT DIAGNOSIS
Ä Perform triage to determine the status of the patient
Ý presence and quality in the peripheral arteries
Is there a heartbeat Ý
Condition Ý smoothness of breath, dyspnea or apnea is there, is there any barriers in the airway.
Quality Ý respiration.
Ä Is there a traumatic lesion
Ý stab wounds or bullet wounds penetrating
Is there Ý rib fractures, clavicle or scapula
Ý Beware the consequences of traumatic spinal paraplegia / para-paresis
Evaluation of abnormalities intratoraks Ä
Ý Pneumothorax, especially the tension-pneumothorax and hematotoraks
Ý cardiac tamponade
Ä chest Evaluation framework
Ý hematoma framework chest wall area
Emphysema Ý subcutis
Respiration Ý paradoxical result of "Flail Chest" in the state of multiple rib fractures
Ä Evaluation of medical support
Ý Examination of blood hemoglobin and hematocrit
AP Investigation Ý rongten thorax and a half sitting and lateral
RESPONSE ACTION
Emphysema Ä subcutis:
Fixed on the main causes.
In the subcutis the great state of emphysema, which occurs when the throat and respiratory suppression, and an incision made tracheostomy kutis-subcutis.
Ä Tension Pneumothorax:
In emergency with considerable menusukan needle into the pleural space for drainage of air.
Ä Pneumothorax and Hematotoraks:
In circumstances where there is disturbance of ventilation and / or a collapsed lung, installed the "Water Sealed Drainage" of the pleural cavity (Bedside Drainage Water pleura cavity).
Ä "Flail Chest"
Filtration can be mounted on kutis chest wall plaster. If not successful, should be the operative fixation of the ribs.
Ä Hemoperikardium
What causes the "Cardiac Distress" cardiac tamponade due to aspiration of blood to be a temporary measure. Selected action is carried out immediately Thoracotomy surgery.
Pulmonary laceration Ä Network
In the case of lung tissue caused lacerations in a progressive disorder ventilation, need to consider immediate action if necessary invasive Thoracotomy and lobectomy.
SPECIAL CIRCUMSTANCES:
There are two special circumstances that need to didalami seriously, because without abnormalities of other organs, can cause sudden death in patients with blunt trauma chest frame:
Ä "Traumatic Wet Lung", where there was an increase drastically the number of lung interstitial fluid and intra-alveolar, and will cause anoksia anoksia tissue and alveolar.
Ä The progressive cardiac tamponade, occurred triads and Beck, namely increasing the number hemoperikardium at each systolic systolic voice growing weaker on continuing observation, which decreases arterial pressure and increased venous pressure.
CLOSING
Facing a patient with thoracic trauma, triage is the first evaluation of cardio-pulmonary function in a very careful and meticulous. When we have been able to be enforced "Assessment" cardio pulmonary and countermeasures have been implemented major medical emergencies, need to be done "Assessment" framework and thoracic cavity thoroughly.
Mastery of science and techniques of physical examination chest will strongly support the quality of aid given.
