胸部創(chuàng)傷（英文版）課件

ChesttraumaChestanatomyInthechestaretheheart,lungs,trachea,esophagusandmajorbloodvesselsthatgotoandfromtheheartTheorgansofthechestaresurroundedbytheribs,musclesbetweentheribsandthediaphragmThediaphragmseparatesthechestfromtheabdomen.Itisthemainmuscleusedforbreathing.IncidenceChestinjuriescauseoneineveryfourtraumadeathsinNorthAmerica.

Manyofthesepatientsdieafterreachingthehospital,andmanyofthesedeathscouldbepreventedwithpromptdiagnosisandtreatment.Pathophysiology

Hypoxia:resultsfrominadequatedeliveryofoxygentothetissues

Hypovolemia:Inadequateintravascularvolume,i.e..Bloodloss

Pulmonaryventilation/perfusionmismatch-e.g.contusion,hematoma,alveolarcollapse

Changesinintrathoracicpressurerelationships-

tensionpneumothorax,openpneumothorax

Respiratoryacidosis,Hypercarbia(increasedCO2)mostoftenresultsfrominadequateventilationcausedbychangesinintrathoracicpressurerelationshipsanddepressedlevelofconsciousness

Metabolicacidosis

canbecausedbyhypoperfusionofthetissues(shock).

InitialresuscitationPrinciplesfortheresuscitation:ABCsAairwayBbreathingCcirculation

AirwayBreathingCirculationRibfractureCauseofribfractureDirectviolencePathologicfracturemetastaticmalignance,bonedisease.SymptomsandsignsPainlocalizedtothefracturesiteandaggravatedbyrespiration.Limitationofrespiratorymotion.Tenderness,crepitationatthefracturesiteisheard.Severeinjurycomplicatedbysubcutaneousemphysema,pneumothorax,hemothorax.DiagnosisofribfractureSymptomsSignsX-raysEnvenifchestx-rayswithdetailsviewsoftheribsdonotdemanstratethefracture.Mutiplebreaksinmutipleribscreateafree-floatingsegment.free–floatingsegmentofthechestwallmovesparadoxicallywithspontaneousrespiration.Complications

AtelectasisPneumonitisRespiratoryfailureTreatment

Painreliefanalgesicsorintercostalnerveblock.ClearanceofpulmonarysecretionsProventionpneumonitisLocalizedstrappingtocontrolpainandslightparadoxicallymotions.Severethoracictraumarequireintubationpositivepressureventilationisneeded.Pneumothorax

OpenpneumothoraxSimplepneumothoraxTentionpneumothoraxOpenPneumothorax

Anopen/suckingchestwoundallowsfreepassageofairintoandoutofthepleuralspace.

Ifopeninginchestistwo-thirdsthediameterofthetrachea,airpassesthroughchestdefectwitheachrespiratoryeffort,becauseairtendstofollowthepathofleastresistancethroughthechestwalldefect.

EffectiveventilationisimpairedleadingtohypoxiaandhypercarbiaOpenpneumothoraxcausesmediastinumfroshifting.SignsandSymptomsDyspnea

Chestpain

Penetratingwoundtothechest

Hyperresonanceoftheaffectedhemithorax

Decreasedorabsentbreathsoundsonaffectedside

Suckingsoundoninspiration

Intervention

Promptlyclosingthedefectwithasterileocclusivedressing,largeenoughtooverlapthewound’sedges,thatistapedsecurelyonthreesides.

Iftensionpneumothoraxdevelopsimmediatelyremovedressing.

Definitivetreatmentischesttubetherefore,rapidtransporttoappropriatefacility.

TensionPneumothorax

Developswhena“one-wayvalve”airleakoccurseitherfromthelungorthroughthechestwall.

*Airisforcedintothethoraciccavitywithoutanymeansofescape.Causingacollapseoftheaffectedlung,displacementofmediastinumtooppositeside,decreaseinvenousreturn,andcompressionoftheoppositelung.

CausesofTensionPneumothorax

1.Mechanicalventilationwithpositivepressureventilationinthethepatientwithvisceralinjury

2.Simplepneumothoraxfollowingapenetratingorbluntchesttraumainwhichlunginjuryhasfailedtoseal

3.Misguidedattemptatsubclavianorinternaljugularvenouscatheterinsertion

4.Incorrectlycoveredchestwallinjurywithocclusivedressing

5.MarkedlydisplacedthoracicspinefracturesSignsandSymptoms

Chestpain

Airhunger

Respiratorydistress

Tachycardia

Hypotension

Trachealdeviation

Unilateralabsenceofbreathsounds

Neckveindistention

Cyanosis

Intervention:

ImmediateDecompression,Rapidlyinsertingalarge-boreneedleintothe2ndintercostalspace,midclavicularlineoftheaffectedside,Convertstensionpneumothoraxintoasimplepneumothorax.

Definitivetreatmentischesttubetherefore,rapidtransporttoappropriatefacility.

SimplepneumothoraxLungcollapseisnomorethan10%,specialtreatmentisnotnecessary.Lungcollapseismorethan25%,thoracentesis.Tubethoracostomyisindicated.Hemothorax

Causes:penetratingwoundthatdisruptsthesystemicorhilarvessels

Blunttrauma(decelerationinjury)

SignsandSymptoms

Dyspnea

Chestpain

Dullnessontheaffectedhemithorax

Decreasedbreathsoundsonaffectedside

Trachealshift

Shock

Interventions

Aggressivecrystalloidinfusion

Typespecificbloodtransfusion

Decompressionofchestcavity

Chesttube.REMEMBERthatchesttubecancauseanavenueforexsanguinationbyeliminatinganytamponadeeffectoftheclosedchestinjury.>1000ccoutatonce,considerclampingthechesttube.

Treatment

ImmediatereplacementofbloodlossCloseddrainagebytubethoracostomy.CirculationAssessment

Patient’spulseshouldbeassessedforquality,rate,andregularity.

Inhypovolemicpatients,radialandpedalpulsesmaybeabsentduetovolumedepletion.

Bloodpressureandpulsepressureshouldbemeasuredandperipheralpulsesshouldbeassessedbyobservingandpalpatingtheskinforcolorandtemperature.

REMEMBER,neckveinsma