TRAUMA CERRADO DE TRAX

Ana Caldern Alexandra Pealoza

Ciruga 2012-I

Contenido
1. 2. 3. 4. 5. 6. 7. 8. 9. Anatoma del trax Definicin Epidemiologa Fisiopatologa Clasificacin Manejo inicial Desarrollo por tipo de trauma Indicaciones Tubo Toracotoma

Contenido
1. 2. 3. 4. 5. 6. 7. 8. 9. Anatoma del trax Definicin Epidemiologa Fisiopatologa Clasificacin Manejo inicial Desarrollo por tipo de trauma Indicaciones Tubo Toracotoma

Neumotrax a Tensin Hemotorax Trax inestable Contusin pulmonar Taponamiento Cardaco

1. Anatoma del Trax

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Cavidad Pleural

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Lquido Pleural
Cantidad Protenas Clulas mm3 pH PCO2 Glucosa LDH 2 a 10ml (0.1 a 0.2/kg peso) 10-20g/L (50-70% Albmina) 1500 4500 (blancos 15-30%) 7.38 45mmHg 100% plasmtica <50% del plasma

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2. Definicin
Trauma cerrado de trax

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3. Epidemiologa
El trauma representa la principal causa de
muerte en las 3 primeras dcadas De las lesiones torcicas el 90% corresponden a trauma cerrado

15 % pacientes URG ameritan toracotoma

Causa ms frecuente de muerte es la insuficiencia respiratoria.

ASPECTOS EPIDEMIOLGICOS DEL TRAUMA EN COLOMBIA, HUGO EUGENIO LEN T. M.D. FACULTAD DE MEDICINA UNIVERSIDAD DE MANIZALEZ,2008

4. Fisiopatologa
T R A U M A T O R A C I C O
CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

5. Clasificacin

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

6. Manejo Inicial
A

Va area Ventilacin Circulacin Dficit neurolgico

Exposicin
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7. Desarrollo por tipo de trauma

Neumotrax a tensin

Contusin pulmonar
Taponamiento Cardiaco

Hemotorax
Trax inestable
CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

7. Tipo de trauma

Neumotrax

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Clasificacin
NEUMOTRAX ESPONTANEO (60.3%)

PRIMARIO SECUNDARIO

NEUMOTRAX TRAUMTICO (33.6%) ABIERTO CERRADO

Diagnstico clnico

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 Cmo se ve ?

Principles of diagnosis and management of traumatic pneumothorax, Anita Sharma, Parul Jindal, Journal of Emergencies, Trauma and Shock Dehradun, Uttarakhand, India, 2008

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Neumotrax izq. moderado. La pleura visceral puede verse en el vrtice pulmonar (flecha curva) y aparecen zonas de hiperlucencia (flechas) en la parte inferior del hemitrax izquierdo debido a la presencia de aire en el interior de la porcin no dependiente del espacio pleural anteroinferior.

Traumatismos de la pared torcica,del pulmn y del espacio pleural Lisa A. Miller, MD*CLNICAS RADIOLGICAS DE NORTEAMRICA Radiol Clin N Am 44 (2006) 213-224

Neumotrax subpulmonar. Rx. muestra un signo del surco profundo (flecha) dentro del ngulo costofrnico der. debido a un neumotrax de distribucin inferior.

Traumatismos de la pared torcica,del pulmn y del espacio pleural Lisa A. Miller, MD*CLNICAS RADIOLGICAS DE NORTEAMRICA Radiol Clin N Am 44 (2006) 213-224

Neumotrax a tensin. El pulmn izq est comprimido hacia el hilio (flechas), y el mediastino est desplazado hacia la de. Ensanchamiento espacios intercostales lado izq y el hemidiafragma homolateral bien delimitado y descendido.

Traumatismos de la pared torcica,del pulmn y del espacio pleural Lisa A. Miller, MD*CLNICAS RADIOLGICAS DE NORTEAMRICA Radiol Clin N Am 44 (2006) 213-224

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Tratamiento

Evacuacin de aire Re expansin pulmonar

Principles of diagnosis and management of traumatic pneumothorax, Anita Sharma, Parul Jindal, Journal of Emergencies, Trauma and Shock Dehradun, Uttarakhand, India, 2008

7. Tipo de trauma
Hemotrax
Traumatismos torcicos Yatrgenas: Sondas de drenaje pleural Cateterismos centrales Toracocentesis y biopsias pleurales. Neoplasias Coagulopatas vasculares Aneurismas rotos. Fstulas arteriovenosas
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Causas de hemotrax por trauma

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Clasificacin de hemotrax

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Diagnstico clnico
Vaso y su grado lesin

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Diagnstico radiolgico

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Rx. de trax. Aumento de la opacidad de todo el hemitrax izq. Desplazamiento del mediastino hacia la der. como consecuencia del extenso hemotrax izq.

Traumatismos de la pared torcica,del pulmn y del espacio pleural Lisa A. Miller, MD*CLNICAS RADIOLGICAS DE NORTEAMRICA Radiol Clin N Am 44 (2006) 213-224

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La TC muestra un gran hemotrax izq. con desplazamiento del mediastino hacia la der. Mltiples focos de gran atenuacin en el interior del pulmn izq. comprimido que indican la presencia de hemorragia activa (puntas de flecha) en el parnquima pulmonar.

Traumatismos de la pared torcica,del pulmn y del espacio pleural Lisa A. Miller, MD*CLNICAS RADIOLGICAS DE NORTEAMRICA Radiol Clin N Am 44 (2006) 213-224

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7. Tipo de trauma
Trax inestable
Fractura de cuatro o ms arcos costales contiguos en dos sitios diferentes del mismo arco costal
CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Clasificacin fracturas
Esternn Costales: Altas Medias Superiores

* Fractura Esternal

An. Med. Interna (Madrid) v.24 n.3 Madrid mar. 2007 Disrupcin esternal sin existencia de fractura tras traumatismo torcico

* Fractura Esternal

An. Med. Interna (Madrid) v.24 n.3 Madrid mar. 2007 Disrupcin esternal sin existencia de fractura tras traumatismo torcico

* Fractura Esternal
SNTOMAS Rx.
AnteroPosterior COMPLICACIONES

Contusin Miocrdica

Dolor
Esternal Lateral Rotura de aorta

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Tratamiento
Analgesia IV Bloqueo nervioso Terapia respiratoria

7. Tipo de trauma
Trax inestable

Fractura de cuatro o ms arcos costales contiguos en dos sitios diferentes del mismo arco costal

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Diagnstico clnico

Symbas PN. Contusion of the lung. En: Cardiothoracic Trauma. WB Saunders Company. Philadelphia, 2010

Diagnstico radiolgico

Diagnstico radiolgico

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Diagnstico radiolgico

Rx. AP. Muestra fracturas en 2 localizaciones en la zona post. de la parrilla costal izq entre las costillas 3 y 8.

Traumatismos de la pared torcica,del pulmn y del espacio pleural Lisa A. Miller, MD*CLNICAS RADIOLGICAS DE NORTEAMRICA Radiol Clin N Am 44 (2006) 213-224

7. Tipo de trauma
Contusin pulmonar

Laceracin pulmonar, resultado de un trauma cerrado o abierto con hemorragia intraalveolar .

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Escala traumatismos pulmonares

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Diagnstico clnico
SINTOMATOLOGA
Sx. De dificultad respiratoria Cambios en la frecuencia respiratoria Hiperventilacin Cambios en los gases arteriales

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Diagnstico TAC
1
Lesiones con cavidades intraparenquimatosas llenas de aire o sangre.

Localizacin: zona media del pulmn.

Se observa un hematoma intrapulmunar ovalado en el pulmn derecho, y fracturas costales del mismo lado, por un traumatismo cerrado por un accidente autopedestre.
CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Diagnstico TAC
2
Cavidades llenas de aire o llenas de sangre. Localizacin: para-vertebral. Mecanismo :desgarro.

Cavidades pequeas y perifricas. Localizacin: sub-pleural. Mecanismo: penetracin costal.

Lesiones que se forman por la existencia de adherencias pleuropulmonares previas. Localizacin: sub-pleural. Mecanismo: desgarro por adherencias.

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Diagnstico Rx.

Muestra una afectacin parcheada del espacio areo que afecta a toda la cara lateral del pulmn izquierdo

Diagnstico Rx.

Evidencia una contusin pulmonar moderada que afecta la periferia del pulmn derecho.

Diagnstico Rx.

Evidencia de contusin pulmonar junto con fracturas costales del hemitrax derecho

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Diagnstico Rx.

Evidencia de contusin pulmonar junto con fracturas costales mltiples del hemitrax derecho

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Tratamiento
Manejo del dolor

Manejo de las lesiones asociadas

Terapia respiratoria

Drenaje postural

CIRUGA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

7. Tipo de trauma
Taponamiento Cardaco

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LIBROS VIRTUALES INTRAMED, POLITRAUMATIMO, VOL2, 3 EDICION,2009

Etiologa
AGUDA
Hemopericardio IAM Aneurisma A. roto Anticoagulante POP Qx. reciente Pericarditis aguda IRC Cateterismo central
100 ML

CRNICA
Neoplasia Enf. de T.Conectivo

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Clnica
presin arterial sistmica presin venosa sistmica Ruidos cardacos velados Claude Schaeffer Beck (1894 1971)

KUSSMAUL
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Signos de bajo gasto

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Exploraciones complementarias
Rx. de trax y EKG Ecocardiograma
Dilatacin cava inferior Colapso AD y VD Protodistole Septum Desviado

Cateterismo
S: 90% E: 97%

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Tratamiento
ABCD Lquidos IV: Mejora PVC y GC Pericardicentesis Ventana pericrdica

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8. Indicaciones tubo de trax en fase aguda del trauma

CIRUGIA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

Colocacin tubo de trax

CIRUGIA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

9. Toracotoma
Indicaciones en URG Colapso cardiovascular Toracotoma traumtica Herida que atraviesa mediastino Embolismo del proyectil y arreo HEMOTORAX MASIVO Y TAPONAMIENTO

CIRUGIA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008

CIRUGIA GENERAL EN EL NUEVO MILENIO, CAYCEDO RUBEN 2 EDICIN 2008