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Health-ProcessEvidence-Based
Clinical Practice Guidelinesfor
Trauma on Thoracic Area
Jonathan Malabanan MD
OMMC
October 11, 2007
Thoracic Trauma
A. Overview of the Problem• Concept• Common Types• Common CausesB. General Management Guidelines• Clinical Diagnosis• Paraclinical Diagnosis• Treatment
Clinical Questions1. What is a operational concept of
trauma on the thoracic area?
Trauma - body injury produced by
sudden force
Thorax- region
Clinical Questions2. What is a operational concept of
“Non- Penetrating Thoracic Injury”?
- Blunt trauma to the thoracic area
Clinical Questions3. What is a operational concept of
“Penetrating Thoracic Injury”?
-Potential surgical patient
4. How is head trauma classified in terms of mechanism of injury?
- Blunt/ non- penetrating trauma
- Penetrating trauma
Clinical Questions
Clinical Questions
5. What are the most common causes of penetrating thoracic injury?
- Assault with sharp object
- Gunshot Injury
Clinical Questions
7. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury?
- difficulty of breathing
- decreased breath sounds on the affected lung field
Clinical Questions
7. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury?
- tachycardia
- increased respiratory rate
Clinical Questions
7. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury?
- presence of paradoxical pulse
8. If a paraclinical diagnostic procedure is needed for trauma to the thoracic area, the most
cost effective would be:
Benefit Risk Cost Availability
X-RayPneumothorax: (+)
Hemothorax:(+)
Exposure to radiation
P200 available
UltrasoundPneumothorax: (++)
Hemothorax:(+)
No radiation exposure
P600 available
CT-ScanPneumothorax: (+++)
Hemothorax: (+++)
Exposure to radiation P6000
Not readily available
http://www.diagnosticimaging .com
9. What are the goals of treatment for the following?
A. Non- Penetrating Thoracic Injury
B. Penetrating Thoracic Injury
GOALS OF TREATMENT
• Resolution of hemothorax or pneumothorax
• Full re- expansion of left lung• Monitor for ongoing bleeding
11. What is the most cost-effective operative treatment for the following?
A. Non- Penetrating Thoracic Injury
B. Penetrating Thoracic Injury
Treatment Options
Benefit Risk Cost Availability
Tube Thoracostomy
-Complete evacuation of fluid
-can monitor ongoing bleeding
-hemostatic
- Injury to adjacent structure
P10000 available
Thoracentesis -Useful in small hemothorax-incomplete evacuation
-Injury to adjacent structure
P5000 available
Practice Level of Evidence
• Standards (I) need to be followed
• Guidelines (II) suggested
• Options (III) considered
Protocol on CTT
• May proceed to thoracotomy if:– initial output is ≥ 1000 cc of blood– There is continuous CTT output of more than
150cc/hour
Protocol on Prevention of Posttraumatic Retained Hemothorax
Department of Surgery, OMMC
Hemothorax
CTT
Thoracotomy>1 Liter>150cc/hr x 4 hrs
Suctioning>1/3 retained
Hemothorax by CXR
Active ObservationGomco
< 1/3 retained hemothorax
•Turiñgan H, Hernandez D, Joson O. Posttraumatic Retained Hemothorax – Incidence, Prevention and Management with Suctioning. Published PJSS,2004
What is the role of fluid resuscitation prior to surgery in the treatment of significant
thoracic injury?
• Fluid resuscitation should be given to avoid hypotension (II)