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1、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 durin
2、g 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 fl
3、uid 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
4、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,G
5、eneral 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 th
6、oracic 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, di
7、aphragm, 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: Evacuation to an appropriate facility Resuscitation
8、: restore the organs function Airway: suction of mouth and pharynx, introduction of oral airway suffice, intubation with hyperventilation (or cricothyroidotomy) Adequate circulation: blood and transfusion for hypovolemia shock Management for returning negative pressure in the pleural cavities Histor
9、y and physical examination for any complication,General consideration (9),Indication for thoracotomy Uncontrolled hemorrhage Massive and continuos air leak Thoraco-abdominal injury with ruptured diaphragm Cardiac or great vessels injury Foreign body remain Rupture of esophagus Severe lung or air way
10、 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 wi
11、th 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 r
12、ibs 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 ch
13、est 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 treatmen
14、t 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
15、 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
16、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,
