12.07.2015 Views

Traumatisme toracice rapid letale - Cursul national de ghiduri si ...

Traumatisme toracice rapid letale - Cursul national de ghiduri si ...

Traumatisme toracice rapid letale - Cursul national de ghiduri si ...

SHOW MORE
SHOW LESS
  • No tags were found...

You also want an ePaper? Increase the reach of your titles

YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.

‣ blocuri intercostale: lidocaina + bupivacaina‣ analgezie epidurala‣ combinatie analgezie i.v. cu blocuri intercostale• restrictie <strong>de</strong> lichi<strong>de</strong>• fixarea voletului costal: pacienti cu volet costal mare, instabil careprezinta respiratie paradoxala <strong>si</strong> anomalii ale VT in timpul ventilatieimecanice sau care au indicatii <strong>de</strong> alte proceduri chirurgicale <strong>toracice</strong>.2. Terapia ventilatorie:Principiu: oxigenare cu flux ridicat.Indicatiile IOT in traumatismele <strong>toracice</strong> (1,2,3):• insuficienta respiratorie acuta (PaO 255mmHg)• FR30/min mai ales in cazul unei analgezii a<strong>de</strong>cvate• traumatisme <strong>toracice</strong> associate cu boli pulmonare cronice• acidoza metabolica• soc• coma• varsta >65ani• traumatisme severe asociate• nece<strong>si</strong>tate <strong>de</strong> sedare• nece<strong>si</strong>tate <strong>de</strong> interventie chirurgicala in anestezie generala337Ventilatia mecanica (6, 7):• volet costal: CMV sau SIMV in functie <strong>de</strong> prezenta respiratiei paradoxalesau anomaliilor <strong>de</strong> VTTabel 3. Setarea ventilatorului in caz <strong>de</strong> volet costalMod ventilatieFRVTCMV14-16/min8-10 ml/kgFiO 2100%PEEP -I:E 1:2/1:3PIP


• volet costal + contuzie pulmonara: CMV cu PEEP / SIMV cu PEEP338Particularitati:‣ CMV cu PEEP mai buna pentru confortul pacientului‣ Introducerea precoce a PEEP‣ PEEP uzual 5-10 cm H 2O creste progre<strong>si</strong>v cu 2-5 cm H 2O functie <strong>de</strong> VT‣ PIP < 35 cm H 2O <strong>si</strong> VT = 6-8 ml/kg pentru a evita barotruma‣ PaO 2= 80-100mmHg la un FiO 2cat mai mic <strong>si</strong> PaO 2/FiO 2cat maimare2. Pneumotorax compre<strong>si</strong>v (sufocant)Cauze: plagi penetrante sau traumatisme inchise care <strong>de</strong>zvolta trecereacontinua a aerului din plamani, trahee, bronhii in spatiul pleuralClinic:• Soc obstructiv• Detresa respiratorie• Trahee <strong>de</strong>viata• Disten<strong>si</strong>a venelor gatului• Absenta murmurului vezicular/hipersonoritate• Emfizem subcutanat (plagi penetrante)• Asociere cu volet costal, fracturi costale, hemotorace, fistula bronho-pleuralaEvaluare primaraReevaluarerespiratie + circulatiesuspiciune clinica <strong>de</strong> pneumotorax compre<strong>si</strong>v± FASTDecomprimareToracocentezăpe ac urmată<strong>de</strong> drenajradiografie toracemonitorizare continua a ventilatieievaluarea cauzei sala operatieCTFigura 8. Managementul pneumotoraxului compre<strong>si</strong>vFigura 8. Managementul pneumotoraxului compre<strong>si</strong>vPrincipii:• Tratamentul va fi initiat pe baza suspiciunii clinice, fara a asteptaconfirmarea radiologica, <strong>si</strong> consta in toracocenteza <strong>si</strong> drenaj aspirativActualitati in anestezie, terapie inten<strong>si</strong>va <strong>si</strong> medicina <strong>de</strong> urgenta


• Pacientul va fi monitorizat continuu• Diagnosticul pozitiv va fi pus pe examinarea radiologica la sfar<strong>si</strong>tulexaminarii primare• Dupa confirmarea radiological se incepe evaluarea cauzei care adus la aparitia pneumotoraxului sufocant sau pacientul va lua calea salii<strong>de</strong> operatieTratament1. Toracocenteza pe ac:• ac <strong>de</strong> 14G in spatiul 2 intercostal linia medioclaviculara;• indicatii: soc (hemodinamica compromisa), <strong>de</strong>tresa respiratorie, trahee<strong>de</strong>viata, disten<strong>si</strong>a venelor gatului, diminuarea murmului ve<strong>si</strong>cular; nu vafi efectuata doar pentru ca nu auzim murmurul vezicular.2. Drenaj toracic aspirativ:• tub <strong>de</strong> 32-36 Fr in spatial 5 intercostal (in dreptul mamelonului) liniaaxilara medie sau anterioara.• se conecteaza la <strong>si</strong>stemul <strong>de</strong> vase cu apa <strong>si</strong> apoi la aspiratie cu pre<strong>si</strong>unenegative 20 cm H 2O.3. Restrictie <strong>de</strong> lichi<strong>de</strong>4. IOT cu ventilatie mecanica in caz <strong>de</strong> nece<strong>si</strong>tate:‣ PSV la o pre<strong>si</strong>une <strong>de</strong> 25-30 cm H 2O3393. Pneumotorax <strong>de</strong>schis (cu supapa)Clinic:• Plaga a peretelui toracic insotita <strong>de</strong> bule <strong>de</strong> aer• Tahipnee cu <strong>de</strong>tresa respiratorie• Poate asocia semnele pneumotoraxului compre<strong>si</strong>v• Emfizem subcutanatEvaluare primaraSuspiciune clinica <strong>de</strong> pneumotorax <strong>de</strong>schisBandaj ocluzivDecomprimareDrenaj aspirativmonitorizare continua a ventilatieiReevaluareRespiratie-circulatieTimisoara 2007Radiografie toraceRefacerea chirurgicala a peretelui toracicFigura 9. Managementul pneumotoraxului <strong>de</strong>schisFigura 9. Managementul pneumotoraxului <strong>de</strong>schis


Tratament:• Toaleta, bandaj ocluziv• Drenaj toracic aspirativ• IOT cu ventilatie mecanica in caz <strong>de</strong> nece<strong>si</strong>tate: PSV• Refacerea chirurgicala a peretelui thoracic3404. Embolia gazoasa (aer) postraumatica (1,2,3)Cauze:• Plagi penetrante <strong>toracice</strong> (mai frecvent)• Contuzia pulmonaraPatogenie:Cauzele <strong>de</strong> mai sus permit comunicarea directa intre <strong>si</strong>stemul venos pulmonar<strong>si</strong> caile aeriene intrapulmonare, astfel incat aerul ajunge la cord <strong>si</strong>ulterior in circulatia <strong>si</strong>stemica; manifestarile clinice se datoreaza patrun<strong>de</strong>riiaerului in circulatia coronariana insotita <strong>de</strong> <strong>de</strong>primarea miocardului <strong>si</strong> incirculatia cerebrala insotita <strong>de</strong> semne neurologice.Factori favorizanti:• Hipovolemie cu sca<strong>de</strong>rea pre<strong>si</strong>unii venoase pulmonare• Pre<strong>si</strong>une crescuta in caile aeriene: ventilatie cu pre<strong>si</strong>une pozitiva, pneumotoraxcompre<strong>si</strong>vScenariu tipic: Pacient cu traumatism penetrant toracic care intra in socsau in stop cardiac dupa IOT <strong>si</strong> ventilatie mecanica cu pre<strong>si</strong>une pozitiva.Clinic:• Soc sau stop cardiac precoce dupa IOT <strong>si</strong> ventilatie cu pre<strong>si</strong>une pozitiva• Hemoptizie• Alterarea statusului neurologic, semne focaleDiagnostic‣ Suspiciune clinica mai ales in cazul scenariului tipic‣ Prezenta bulelor <strong>de</strong> aer la recoltarea sangelui arterialTratament: chirurgical - toracotomie cu clamparea hilului pulmonar <strong>si</strong>apoi masaj cardiac intern viguros.5. Hemotoracele ma<strong>si</strong>vDefinitie: acumularea <strong>de</strong> sange peste 1500ml in cavitatea pleuralaEtiologie: traumatisme <strong>toracice</strong> inchise sau plagi penetrante in parenchimpulmonar, perete toracic, inima sau vase mari.Actualitati in anestezie, terapie inten<strong>si</strong>va <strong>si</strong> medicina <strong>de</strong> urgenta


C. Evaluarea <strong>si</strong> controlul circulatieiObiectiv principal: i<strong>de</strong>ntificarea surselor <strong>de</strong> sangerare <strong>si</strong> oprirea lor342Monitorizarea circulatiei (1,2)1. Puls central2. Puls periferic3. Puls capilar4. ECG5. Ten<strong>si</strong>unea arteriala6. Ten<strong>si</strong>unea arteriala medie7. Pvc8. Staus mental (respon<strong>si</strong>vitate)9. Temperatura10. Diureza oraraIn caz <strong>de</strong> stop cardiac se incepe resuscitarea cardiorespiratorie.Pacient in extremisEKS: orice ritm Nu DecesDaCPR ?Ritm EKSDaToracotomieNu?trauma inchisaNutrauma penetrantaFAST(tamponada cardiaca)NuDaCPRDeces ToracotomieFigura 11. Management pacient in extremis in extremis (1,5) (1,5)Toracotomia in urgenta (toracotomia resuscitativa) (1,2)Comentariu: nu intra in competenta medicilor <strong>de</strong> urgenta din RomaniaIndicatii1. Pacienti cu trauma toracica inchisa sau penetranta cu semne vitale prezentela so<strong>si</strong>re in ER sau care au martori ai stopului cardiac.2. Hipoten<strong>si</strong>une severa per<strong>si</strong>stenta (TAS < 60mmHg) la pacienti cu:Actualitati in anestezie, terapie inten<strong>si</strong>va <strong>si</strong> medicina <strong>de</strong> urgenta


• tamponada cardiaca;• hemoragie intratoracica;• embolie gazoasa postraumatica;• hemoragie active intraabdominala.Obiective1. Efectuarea masajului cardiac intern2. Controlul hemoragiei intrapericardice3. Controlul hemoragiei intra<strong>toracice</strong> produse prin lezarea cordului <strong>si</strong> avaselor mari4. Eliminarea aerului embolizat5. Clamparea aortei <strong>de</strong>scen<strong>de</strong>nteResuscitarea volemicaPrincipii generale:1. Resuscitarea volemica <strong>de</strong>pin<strong>de</strong> <strong>de</strong> statusul hemodinamic la prezentare.2. Evaluarea clinca initiala (frecventa cardiaca, pre<strong>si</strong>unea pulsului, pulsulcapilar, statusul mental) ofera informatii asupra cantitatii <strong>de</strong> sangepierduta.3. Se incepe cat mai precoce4. Hipoten<strong>si</strong>une arteriala permi<strong>si</strong>va (TAM = 55-60 mmHg) cand nu existacontraindicatii (trauma inchisa la care nu s-a ga<strong>si</strong>t cauza, traumatismecraniocerebrale <strong>si</strong> medulare, pacienti varstnici cu functie cardiovascularaprecara) (1)343Tabel 4. Estimarea cantitatii <strong>de</strong> sange pierdut (4)stadiul 1 STADIUL 2 StADIUL 3 STADIUL 4Pier<strong>de</strong>re < 750ml 750 - 1500ml 1500-2000ml >2000mlPier<strong>de</strong>re % < 15% 15 – 30% 30 – 40% >40%TA N N scazuta scazutaPuls 140Pres. Puls N scazuta scazuta scazutaFR 14 - 20 20 - 30 30 - 40 >40SNC Usor anxios Mo<strong>de</strong>rat anxios Confuz ComaDiureza/h 30 20 - 30 5 - 15


Meto<strong>de</strong>:• se vor monta doua vene <strong>de</strong> calibru mare 14 -16 G• cale venoasa centrala – la indicatie• solutiile administrate vor fi cristaloi<strong>de</strong>: ser fiziologic, Ringer lactate,sange 0 I Rh negativ (femei), sange 0 pozitiv (barbati), masa eritrocitara,sange izogrup – izoRh;• solutiile vor fi administrate foarte <strong>rapid</strong>.ABC + grup sanguin/Rh344Hemodinamic instabil Hemodinamic stabilAdministrare cristaloi<strong>de</strong> 2l Stabileste dg. <strong>si</strong> prioritatiRaspun<strong>de</strong> nu raspun<strong>de</strong> hemoragie continua ramane stabilHR>120/mincu Hb >8 g/dlBP< 90hemoragie continuaramane stabilcu Hg>8g/dlraspun<strong>de</strong> tranzitorhemoragie continuafara transfuzie transfuzie sange izogr./ transfuzie sange/ transfuzie sange fara transfuziemasa eritrocitara masa eritrocitar izogr/masa eritr.Figura 12. Principii Figura <strong>de</strong> resuscitare 12. Principii volemica <strong>de</strong> resuscitare (1) volemica (1)1. Leziuni <strong>de</strong> vase mari (1)Semne clinice:• hipoten<strong>si</strong>une• hiperten<strong>si</strong>une in extremitatea superioara• inegalitate ten<strong>si</strong>une arteriala• marca traumatica a unei traume <strong>toracice</strong> majore• hematom in crestere la nivelul gatului• fractura palpabila a sternului• volet costal• fractura palpabila a coloanei toracaleSemne radiologice:• hemotorace ma<strong>si</strong>v• evi<strong>de</strong>ntierea corpului strain in proximitatea vaselor sau pe aria <strong>de</strong> proiectieActualitati in anestezie, terapie inten<strong>si</strong>va <strong>si</strong> medicina <strong>de</strong> urgenta


• evi<strong>de</strong>ntierea corpului strain in aria <strong>de</strong> proiectie a cordului• largirea mediastinului• lichid in domul pleural stang• <strong>de</strong>vierea traheei sau a son<strong>de</strong>i nazogastrice• stergerea butonului aortic• compre<strong>si</strong>a bronhiei pulmonare stangi• fracturi <strong>de</strong> stern, clavicula, scapula• volet costalManagement – pacient instabil hemodinamic1. Resuscitare volemica2. Toracostomie3. Toracotomie4. Tratament chirurgical <strong>de</strong>finitivDiagnostic – pacient stabil hemodinamic1. Semne clinice2. Radiografie3. CT spiral – hematom mediastinal4. Arteriografie (gold standard)‣ mecanism violent <strong>de</strong> producere a traumei <strong>toracice</strong>‣ semne clinice‣ semne clinice <strong>de</strong> probabilitate la radiografie3452. Tamponada cardiacaDiagnostic:• pacient socat• triada Beck:1. Hipoten<strong>si</strong>une2. Disten<strong>si</strong>a venelor gatului3. Zgomote cardiace asurziteMonitorizare biologica (1,2):• grup sanguin, Rh• gaze sanguine, lactat, status acido-bazic• hemograma• teste coagulare• glucoza• test sarcina• test toxicologicTimisoara 2007


Evaluare primaraABCHemodinamica stabila Hemodinamica instabila PVCEcografie B-mo<strong>de</strong> FAST reevaluareABCnegativa pozitiva pericardiocenteza lapacientii in extremis346toracotomieFigura 13. Managementul tampona<strong>de</strong>i cardiace (1)Figura 13. Managementul tampona<strong>de</strong>i cardiace (1)Abrevieri:SMP - servicii medicale pre-spitalRSI - Rapid Sequence InductionLMA - masca laringianaBibliografie1. Moore EE, Feliciano DV, Mattox KL. Trauma, Fifth Edition 2004, McGraw-Hill Companies.2. Tintinalli JE, Kelen GD, Stepczynsky S, et al. The American College of Emergency Phy<strong>si</strong>cian: Tintinalli’sEmergency Medicine: A Comprehen<strong>si</strong>ve Study Gui<strong>de</strong>, 6 th Edition, McGraw Hill Companies 2004.3. Stone CK, Humphries RL. Current Emergency Diagno<strong>si</strong>s & Treatment, McGraw Hill Companies 2004.4. Gerard MD, Way LW. Current Surgical Diagno<strong>si</strong>s and Treatment, 12 th Edition, McGraw Hill Companies2006.5. European Resuscitation Council Gui<strong>de</strong>lines for Resuscitation 2005. Traumatic cardiorespiratory arrest.6. EAST - Practice Management Gui<strong>de</strong>line for Pulmonary Contu<strong>si</strong>on and Fail Chest 2006.7. ITACCS – Gui<strong>de</strong>lines for Management of Mechanichal Ventilation in Critically Injured Pacients 2004.Actualitati in anestezie, terapie inten<strong>si</strong>va <strong>si</strong> medicina <strong>de</strong> urgenta

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!