THORACIC

TRAUMA Mentor:
dr. Marshal, Sp. B, Sp.
BTKV(K)
Arrenged by:
Merinda 150100025
Edi Sunarto 15010007
Yustry Meliani 150100167
Ummilia Saimima 150100205
Dg Ku Nur Syahrina 150100207

PROGRAM PENDIDIKAN PROFESI DOKTER DEPARTEMEN ILMU BEDAH

FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA - RSUP HAJI ADAM MALIK, MEDAN
2020
 Section 1

INTRODUCTION
Anatomi Thorax
 Definition
Trauma thorax encompasses the
sequalae secondary to trauma to all
of the thoraacic organs: heart, great
vessels, lungs, airways, esophagus,
diaphragm, and chest wall.

Symbas, J.D., Ng, T.T., Margulies, D.R., Symbas, P.N. 2010. Management of Thoracic Trauma. Chp. 55. Medical Management of the Thoracic Surgery Patient. pp. 494-505. [Link]
3993-8.00055-6
 Epidemiology

• blunt chest trauma > penetrating trauma  20% -25% trauma deaths
• < 10% blunt trauma (operative intervention), 15% -30% patient with
penetrating trauma (operative intervention)
• Morbidity and mortality occur as the result from disruption of respiratory,
circulatory or combination.

Edgecombe; L., Sigmon, D.F., Galuska, M.A., Angus, L.D. 2020. Thoracic Trauma. StatPearls (Internet). [Link]
%20seat%20belt%20use.
 Etiology

Ahmad et al. 2019. A University Hospital Based Study on Thoracic Trauma: Life Threatening Event, Its Etiology, Presentation, and Management. Cureus 11(12): e6306.
 Etiology
80% Gunshot,
stabbing

NB :
• blunt trauma : organ damage by compression, acceleration/deceleration
• penetrating trauma : all mediastinum structures are equally susceptible and injury depends on anatomical location and trajectory of the wound

Ahmad et al. 2019. A University Hospital Based Study on Thoracic Trauma: Life Threatening Event, Its Etiology, Presentation, and Management. Cureus 11(12): e6306.
EB Medicine. Ballistic Injuries In The Emergency Department (Trauma CME). [Link]
 DEADLY DOZEN

Lethal Six Hidden Six

● Airway Obstruction • Thoracic aortic disruption

● Tension Pneumothorax • Tracheobronchial disruption
● Cardiac Tamponade
• Myocardial contusion
● Open Pneumothorax
• Traumatic diaphragmatic tear
● Massive Hemathorax
● Flail Chest • Esophageal disruption

• Pulmonary contusion

Yamamoto, L., Schroeder, C. Morley, D., Beliveau, C. 2005. Thoracic Trauma.. Critical Care Nursing Quarterly volume 28, issue 1, P22-40 2005 DOI: 10.1097/00002727-200501000-00004
 Section 2

PNEUMOTHORAX
 DEFINITION

Accumulation of air within pleural space =>

collapse

Townsend, C., Sabiston, D., Beauchamp, R., Evers, B. and Mattox, K., 2017. Sabiston Textbook Of Surgery. 20th ed. Philadelphia: Elsevier.
 ETIOLOGY AND CLASSIFICATION

[Link]. 2020. Pneumothorax – Knowledge For Medical Students And Physicians. [online] Available at:
[Link]. 2020. Pneumothorax
– Knowledge For Medical Students
And Physicians. [online] Available
at:
[Link]. 2020. Pneumothorax – Knowledge For Medical Students And Physicians. [online] Available at:
<[Link] [Accessed 1 September 2020].
PATOGENESIS AND CLINICAL
MANIFESTATION

Elliott, M., 2020. Tension

Pneumothorax: Pathogenesis And
Clinical Findings | Calgary Guide.
[online] [Link].
Available at:
<[Link]
n-pneumothorax-pathogenesis-and-
clinical-findings/> [Accessed 1
September 2020].
 DIAGNOSIS
History • Pleuritic chest pain
• Dyspnea

Taking • Tension pneumothorax = diaphoresis, cyanosis, weakness, symptoms oh

hypotension and cardiovascular collapse

Physical • Tachypnea, tachycardia * Hiperresonance * Vocal fremitus (-)

• Tracheal deviation (tension pneumothorax)

Examination • Decreased breath sound

Laboratoriu • Hypoxia, hypocapnia

• ECG = axis deviation, non specific ST segment changes, invertion of T wave
m
• Chest radiograph (PA and Lateral)
Imaging • CT scan

Doherty, G., 2015. Current Diagnosis & Treatment. 14th ed. New York: McGraw Hill, pp.350-352.
Jones, J., 2020. Pneumothorax (Summary) | Radiology Reference Article | [Link]. [online] [Link]. Available at:
<[Link] [Accessed 1 September 2020].
 TREATMENT

2008. ATLS. 8th ed. Chicago, IL: American College of Surgeons, pp.88-89.
 Indications for surgical intervention:
• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Bilateral spontaneous pneumothorax
• Spontaneous hemothorax
• Risky professions (eg diver, pilot)
• Pregnant

Definitive Therapy:
• Pleurectomy
• Pleurodesis

Truskett, P., 2014. Bailey and Love's Short Practice of Surgery; Edited by NS Williams, CJK
Bulstrode and PRO'Connell. Boca Raton, FL: CRC Press, 2013. Pp 855
 Section 3

HEMATOTHORAX
 HEMOTHORAX
• Blood collection in the pleural space or as a pleural fluid
hematocrit is> 50%.
• Can come from the chest wall, intercostal blood
Definiton vessels, mammary internal arteries, large blood
vessels, mediastinum, myocardium, diaphragm /
abdominal pulmonary parenchyma.

• Traumatic thorax injuries (blunt/penetrating)

Etiology • Iatrogenic
• Spontaneous

• <400mL = Minimal
Classification • 400-1000mL = Medium
• >1000mL = Massive
Zeiler, J., Idell, S., Norwood, S., & Cook, A. (2020). Hemothorax. Clinical Pulmonary Medicine, 27(1), 1–12. doi:10.1097/cpm.0000000000000343 
 PATHOPHYSIOLOGY

Haemo
Respiratory Hydrostatic
dynamic Response Pressure
Response

Gomez, L.P. and Tran, V.H., 2019. Hemothorax. In StatPearls [Internet]. StatPearls Publishing.
 • Chest pain, dyspnea, mechanism of injury (falls, direction, and speed), drug / alcohol
Histrory use, comorbidities, history of surgery, and anticoagulation / antiplatelet therapy.
Taking

• Respiratory distress, tachypnea, reduced or absent breath sounds, blunt percussion,

chest wall asymmetry, tracheal deviation, hypoxia, narrow pulse pressure and
hypotension.
Haemo
dynamic
• Contusions, abrasions, "seat belt sign", penetrating injuries, paradoxical movements
Response ("flail chest"), ecchymosis, deformities, crepitus, and point ternderness

• Chest radiography
Imaging • Focal Assessment with Sonography in Trauma (FAST)
• Ct scan

Gomez, L.P. and Tran, V.H., 2019. Hemothorax. In StatPearls [Internet]. StatPearls Publishing.
Mancini, M., 2020. Hemothorax Workup: Approach Considerations, Laboratory Studies, Chest Radiography. [online] [Link]. Available at:
 TREATMENT

Initial resuscitation and management of trauma patients according to the ATLS

protocol.
Tube thoracostomy
Urgent anterior thoracotomy:
1500 ml of blood drainage in 24 hours via chest tube
300-500 ml / hour for 2 to 4 consecutive hours after insertion of the chest tube
Injury to large blood vessels or chest wall
Pericardial tamponade

Gomez, L.P. and Tran, V.H., 2019. Hemothorax. In StatPearls [Internet]. StatPearls Publishing.
 Section 4

LUNG CONTUSION
 Definition

A pulmonary contusion is a bruise of the lung, caused by thoracic

trauma. Blood and other fluids accumulate in the lung tissue,
interfering with ventilation and potentially leading to hypoxia.
Pulmonary contusion can occur without rib fractures or flail chest,
particularly in young patients without completely ossified ribs.

Rendeki, S. and Molnár, T.F., 2019. Pulmonary contusion. Journal of thoracic disease, 11(Suppl 2),p.S141.
 CLINICAL MANIFESTATION

Mild Contusion Asymptomatic

Severe Contusion
• Dyspneu • Coughing up blood
• Takipneu • Auscultation Rales / breathe’s sound
• Tachycardia • Hypotension
Rendeki, S. and Molnár, T.F., 2019. Pulmonary contusion. Journal of thoracic disease, 11(Suppl 2),p.S141.
 Diagnosis

Hitory Taking Mechanism of trauama

Diagnostic Tests

• Chest X-Ray
• Patchy or diffuse areas in maximal trauma location
• Appeared 6 hours after trauma and will be
disappeared after 72 hours (blood being absorbed)

Rendeki, S. and Molnár, T.F., 2019. Pulmonary contusion. Journal of thoracic disease, 11(Suppl 2),p.S141.
McCloud, T., 2018. Learning Radiology - Pulmonary Contusion. [online]
Lung Contusion
Diagnosis

Diagnostic Tests
•CT Scan
• More sensitive (diagnosis and evaluation)
• Nonsegmental coarse ill-defined crescentic
(50%) / amorphous (45%) opacification of lung
parenchyma without cavitation
• Lung contusion can be detected soon after trauma

Rendeki, S. and Molnár, T.F., 2019. Pulmonary contusion. Journal of thoracic disease, 11(Suppl 2),p.S141.
Chung, D.H. 2017. Chapter 66: Pediatric Surgery in Townsend Sabiston Textbook of Surgery. Ed 20th. Elsevier-Saunders. Philadelphia, pp. 1879
 Management

1 prevent respiratory failure,

2
Supportive supply adequate oxygen to
Main Aim
theraphy blood, paien relief, prevent
futher complications
fluid balance, 4
3 Gives oxygen,
respiratory Mild
Monito aggressive pulmonary
function, dan contusion
r toilet and anelgesics
oxygen saturation
5
Severe
Mechanical Ventilation contusion
 Section 5

TRAUMATIC AORTIC INJURY

 Traumatic Aortic Injury (TAI)

● TAI is a life-threatening condition in which the aorta is injured due to

trauma. This condition requires prompt diagnosis and management.
● Is a condition that causes death in the case of a vehicle accident or falls
from a high place. (deceleration trauma and blunt trauma)
● Fatality rate —> 57% died at the scene / upon arrival at the hospital, 37%
died during the first 4 hours at the hospital, and 4% died after 4 hours in
the hospital.

Doherty, G., 2015. Current Diagnosis & Treatment Surgery. 14th ed. Boston: McGraw-Hill Education.
Traumatic Aortic Injury (TAI)

Neschis, D., Scalea, T., Flinn, W. and Griffith, B., 2008. Blunt Aortic Injury. New England Journal of Medicine, 359(16), pp.1708-1716.
Traumatic Aortic Injury (TAI)

● Common sites of trauma —>

○ isthmus aorta (80-90%),

○ ascending aorta (20-25%),

○ descending aortic distal,

○ abdominal aorta.

Doherty, G., 2015. Current Diagnosis & Treatment Surgery. 14th ed. Boston: McGraw-Hill Education.
Neschis, D., Scalea, T., Flinn, W. and Griffith, B., 2008. Blunt Aortic Injury. New England Journal of Medicine, 359(16), pp.1708-1716.
Traumatic Aortic Injury (TAI)
● Types of injury —>

○ Intimal tear

○ Mediastinal hematoma

○ Transaction of the aorta

● Severity of aortic injury —>

○ Tipe 1 : Intimal tear

○ Tipe 2 : Intramural hematoma

○ Tipe 3 : Pseudo-aneurysm

○ Tipe 4 : Ruptur
Doherty, G., 2015. Current Diagnosis & Treatment Surgery. 14th ed. Boston: McGraw-Hill Education.
Neschis, D., Scalea, T., Flinn, W. and Griffith, B., 2008. Blunt Aortic Injury. New England Journal of Medicine, 359(16), pp.1708-1716.
DIAGNOSIS
Diagnosis
Physical Examination
History Taking
•Seatbelt sign
● Chest pain •The femoral pulse may be reduced or
● Breathing difficulty absent
•Pseudo-coarctation: Increased blood
● Dysphagia, stridor or hoarseness,
pressure in the upper extremities and low
may occur due to pressure from a
blood pressure in the lower extremities
mediastinal hematoma.
•New heart murmur

Igiebor OS, Waseem M. Aortic Trauma. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: [Link]
Traumatic Aortic Injury (TAI)
Diagnosis
Chest X-Ray CT Scan

Igiebor OS, Waseem M. Aortic Trauma. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: [Link]
Traumatic Aortic Injury (TAI)
Diagnosis
CT Angiography

Case courtesy of Dr Andrew Dixon, [Link], rID: 45368

Traumatic Aortic Injury (TAI)
Diagnosis
Angiography

Igiebor OS, Waseem M. Aortic Trauma. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: [Link]
 Traumatic Aortic Injury (TAI)
Management
Rapid identification
Prompt diagnosis
Prompt management
Emergency !

Primary survey —> ABCDE (ATLS)

Management depends on :
● Haemodynamic - Unstable—> Operation
● Severity of the trauma —> Type 1 : Non-operative management; Type
2,3,4 : Operative management

Igiebor OS, Waseem M. Aortic Trauma. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Mouawad, N.,
Paulisin, J., Hofmeister, S. and Thomas, M., 2020. Blunt thoracic aortic injury – concepts and management. Journal of Cardiothoracic Surgery, 15(1).
Traumatic Aortic Injury (TAI)
Management
● Beta blocker (Contraindication ; Ca-channel blocker)—> Systolic BP
100mmHg (or 110-120mmHg for older age patients) and MAP between
60-70mmHg
● Stabil Hemodynamic —> possible aortic rupture can occur within 24
hours —> Definitive management TAI
● Polytrauma —> grade 2 or greater, without active bleeding from the aorta
—> delay aortic repair

William, N.S., Bulstrode, C. J. and O’connell, P.R., 2018. Bailey & Love’s short practice of surgery. Crc Press. Ed.27th pp. 1186-90.
Traumatic Aortic Injury (TAI)
Management
Indication to operative repair:
● Unstable patient
● Large amount of blood return from chest tube (more than 200 ml)

● Contrast extravasation on CT scan

● Rapidly expanding mediastinal hematoma

● Penetrating aortic injury

Igiebor OS, Waseem M. Aortic Trauma. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: [Link]
Traumatic Aortic Injury (TAI)
Management
Indication to delay operative repair
● Trauma to the central nervous system (Coma)

● Respiratory failure due to pulmonary contusions

● Extensive burns

● Cardiac blunt trauma

● 50 years and over

Igiebor OS, Waseem M. Aortic Trauma. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: [Link]
 Open Surgical Repair Endovascular Stent Theraphy - TEVAR

On diagnosis: a: thoracic aorta rupture (black arrow) on an axial CT

slice. After endoprosthesis treatment: b: diagram of the
endoprosthesis (black arrow); c: axial CT slice of the endoprosthesis
The different operative techniques for aortic ruptures: simple suture (white arrow); d: endoprosthesis in its greater axis on an oblique
 as a diagram (a) and in an intraoperative view (b); prosthetic repair sagittal reconstruction (white arrowhead); e: 3D view of the
as a diagram (c) and in an intraoperative view (d). endoprosthesis.
 Section 6

FLAIL CHEST
 Flail Chest

Occurs when a segment of the rib cage breaks under

extreme stress and becomes detached from the rest of
the chest wall

?
 Pathophysiology

During normal inspiration, the diaphragm and

intecostal muscle pull the rib cage out, volume
increases, the air pressure inside the cavity
decreases not just the air is sucked out, but the
flail segment/float will also be 'sucked' towards
the inside/medial, opposite to the movement of
the intact chest wall. It is similar to that in the
expiration. This movement is called
'paradoxical'
Clinical Manifestations & Diagnose

Paradoxical breathing Crepitation

Pain Dispnea
Chest x-ray
49
Management
Establish Airway

Pain Relief

Intubation and Ventilation

Chest Tube Insertion • To treat hemothorax and pneumothorax

Rib Fracture Fixation

Supportive Care
 Section 7

CARDIAC TAMPONADE
 Cardiac Tamponade

Mechanical compression of the heart by large amounts of fluid or blood

within the pericardial space.
Etiology Gunshot/
stab wounds
pericarditis

Blunt trauma

Accidental
perforation after
cardiac
catheterization

Ruptured aortic
aneurysm
 Signs and Symptoms

Beck’s Triad
Distance Hypote Distended
heart sound jugular veins
nsion
 Diagnosis

History takings Physical Examination Other Examination

Chest pain Beck’s Triad Lab Test

Chest X-Ray (Bottle

Palpitations Pulsus paradoxus
shaped)

ECG ( Sinus
Shortness of breath Kussmaul sign
Tachycardia)

Tiredness /
Ewart Sign Echocardiography
dizziness
 Treatment
a
omy
rdiect d Th
T
Pe ri c
ypho
i oraco
c(Subx diia a l to
io periiccar m y
rd ndow
)
ca is wiin
ri c t e s
e
P en
 Section 8

DIAPHPRACMATIC RUPTURE
 Diaphragmatic Rupture

• Left-sided injury is more common with left-to-right ratio 3:1, possibly

because the liver has a buffering effect.
The incidence of diaphragmatic rupture is 0.8-5.8% in blunt trauma
2.5- 5% in blunt abdominal trauma => sudden increase in intra-
abdominal pressure  tear at the top of the diaphragm.
1.5% in lower thoracic blunt trauma =>7th rib fracture down  rib
fracture fragment tearing the diaphragm

59
 Diaphragmatic Rupture
Diaphragm => the muscular aponeurotic organ separating the thoracic and abdominal cavities., Rarely happening

80% of traffic
accidents

10% fall from a

height
10% penetrating injury
Amaliah, R. 2020. Diagnosis dan Tatalaksana Ruptur Diafragma pada Fase Akut dan Fase Laten. JBN (Jurnal Bedah Nasional). DOI: [Link]
Weerakkody et al. 2019. Diaphragmatic rupture. Available at: <[Link] Accessed 1 September 2020
 ● The most common site of rupture => posterolateral aspect of the
hemidiaphragm between the lumbar and intercostal muscle slips 
these sites are structurally weak because they are pleuroperitoneal
membranes.

●Ruptures occur radially and most are >10 cm in length.

● The most commonly herniated viscera are the stomach and colon
● It is frequently not recognized at the time of trauma and the interval
between injury and the onset of symptoms => if the diagnosis is not
made in the first 4 hours, it may be undiagnosed for months or years.

Amaliah, R. 2020. Diagnosis dan Tatalaksana Ruptur Diafragma pada Fase Akut dan Fase Laten. JBN (Jurnal Bedah Nasional). DOI: [Link]
Weerakkody et al. 2019. Diaphragmatic rupture. Available at: <[Link] Accessed 1 September 2020
Signs and Symptoms of Diaphragm Rupture According to Grimes

Grimes, O. F. 1974. Traumatic injuries of the diaphragm: Diaphragmatic hernia. The American Journal of Surgery, 128(2), 175-181.
 Chest X-ray
● Specific features => abdominal viscera or
nasogastric tube to the chest, a “collar sign”
(herniation of the abdominal viscera with /
without narrowing of the focus of the viscus at
the site of the tear) and elevation of the left
hemidiaphragm.
● Other sign that is sensitive but not specific
inability to trace the normal hemidiaphragm
contour
if large, the positive mass effect may cause a
contralateral mediastinal shift
Atelectasis of the lower lobe of the lung and
pleural effusions
Amaliah, R. 2020. Diagnosis dan Tatalaksana Ruptur Diafragma pada Fase Akut dan Fase Laten. JBN (Jurnal Bedah Nasional). DOI: [Link]
Weerakkody et al. 2019. Diaphragmatic rupture. Available at: <[Link] Accessed 1 September 2020
CT- Scan
Direct discontinuity of the hemidiaphragm may be seen with or without intrathoracic herniation of
abdominal contents.
Other signs of diaphragmatic rupture include:
● the collar sign (or hourglass sign): a waist-like constriction of the herniating hollow viscus
from the abdomen into the chest at the site of the diaphragmatic tear, which is classical for
diaphragmatic rupture.
● the dependent viscera sign: when a patient with a ruptured diaphragm lies supine at CT
examination, the herniated viscera (bowel or solid organs) are no longer supported posteriorly
by the injured diaphragm and fall to a dependent position against the posterior ribs.
● The hump sign and the band sign => two features on the sagittal and coronal sections showing
herniated liver
● segmental non-recognition of the diaphragm
● focal diaphragmatic thickening
● thoracic fluid abutting the abdominal viscera
 DIAGNOSIS

Focused Abdominal Sonography for Trauma (FAST)

● Ultrasound can also be a diagnostic tool in patients with a ruptured diaphragm,
especially if it can be extended toward the thoracic cavity to view hemothorax and
assess diaphragmatic movement (using m-mode if possible).
● This examination takes time, but may reveal diaphragmatic movement, visceral
herniation, or flap from diaphragmatic rupture.
 MANAGEMENT

1 2 3
Suturing the diaphragm
ATLS insert tear and repositioning of
nasogastric tube intra-abdominal organs
via thoracotomy or
laparotomy
 Section 9

TRACHEOBRANCHIAL RUPTURE
 Ruptur Trakeobronkial

● Uncommon
 <3% of thoracic injuries
 May occur with blunt or penetrating trauma
 High mortality rate (> 30%)
 The cervical trachea is the most injured site in penetrating injury, whereas
injury to the distal trachea (within 2.5cm of the carina) is seen most
commonly following blunt chest trauma.
RUPTUR TRAKEOBRANKIAL

The site of injury can be identified in 70% of patients with CT

Typical: persistent pneumothorax after chest tube insertion

Chest X-ray: pneumothorax, "Fallen Lung Sign",
pneumomediastinum, pneumopericardium, subcutis emphysema
Bronchoscopy
 MANAGEMENT

Water sealed Endotracheal Transfer for

ATLS drainage Tube (ETT) tracheo
(WSD) intubation into
bronchial
insertion the contralateral
bronchus
repair
THANK YOU

BST TRAUMA TORAKS

Minggu 6

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