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1、2003-3-31,Trauma M&M Conference,1,Blunt Thoracic Injury,Chao-Wen ChenAttending SurgeonTrauma Service,KMUH,2003-3-31,Trauma M&M Conference,2,Preface,2/3 of victims of major blunt trauma suffer from thoracic injury.Thoracic injuries account for 20-25%of deaths due to trauma.Major thoracic trauma is as
2、sociated with multisystem injuries in 70%of cases.,2003-3-31,Trauma M&M Conference,3,Common Injuries Develop After Blunt Chest Trauma,Thoracic cage fracturesLung contusion and tearsMyocardium contusionAortic rupture,2003-3-31,Trauma M&M Conference,4,Initial Survey,Assume the existence of C-spine inj
3、ury ABCsGerneral evaluation:PE,PH,ECG,or ABGChest x-ray Administer oxygen,2003-3-31,Trauma M&M Conference,5,處理原則,謹記ABC 順序與原則初級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理：張力性氣胸（Tension Pneumothorax）連枷胸（flail chest）開放性胸壁傷口（open chest wound）大量血胸（massive hemothorax）心包填塞（cardiac tamponade）,2003-3-31,Trauma M&M Conferenc
4、e,6,如何處理？,張力性氣胸連枷胸 開放性胸壁傷口大量血胸心包填塞,2003-3-31,Trauma M&M Conference,7,如何處理？,張力性氣胸 Needle decompression/Chest Tube 連枷胸 Pain control/O2/MV開放性胸壁傷口 Wound coverage/Chest tube大量血胸 Chest tube/Thoracotomy心包填塞 Pericardial window,2003-3-31,Trauma M&M Conference,8,Imaging Survey,Chest x-ray:serve as a screening
5、 rather than a definite test repeat radiography should be ordered if suspiciousComputed tomography:highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest traumaAngiogram:for suspicious great vessel injuriesChest ult
6、rasound:detect hemothorax,FAST,2003-3-31,Trauma M&M Conference,9,處理原則,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：主動脈破裂（contained aorta rupture）氣管或支氣管破裂（rupture of tracheobronchial tree）食道破裂（perforation of esophagus）橫膈破裂（rupture of diaphragm）心肌挫傷（myocardial contusion）肺部挫傷（pulmonary contusion）,2003-3-31,Trauma M&M
7、 Conference,10,Contained aortic tear,2003-3-31,Trauma M&M Conference,11,Pneumothorax,2003-3-31,Trauma M&M Conference,12,Hemothorax,2003-3-31,Trauma M&M Conference,13,Troublesome Injuries,Sternal fractureMore serious injuries may accompanyIf suspected,a lateral CXR may be diagnosticOperative reductio
8、n is usually unnecessary Hospitalization is not mandatory if the ECG is normal and the patients vital sign is stable,2003-3-31,Trauma M&M Conference,14,Troublesome Injuries,Flail chestFracture of 2 or more consecutive ribs in at least 2 places eachAbout 30-40%of patients need mechanical ventilationA
9、RDS is increased 20-30%in the presence of flail chest,2003-3-31,Trauma M&M Conference,15,Troublesome Injuries,Flail chestClose monitoring of respiratory performanceAdequate analgesic therapyProvide oxygen therapy and ventilatory supportAggressive pulmonary toilet,2003-3-31,Trauma M&M Conference,16,T
10、roublesome Injuries,Lung contusionCxR finding may range from minimal interstitial infiltrate to extensive lobar consolidationChest CT 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 sti
11、ll controversial,2003-3-31,Trauma M&M Conference,17,Pulmonary contusion,2003-3-31,Trauma M&M Conference,18,Troublesome Injuries,Blunt Cardiac Trauma-spectrumAsymptomatic myocardiac contusionSymptomatic myocardiac contusionFree wall or septal wall ruptureValvular tearsCoronary artery thrombosis,2003-
12、3-31,Trauma M&M Conference,19,Troublesome Injuries,Blunt Cardiac Trauma risk factorsChest impact 15 mphMarked precordial tenderness,ecchymosis or contusion PH of cardiac diseaseFractured sternumThoracic spine or ribs fracturesHemodynamic instability,or multiple injuriesAge 50,2003-3-31,Trauma M&M Co
13、nference,20,Troublesome Injuries,Blunt Cardiac Trauma-assessmentMost are asymptomatic;severe cases die before arrivalCommon manifestation:arrhythmia,hemo-dynamic instability Evaluation:CxR,ECG,cardiac enzymes,echo-cardigram,MUGA,2003-3-31,Trauma M&M Conference,21,Troublesome Injuries,Blunt cardiac t
14、rauma-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 finding or MUGA keep hospitalization till a repeat test show acceptable findingCardiac rupture prompt
15、surgical repair,2003-3-31,Trauma M&M Conference,22,Troublesome Injuries,Blunt cardiac trauma-Guideline(USC+LAC)Obtain admission ECG and CPK-MB/TnT in patient with suspect BCIRepeat ECG 8-12 hours after admissionFor unexplained hemodynamic instability,abnormal ECG,and abnormal cardiac enzyme levels p
16、erform cardiac echogramIf no suspect symptomatolgy,lab tests or ECG finding discharge after 12 hours,2003-3-31,Trauma M&M Conference,23,胸部鈍傷處理流程,PE Survey,2003-3-31,Trauma M&M Conference,24,X-ray,2003-3-31,Trauma M&M Conference,25,胸部鈍傷病患住院照護準則,Admission OrderDay 1 Consider ICU admission for elderly
17、patients,or if other complicating factors exist.NPO Chest tube to suction,follow chest tube output Follow-up CXR Analgesia(oral epidural PCA)Pulmonary toilet OOB to chair,2003-3-31,Trauma M&M Conference,26,胸部鈍傷病患住院照護準則,Day 2 Advance diet Chest tube to suction,follow chest tube output Morning CXR Ana
18、lgesia(oral epidural PCA)Pulmonary toilet OOB to chair,2003-3-31,Trauma M&M Conference,27,胸部鈍傷病患住院照護準則,Day 3 if no air leak,chest tube to water seal,otherwise to suction.follow output Morning CXR Analgesia(oral epidural PCA)Pulmonary toilet Ambulate tid once chest tube is off suction,2003-3-31,Traum
19、a M&M Conference,28,胸部鈍傷病患住院照護準則,Day 4 Check CXR after 6-8 hours on water seal,if lung expanded and output150ml remove chest tube Recheck CXR 6 hours post removal,discharge if expanded.Change analgesia to orat Keep site dressing in place 48 hrs,2003-3-31,Trauma M&M Conference,29,胸部鈍傷病患住院照護準則,無併發症病患預計留院時間“4”天 出院時應注意下列狀況：病患呼吸狀況應符合生理基本需求，無窘迫情形 疼痛之適度處理 肺部擴展完全且血胸已順利引出 病患了解傷口後續照護原則,2003-3-31,Trauma M&M Conference,30,Thank you for your attention!,2003-3-31,Trauma M&M Conference,31,
