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Trauma torácico ATLS

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Trauma torácico ATLS

  1. 1. R1CG Var gas Fl or es Edgar
  2. 2. Def i ni ci ón • Golpe o agresión sobre las paredes del tórax con daño de las estructuras comprendidas en la caja torácica. • Pueden ser: – cerrados (contusos) – abiertos (penetrantes). Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  3. 3. • Traumatismo abierto: lesión que rompe la integridad del tejido (atraviesa pleura parietal). • Traumatismo cerrado: la lesión no daña la integridad de los tejidos. Brunicardi FC, Andersen DK, Billiar TR et al. Schwartz’s Principles of Surgery, 9th edition. McGraw Hill; 2009.
  4. 4. Epi demi ol ogí a La segunda causa de muerte después del TCE grave. 25% de todos los fallecidos por trauma grave Mortalidad: 10 % Si aislado 5 % Si asociado a TCE o abdominal 25 % Si coexisten TCE + TT + T abd. 40 % Superior en niños Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  5. 5. Traumat i smo Toráci co 5% 20% 25% 50% Pared torácica * fx. costales * torax inestable * fx. esternal Les. cardiovasculares * contusión cardíaca * rotura aórtica * rotura / taponamiento cardíaco Lesiones pulmonares * contusión pulmonar * hemotórax * neumotórax * rotura tráqueo-bronquial Otras: * rotura esofágica * lesiones diafragmáticas Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  6. 6. • Asociada a compresión y aceleración desaceleración • Hay fracturas costales múltiples • Puede haber hemo o neumotórax tardío (> 24 horas del trauma). • El trauma de grandes vasos se puede manifestarse tardíamente. • Tratamiento quirúrgico: requerido en menos del 10 % de los lesionados. • Asociada a heridas por arma blanca y arma de fuego. • Puede no haber fracturas costales. • Hemo o neumotórax inmediato. • El trauma de grandes vasos y corazón es inmediato. • Tratamiento quirúrgico: requeridos entre el 15 y el 30 % de los lesionados. Traumatismo Cerrado Traumatismo Abierto Brunicardi FC, Andersen DK, Billiar TR et al. Schwartz’s Principles of Surgery, 9th edition. McGraw Hill; 2009.
  7. 7. • Lesiones torácicas graves: – Obstrucción de la Vía Aérea. – Neumotórax a Tensión. – Neumotórax Abierto. – Hemotórax Masivo. – Tórax Inestable. – Taponamiento Cardiaco. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008 Trauma Toráci co
  8. 8. Trauma Toráci co • Otras lesiones potencialmente letales: – contusión pulmonar – rotura traqueo bronquial – contusión cardiaca (cerrada) – lesión traumática de aorta – rotura diafragmática – lesión mediastínica (penetrante) Feliciano DV, Mattox KL et al. Trauma. 8th edition. 9th edition. McGraw Hill; 2008-
  9. 9. Fi si opat ol ogí a • Hipoxia – hipovolemia – alteración Va/Q pulmonar (Relación entre la ventilación alveolar y la perfusión capilar por minuto) – alteraciones en las presiones intratorácicas • Hipercapnia – alteraciones en las presiones intratorácicas – reducción del nivel de conciencia • Acidosis – hipoxia-hipoxemia-hipoxia tisular Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  10. 10. Abordaj e • Historia clínica • Exploración física – Inspección – Palpación – Auscultación – Percusión Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008 Revisión primaria Revisión secundaria
  11. 11. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  12. 12. ! La ausencia de ruidos durante la intubación no siempre significa hemo o neumotorax Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  13. 13. Fract uras cost al es • La lesión más frecuente en el trauma directo • Ancianos > adultos >> niños • Costillas 5ª a 9ª • aislada / múltiples: busque lesiones asociadas Manejo: – Oxígeno a alto flujo – Analgesia. – No vendajes circunferenciales – Vigilar factores de riesgo: EPOC, anciano, etc. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  14. 14. Fract uras cost al es • Fracturas 1ª - 2ª – Más energía – Frecuentes lesión de aorta y/o bronquios – 90 % de roturas traqueo-bronquiales – Posible lesión arteria subclavia – Puede producir neumotórax • Fracturas 10ª - 12ª – Lesiones de órganos sólidos abdominales Mortalidad hasta 30 % Presentes hasta en un 30 % Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  15. 15. Fract ura est ernón • Infrecuente: 5-8% en TT cerrado • alta energía • Trauma frontal directo por: – Deceleración – Otros objetos • Sospeche lesiones graves: – Desgarro aorta torácica – Rotura traqueo-bronquial – Rotura diafragmática – Tórax inestable – Trauma cardíaco Mortalidad 25-45 % Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  16. 16. Tórax i nest abl e • Causa: – Trauma cerrado (accidente tránsito) – Otras: caídas, agresiones – Frecuente en ancianos Mortalidad 25-40 % Factores pronósticos: • edad avanzada • ≥ 7 fx. costales • ≥ 3 les. Asociadas • shock • TCE grave Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  17. 17. Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  18. 18. ! El manejo analgésico agresivo es la clave del tratamiento de fracturas costales Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  19. 19. Neumot órax si mpl e • Incidencia –10-30% TT cerrado –casi en el 100 % del TT penetrante –morbi-mortalidad depende de: • lesiones asociadas Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  20. 20. Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  21. 21. ! Un neumotórax simple puede progresar a uno a tensión Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  22. 22. Neumot órax abi ert o • Herida en pared • Mov. paradójico pulmón afectado • Se igualan presiones • Manejo – Apósito oclusivo – Oxígeno a alto flujo – Valore VM a presión positiva – Monitor ECG / limite líquidos IV Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  23. 23. Neumot órax abi ert o • Tratamiento: – Cubrir la herida con un apósito estéril. – Drenaje pleural. • Causas de persistencia de neumotórax: – Falla en el sistema de drenaje. – Desgarros traqueo bronquiales. – Desgarros pulmonares. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  24. 24. Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  25. 25. Neumot órax a t ensi ón • Trauma cerrado / penetrante • Hipoventilación MUY GRAVE • Paro Cardiorespiratorio en minutos Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  26. 26. Neumot órax a t ensi ón • Fuga de aire a la cavidad pleural, con efecto de válvula que produce el colapso del pulmón. • Causas: – neumotórax espontáneo – trauma torácico cerrado. • El mediastino y la tráquea se desplazan hacia el lado opuesto comprimiendo al pulmón sano y afectando el retorno venoso. • Clínicamente : disnea grave, taquicardia, hipotensión, sensación de muerte, desviación de la traquea, ausencia del MV, timpanismo del pulmón afectado, ingurgitación yugular y cianosis tardía. • Tratamiento: Drenaje pleural urgente. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  27. 27. Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  28. 28. Hemot órax Masi vo • Sangre en cavidad igual o superior a 1500 ml. • Causa: Lesión de vasos hiliares y mediastínicos generalmente por heridas penetrantes, • Clínicamente: Paciente en shock, hipóxico, ausencia de MV en el hemitórax dañado y matidez a la percusión. • El tratamiento: – Reposición de volumen: cristaloides, coloides y sangre. – descompresión del hemitórax lesionado :Drenaje Feliciano DV, Mattox KL et al. Trauma. 8th edition. 9th edition. McGraw Hill; 2008-
  29. 29. ! Un hemotórax mal drenado puede resultar en empiema Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  30. 30. Hemot órax Masi vo • Se hará toracotomía sí: – Drenaje inicial mayor de 1,5000 cc (20 cc/Kg) – Drenaje mayor de 1500 ml en las primeras 12 – 24 horas. – Drenaje mayor de 200 cc/hora en 4 horas ó >500 ml/hora (7ml/Kg x h) – Hemotórax creciente en Rx – Deterioro hemodinámico persistente sin otra justificación. Feliciano DV, Mattox KL et al. Trauma. 8th edition. 9th edition. McGraw Hill; 2008-
  31. 31. ! La diferencia entre hemotórax masivo y neumotórax a tensión se hace con palpación Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  32. 32. Cont usi ón Pul monar • Lesión que causa hemorragia y edema localizado del parénquima pulmonar • Clínicamente: disnea progresiva. • Manejo: – Monitoreo constante: gasometría. – Reevaluación permanentes. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  33. 33. Trauma Cardi ovascul ar • Sospecharlo en trauma torácico grave – Contusión cardiaca – Disección o rotura de Aorta – Taponamiento cardiaco Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  34. 34. ! Toda sospecha de lesión de aorta torácica requiere evaluación especializada Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  35. 35.   Cont usi ón mi ocárdi ca • Difícil de diagnosticar • Se sospecha por: – Arritmias inexplicables o signos de infarto. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  36. 36. Rupt ura/Di secci ón de Aort a • Causa: – Accidente de tránsito . – Efectos de Aceleración y desaceleración. – Patada de animales • Signos clínicos alertan el diagnostico: -Mediastino ensanchado. -Fracturas costales: 1era y 2da costillas -Opacidad pleural apical • Tratamiento: quirúrgico Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  37. 37. – Laceración o arrancamiento de los puntos de fijación de la Aorta. • Presente en 1 de cada 6 fallecidos en Accidentes de Tránsito – 85% de forma instantánea – 10-15% sobrevive al traslado Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008 Rupt ura/Di secci ón de Aort a
  38. 38. • Manejo – ABC, O2 a alto flujo – TAS mínima en la disección • limitando el uso de líquidos – Transporte en SVA a Centro de Trauma • Dotado de cirugía vascular Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008 Rupt ura/Di secci ón de Aort a
  39. 39. Rupt ura Di af ragmát i ca: • Causa: Traumatismos abiertos o cerrados. • Clínicamente: Ruidos peristálticos en hemitórax afectado. • Radiográfías: • Presencia de intestino, estomago en hemitórax • Niveles hidroaéreos. • Pueden pasar inadvertidos. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  40. 40. ! El diagnóstico tardío de lesión diafragmática puede llevar a compromiso pulmonar o visceral. Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  41. 41. Fildes J, Wayne J, et al. Advanced Trauma Life Support. Student course manual. Eight edition. American College of Surgeons; 2008.
  42. 42. Lesi ón Traqueobronqui al • Tráquea: – Causa: Traumatismos abiertos o cerrados. – Se asocia a lesión de esófago y grandes vasos. • Bronquios: La lesión de un bronquio mayor es rara y mortal, y ocurren a 2-3 cm. de la carina. – Diagnóstico: se presenta con hemoptisis y enfisema subcutáneo, y se sospecha en neumotórax a tensión con gran escape de aire y es confirmado por broncoscopía. • Tratamiento: Reparación quirúrgica. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  43. 43. Rupt ura Esof ági ca • Se sospechara cuando exista neumo o hemotórax izquierdo sin fracturas costales, trauma directo al esternón o epigastrio con dolor y shock no explicado, además puede haber salida de partículas de contenido digestivo por tubo de tórax. • Tratamiento: La conducta será la reparación directa, esofagostomía cervical de escape y yeyunostomía de alimentación. Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  44. 44. Taponami ent o Car di aco • Causa: Traumatismo cerrado o abierto (penetrante) . • Clínicamente: aumento de la presión venosa central, disminución de la presión arterial y apagamiento de los ruidos cardiacos (Triada de Beck) • Signo de Kussmaul: Ingurgitación yugular con la inspiración • Tratamiento: – Pericardiocentesis – Ventana pericárdica Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
  45. 45. Feliciano DV, Mattox KL et al. Trauma. 8th edition. 9th edition. McGraw Hill; 2008-
  46. 46. • Gracias

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