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1、Blunt Thoracic Injury Blunt Thoracic Injury Chao-Wen ChenChao-Wen ChenAttending SurgeonAttending SurgeonTrauma Service, KMUHTrauma Service, KMUH2003-3-311处理原则Preface t2/3 of victims of major blunt trauma suffer from thoracic injury.tThoracic injuries account for 20-25% of deaths due to trauma. tMajo
2、r thoracic trauma is associated with multisystem injuries in 70% of cases.2003-3-312处理原则Common Injuries Develop After Blunt Chest TraumatThoracic cage fracturestLung contusion and tearstMyocardium contusiontAortic rupture2003-3-313处理原则Initial SurveytAssume the existence of C-spine injury tABCstGerne
3、ral evaluation: PE, PH, ECG, or ABGtChest x-ray tAdminister oxygen2003-3-314处理原则處理原則t謹記ABC 順序與原則t初級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理：t張力性氣胸 （Tension Pneumothorax）t連枷胸 （flail chest）t開放性胸壁傷口 （open chest wound）t大量血胸 （massive hemothorax）t心包填塞 （cardiac tamponade）2003-3-315处理原则如何處理？t張力性氣胸t連枷胸t開放性胸壁傷口t大量血胸t心包填塞2
4、003-3-316处理原则如何處理？t張力性氣胸Needle decompression/ Chest Tube t連枷胸Pain control/ O2 / MVt開放性胸壁傷口Wound coverage/Chest tubet大量血胸Chest tube / Thoracotomyt心包填塞Pericardial window2003-3-317处理原则Imaging Surveyt tChest x-rayChest x-ray : serve as a screening rather than a definite test repeat radiography should be
5、 ordered if suspicioust tComputed tomographyComputed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest traumat tAngiogramAngiogram : for suspicious great vessel injuriest tChest ultrasoundChest ult
6、rasound : detect hemothorax, FAST2003-3-318处理原则處理原則t二級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理：t主動脈破裂（contained aorta rupture）t氣管或支氣管破裂（rupture of tracheobronchial tree）t食道破裂（perforation of esophagus）t橫膈破裂（rupture of diaphragm）t心肌挫傷（myocardial contusion）t肺部挫傷（pulmonary contusion） 2003-3-319处理原则Contained aortic t
7、ear2003-3-3110处理原则Pneumothorax2003-3-3111处理原则Hemothorax2003-3-3112处理原则Troublesome Injuriest tSternal fractureSternal fractureMore serious injuries may accompanyIf suspected, a lateral CXR may be diagnosticOperative reduction is usually unnecessary Hospitalization is not mandatory if the ECG is norma
8、l and the patients vital sign is stable2003-3-3113处理原则Troublesome Injuriest tFlail chestFracture of 2 or more consecutive ribs in at least 2 places eachAbout 30-40% of patients need mechanical ventilationARDS is increased 20-30% in the presence of flail chest2003-3-3114处理原则Troublesome Injuriest tFla
9、il chestClose monitoring of respiratory performanceAdequate analgesic therapyProvide oxygen therapy and ventilatory supportAggressive pulmonary toilet2003-3-3115处理原则Troublesome Injuriest tLung contusionCxR finding may range from minimal interstitial infiltrate to extensive lobar consolidationChest C
10、T is accurate diagnostic tool but not always mandatoryTx : same as flail chest, but pay attention to avoid overhydration; use of steroid and prophylactic antibiotic are still controversial2003-3-3116处理原则Pulmonary contusion2003-3-3117处理原则Troublesome Injuriest tBlunt Cardiac Trauma - spectrumAsymptoma
11、tic myocardiac contusionSymptomatic myocardiac contusionFree wall or septal wall ruptureValvular tearsCoronary artery thrombosis2003-3-3118处理原则Troublesome Injuriest tBlunt Cardiac Trauma risk factorsChest impact 15 mphMarked precordial tenderness, ecchymosis or contusion PH of cardiac diseaseFractur
12、ed sternumThoracic spine or ribs fracturesHemodynamic instability, or multiple injuriesAge 502003-3-3119处理原则Troublesome Injuriest tBlunt Cardiac Trauma - assessmentMost are asymptomatic; severe cases die before arrivalCommon manifestation : arrhythmia, hemo-dynamic instability Evaluation : CxR, ECG,
13、 cardiac enzymes, echo-cardigram, MUGA2003-3-3120处理原则Troublesome Injuriest tBlunt cardiac trauma - managementMost cases do not require Tx; Symptomatic arrhythmia (2-5%) antiarrthythmicsAbnormal ECG and cardiac enzymes almost return to normal within one week.Patients with abnormal cardiac echo findin
14、g or MUGA keep hospitalization till a repeat test show acceptable findingCardiac rupture prompt surgical repair2003-3-3121处理原则Troublesome Injuriest tBlunt cardiac trauma - Guideline (USC+LAC)Obtain admission ECG and CPK-MB/TnTTnT in patient with suspect BCIRepeat ECG 8-12 hours after admissionFor un
15、explained hemodynamic instability, abnormal ECG, and abnormal cardiac enzyme levels perform cardiac echogramIf no suspect symptomatolgy, lab tests or ECG finding discharge after 12 hours2003-3-3122处理原则胸部鈍傷處理流程 tPE Survey理學檢查氣胸Needle decompression/ Chest tubeSubxyphoid windowthoracotomyNeedle decompr
16、ession/ Chest tube張力性氣胸血胸心包填塞2003-3-3123处理原则tX-rayCXR檢查氣胸Chest tubePain controlOxygen supplyAvoid fluid overloadResp. Distress(+)MVNGTrepeat X-rayUGI seriesU/S or CT scan血胸橫膈？連枷胸、肺挫傷若出血1200ml 或200ml/hr，考慮開胸術縱膈積氣氣胸() Chest Tube氣胸() 氣管支氣管鏡檢食道鏡檢或食道造影 縱膈腔變寬Chest CTAortic Angiogram2003-3-3124处理原则胸部鈍傷病患住院
17、照護準則tAdmission OrdertDay 1 t Consider ICU admission for elderly patients, or if other complicating factors exist.t NPOt Chest tube to suction, follow chest tube outputt Follow-up CXRt Analgesia ( oral epidural PCA)t Pulmonary toilett OOB to chair2003-3-3125处理原则胸部鈍傷病患住院照護準則tDay 2t Advance diett Chest
18、 tube to suction, follow chest tube outputt Morning CXRt Analgesia ( oral epidural PCA)t Pulmonary toilett OOB to chair2003-3-3126处理原则胸部鈍傷病患住院照護準則tDay 3t if no air leak, chest tube to water seal, otherwise to suction. follow outputt Morning CXRt Analgesia ( oral epidural PCA)t Pulmonary toilett Ambu
19、late tid once chest tube is off suction2003-3-3127处理原则胸部鈍傷病患住院照護準則tDay 4t Check CXR after 6-8 hours on water seal, if lung expanded and output150ml remove chest tubet Recheck CXR 6 hours post removal, discharge if expanded.t Change analgesia to oratt Keep site dressing in place 48 hrs2003-3-3128处理原则
20、胸部鈍傷病患住院照護準則t無併發症病患預計留院時間 “4 4” 天 t出院時應注意下列狀況：t 病患呼吸狀況應符合生理基本需求，無窘迫情形t 疼痛之適度處理t 肺部擴展完全且血胸已順利引出t 病患了解傷口後續照護原則2003-3-3129处理原则Thank you for your attention!Thank you for your attention!2003-3-3130处理原则F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s
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