CholelithiasisMost patients with cholelithiasis have no significantphysical symptoms. Approximately 80% of gallstones donot cause significant discomfort. Patients who developbiliary colic generally do have some symptoms. Whengallstones obstruct the cystic duct, intermittent, extreme,cramping pain typically develops in the right upperquadrant of the abdomen. This pain generally occurs atnight and can last from a few minutes to several hours.An acute attack of cholecystitis is often associated withthe consumption of a large, high-fat meal.The medical management of gallstones depends to agreat degree on the presentation of the patient. Patientswith no symptoms generally do not require any medicaltreatment. The best treatment for patients with symptomsis usually surgery. Laparoscopic cholecystectomy is typicallypreferred over the open surgical approach because ofthe decreased recovery period. Patients who are not goodcandidates for either type of surgery can obtain somesymptom relief with drugs, especially oral bile salts.

(Senagore, Anthony. Cholelithiasis. Dalam : Gale Encyclopedi of Surgery. New York : Gale.

2004 : 293)

Cholelithiasis_ Essentials of Diagnosis• Divided into symptomatic and asymptomatic; caused by cholesterol(most common), black pigment, or brown pigment stones• Cholesterol stones form in 20% of women and 10% of men by age60 years• Overall risk factors include female gender, age, obesity, estrogenexposure, fatty diet, rapid weight loss• Black pigment stone risk factors include hemolytic disorders,living in Asia• Brown pigment stone risk factors include biliary stasis, biliaryinfections• Each year, complicated gallstone disease affects 3–5% of patientswho are symptomatic and 0.5% of patients who are asymptomatic• Symptoms and signs range from asymptomatic to biliary colic• Right upper quadrant ultrasound shows acoustically dense stonesin gallbladder• Evaluate amylase and lipase; perform right upper quadrant ultrasound_ Differential Diagnosis• Cholecystitis• Choledocholithiasis• Pancreatitis_ Treatment• Laparoscopic cholecystectomy for symptomatic cholelithiasis orporcelain gallbladder (25% risk of carcinoma)_ PearlPatients at risk: fair, fat, forty, fertile, and female.

( Doherty, Gerard. Cholelithiasis. Dalam : Current Essentials of Surgery. New York : Mc Graw-Hill.

2005 : 315)

OPEN PNEUMOTHORAX

Open Pneumothorax (‘‘Sucking Chest Wound’’)Open pneumothorax results from a large defect of chest wallusually caused by a wound that creates a communicationbetween the pleural space and external environment.As the size of this chest wall defect approaches two-thirdsthe diameter of the trachea, air passes preferentiallythrough the lower resistance injury tract with each respiratoryeffort rather than through the normal airways. Inan open or “sucking” wound of the chest wall, the lungon the affected side is exposed to atmospheric pressure,and equilibration between intrathoracic pressure andatmospheric pressure is immediate, resulting in the lung’scollapse and a shift of the mediastinum to the unaffectedside. The severe venoarterial shunting that occurs inboth lungs produces profound ventilation-perfusion (V˙ /Q ˙ )mismatch. The patient’s effective oxygenation and ventilationis thereby severely compromised, leading to hypoxiaand hypercarbia. This is an immediate life-threateningcondition.In the spontaneously ventilating patient, open pneumothoraxis initially treated by application of a sterile-occlusivedressing with Vaseline gauze which must be largeenough to cover the entire wound and is taped securely onthree sides. This will then act as a one-way valve so thatair can escape the pleural space but not reenter. Tapingall edges of the dressing before a chest tube placed iscontraindicated because accumulation of air in the affectedthoracic cavity will lead to the development of tensionpneumothorax.Tube thoracotomy should be performed as soon aspossible at a remote site away from the wound. If the chestwall defect is relatively small, the pleura may soon sealand no further intervention is necessary. In patients withairway or breathing difficulty, early intubation and initiationof positive pressure ventilation should be considered. Forlarge open chest wall defects, surgical debridement ofdead and devitalized tissue and closure of the wound(with or without prosthetic patch) are often required undergeneral anesthesia.Massive HemothoraxMassive hemothorax is defined as a rapid accumulation ofmore than 1500 cm3 of blood in the pleural space (Figs. 3and 4). Such a massive hemorrhage usually indicates largepulmonary laceration or great vessel or intercostal vesselinjury. One hemithorax can accommodate as much as 50%to 60% of the entire blood volume. Massive hemothoraxmay induce hemodynamic instability by loss of intravascularvolume and by decreased central venous return withincreasing intrathoracic pressure and mediastinal shift.Hemothorax also causes respiratory compromise by lungcompression secondary to blood accumulation.The diagnosis is readily made from the clinical picture.Radiographic evidence of fluid in the pleural space canbe seen, but the astute physician should not rely on CXRto make the diagnosis of massive hemothorax. Atrauma patient in shock, associated with the absence

of breath sounds and/or dullness on one side of thechest, should be treated for massive hemothorax untilproven otherwise.The initial management includes the simultaneousresuscitation of blood volume and decompression of thechest cavity with a large (36–40 French) chest tube. Autotransfusionof the blood from massive hemothorax ishighly desired whenever possible. A moderate-sizedhemothorax (less than 1500 mL) that stops bleeding aftertube thoracotomy can generally be treated by closeddrainage alone. Most cases of hemothorax can beadequately treated by a tube thoracotomy and restorationof circulating blood volume. An urgent thoracotomyshould be strongly considered for an initial chest tubeoutput of greater than 1500 mL or with continued bleedingFigure 3 Massive Right Hemothorax. Chest radiograph showingmassive right hemothorax in a 35 year old repeat trauma victim(note previous thoraco-lumbar spine fixation). A hemothoraxcan occur secondary to blunt or penetrating trauma of the lung,intercostal vessels, internal thoracic artery, mediastinal vessesls,heart; or from abdominal structures (e.g. liver, spleen) when thediaphragm is injured.Chapter 25: Cardiothoracic Trauma 473of more than 250 mL/hr for more than three consecutivehours, or requiring persistent blood transfusion (10).The most common mechanism of hemothorax is penetratingtrauma; however, the descending thoracic aorta, theinnominate artery, the pulmonary veins, and the venacavae are susceptible to rupture from blunt trauma. Theincidence of hemothorax in adult patients presenting to theOR for emergency surgery has been reported as 26% (4).Bleeding occurs from lung, intercostal vessels, internal thoracic(internal mammary) artery, thoracoacromial artery,lateral thoracic artery, azygous system (18), mediastinalgreat vessels, heart, and even abdominal structures (liver,spleen) when there is diaphragmatic rupture (Fig. 5). Persistenthemorrhage usually arises from an intercostal orinternal thoracic artery and less frequently from the majorhilar vessels. Bleeding from the lung generally stopswithin a few minutes after lung expansion, although initiallyit may be profuse

(Wilson, William, dkk. Open Pneumothorax. Dalam : Trauma Critical Care Vol 1. New York : Informa

Healthcare USA. 2007 : 473)

(Mahadevan S., dan Gus M.Garmel. Breathing. Dalam : Clinical Emergency Medicine.

UK : Cambridge Press. 2005 : 97)

OPEN PNEUMOTHORAXLarge penetrating wounds to the chest which penetrateto the pleura will produce an open pneumothorax.The patient is likely to be in respiratorydistress, and if the wound has a diameter morethan two-thirds that of the trachea, air will passpreferentially through it on inspiration instead ofventilating the lungs. This is known as a 'sucking'chest wound (Fig. 23.5). A one-way valve effectmay cause a rapidly developing tension pneumothoraxif the air cannot escape in expiration.The most effective emergency treatment for anopen pneumothorax is an Aschermann Chest Seal®(Fig. 23.6). The older method of a sterile dressingfixed on three sides forming a valve in order toprevent a tension pneumothorax can also be used.A chest drain should be inserted away from thewound. The definitive treatment is surgical closureof the wound.

(Graves, Ian dan Graham Johnson. Open Pneumothorax. In : Practical Emergency Medicine. New York : Oxford

Press. 2005 : New York)