traumatic pneumothorax
Introduction
Introduction to traumatic pneumothorax The gas in the pleural cavity is called pneumothorax. The incidence of traumatic pneumothorax accounts for 15% to 50% in blunt trauma and 30% to 87.6% in penetrating injuries. In most cases, the air in the pneumothorax is caused by the lungs being pierced by the broken ends of the ribs (the superficial one is called the lung rupture, the deep bronchus is called the lung laceration), and the bronchial or lung tissue is also blocked due to violence. Injury, or bronchial or pulmonary rupture caused by a sharp increase in pressure in the airway, sharp injury or firearm injury through the chest wall, injury to the lungs, bronchus and trachea or esophagus, can also cause pneumothorax, and most of the blood pneumothorax or pus . Occasionally, the rupture of the closed or penetrating diaphragm is accompanied by a rupture of the stomach that causes a pus. basic knowledge The proportion of illness: 0.005% Susceptible people: no specific population Mode of infection: non-infectious Complications: Traumatic pneumothorax
Cause
Traumatic pneumothorax
The chest wall defect is caused by firearm injury or sharp injury. The pleural cavity communicates directly with the outside atmosphere. The air can freely perform pleural cavity with breathing, forming an open pneumothorax. The pressure on the injured side is equal to atmospheric pressure, and the lung is collapsed and collapsed. The degree depends on lung compliance and pleural adhesion, the pleural cavity of the healthy side is still negative pressure, lower than the injured side, causing the mediastinum to shift to the healthy side, and the healthy lung also has a certain degree of collapse, and at the same time Chest pressure can still increase or decrease with the respiratory cycle, causing mediastinal sway (or flutter) and residual convection (or oscillating gas), leading to severe ventilation, ventilation dysfunction, mediastinal swing caused by large and large heart veins twisting and chest cavity Negative pressure is impaired, venous return is blocked, and cardiac output is reduced.
Mediastinal swing can stimulate the mediastinum and hilar plexus, causing or aggravating shock (called pleural pulmonary shock). In addition, the outside cold air continuously enters and exits the pleural cavity, which not only stimulates the nerves on the pleura, but also makes a lot of body temperature and Loss of body fluids, and can bring bacteria or foreign bodies, increase the chance of infection, accompanied by chest internal organs or major bleeding, making the injury more serious, the greater the open wound (sucking wound) of the chest wall, the respiratory and circulatory function The more severe the disorder, when the wound is larger than the diameter of the trachea, if it is not sealed in time, it often leads to death, and some chest penetrating injury, although the air can enter the pleural cavity from the outside when injured, but the wound is quickly closed, the pleural cavity and Isolated from the outside world, the formed pneumothorax cannot be called an open pneumothorax.
Prevention
Traumatic pneumothorax prevention
For the prevention of this disease, positive observation and prevention of complications, medical staff should try to do the following:
1, closely observe the patient's vital signs
Post-traumatic blood pneumothorax can be further developed, and more often combined with visceral and other organ damage, combined with other organ damage, the mortality rate is high, so it is necessary to closely observe the patient to prevent the occurrence of combined injuries.
2, blood chest observation and care
The incidence of hemothorax in chest trauma can be as high as 75%. To determine whether chest bleeding continues and the bleeding rate in time, you can judge according to the following 2 points:
1 After blood transfusion and rehydration, the patient's blood pressure and respiratory condition were not improved significantly.
2 After closed drainage of the thoracic cavity, if the blood is released, the average drainage volume per hour is greater than 100 mL and it is blood.
3, psychological care
Because the trauma is mostly sudden, the patient has no mental preparation for the sudden accident, it is difficult to accept the reality, and it is easy to be nervous and fearful. The nursing staff must first warmly receive the patient, comfort, care, considerate the patient, and actively communicate with the patient. Simple Introduce the treatment plan, precautions and prognosis, so that it can eliminate the tension, establish the confidence to overcome the disease and actively cooperate with the treatment, at the same time as soon as possible intravenous infusion, oxygen, for the implementation of thoracic closed drainage, should be given before surgery The necessary explanations enable the patient to fully understand and maintain a good psychological state. During the operation, the nurse should guard the patient, care for the patient, make their emotions stable, and actively cooperate with the rescue.
Complication
Traumatic pneumothorax complications Complications, traumatic pneumothorax
Traumatic pneumothorax is often associated with hemothorax, so it is not only necessary to treat pneumothorax and hemothorax at the same time, but also to deal with combined injuries and complications in a timely manner:
1 treatment of cardiac vascular injury: the key to successful rescue is rapid diagnosis and early surgery, open heart injury accompanied by major bleeding, shock or suspected pericardial tamponade, should be immediately sent to the operating room for thoracotomy, to avoid any delay in treatment .
2 Do not miss the abdominal injury when chest injury: When the chest and abdomen joint injury, the abdominal injury may be more concealed and easily overlooked, because at the moment of injury, the abdominal pressure increases suddenly, and the diaphragm and abdominal cavity are lifted up, which may cause damage. In the case of lower chest injury, the diaphragm and visceral injury should be thought of. If the diaphragmatic injury is found during surgery, the abdominal cavity should be explored, and the injured organ should be repaired as much as possible. If the patient has bloody pneumothorax and peritoneal irritation, the abdominal cavity puncture should be performed as early as possible. Line examination, early diagnosis, once diagnosed or highly suspected, first establish an effective venous access, identify the main contradictions that endanger the patient's life, targeted rescue, chest injury combined with multiple injuries, especially abdominal injuries, often shock And respiratory failure, high mortality, according to the history of trauma combined with physical examination, chest and abdominal puncture is a simple and reliable diagnostic method, and then based on X-ray and CT examination is basically clear diagnosis.
3 treatment priority treatment of major bleeding, if there is heart and large blood vessel damage, tracheal and bronchial injury should be preferentially thoracic, no thoracotomy indication first laparotomy, before the anesthesia need to be placed in the thoracic closed drainage, to avoid breathing difficulties during surgery The chest can be detected, and the traumatic blood pneumothorax is often accompanied by rib fracture and lung contusion. For example, the patient has a long period of shock and infection, and a large amount of crystal liquid is input during anti-shock, which is easy to induce ARDS. For traumatic blood pneumothorax, Especially in patients with bilateral pulmonary contusion and laceration combined with shock and multiple organ injury, the possibility of ARDS should be considered. After shock correction, the infusion volume should be strictly controlled, plasma and albumin should be supplemented early, liver and kidney function and blood biochemistry should be detected in time, and blood gas should be detected regularly. Timely detection of ARDS tendencies in order to rescue treatment early.
Symptom
Traumatic pneumothorax symptoms Common symptoms Difficulty breathing Chest has excessive reverberation Shock purple crest pulse fine speed multiple rib fracture fluid pneumothorax
Patients with open pneumothorax often have severe dyspnea after the injury, fear and anxiety, frequent pulse frequency, cyanosis and shock. When the examination shows, the chest wall has obvious wounds into the chest cavity, and the air can be heard with the breathing. The sound, the side of the percussion drum sound, the breath sound disappears, and sometimes the mediastinal swing sound can be heard.
Examine
Traumatic pneumothorax examination
Thoracic and abdominal puncture
If the patient's blood pneumothorax and peritoneal irritation sign are present at the same time, chest and abdominal puncture should be performed as soon as possible. Thoracic and abdominal puncture is a simple and reliable diagnostic method.
X-ray examination
X-ray examination is an important method for diagnosing pneumothorax #FormatImgID_0# can show the degree of lung atrophy, lung lesions and presence or absence of pleural adhesions, pleural effusion and mediastinal shift, etc., and the light-transmitting band along the mediastinum suggests mediastinal emphysema. Outside the pneumothorax line, the brightness is increased, no lung pattern is visible, sometimes the pneumothorax line is not enough, the patient can exhale, the lung volume is reduced, the density is increased, and the contrast is compared with the external gas-trapping light belt, which is beneficial to the discovery of pneumothorax and a large number of pneumothorax. The lungs are retracted to the hilum and the outer edge is curved or lobulated.
CT examination
In the blunt trauma of the chest, hemothorax and pneumothorax exist at the same time. It is mainly caused by lung contusion and lung rupture caused by chest compression and rib fracture. The gas-liquid plane across one or both chests is characteristic.
Diagnosis
Diagnosis of traumatic pneumothorax
Clinically, traumatic pneumothorax is not difficult to diagnose. According to the history of trauma and clinical manifestations, diagnosis can be made, but it needs to be differentiated from traumatic hernia:
Traumatic spasm: Traumatic spasm is mainly caused by chest and abdomen violence. It is often multiple injuries. It refers to the rupture of the diaphragm under the action of external force. The internal organs of the abdominal cavity enter the thoracic cavity through the diaphragm of the diaphragm, that is, the traumatic diaphragm, due to the stomach, jejunum and ileum. The cecum, transverse colon, sigmoid colon and spleen are the activities of the internal organs of the abdomen. Therefore, when the diaphragm is broken, these organs are easy to break into the chest cavity. Therefore, the patient is critically ill and the symptoms of the sputum are easily concealed. Therefore, it is often difficult to diagnose or promptly during the treatment. Missed diagnosis, traumatic sputum once misdiagnosed, missed diagnosis, its prognosis is poor, and mortality is also high, therefore, high-level suspected sputum should be targeted to improve the success rate of treatment, especially pay attention to serious chest damage, the condition In critical cases; a strong chest-abdominal pressure difference can also cause diaphragmatic rupture, but because the diaphragmatic rupture is small, the time after injury is short, and the sputum has not yet formed. At this time, CT examination of the patient has not been diagnosed, so the patient is The ventilator is required, and the positive pressure of the ventilator can control the formation of the sputum. After being taken offline, the contents of the abdominal cavity continuously flow into the chest cavity due to the continuous action of the negative pressure in the chest. Suction difficulties continue to increase, at this time abdominal abdominal film, barium meal, chest CT and other examinations can confirm the diagnosis of sputum, so in the case of severe chest injury, at the same time the occurrence of qi and blood chest, should fully consider the possibility of sputum, timely inspection , identification.
