Trauma of the chest
Скачати 26.88 Kb.
|
|
TRAUMA OF THE CHEST The modern traumatism represents the important social problem. Recently observed the increase of major combined trauma, which complications often result in death. The trauma of the chest is usually accompanied by dysfunction of the vital organs. Therefore it is necessary constantly to improve diagnostics and treatment of the patients who suffer from trauma. Mechanism of Injury Mechanism of injury is important in so far as blunt and penetrating injuries have different pathophysiologies and clinical courses. Most blunt injuries are managed non-operatively or with simple interventions like intubation and ventilation and chest tube insertion. Diagnosis of blunt injuries may be more difficult and require additional investigations such as CT scanning. In contrast, penetrating injuries are more likely to require operation, and complex investigations are required infrequently. Patients with penetrating trauma may deteriorate rapidly, and recover much faster than patients with blunt injury CLASSIFICATION According to character of trauma: Blunt (closed) trauma. opened trauma. The closed damages of the chest are divided: I. According to the injury of other organs: Isolated trauma. Combined trauma (craniocerebral, with the damage of abdominal organs, with the damage of bones). ^ Contusion. Compression. Commotion. Fracture. III. According to the character of the damage of chest organs: Without damage of organs. With damage of organs (lungs, trachea, bronchi, esophagus, heart, vessels, diaphragm etc.). ^ Uncomplicated. Complicated: Early (pneumothorax, haemothorax, subcutaneous, mediastinal emphysema, flail fracture, traumatic shock, asphyxia); Late (posttraumatic pneumonia, posttraumatic pleuritis, suppurated diseases of lungs and pleura). ^ Without phenomena of respiratory failure. Acute respiratory failure (of I, II, III degree). Without phenomena of cardiovascular failure. Acute cardiovascular failure (of I, II, III degree). VI. According to the severity of trauma: Mild. Moderate. Severe. 1.2.1 Rib fracture ^ 1. Complaints and history of the disease. 2. Physical examination. 3. Chest X-radiography in 2 planes. 4. Thoracentesis. 5. ECG. 6. CT- scan CLASSIFICATION OF PNEUMOTHORAX I. According to extension of the process: Unilateral. Bilateral. II. According to the degree of a lung collapse: Partial (collapse of lung lessl/3 of its volume). Subtotal (collapse of lung less 2/3 of its volume). Total (collapse of lung exceeding 2/3 of its volume). III. According to the mechanism of occurrence: Closed. Open. Tension. ^ I. According to extent: Unilateral. Bilateral. II. According to the degree of hemorrhage: Small (the loss less 10 % of volume of circulating blood). Moderate (loss of 10-20 % of volume of circulating blood). Great (loss of 20-40 % of volume of circulating blood). Total (exceeds 40 % of volume of circulating blood). ^ With continued hemorrhage. With the stopped bleeding. IV. According to the presence of clots in a pleural space: Coagulated. Non-coagulated. V. According to the presence of infection: Non-infected. Infected (suppurative). ^
Chest Drain Placement Chest tube placement is the definitive treatment of traumatic pneumothorax. In most centres, chest tubes should be immediately available in the resuscitation room and placement is usually rapid. The controlled placement of a chest tube is preferable to blind needle thoracostomy. This is provided the patient's respiratory and haemodynamic status will tolerate the extra minutes it takes to perform the surgical thoracostomy. Once the pleura is entered (blunt dissection), the tension is decompressed and chest tube placement can be performed without haste. This is especially true of the patient who is being manually ventilated with positive pressure, and surgical thoracostomies without chest tube placement have been described in the prehospital setting. Thoracotomy Thoracotomy is required in under 10% of thoracic trauma patients. Most haemothoraces stem from injury to lung parenchyma or venous injury and will stop bleeding without intervention. Penetrating trauma is more likely to be associated with arterial haemorrhage requiring surgery. The indications for thoracotomy are usually quoted as the immediate drainage of 1000-1500mls of blood from a hemithorax. However the initial volume of blood drained is not as important as the amount of on-going bleeding. If the patient remains haemodynamically stable they may be admitted and observed. The colour of the blood is also important - dark, venous blood being more likely to cease spontaneously than bright red arterial blood. Patients admitted for observation who have continuing drainage with no signs of reduction in chest tube output over 4-5 hours should also undergo thoracotomy. The threshold for this is usually stated at around 200-250mls of blood per hour. Flail Chest A flail chest occurs when a segment of the thoracic cage is separated from the rest of the chest wall. This is usually defined as at least two fractures per rib (producing a free segment), in at least two ribs. A segment of the chest wall that is flail is unable to contribute to lung expansion. Large flail segments will involve a much greater proportion of the chest wall and may extend bilaterally or involve the sternum. In these cases the disruption of normal pulmonary mechanics may be large enough to require mechanical ventilation. The main significance of a flail chest however is that it indicates the presence of an underlying pulmonary contusion. In most cases it is the severity and extent of the lung injury that determines the clinical course and requirement for mechanical ventilation. Thus the management of flail chest consists of standard management of the rib fractures and of the pulmonal contusions underneath |
