1. การดูแลรักษาผู้บาดเจ็บฉุกเฉินที่ทรวงอก

2. ประวัติ พบ. วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า แพทย์ใช้ทุน รพ. สก.พร.
วุฒิบัตรสาขาศัลยศาสตร์ทั่วไป
วุฒิบัตรสาขาศัลยศาสตร์ทรวงอก หัวใจ และหลอดเลือด
อนุมัติบัตรสาขาเวชศาสตร์ครอบครัว
ศัลยแพทย์ รพ. สก.พร.
หลักสูตรเสนาธิการทหารเรือ
นกพ.พร. และ หน.แผนกศัลยกรรม รพ.ทร. กรุงเทพ
ผบ.พัน พ. กรม สน. สอ.รฝ.
นยก.พร. และ หน.แผนกศัลยกรรม รพ.ทร. กรุงเทพ
หน.แผนกศัลยกรรมทรวงอก รพ.ปก.พร. และ รรก.รอง หก. กวตบ. พร.

3. Introduction
Trauma is leading cause of death, long-term disability for all ages from first –forty years.
25% of all trauma death due to chest injuries
20-33% death preventable.
Deaths occur within first 4 hours trauma.
85% of pt with life threatening injuries can be managed simple interventions easily mastered by physicians and ER service personnel
Most life-threatening injuries identified in primary survey

4. Trimodal Death Distribution

5. CAUSES OF THORACIC TRAUMA:
Falls
3 times the height of the patient
Blast Injuries
overpressure, plasma forced into alveoli
Blunt Trauma
PENETRATING TRAUMA

7. 6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
“sucking chest wound”
4. Flail chest
5. Massive hemothorax
6. Cardiac tamponade

8. ADVANCE TRAUMA LIFE SUPPORT
CONCEPT
The most important was to treat the greatest threat to life first.
The definitive diagnosis should never impede the application of an indicated treatment.
A detailed history was not essential to begin the evaluation of an acutely injured patient
ABCDE-approach to evaluation and treatment

9. GOALS Rapid, accurate, and physiologic assessment
Resuscitate, stabilized and monitor by priority
Determine needs, and capabilities
Prepare to transfer to definitive care
Assure optimal, safe patient care
“The primary focus of ATLS is on the first hour
of trauma management , rapid assessment and resuscitation”

10. ADVANCE TRAUMA LIFE SUPPORT
1. Preparation
2. Triage
3. Primary survey ( A B C D E )
4. Resuscitation
5. Adjuncts to primary survey and resuscitations
6. Secondary survey (head‐to‐toe)
7. Adjuncts to the secondary survey
8. Continued post‐resuscitation monitoring and resuscitation
9. Definitive care

11. Initial assessment and management

12. Standard precaution Cap Gown Gloves Mask Shoe covers
Goggles/face shield

13. Primary survey: Airway
Assess for airway patency
Airway obstruction
Snoring
Gurgling
Stridor
Rocking chest wall movement
Maxillofacial injury/ laryngeal injury
Things to remember...
C-Spine Protection

14. Assessment: Breathing
Inspection RR, paradoxical ,symetrical motion of the chest wall, or obvious chest wounds.
Palpation should seek pain, crepitus or subcutaneous emphysema as clues to underlying pathology.
Auscultation of the lung fields may detect a pneumothorax or hemothorax before a chest x-ray is performed, as well as assessing the adequacy of air entry.
Percussion theoretically of use in differentiating between pneumo and hemothorax

15. Resuscitation :Breathing
Supplemental oxygen
Ventilate as needed
Tension pneumothorax
-Needle decompression
Open pneumothorax
-Occlusive dressing
Reassess frequently

16. Air within thoracic cavity that cannot exit the pleural space
TENSION PNEUMOTHORAX
Air within thoracic cavity that cannot exit the pleural space
Fatal if not immediately identified, treated, and reassessed for effective management

17. Tension Pneumothorax Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

18. Tension Pneumothorax Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

19. Tension Pneumothorax The trachea is pushed to the good side
Heart is being
compressed

20. EARLY S/S OF TENSION PNEUMOTHORAX
ANXIETY!
Increased respiratory distress
Unilateral chest movement
Unilateral decreased or absent breath sounds

21. LATE S/S OF TENSION PNEUMOTHORAX
Jugular Venous Distension (JVD)
Tracheal Deviation
Narrowing pulse pressure
Signs of decompensating shock

22. JVD & TRACHEAL SHIFT
Decreased input and output from the heart with compression of the great vessels

23. JVD & TRACHEAL SHIFT
Increased pressure moves mediastinum and compresses the lung on the uninjured side

24. MANAGEMENT OF TENSION PNEUMOTHORAX
Asherman Chest Seal
Needle Decompression
High flow oxygen (If available)
Chest Tube

25. Tension Pneumothorax Pleural Decompression
2nd intercostal space in mid-clavicular line at
TOP OF RIB
Consider multiple decompression sites if patient remains symptomatic
Large over the needle catheter: 14ga
Create a one-way-valve: Glove tip or Heimlich valve

26. Needle Decompression

27. NEEDLE THORACENTESIS

28. Tension Pneumothorax 􀁺 Respiratory distress 􀁺 Distended neck veins
􀁺 Tracheal deviation
􀁺 Hyperresonance
􀁺 Cyanosis (late)
􀁺 Unilateral decrease in breath sounds
Tension pneumothorax is not an x-ray diagnosis – it MUST be recognized clinically
Treatment is decompression – needle into 2nd intercostal space of mid-clavicular line followed by thoracostomy tube

29. OPEN PNEUMOTHORAX
Develops when penetration injury to the chest allows the pleural space to be exposed to atmospheric pressure - “Sucking Chest Wound”
Q- WHAT MAY CAUSE A SCW?
Examples Include:
GSW, Stab Wounds, Impaled Objects, Etc...

30. LARGE VS SMALL
Severity is directly proportional to the size of the wound
Atmospheric pressure forces air through the wound upon inspiration

31. S/S: OPEN PNEUMOTHORAX
Shortness of Breath (SOB)
Pain
Sucking or gurgling sound as air moves in and out of the pleural space through the wound

32. Open Pneumothorax Dyspnea Subcutaneous Emphysema
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound (Sucking chest wound)

33. Open Pneumothorax

34. Open Pneumothorax
Inhale

35. Open Pneumothorax
Exhale

36. Open Pneumothorax
Inhale

37. Open Pneumothorax
Exhale

38. Open Pneumothoarx
Inhale

39. Open Pnuemothorax
Inhale

40. Open Pneumothorax Initial management High flow O2
Cover site with sterile occlusive dressing taped on three sides
Progressive airway management if indicated

41. Tension Pneumothorax MANAGEMENT OF SCW Apply an Asherman Chest Seal
Occlusive dressing with a release valve
Observe for development of a
Tension Pneumothorax

44. Hemothorax Occurs when pleural space fills with blood
Usually occurs due to lacerated blood vessel in thorax
As blood increases, it puts pressure on heart and other vessels in chest cavity
Each Lung can hold 1.5 liters of blood

45. Hemothorax

46. Hemothorax

47. Hemothorax

48. Hemothorax

49. Hemothorax

50. Hemothorax
May put pressure on the heart

51. Hemothorax
Where does the blood come from.
Lots of blood vessels

52. S/S of Hemothorax Anxiety/Restlessness Tachypnea Signs of Shock
Frothy, Bloody Sputum
Diminished Breath Sounds on Affected Side
Tachycardia
Flat Neck Veins

53. Treatment for Hemothorax
ABC’s with c-spine control as indicated
Secure Airway assist ventilation if necessary
General Shock Care due to Blood loss
Consider Left Lateral Recumbent position if not contraindicated
RAPID TRANSPORT
Contact Hospital and ALS Unit as soon as possible

54. Flail chest
“Free-floating” chest segment, usually from multiple ribs fractures
Pain and restricted movement
Paradoxicalmovement of chest wall with respiration
Clinical diagnosis
Pulmonary contusion is the major problem

55. Flail chest

56. Flail chest

57. Flail chest 􀁺 Oxygen 􀁺 Aggressive pulmonary physiotherapy
􀁺 Definitive treatment: reexpand the lung
􀁺 Effective analgesia, intercostal nerve blocks,high segmental epidural analgesia
􀁺 Intubation
RR > 35 /min or < 8 /min
PaO2 < 60 mm Hg at FiO2 >= 0.5
PaCO2 > 55 mm Hg at FiO2 >= 0.5
Alveolar-arterial oxygen gradient > 450
Severe shock
Severe head injury
Requiring surgery
Internal splint

58. Massive Hemothorax 􀁺 Hypovolemia & hypoxemia 􀁺 ≥ 1500 mL BL; 1/3 of
blood volume
􀁺 Neck veins may be:
Flat: hypovolemia
Distended: intra - thoracic blood
􀁺 Shock with no breath sounds and / or
percussion dullness

59. The “safe triangle”for insertion of ICD
Intercostal Drainage
The “safe triangle”for insertion of ICD
Cross-section of the intercostalspace

60. Assessment: Circulation
􀂇 Hemorrhagic Shock
External bleeding
Internal bleeding
􀂇 Non-hemorrhagic shock
Cardiac tamponade
Tension pneumothorax
Neurogenic

61. Resuscitation :Circulation
􀂇Stop bleeding !
􀂇Restore circulating volume
RLS 1-2 L
Colloid / Blood component
􀂇Reassess frequently
􀂇Venous access
Things to remember…
Direct pressure
Avoid blinding clamp

62. Resuscitation :Circulation
Hypotension in thoracic trauma is usually associated with hypovolemia it should be aggressively treated initially with volume expansion with crystalloids while other possible etiologies, i.e. pneumothorax, cardiac tamponade and blunt cardiac injury are assessed.
Arrhythmia should raise suspicion of blunt cardiac injury

63. Cardiac tamponade Usually from penetrating injuries
Classic “Beck’s triad”
elevated venous pressure - neck veins
decreased arterial pressure - BP
muffled heart sounds
Blood in sac prevents cardiac activity
May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP during inspiration
Systolic to diastolic gradient of less than 30 mm Hg also suggestive