1、1Chest trauma Cardiothoracic department,the second affiliated hospital of Chongqing medical university 2Aim and results of this lesson3 a serious injury of the chest leading cause of death from physical trauma after head and spinal cord injury Time-traumas Blunt thoracic injuries-cause of about a qu
2、arter of all trauma-related deaths Many die after reaching hospitalpreventable if recognized4Classification penetrating Blunt5Penetrating trauma open wound cause External bleeding The amount of external bleeding multiple organ damage 6Blunt trauma large contusions,fractured ribs and flail segments m
3、ultiple and severe organ,vascular and structural injury.7Pathophysiologic compromise of chest truma Lung and heart function Impaired Oxygenation:rib fractures-inadequate mechanical ventilation,pulmonary contusion or collapsed lung tissue Hypotension:compressed myocardium or hemothorax 8AssessmentIni
4、tial assessment:Identify any obvious life-threatening injuries or conditions that may require immediate management Assess tidal volume and respiratory rate Assess the circulation 9Trauma assessment Threatening thoracic injuries include tension pneumothorax,open pneumothorax,pericardial tamponade,sev
5、ere hemothorax and a flail chest.A detailed exam is only done if time and the patients condition allow it.10Specific Thoracic Injuries Injuries to the chest wall Pulmonary injury(injury to the lung)Injury to the airways Cardiac injury Blood vessel injuries Injuries to other structures111.Injuries to
6、 the chest wall Chest wall contusions or hematomas.Rib fractures Flail chest Sternal fractures Fractures of the clavicle and shoulder girdle12Rib fracture human rib cage:24 ribs,the sternum,costal cartilages(肋软骨),and the 12 thoracic vertebrae.Function of the cage13 First-third rib Weakest part of a
7、rib is just anterior to its angle most commonly fractured ribs are the 4th-7th A lower rib fracture 14Causes direct/indirect trauma sustained coughing various sports diseases:cancer,infection Fragility fractures of ribs 15DiagnosisSings and symptoms:Pain when breathing or with movement A portion of
8、the chest wall moving separately from the rest of the chest(flail chest)A grating sound with breathing or movement 16Medical Examination Physical examination:Laboratory 17Treatment Simple rib fracture Spontaneous fractures Flail chestAdhesive tape18Flail chest 連枷胸 Concept:1.extreme stress 2.multiple
9、 adjacent ribs are broken in multiple places 3.separating a segment result paradoxical motion-a part of the chest wall moves independently,the flail segment moves in the opposite direction to the rest of the chest wall,it goes in while the rest of the chest is moving out,and vice versa 19Causes sign
10、ificant blunt trauma approximately 30%of patients with extensive thoracic trauma have a flail chest20Presentation During normal inspiration,intercostal muscles push the rib cage out.a flail segment will appear to be push in while the rest of the rib cage expands.During normal expiration,a flail segm
11、ent will also be pushed out while the rest of the rib cage contracts.The constant motion of the ribs in the flail segment at the site of the fracture is incredibly painful,and untreated,the sharp broken edges of the ribs are likely to eventually puncture the pleural sac and lung,possibly causing a p
12、neumothorax21胸壁浮动 纵隔摆动 残气对流阐述有关争议？阐述有关争议？22TreatmentAdvanced Trauma Life Support A:Airway Maintenance with Cervical Spine Protection B:Breathing and Ventilation C:Circulation with Hemorrhage Control D:Disability(Neurologic Evaluation)E:Exposure and Environment23Further treatment includes:Analgesia:i
13、ncluding intercostal blocks Positive pressure ventilation Chest tubes Adjustment of position to make the patient most comfortable and provide relief of pain.Surgical fixation is usually not required.24Sternal fracture In 1864,E.Guilt published a handbook recording sternal fractures as a rare injury
14、found in severe trauma.The injury became more common with the introduction and wide use of vehicles and the subsequent rise in traffic accidents.2526Causes Vehicle collisions,the injury is estimated to occur in about 3%of auto accidents.It was common enough for the sternum to be injured by the seatb
15、elt that it was included in the safety belt syndrome The injury can also occur when the chest suddenly flexes27Associated injuries myocardial and pulmonary contusions blood vessels in the chest,myocardial rupture,head and abdominal injuries,flail chest,and vertebral fracture.rib fractures bronchial
16、tears ruptures of the bronchioles mortality rate estimated 2545%.However,when sternal fractures occur in isolation,their outcome is very good.28Signs and symptoms Crepitus(捻发音捻发音)(a crunching sound made when broken bone ends rub together),Pain,tenderness,bruising(挫伤),and swelling over the fracture s
17、ite.The fracture may visibly move when the person breathes,and it may be bent or deformedBroken bone ends is detectable by palpation.Associated injuries:The upper and middle parts of the sternum are those most likely to fracture,but most sternal fractures occur below the sternal angle29Assessment an
18、d treatment X-rays of the chest:CT scanning.people with sternal fractures but no other injuries do not need to be hospitalized.it is common for cardiac injuries to accompany sternal fracture,heart function is monitored with electrocardiogram.Fractures that are very painful or extremely out of place
19、can be operated on to fix the bone fragments into place,in most cases treatment consists mainly of reducing pain and limiting movement.The fracture may interfere with breathing,requiring intubation and mechanical ventilation.30Traumatic asphyxia创伤性窒息 Cyanotic asphyxia due to trauma:1.a sudden mechan
20、ical increase in venous pressure 2.the extravasation of blood into the skin and conjunctivae(结膜).3.sings of traumatic asphyxia:conjunctival haemmorhages,petechial(瘀点的)blue-purple discoloration变色 of head and neck.Neurological findings:confusion or unconsciousness and convulsions(抽搐).31创伤性窒息机理驱逐驱逐3233
21、Treatment The treatment includes rapid chest decompression and cardiopulmonary resuscitation.The prognosis is good but a prolonged thoracic compression could lead to cerebral anoxia and neurological sequelae(后遗症).342.Pulmonary injury and injuries involving the pleural space Pulmonary contusion Pulmo
22、nary laceration Pneumothorax Hemothorax Hemopneumothorax 35Pulmonary contusionConcept:pulmonary contusion:chest traumalung contusion-damage to capillaries-blood and other fluids accumulate in the lung tissue-excess fluid interferes with gas exchange-hypoxia 36 Contusion involves hemorrhage in the al
23、veoli(肺泡)Differentiate Pulmonary laceration,in which lung tissue is torn or cut,involves disruption of the macroscopic architecture of the lung.When lacerations fill with blood,the result is pulmonary hematoma,a collection of blood within the lung tissue37Signs and symptoms mild contusion may have n
24、o symptoms SO2,BLOOD GAS,cyanosis,Dyspnea,tolerance for exercise may be lowered,Rapid breathing and a rapid heart rate breath sounds:decreased,or rales bronchorrhea(the production of watery sputum)Wheezing and coughing Coughing up blood or bloody sputum Cardiac output-reduced,hypotension is frequent
25、ly present.chest wall may be tender or painful Signs and symptoms take time to develop,asymptomatic at the initial presentation.In severe cases,symptoms may occur three or four hours after the trauma.Hypoxemia typically becomes progressively worse over 48-72 hours,it may also cause rapid deteriorati
26、on or death if untreated.38Causes occurs in 2535%of all blunt chest trauma,About 70%of cases result from motor vehicle collisions,Falls,assaults,and sports injuries Blast lung(肺爆震伤)is severe pulmonary contusion,bleeding,or edema with damage to alveoli and blood vessels.This is the primary cause of d
27、eath among people who initially survive an explosion.penetrating trauma also can cause pulmonary contusion.penetrating trauma causes less widespread lung damage than does blunt trauma.An exception is shotgun wounds,which can seriously damage large areas of lung tissue through a blast injury mechanis
28、m.39Mechanism lung tissue can be crushed when the chest wall bends inward on impact inertial effect(惯性作用）惯性作用）,the lighter alveolar tissue is sheared from the heavier hilar structures,It results from the fact that different tissues have different densities,and therefore different rates of accelerati
29、on or deceleration.spalling effect(剥落作用):in areas with large differences in density;particles of the denser tissue are spalled(thrown)into the less dense particles implosion effect:a pressure wave passes through a tissue containing bubbles of gas:the bubbles first implode,then rebound and expand bey
30、ond their original volume.The air bubbles cause many tiny explosions,resulting in tissue damage;the overexpansion of gas bubbles stretches and tears alveoli.40Pathophysiology Lung tissue Bleeding and edema:The membrane between alveoli and capillaries is torn;damage to this capillaryalveolar membrane
31、 and small blood vessels causes blood and fluids to leak into the alveoli and the interstitial space of the lung.Fluid accumulation interferes with gas exchange,and can cause the alveoli to fill with proteins and collapse due to edema and bleeding.41 Consolidation:Consolidation occurs when the parts
32、 of the lung fill with material from the pathological condition,such as blood.Over a period of hours after the injury,the alveoli in the injured area thicken and may become consolidated.collapse A decrease in the amount of surfactant produced also contributes to the collapse and consolidation of alv
33、eoli;inactivation of surfactant increases their surface tension.42 Inflammation of the lung can cause parts of the lung to collapse.Macrophages,neutrophils,and other inflammatory cells and blood components can enter the lung tissue and release factors that lead to inflammation,increasing the likelih
34、ood of respiratory failure.In response to inflammation,excess mucus is produced,potentially plugging parts of the lung and leading to their collapse.Even when only one side of the chest is injured,inflammation may also affect the other lung.Uninjured lung tissue may develop edema,thickening of the s
35、epta of the alveoli,and other changes.43 Ventilation/perfusion mismatch:1.fluid-filled alveoli cannot fill with air,oxygen does not fully saturate the hemoglobin,and the blood leaves the lung without being fully oxygenated.2.Insufficient inflation of the lungs,which can result from inadequate mechan
36、ical ventilation or an associated injury such as flail chest,can also contribute to the ventilation/perfusion mismatch 3.Pulmonary hypoxic vasoconstriction,in which blood vessels near the hypoxic alveoli constrict(narrow their diameter)in response to the lowered oxygen levels,can occur in pulmonary
37、contusion 44 Gas exchange is impaired when alveoli fill with fluid45Diagnosis X-ray:Consolidated areas appear white on an X-ray film.The X-ray appearance of pulmonary contusion is similar to that of aspiration,and the presence of hemothorax or pneumothorax may obscure the contusion on a radiograph.I
38、t is often not sensitive enough to detect the condition early after the injury.In a third of cases,pulmonary contusion is not visible on the first chest radiograph performed.It takes an average of six hours for the characteristic white regions to show up on a chest X-ray,and the contusion may not be
39、come apparent for 48 hours.When a pulmonary contusion is apparent in an X-ray,it suggests that the trauma to the chest was severe and that a CT scan might reveal other injuries that were missed with X-ray.4647A chest X-ray showing right sided pulmonary contusion associated with rib fractures and sub
40、cutaneous emphysema48Computed tomography Unlike X-ray,CT scanning can detect the contusion almost immediately after the injury.However,in both X-ray and CT a contusion may become more visible over the first 2448 hours after trauma as bleeding and edema into lung tissues progress.CT scans also help d
41、ifferentiate between contusion and pulmonary hematoma 49Treatment No treatment is known to speed the healing of a pulmonary contusion;the main care is supportive Treatment aims to prevent respiratory failure and to ensure adequate blood oxygenation 50Ventilation Positive pressure ventilation,in whic
42、h air is forced into the lungs,is needed when oxygenation is significantly impaired Pulmonary contusion or its complications such as acute respiratory distress syndrome may cause lungs to lose compliance(stiffen),so higher pressures may be needed to give normal amounts of air and oxygenate the blood
43、 adequately 51Fluid therapy Excessive fluid in the circulatory system can worsen hypoxia because it can cause fluid leakage from injured capillaries(pulmonary edema),which are more permeable than normal.Low blood volume resulting from insufficient fluid has an even worse impact,potentially causing h
44、ypovolemic shock;for people who have lost large amounts of blood,fluid resuscitation is necessary Furosemide(速尿),a diuretic used in the treatment of pulmonary contusion,also relaxes the smooth muscle in the veins of the lungs,thereby decreasing pulmonary venous resistance and reducing the pressure i
45、n the pulmonary capillaries 52Supportive care an important part of treatment is pulmonary toilet(is a set of methods used to clear mucus and secretions from the airways)People who do develop infections are given antibiotics Pain control is another means to facilitate the elimination of secretions 53
46、 Prognosis Most contusions resolve in five to seven days after the injury.Signs detectable by radiography are usually gone within 10 days after the injury Chronic lung disease correlates with the size of the contusion and can interfere with an individuals ability to return to work Fibrosis of the lu
47、ngs can occur,resulting in dyspnea(shortness of breath),low blood oxygenation,and reduced functional residual capacity for as long as six years after the injury As late as four years post-injury,decreased functional residual capacity has been found in most pulmonary contusion patients studied During
48、 the six months after pulmonary contusion,up to 90%of people suffer difficulty breathing Contusion can also permanently reduce the compliance of the lungs 54 Complications Pulmonary contusion can result in respiratory failure infections acute respiratory distress syndrome(ARDS)55 Pulmonary laceratio
49、n 肺裂伤 Pulmonary laceration:in which lung tissue is torn or cut,involves disruption of the macroscopic architecture of the lung.When lacerations fill with blood,the result is pulmonary hematoma,a collection of blood within the lung tissue56 Causes penetrating trauma but may also be caused by blunt tr
50、auma broken ribs may perforate the lung the tissue may be torn due to shearing forces Violent compression of the chest can cause lacerations by rupturing or shearing the lung tissue 57Pathophysiology A pulmonary laceration can cause air to leak out of the lacerated lung and into the pleural space,re
