醫(yī)學(xué)精品課件：10.Chest trauma

1ChesttraumaCardiothoracicdepartment,thesecondaffiliatedhospitalofChongqingmedicaluniversity2Aimandresultsofthislesson3aseriousinjuryofthechestleadingcauseofdeathfromphysicaltraumaafterheadandspinalcordinjury

Time---traumasBluntthoracicinjuries-----causeofaboutaquarterofalltrauma-relateddeathsManydieafterreachinghospital—preventableifrecognized4ClassificationpenetratingBlunt5PenetratingtraumaopenwoundcauseExternalbleedingTheamountofexternalbleedingmultipleorgandamage6Blunttraumalargecontusions,fracturedribsandflailsegmentsmultipleandsevereorgan,vascularandstructuralinjury.7PathophysiologiccompromiseofchesttrumaLungandheartfunction

ImpairedOxygenation:ribfractures-inadequatemechanicalventilation,pulmonarycontusionorcollapsedlungtissue

Hypotension:compressedmyocardiumorhemothorax

8AssessmentInitialassessment:Identifyanyobviouslife-threateninginjuriesorconditionsthatmayrequireimmediatemanagementAssesstidalvolumeandrespiratoryrateAssessthecirculation9Traumaassessment

Threateningthoracicinjuriesincludetensionpneumothorax,openpneumothorax,pericardialtamponade,severehemothoraxandaflailchest.

Adetailedexamisonlydoneiftimeandthepatient'sconditionallowit.10SpecificThoracicInjuriesInjuriestothechestwallPulmonaryinjury(injurytothelung)InjurytotheairwaysCardiacinjuryBloodvesselinjuriesInjuriestootherstructures111.InjuriestothechestwallChestwallcontusionsorhematomas.RibfracturesFlailchestSternalfracturesFracturesoftheclavicleandshouldergirdle12Ribfracturehumanribcage:24ribs,thesternum,costalcartilages(肋軟骨),andthe12thoracicvertebrae.Functionofthecage13First-thirdribWeakestpartofaribisjustanteriortoitsanglemostcommonlyfracturedribsarethe4th--7thAlowerribfracture14Causesdirect/indirecttraumasustainedcoughingvarioussportsdiseases:cancer,infectionFragilityfracturesofribs15DiagnosisSingsandsymptoms:PainwhenbreathingorwithmovementAportionofthechestwallmovingseparatelyfromtherestofthechest(flailchest)Agratingsoundwithbreathingormovement16MedicalExamination

Physicalexamination:Laboratory17TreatmentSimpleribfractureSpontaneousfracturesFlailchestAdhesivetape18Flailchest

連枷胸

Concept:1.extremestress2.multipleadjacentribsarebrokeninmultipleplaces3.separatingasegmentresultparadoxicalmotion--apartofthechestwallmovesindependently,theflailsegmentmovesintheoppositedirectiontotherestofthechestwall,itgoesinwhiletherestofthechestismovingout,andviceversa19Causes

significantblunttraumaapproximately30%ofpatientswithextensivethoracictraumahaveaflailchest20PresentationParadoxRespiration:

Duringnormalinspiration,intercostalmusclespushtheribcageout.aflailsegmentwillappeartobepushinwhiletherestoftheribcageexpands.Duringnormalexpiration,aflailsegmentwillalsobepushedoutwhiletherestoftheribcagecontracts.

Theconstantmotionoftheribsintheflailsegmentatthesiteofthefractureisincrediblypainful,anduntreated,thesharpbrokenedgesoftheribsarelikelytoeventuallypuncturethepleuralsacandlung,possiblycausingapneumothorax21胸壁浮動(dòng)縱隔擺動(dòng)殘氣對(duì)流FlailChest浮動(dòng)胸壁ParadoxResp.反常呼吸Pendelluft?殘氣對(duì)流?Mediastin.Flutter縱隔撲動(dòng)闡述有關(guān)爭(zhēng)議？22Treatment

AdvancedTraumaLifeSupportA:AirwayMaintenancewithCervicalSpineProtectionB:BreathingandVentilationC:CirculationwithHemorrhageControlD:Disability(NeurologicEvaluation)E:ExposureandEnvironment23Furthertreatmentincludes:Analgesia:includingintercostalblocksPositivepressureventilationChesttubesAdjustmentofpositiontomakethepatientmostcomfortableandprovidereliefofpain.Surgicalfixationisusuallynotrequired.24SternalfractureIn1864,E.Guiltpublishedahandbookrecordingsternalfracturesasarareinjuryfoundinseveretrauma.Theinjurybecamemorecommonwiththeintroductionandwideuseofvehiclesandthesubsequentriseintrafficaccidents.2526CausesVehiclecollisions,theinjuryisestimatedtooccurinabout3%ofautoaccidents.Itwascommonenoughforthesternumtobeinjuredbytheseatbeltthatitwasincludedinthe'safetybeltsyndrome'Theinjurycanalsooccurwhenthechestsuddenlyflexes27Associatedinjuriesmyocardialandpulmonarycontusionsbloodvesselsinthechest,myocardialrupture,headandabdominalinjuries,flailchest,andvertebralfracture.ribfracturesbronchialtearsrupturesofthebronchiolesmortalityrateestimated25–45%.However,whensternalfracturesoccurinisolation,theiroutcomeisverygood.28SignsandsymptomsCrepitus(捻發(fā)音)(acrunchingsoundmadewhenbrokenboneendsrubtogether),Pain,tenderness,bruising(挫傷)

,andswellingoverthefracturesite.Thefracturemayvisiblymovewhenthepersonbreathes,anditmaybebentordeformedBrokenboneendsisdetectablebypalpation.Associatedinjuries:Theupperandmiddlepartsofthesternumarethosemostlikelytofracture,butmoststernalfracturesoccurbelowthesternalangle29AssessmentandtreatmentX-raysofthechest:CTscanning.peoplewithsternalfracturesbutnootherinjuriesdonotneedtobehospitalized.itiscommonforcardiacinjuriestoaccompanysternalfracture,heartfunctionismonitoredwithelectrocardiogram.Fracturesthatareverypainfulorextremelyoutofplacecanbeoperatedontofixthebonefragmentsintoplace,inmostcasestreatmentconsistsmainlyofreducingpainandlimitingmovement.Thefracturemayinterferewithbreathing,requiringintubationandmechanicalventilation.30Traumaticasphyxia創(chuàng)傷性窒息

Cyanoticasphyxiaduetotrauma:1.asuddenmechanicalincreaseinvenouspressure2.theextravasationofbloodintotheskinandconjunctivae(結(jié)膜).3.singsoftraumaticasphyxia:conjunctivalhaemmorhages,petechial(瘀點(diǎn)的)blue-purplediscoloration變色ofheadandneck.Neurologicalfindings:confusionorunconsciousnessandconvulsions(抽搐).31創(chuàng)傷性窒息機(jī)理驅(qū)逐3233TreatmentThetreatmentincludesrapidchestdecompressionandcardiopulmonaryresuscitation.Theprognosisisgoodbutaprolongedthoraciccompressioncouldleadtocerebralanoxiaandneurologicalsequelae(后遺癥).342.PulmonaryinjuryandinjuriesinvolvingthepleuralspacePulmonarycontusionPulmonarylacerationPneumothoraxHemothoraxHemopneumothorax35Pulmonarycontusion肺挫傷Concept:pulmonarycontusion:chesttrauma—lungcontusion--damagetocapillaries--bloodandotherfluidsaccumulateinthelungtissue--excessfluidinterfereswithgasexchange--hypoxia36Contusioninvolveshemorrhageinthealveoli(肺泡)DifferentiatePulmonarylaceration,inwhichlungtissueistornorcut,involvesdisruptionofthemacroscopicarchitectureofthelung.Whenlacerationsfillwithblood,theresultispulmonaryhematoma,acollectionofbloodwithinthelungtissue37SignsandsymptomsmildcontusionmayhavenosymptomsSO2,BLOODGAS,cyanosis,Dyspnea,toleranceforexercisemaybelowered,Rapidbreathingandarapidheartratebreathsounds:decreased,orralesbronchorrhea(theproductionofwaterysputum)WheezingandcoughingCoughingupbloodorbloodysputumCardiacoutput--reduced,hypotensionisfrequentlypresent.chestwallmaybetenderorpainfulSignsandsymptomstaketimetodevelop,asymptomaticattheinitialpresentation.Inseverecases,symptomsmayoccurthreeorfour

hoursafterthetrauma.Hypoxemiatypicallybecomesprogressivelyworseover48-72

hours,itmayalsocauserapiddeteriorationordeathifuntreated.38Causesoccursin25–35%ofallbluntchesttrauma,About70%ofcasesresultfrommotorvehiclecollisions,Falls,assaults,andsportsinjuriesBlastlung(肺爆震傷)

isseverepulmonarycontusion,bleeding,oredemawithdamagetoalveoliandbloodvessels.Thisistheprimarycauseofdeathamongpeoplewhoinitiallysurviveanexplosion.penetratingtraumaalsocancausepulmonarycontusion.penetratingtraumacauseslesswidespreadlungdamagethandoesblunttrauma.Anexceptionisshotgunwounds,whichcanseriouslydamagelargeareasoflungtissuethroughablastinjurymechanism.39Mechanismlungtissuecanbecrushedwhenthechestwallbendsinwardonimpactinertialeffect(慣性作用）,thelighteralveolartissueisshearedfromtheheavierhilarstructures,Itresultsfromthefactthatdifferenttissueshavedifferentdensities,andthereforedifferentratesofaccelerationordeceleration.spallingeffect(剝落作用):inareaswithlargedifferencesindensity;particlesofthedensertissuearespalled(thrown)intothelessdenseparticlesimplosioneffect:apressurewavepassesthroughatissuecontainingbubblesofgas:thebubblesfirstimplode,thenreboundandexpandbeyondtheiroriginalvolume.Theairbubblescausemanytinyexplosions,resultingintissuedamage;theoverexpansionofgasbubblesstretchesandtearsalveoli.40PathophysiologyLungtissueBleedingandedema:

Themembranebetweenalveoliandcapillariesistorn;damagetothiscapillary–alveolarmembraneandsmallbloodvesselscausesbloodandfluidstoleakintothealveoliandtheinterstitialspaceofthelung.Fluidaccumulationinterfereswithgasexchange,andcancausethealveolitofillwithproteinsandcollapseduetoedemaandbleeding.41Consolidation:Consolidationoccurswhenthepartsofthelungfillwithmaterialfromthepathologicalcondition,suchasblood.

Overaperiodofhoursaftertheinjury,thealveoliintheinjuredareathickenandmaybecomeconsolidated.

collapse

Adecreaseintheamountofsurfactantproducedalsocontributestothecollapseandconsolidationofalveoli;inactivationofsurfactantincreasestheirsurfacetension.

42

Inflammationofthelungcancausepartsofthelungtocollapse.Macrophages,neutrophils,andotherinflammatorycellsandbloodcomponentscanenterthelungtissueandreleasefactorsthatleadtoinflammation,increasingthelikelihoodofrespiratoryfailure.Inresponsetoinflammation,excessmucusisproduced,potentiallypluggingpartsofthelungandleadingtotheircollapse.

Evenwhenonlyonesideofthechestisinjured,inflammationmayalsoaffecttheotherlung.Uninjuredlungtissuemaydevelopedema,thickeningoftheseptaofthealveoli,andotherchanges.

43Ventilation/perfusionmismatch:1.fluid-filledalveolicannotfillwithair,oxygendoesnotfullysaturatethehemoglobin,andthebloodleavesthelungwithoutbeingfullyoxygenated.2.Insufficientinflationofthelungs,whichcanresultfrominadequatemechanicalventilationoranassociatedinjurysuchasflailchest,canalsocontributetotheventilation/perfusionmismatch3.Pulmonaryhypoxicvasoconstriction,inwhichbloodvesselsnearthehypoxicalveoliconstrict(narrowtheirdiameter)inresponsetotheloweredoxygenlevels,canoccurinpulmonarycontusion44Gasexchangeisimpairedwhenalveolifillwithfluid45DiagnosisX-ray

:ConsolidatedareasappearwhiteonanX-rayfilm.TheX-rayappearanceofpulmonarycontusionissimilartothatofaspiration,andthepresenceofhemothoraxorpneumothoraxmayobscurethecontusiononaradiograph.Itisoftennotsensitiveenoughtodetecttheconditionearlyaftertheinjury.Inathirdofcases,pulmonarycontusionisnotvisibleonthefirstchestradiographperformed.Ittakesanaverageofsix

hoursforthecharacteristicwhiteregionstoshowuponachestX-ray,andthecontusionmaynotbecomeapparentfor48

hours.WhenapulmonarycontusionisapparentinanX-ray,itsuggeststhatthetraumatothechestwassevereandthataCTscanmightrevealotherinjuriesthatweremissedwithX-ray.4647AchestX-rayshowingrightsidedpulmonarycontusionassociatedwithribfracturesandsubcutaneousemphysema48Computedtomography

UnlikeX-ray,CTscanningcandetectthecontusionalmostimmediatelyaftertheinjury.

However,inbothX-rayandCTacontusionmaybecomemorevisibleoverthefirst24–48

hoursaftertraumaasbleedingandedemaintolungtissuesprogress.CTscansalsohelpdifferentiatebetweencontusionandpulmonaryhematoma

49TreatmentNotreatmentisknowntospeedthehealingofapulmonarycontusion;themaincareissupportiveTreatmentaimstopreventrespiratoryfailureandtoensureadequatebloodoxygenation50VentilationPositivepressureventilation,inwhichairisforcedintothelungs,isneededwhenoxygenationissignificantlyimpaired

Pulmonarycontusionoritscomplicationssuchasacuterespiratorydistresssyndromemaycauselungstolosecompliance(stiffen),sohigherpressuresmaybeneededtogivenormalamountsofairandoxygenatethebloodadequately51Fluidtherapy

Excessivefluidinthecirculatorysystemcanworsenhypoxiabecauseitcancausefluidleakagefrominjuredcapillaries(pulmonaryedema),whicharemorepermeablethannormal.Lowbloodvolumeresultingfrominsufficientfluidhasanevenworseimpact,potentiallycausinghypovolemicshock;forpeoplewhohavelostlargeamountsofblood,fluidresuscitationisnecessaryFurosemide(速尿),adiureticusedinthetreatmentofpulmonarycontusion,alsorelaxesthesmoothmuscleintheveinsofthelungs,therebydecreasingpulmonaryvenousresistanceandreducingthepressureinthepulmonarycapillaries52Supportivecare

animportantpartoftreatmentispulmonarytoilet(isasetofmethodsusedtoclearmucusandsecretionsfromtheairways)PeoplewhododevelopinfectionsaregivenantibioticsPaincontrolisanothermeanstofacilitatetheeliminationofsecretions

53PrognosisMostcontusionsresolveinfivetoseven

daysaftertheinjury.Signsdetectablebyradiographyareusuallygonewithin10

daysaftertheinjuryChroniclungdiseasecorrelateswiththesizeofthecontusionandcaninterferewithanindividual'sabilitytoreturntoworkFibrosisofthelungscanoccur,resultingindyspnea(shortnessofbreath),lowbloodoxygenation,andreducedfunctionalresidualcapacityforaslongassixyearsaftertheinjuryAslateasfouryearspost-injury,decreasedfunctionalresidualcapacityhasbeenfoundinmostpulmonarycontusionpatientsstudiedDuringthesixmonthsafterpulmonarycontusion,upto90%ofpeoplesufferdifficultybreathingContusioncanalsopermanentlyreducethecomplianceofthelungs54ComplicationsPulmonarycontusioncanresultinrespiratoryfailureinfectionsacuterespiratorydistresssyndrome(ARDS)55Pulmonarylaceration肺裂傷

Pulmonarylaceration:inwhichlungtissueistornorcut,involvesdisruptionofthemacroscopicarchitectureofthelung.Whenlacerationsfillwithblood,theresultispulmonaryhematoma,acollectionofbloodwithinthelungtissue56CausespenetratingtraumabutmayalsobecausedbyblunttraumabrokenribsmayperforatethelungthetissuemaybetornduetoshearingforcesViolentcompressionofthechestcancauselacerationsbyrupturingorshearingthelungtissue57PathophysiologyApulmonarylacerationcancauseairtoleakoutofthelaceratedlungandintothepleuralspace,resultsinpneumothorax(duetotornairways),hemothorax(duetotornbloodvessels),orahemopneumothoraxThelacerationmayalsocloseupbyitself,whichcancauseittotrapbloodandpotentiallyformacystorhematoma,calledatraumaticaircystthatmaybefilledwithair,blood,orbothandthatusuallyshrinksoveraperiodofweeksormonths.58DiagnosisPulmonarylacerationmaynotbevisibleusingchestX-raybecauseanassociatedpulmonarycontusionorhemorrhagemaymaskit.CTscanningismoresensitiveandbetterthanX-raysare,OnaCTscan,pulmonarylacerationsshowupinacontusedareaofthelung,typicallyappearingascavitiesfilledwithairorfluidthatusuallyhavearoundorovoidshapeduetothelung'selasticity.59apatientwithcompletedisruptionoftherightbronchus.Captionreads,“Coronalviewdemonstratingmultipleareasofalveolarconsolidationintherightupperandlowerlobes:intraparenchymal（薄壁）lucencies（透光區(qū)）resultingfromlunglacerationsarevisibleontherightside(thickarrows)."60PulmonarylacerationisusuallyaccompaniedbyhemoptysisAhealinglacerationmayresembleanodulesonradiographs,butunlikepulmonarynodules,lacerationsdecreaseinsizeovertimeonradiographs61Treatmentpulmonarylacerationcanoftenbetreatedwithjustsupplementaloxygen,ventilation,anddrainageoffluidsfromthechestcavity.About5%ofcasesrequiresurgery.Thoracotomyisespeciallylikelytobeneededifalungfailstore-expand;ifpneumothorax,bleeding,orcoughingupbloodpersist;orinordertoremoveclottedbloodfromahemothorax.62PrognosisFullrecoveryiscommonwithpropertreatment.Pulmonarylacerationsusuallyhealwithinthreetofiveweeks,andlacerationsfilledwithairwillcommonlyhealwithinonetothreeweeksHowever,theinjuryoftentakesweeksormonthstoheal,andthelungmaybescarred.Smallpulmonarylacerationsfrequentlyhealbythemselvesifmaterialisremovedfromthepleuralspacesurgerymayberequiredforlargerlacerationsthatdonothealproperlyorthatbleed.63ComplicationsComplicationsarenotcommonbutincludeinfection,andbronchopleuralfistulaAirembolism,inwhichairentersthebloodstream,ispotentiallyfatal,especiallywhenitoccursontheleftsideoftheheart.Aircanenterthecirculatorysystemthroughadamagedveinintheinjuredchestandcantraveltoanyorgan;itisespeciallydeadlyintheheartorbrain.Positivepressureventilationcancausepulmonaryembolismbyforcingairoutofinjuredlungsandintobloodvessels.64Pneumothorax

AirinpleuralspacePartialorcompletelungcollapseoccurs6566Traumaticpneumothoraxoccurseitherbecauseaholeinthechestwall,suchasastabwoundorgunshotwound,allowsairtoenterthepleuralspace,orbecauseofinjurytothelungTraumaticpneumothoraxcancreatea1-wayvalveinthepleuralspace(onlylettinginairwithoutescape)andcanleadtoatensionpneumothorax67thecausesofatraumaticpneumothorax

Atraumaticpneumothoraxmayresultfrombothblunttraumaandpenetratinginjuriestothechestwall.Itmaybeobservedinthoseexposedtoanexplosiveblast,evenifnodirectinjurytothechesthasoccurred.Themostcommonmechanismisacuttothepleurabyafracturedrib.Stab,gunshot,Medicalproceduresofthechest(iatrogenic):suchasthetakingofbiopsysamplesfromlungtissue,insertingacentralvenouscatheterintooneofthechestveins,administrationofpositivepressureventilation,mechanicalventilationornon-invasiveventilation68SimplePneumothoraxSignsandSymptomsPainoninhalationDifficultybreathingTachypneaDecreasedorabsentbreathsoundsSeverityofsymptomsdependsonsizeofpneumothorax,speedoflungcollapse,andpatient’shealthstatus69SimplePneumothoraxManagementMonitorfortensionpneumothoraxSuction,drainage70OpenPneumothoraxHoleinchestwallAllowsairtoenterpleuralspaceLargerhole=Greaterchanceairwillentertherethanthroughtrachea“SuckingChestWound”71OpenPneumothoraxManagementCloseholewithocclusivedressingHighconcentrationO2AssistventilationsConsidertransportoninjuredsideMonitorfortensionpneumothoraxChestdrainage72TensionPneumothoraxOne-wayvalveformsinlungorchestwallAirenterspleuralspace;cannotleavePressurerisesPressurecollapseslung73TensionPneumothoraxTrappedairpushesheart,lungsawayfrominjuredsideVenacavaebecomekinked.Bloodcannotreturntoheart.Cardiacoutputfalls74TensionPneumothoraxSignsandSymptomsExtremedyspneaRestlessness,anxiety,agitationDecreasedbreathsoundsHyperresonancetopercussionCyanosisSubcutaneousemphysema75TensionPneumothoraxSignsandSymptomsRapid,weakpulseDecreasedBPTrachealshiftawayfrominjuredsideJugularveindistensionEarlydyspnea/hypoxia-Lateshock76TensionPneumothoraxManagementSecureairway,chesttubeHighconcentrationO2

Ifavailable,requestALS(AdvancedLifeSupport)interceptforpleuraldecompression77HemothoraxBloodinpleuraspaceMostcommonresultofmajorchestwalltraumaPresentin70to80%ofpenetrating,majornon-penetratingchesttrauma78HemothoraxSignsandSymptomsRapid,weakpulseCool,clammyskinRestlessness煩躁不安,anxietyThirstChillsHypotensionCollapsedneckveins79HemothoraxSignsandSymptomsDecreasedbreathsoundsDullnesstopercussionDyspneaVentilatoryfailureShockprecedesventilatoryfailure80HemothoraxManagementSecureairwayAssistbreathingwithhighconcentrationO2RapidtransportChesttubesurgery81CardiacTamponadeRapidaccumulationofbloodinspacebetweenheart,pericardiumHeartcompressedBloodenteringheartdecreasesCardiacoutputfalls82PathophysiologyTheouterpericardiumismadeoffibroustissuelessandlessbloodenterstheventricles,decreasedstrokevolume-----obstructiveshock----cardiacarrestmayoccur83DiagnosisInitialdiagnosiscanbechallengingClassicalcardiactamponadepresentsthreesigns-----beck'striad:1.Hypotension-----decreasedstrokevolume2.jugular-venousdistension-----impairedvenousreturntotheheart,inpresenceofdecreasedarterialBP3.muffledheartsounds(Smallquietheart,decreasedheartsounds)-----fluidinsidethepericardium84Othersignsoftamponade:pulsusparadoxus(adropofatleast10mmHginarterialbloodpressureoninspiration)STsegmentchangesontheelectrocardiogram,whichmayalsoshowlowvoltageQRScomplexesgeneralsigns&symptomsofshock(suchastachycardia,breathlessnessand