Traumatismos ToràCicos VersiòN Final
Transcript of Traumatismos ToràCicos VersiòN Final
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Traumatismos ToràcicosTraumatismos Toràcicos
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
GeneralidadesGeneralidades
El trauma toracico es considerado un El trauma toracico es considerado un politraumatismo, con mucha frecuencia politraumatismo, con mucha frecuencia encontramos lesiones en: Cráneo, cara, encontramos lesiones en: Cráneo, cara, abdomen alto y otras partes del cuerpoabdomen alto y otras partes del cuerpo
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
CAUSASCAUSAS
* Industrialización
* Medios masivos de transporte
* Criminalidad
* Accidentes automovilísticos
* Deportes extremos
* Crecimiento demográfico
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
TendenciasTendencias
* El manejo del trauma ha cambiado en los últimos años
* El paciente es manejado en el lugar mismo del accidente
* El paciente continua su manejo en el contexto hospitalario
* El tratamiento inicial aumenta la supervivencia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
ClasificaciónClasificación
* CONTUSIONES
a) superficiales
b) profundas
* HERIDAS
a) penetrantes
b) no penetrantes
c) perforantes
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Cuadro clínicoCuadro clínico
* Disnea
* Dolor toracico
* Tos (?)
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
ComplicacionesComplicaciones
* Lesiones letales
* Lesiones potencialmente letales
* Lesiones no necesariamente letales
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Complicaciones LetalesComplicaciones Letales
* Obstrucción de la vía aérea
* Neumotórax a tensión
* Taponamiento cardiaco (hemopericardio)
* Hemotórax masivo
* Neumotórax abierto
* Tórax inestable
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Complicaciones Complicaciones Potencialmente LetalesPotencialmente Letales
* Contusión pulmonar
* Contusión Cardiaca
* Ruptura de aorta
* Ruptura diafragmática
* Ruptura traqueobronquial
* Ruptura de esófago
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Lesiones No Necesariamente Lesiones No Necesariamente LetalesLetales
* Grados tolerables de hemotórax
* Grados tolerables de neumotórax
* Lesiones de tejidos blandos
* Cuerpos extraños intratorácios
* Fracturas óseas
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
FisiopatologíaFisiopatología
* Alteraciones de la ventilación
* Insuficiencia respiratoria
* Es progresiva durante las primeras 24 horas
* Hay una respuesta metabólica al trauma
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Diagnostico RadiológicoDiagnostico Radiológico
• Rx PA de tórax
• Rx en espiración forzada
• Tórax óseo
• Rx lateral de esternon
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
ManejoManejo
* “LA HORA DORADA” de la medicina de urgencias es la que se realiza después del traumatismo
* Se realiza generalmente en el lugar del accidente
* Es donde ocurre el 50% de los decesos por lesiones graves
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
ManejoManejo
* ABC del paciente politraumatizado
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
ABCABC
A- vía aérea permeable + control cervical
B- respiración/ ventilación
C- circulación + control de hemorragia
D- deterioro neurológico (a v d i)
E- exposición + control de hipotermia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
MortalidadMortalidad
Distribución trimodal
* Herida penetrante del corazón 30 minutos
* Neumotórax a tensión menos de 10-15 minutos
* Hemorragia torácica profusa rara vez tiene mas tiempo
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
GraciasGracias
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Chest TraumaChest Trauma
Gráinne MurphyGráinne Murphy
Final MedFinal Med
April 2002April 2002
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
IntroductionIntroduction
• Chest trauma is often sudden and dramatic
• Accounts for 25% of all trauma deaths• 2/3 of deaths occur after reaching hospital• Serious pathological consequnces: -
hypoxia, hypovolaemia, myocardial failure
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Mechanism of InjuryMechanism of Injury
Penetrating injuries
• E.g. stab wounds etc.
• Primarily peripheral lung
• Haemothorax
• Pneumothorax
• Cardiac, great vessel or oesophageal injury
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
• Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury
• Rib fracture is the most common sign of blunt thoracic trauma
• Fracture of scapula, sternum, or first rib suggests massive force of injury
Blunt injuriesBlunt injuries
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Chest wall injuries Chest wall injuries
• Rib fractures
• Flail chest
• Open pneumothorax
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Rib fracturesRib fractures
• Most common thoracic injury
• Localised pain, tenderness, crepitus
• CXR to exclude other injuries
• Analgesia..avoid taping
• Underestimation of effect
• Upper ribs, clavicle or scapula fracture: suspect vascular injury
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Flail chestFlail chest
• Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration
• Significant force required
• Usually diagnosed clinically
• Rx: ABC Analgesia
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Flail chestFlail chest
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Flail Chest - detail
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Open pneumothoraxOpen pneumothorax
• Defect in chest wall provides a direct communication between the pleural space and the environment
• Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax
• “Sucking chest wound”
• Rx: ABCs…closure of wound…chest drain
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Lung injuryLung injury
• Pulmonary contusion
• Pneumothorax
• Haemothorax
• Parenchymal injury
• Trachea and bronchial injuries
• Pneumomediastinum
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
PneumothoraxPneumothorax
• Air in the pleural cavity
• Blunt or penetrating injury that disrupts the parietal or visceral pleura
• Unilateral signs: movement and breath sounds, resonant to percussion
• Confirmed by CXR
• Rx: chest drain
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
PneumothoraxPneumothorax
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Tension pneumothorax Tension pneumothorax
• Air enters pleural space and cannot escape
• P/C: chest pain, dyspnoea
• Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
• Surgical emergency
• Rx: emergency decompression before
CXR
• Either large bore cannula in 2nd ICS,
MCL or insert chest tube
• CXR to confirm site of insertion
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
HaemothoraxHaemothorax
• Blunt or penetrating trauma
• Requires rapid decompression and fluid resuscitation
• May require surgical intervention
• Clinically: hypovolaemia absence of breath sounds dullness to percussion
• CXR may be confused with collapse
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Heart, Aorta & DiaphragmHeart, Aorta & Diaphragm
• Blunt cardiac injury - contusion - ventricular, septal or valvular rupture
• Cardiac tamponade
• Ruptured thoracic aorta
• Diaphragmatic rupture
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Cardiac TamponadeCardiac Tamponade
• Blood in the pericardial sac
• Most frequently penetrating injuries
• Shock, JVP, PEA, pulsus paradoxus
• Classically, Beck’s triad:- distended neck veins
- muffled heart sounds- hypotension
• Rx: Volume resuscitation Pericardiocentesis
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Cardiac Cardiac tamponadetamponade
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Aortic ruptureAortic rupture
• Usually blunt trauma involving deceleration forces; especially RTAs
• ~90% die within minutes
• Most common site near ligamentum arteriosum
• Dx: clinical suspicion, CXR, aortography, contrast CT or TOE
• Rx: surgical…poor prognosis
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Aortic ruptureAortic rupture
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Iatrogenic traumaIatrogenic trauma
• NG tubes: -coiling -endobronchial placement
-pneumothorax• Chest tubes: - subcutaneous
- intraparenchymal - intrafissural
• Central lines: - neck - coronary sinus - pneumothorax
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Line in jugular Line in jugular vein vein
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Misplaced nasogastric Misplaced nasogastric tubetube
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Dr. Luis Castillo SarabiaDr. Luis Castillo Sarabia
Chest trauma: summaryChest trauma: summary
• Common
• Serious
• Primary goal is to provide oxygen to vital organs
• RememberAirway
BreathingCirculation
• Be alert to change in clinical condition