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Künt Toraks Travmasi Müracaat Tarihi / Application Date: 08.09.2017 DERLEME / REWIEV Kabul Tarihi / Acceptance Date: 03.10.2017 KÜNT TORAKS TRAVMASI BLUNT THORACIC TRAUMA Ahmet Gökhan Öz Travma 40 yaş altında görülen ölümlerin en sık nedenidir. Vakaların Gündoğdu*, hemen hemen dörtte biri toraks travmasıdır ve bunların da önemli bir Hasan Ekrem Çamaş*, yüzdesini künt travmalar oluşturur. Yaralanma izgesi minör Rasih Yazkan*. vakalardan ciddi, hayatı tehdit edenlere kadar çeşitlilik gösterebilir. Künt toraks travması hakkında yeterli bilgi sahibi olunması ve travmanın meydana geldiği yerde başlayan uygun bakım, morbidite ve mortalitenin azaltılmasında son derece önemlidir. Anahtar Kelimeler: künt, toraks, travma Abstract: Trauma is the most common cause of death under 40 years of age. Almost a quarter of these cases are thoracic trauma, in which blunt *: Süleyman Demirel ones constitute a major percentage. The spectrum of the injuries may University, Faculty of vary from minor ones to severe lifethreatening cases. Adequate Medicine, Department of knowledge on blunt thoracic trauma and proper care starting at the Thoracic Surgery site of the impact are crucial for decreasing morbidity and mortality rates. Keywords: blunt, thorax, trauma Yazışma Adresi: Ahmet Gökhan Gündoğdu Süleyman Demirel University, Faculty of Medicine, Department of Thoracic Surgery Çünür Mah. 32246 Isparta/ TURKEY gokhangundogdu@hotmail. com 533/2506281 86 Med J SDU / SDÜ Tıp Fak Derg 2018:25(1):86-97 DOI : 10.17343/sdutfd.337201 Gündoğdu ve ark. BLUNT THORACIC TRAUMA the first 2 ribs suggests a high energy trauma Adequate knowledge about thoracic trauma and and damage to the subclavian vessels and associated injuries is crucial for proper brachial plexus may accompany the situation. management of trauma victims. Edwin Smith In cases of lower rib fractures, possible injury papyrus reports on thoracic trauma and related to the abdominal organs must be carefully surgical issues in 1600 BC(1). In the fifth sought. Hepatic and splenic injuries may be century BC, Hippocrates defined hemoptysis observed with the fracture of 11th and 12th caused by rib fractures. He stated this to be a ribs. In cases of rib fractures immediate pain serious pathology, referring to pulmonary relief and pulmonary rehabilitation is crucial. injury. In 1773, William Bromfield mentioned For pain management; oral and parenteral about tension pneumothorax and he performed nonsteroidal anti-inflammatory drugs, thoracentesis. With the advent of closed chest narcotics, intercostal nerve blockade and drainage, thoracic injury management was epidural analgesia may be used (2). better performed. Playfair used the water seal Pulmonary Parechymal Laceration: drainage system for the first time in 1875 (2). Pulmonary parenchymal laceration may be Trauma, although being the third most common observed with blunt thoracic trauma, altough it over 40 years of age, is the most common cause is more common with penetrating chest of death under the age 40 (3). About 25% of wounds. It may be the result of rib fractures or these casualties are due to thoracic trauma. Around 70% of thoracic trauma are blunt. The deceleration type trauma. It is usually associated injuries may range from simple, accompanied by hemoptysis and hemothorax. isolated rib fracture to grave vascular Both the vascular structure and airway injuries hemorrhage necessitating thoracotomy. occur. In most cases the main problem is Pulmonary contusion is the most commonly pneumothorax. If the visceral pleura remains encountered intrathoracic pathology in blunt intact, blood and air may be trapped within the trauma. Severe intrathoracic injuries are more common in multitrauma patients. The mortality parenchyme giving rise to hematoma, cyst or rate of the thoracic trauma is 4 to 12%. This blood filled cystic lesion (7). rate may rise up to 30 to 35% when multiple traumas exist (4). The most common Pulmonary Hematoma: accompanying injuries are fractures of the The incidence of developing pulmonary extremities, head trauma, abdominal injury, hematoma is 4 to 10 % in pulmonary contusion pelvic fractures and spinal injuries with decreasing order of frequency. In about 50% of cases. It may be difficult to differentiate the motor vehicle accidents resulting in death, pulmonary hematoma from pulmonary severe thoracic trauma is present (5, 6). contusion because of the surrounding Rib Fracture: intraparenchymal hemorrhage. Typically, a well-demarcated nodular formation of 2 to 5 Rib fractures are the most common injury cm in size develops within 24 to 48 hours after observed with blunt thoracic trauma. Usually the trauma. Computed tomography of the chest 4th to 9th ribs are affected. The involvement of may help in detection. It is usually Med J SDU / SDÜ Tıp Fak Derg 2018:25(1):86-97 DOI : 10.17343/sdutfd.337201 87 BLUNT THORACIC TRAUMA asymptomatic, but may cause moderate pain Costal Cartilage Damage: and hemoptysis. Most often the pathologic Especially children suffer such phenomenon situation does not interfere with gas exchange when a trauma exerts from the anterior. The and spontaneous resorption takes place within 2 ribs detach from costal cartilages or the to 6 weeks. Rarely, secondary infection and sternum. The usual symptom is pain and the abcess formation, which needs to be drained, situation resolves spontaneously in few weeks. may develop. Fever and dyspnea may be observed then. Usually, immediate chest X-ray Hemothorax: following the trauma yields no sign of Hemothorax develops as a result of damage to hematoma (7). the intercostal artery, lung, diaphragm, heart, Traumatic Pulmonary Pseudocyst: pericardium, aorta and its branches. Occasionally, intraabdominal bleeding may Thoracic trauma, although rare, may give rise leak through the diaphragmatic musculature to a well-demarcated, air, liquid or blood filled into the thoracic cavity. For diagnosis on the cystic cavity lacking an epithelial lining. This basis of chest X-ray, the position of the patient usually takes place after blunt trauma. It is rare is extremely important. Lateral decubitus compared to intrapulmonary hematoma or position or standing upright are favored (2). pulmonary contusion (8). Two mechanisms have been proposed for the development of Pneumothorax: pulmonary pseudocysts in high energy motor Pneumothorax briefly can be described as the vehicle accidents related to the exposure of the entry of air inside the pleural cavity, which lungs to immense forces. First one is the causes pulmonary collapse of varying amounts. closure of a segment of the bronchial tree due Normally, the pleural cavity contains little fluid to sudden compression of a certain area of the amounting to 5 to 10 ml. Presence of air is lung. The closed segment later on enlarges as a abnormal. Pneumothorax develops as a result result of the alveolar rupture. Second probable of disrupted continuity of either the visceral or mechanism is the production of contusion parietal pleura. This may be caused by a blunt waves tearing the pulmonary parenchyma (9). or penetrating trauma or the tear of the lung Children and young adults are more prone to parenchyma along with the visceral pleura such injuries because of the hyperflexibility of which wraps it thoroughly. In case of any the chest wall facillitating the visceral pleura to attachment between the plevral layers, localized stay intact in spite of the massive forces applied pneumothorax may be observed. If there is free on the pulmonary parenchyma. For this specific entry of air inside the pleural cavity during reason 85% of the traumatic pulmonary respiration, the situation is called open pseudocyst patients are less than 30 years of pneumothorax. If the air entering the pleural age (10). The pseudocysts may be solitary or cavity during inspiration fails to leave the multiple, oval or spheric and the size ranges cavity during expiration and goes on from 2 to 14 cm (11). accumulating, it gives rise to tension 88 Med J SDU / SDÜ Tıp Fak Derg 2018:25(1):86-97 DOI : 10.17343/sdutfd.337201 Gündoğdu ve ark. pneumothorax. Fluid may accompany air inside Pneumomediastinum: the pleural cavity, which is called Pneumomediastinum is defined as the presence hydropneumothorax. Blunt or penetrating of air inside the mediastinum. Alveolar rupture thoracic trauma, chronic interstitial pulmonary leads to pneumomediastinum in blunt thoracic diseases, metastatic pulmonary disease and trauma. It may be observed following blunt iatrogenic reasons may give rise to thoracic trauma, tracheostomy, endoscopy, pneumothorax. However, most common reason bronchoscopy and mechanical ventilation due is spontaneous pneumothorax, which is usually to barotrauma. The treatment is usually observed in young, thin, tall and otherwise conservative. healthy individuals. This is generally caused by rupture of the small, subpleural, congenital Sternal Fracture: blebs. These blebs may be bilateral in location. Sternal fractures are quite frequent. Usually, the Spontaneous pneumothorax is observed 8 times fracture axis is transverse. The fracture is more in men compared to women. Spontaneous generally detected with inspection and pneumothorax is recurrent with a possibility of palpation. Lateral chest X-ray confirms the 30 to 70% on the affected side. The diagnosis. Sternum gets fractured either by contralateral side may ve affected 10 % of the direct trauma or by hyperflexion indirectly. In cases after the initial episode. The patients about 55% cases severe intrathoracic injury is usually complain of sudden onset chest
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