Documente Academic
Documente Profesional
Documente Cultură
• CBC count
• A CBC count is a routine laboratory test for
most trauma patients. The CBC count helps
gauge blood loss, although the accuracy of
findings to help determine acute blood loss is
not entirely reliable. Other important
information provided includes platelet and
white blood cell counts, with or without
differential
• Arterial blood gas
• Arterial blood gas (ABG) analysis, though not as
important in the initial assessment of trauma
victims, is important in their subsequent
management. ABG determinations are an
objective measure of ventilation, oxygenation,
and acid-base status, and their results help guide
therapeutic decisions such as the need for
endotracheal intubation and subsequent
extubation.
• Serum chemistry profile
• Patients who are seriously injured and require
fluid resuscitation should have periodic
monitoring of their electrolyte status. This can
help to avoid problems such as hyponatremia
or hypernatremia. The etiology of certain acid-
base abnormalities can also be identified, eg,
a chloride-responsive metabolic alkalosis or
hyperchloremic metabolic acidosis.
• Coagulation profile
• The coagulation profile, including prothrombin
time/activated partial thromboplastin time,
fibrinogen, fibrin degradation product, and D-
dimer analyses, can be helpful in the
management of patients who receive massive
transfusions (eg, >10 U packed RBCs). Patients
who manifest hemorrhage that cannot be
explained by surgical causes should also have
their profile monitored.
• Serum troponin levels
• The rate of cardiac injury in patients with blunt chest
trauma varies widely depending upon the diagnostic
criteria. Troponin is a protein specific to cardiac cells. While
elevated serum troponin I levels correlate with the
presence of echocardiographic or electrocardiographic
abnormalities in patients with significant blunt cardiac
injuries, these levels have low sensitivity and predictive
values in diagnosing myocardial contusion in those without.
As such, troponin I level determination does not, by itself,
help predict the occurrence of complications that may
require admission to the hospital. Accordingly, their routine
use in this clinical situation is not well supported.
• Serum myocardial muscle creatine kinase
isoenzyme levels
• Measurement of serum myocardial muscle
creatine kinase isoenzyme (creatine kinase-MB)
levels is frequently performed in patients with
possible blunt myocardial injuries. The test is
rapid and inexpensive. This diagnostic modality
has recently been criticized because of poor
sensitivity, specificity, and positive predictive
value in relation to clinically significant blunt
myocardial injuries.
• Serum lactate levels
• Lactate is an end product of anaerobic glycolysis
and, as such, can be used as a measure of tissue
perfusion. Well-perfused tissues mainly use
aerobic glycolytic pathways. Persistently elevated
lactate levels have been associated with poorer
outcomes. Patients whose initial lactate levels are
high but are rapidly cleared to normal have been
resuscitated well and have better outcomes.
• Blood type and crossmatch
• Type and crossmatch are some of the most
important blood tests in the evaluation and
management of a seriously injured trauma
patient, especially one who is predicted to
require major operative intervention.
• Chest radiographs
• The chest radiograph (CXR) is the initial radiographic study
of choice in patients with thoracic blunt trauma. A chest
radiograph is an important adjunct in the diagnosis of many
conditions, including chest wall fractures, pneumothorax,
hemothorax, and injuries to the heart and great vessels (eg,
enlarged cardiac silhouette, widened mediastinum).
• In contrast, certain cases arise in which physicians should
not wait for a chest radiograph to confirm clinical suspicion.
The classic example is a patient presenting with decreased
breath sounds, hyperresonant hemithorax, and signs of
hemodynamic compromise (ie, tension pneumothorax).
This should be immediately decompressed before obtaining
a chest radiograph.
• Chest CT scan
• Due to lack of sensitivity of chest radiography to
identify significant injuries, computed tomography (CT)
scan of the chest is frequently performed in the
trauma bay in the hemodynamically stable patient. In
one study, 50% of patients with normal chest
radiographs were found to have multiple injuries on
chest CT scan. As a result, obtaining a chest CT scan in
a supposedly stable patient with significant mechanism
of injury is becoming routine practice.
• .
• Helical CT scanning and CT angiography (CTA)
are being used more commonly in the
diagnosis of patients with possible blunt aortic
injuries. Most authors advocate that positive
findings or findings suggestive of an aortic
injury (eg, mediastinal hematoma) be
augmented by aortography to more precisely
define the location and extent of the injury.
• Aortogram
• Aortography has been the criterion standard for diagnosing
traumatic thoracic aortic injuries. However, its limited
availability and the logistics of moving a relatively critical
patient to a remote location make it less desirable. In
addition, with the new generation spiral CT scanners, which
have 100% sensitivity and greater than 99% specificity, the
role of aortography in the evaluation of trauma patients is
declining. However, where spiral CT is equivocal,
aortography can provide a more exact delineation of the
location and extent of aortic injuries. Aortography is much
better at demonstrating injuries of the ascending aorta. In
addition, it is superior at imaging injuries of the thoracic
great vessels
• Thoracic ultrasound
• Ultrasound examinations of the pericardium,
heart, and thoracic cavities can be expeditiously
performed by surgeons and emergency
department (ED) physicians within the ED.
Pericardial effusions or tamponade can be
reliably recognized, as can hemothoraces
associated with trauma. The sensitivity,
specificity, and overall accuracy of ultrasound in
these settings are all more than 90%
• Contrast esophagogram
• Contrast esophagograms are indicated for patients with
possible esophageal injuries in whom esophagoscopy
results are negative. The esophagogram is first performed
with water-soluble contrast media. If this provides a
negative result, a barium esophagogram is completed. If
these results are also negative, esophageal injury is reliably
excluded.
• Esophagoscopy and esophagography are each
approximately 80-90% sensitive for esophageal injuries.
These studies are complementary and, when performed in
sequence, identify nearly 100% of esophageal injuries
• Focused Assessment for the Sonographic
Examination of the Trauma Patient
• The Focused Assessment for the Sonographic
Examination of the Trauma Patient (FAST) is
routinely conducted in many trauma centers.
Although mainly dealing with abdominal trauma,
the first step in the examination is to obtain an
image of the heart and pericardium to assess for
evidence of intrapericardial bleeding
• Twelve-lead electrocardiogram
• The 12-lead electrocardiogram (ECG) is a standard test
performed on all thoracic trauma victims. ECG findings can
help identify new cardiac abnormalities and help discover
underlying problems that may impact treatment decisions.
Furthermore, it is the most important discriminator to help
identify patients with clinically significant blunt cardiac
injuries.
• Patients with possible blunt cardiac injuries and normal
ECG findings require no further treatment or investigation
for this injury. The most common ECG abnormalities found
in patients with blunt cardiac injuries are tachyarrhythmias
and conduction disturbances, such as first-degree heart
block and bundle-branch blocks.
• Transesophageal echocardiography
• Transesophageal echocardiography (TEE) has been
extensively studied for use in the workup of possible blunt
rupture of the thoracic aorta. Its sensitivity, specificity, and
accuracy in the diagnosis of this injury are each
approximately 93-96%. Its advantages include the easy
portability, no requisite contrast, minimal invasiveness, and
short time required to perform. TEE can also be used
intraoperatively to help identify cardiac abnormalities and
monitor cardiac function.
• The disadvantages include operator expertise, long learning
curve, and the fact that it is relatively weak at helping
identify injuries of the descending aorta.
• Transthoracic echocardiography
• Transthoracic echocardiography (TTE) can
help identify pericardial effusions and
tamponade, valvular abnormalities, and
disturbances in cardiac wall motion. TTEs are
also performed in cases of patients with
possible blunt myocardial injuries and
abnormal ECG findings.
• Flexible or rigid esophagoscopy
• Esophagoscopy is the initial diagnostic procedure of
choice in patients with possible esophageal injuries.
Either flexible or rigid esophagoscopy is appropriate,
and the choice depends on the experience of the
clinician. Some authors prefer rigid esophagoscopy to
evaluate the cervical esophagus and flexible
esophagoscopy for possible injuries of the thoracic and
abdominal esophagus. If esophagoscopy findings are
negative, esophagography should be performed as
outlined above
• Fiberoptic or rigid bronchoscopy
• Fiberoptic or rigid bronchoscopy is performed in
patients with possible tracheobronchial injuries.
Both techniques are extremely sensitive for the
diagnosis of these injuries. Fiberoptic
bronchoscopy offers the advantage of allowing
an endotracheal tube to be loaded onto the
scope and the endotracheal intubation to be
performed under direct visualization if necessary.
Indications and Contraindications
• Indications
• Operative intervention is rarely necessary in
blunt thoracic injuries. In one report, only 8%
of cases with blunt thoracic injuries required
an operation. Most can be treated with
supportive measures and simple
interventional procedures such as tube
thoracostomy.
• The following section reviews indications for
surgical intervention in blunt traumatic
injuries according to the previously presented
classification system. Surgical indications are
further stratified into conditions requiring an
immediate operation and those in which
surgery is needed for delayed manifestations
or complications of trauma
Chest wall fractures, dislocations, and
barotrauma (including diaphragmatic injuries)
• Myocardial infarction
• Arrhythmias
• Pericarditis
• Ventricular aneurysm formation
• Septal defects
• Valvular insufficiency
• Pulmonary and bronchial
Atelectasis
• Pneumonia
• Pulmonary abscess
• Empyema
• Pneumatocele, lung cyst
• Clotted hemothorax
• Fibrothorax
• Bronchial repair disruption
• Bronchopleural fistula
• Vascular
• Graft infection
• Pseudoaneurysm
• Graft thrombosis
• Deep venous thrombosis
• Pulmonary embolism
• Neurological
• Leakage of repair
• Mediastinitis
• Esophageal fistula
• Esophageal stricture .
• Bony skeleton
• Skeletal deformity
• Chronic pain
• Impaired pulmonary mechanics
Future and Controversies