外科学精品教学：Thoracic Trauma.docVIP

Thoracic Trauma Thoracic injuries account for 20% to 25% of all trauma-related deaths, and complications of chest trauma contribute to another 25% of all deaths. Considering immediate deaths after motor vehicles accidents, the most frequent injuries leading to a fatal outcome include blunt cardiac injuries with chamber disruption and injuries to the thoracic aorta. Early deaths (within the golden hour) are caused by airway obstruction, major respiratory problems such as tension pneumothorax or massive hemothorax, and cardiac tamponade. These clinical situations are easily managed if recognized promptly. Chest wall trauma is the most frequent injury after blunt thoracic trauma. The majority of thoracic injuries are managed with simple procedures such as clinical observation, thoracentesis, respiratory support, and adequate analgesia. The remaining 15% to 20% of patients sustaining chest trauma will require thoracotomy for definitive repair of major intrathoracic injuries. Pathophysiology The pathophysiology of chest trauma includes three factors: hypoxia, hypercapnia, and acidosis. Hypoxia can be caused by airway obstruction, changes in intrathoracic pressure, ventilation-perfusion mismatches, and hypovolemia. Hypercapnia is caused by inadequate ventilation as a result of the presence of either a collapsed lung, associated head injuries with altered mental status, or exogenous intoxication (drugs and alcohol). Acidosis is due mainly to hypoperfusion from blood loss. Initial Evaluation The initial evaluation of a patient sustaining chest trauma follows the same principles and guidelines outlined by the ATLS course. The first priority is maintenance of a patent airway, which may be achieved by simply repositioning the head, anteriorizing the mandible (chin lift and jaw thrust), or removing foreign bodies from the oropharynx. Some patients with more severe thoracic or head injuries will require tracheal intubation either by a nasal or oral route or by means of a surg