{"id":1560,"date":"2013-03-25T11:35:36","date_gmt":"2013-03-25T11:35:36","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1560"},"modified":"2013-06-11T07:53:23","modified_gmt":"2013-06-11T07:53:23","slug":"6-poraneni-a-nahle-prihody-hrudni-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1560","title":{"rendered":"6 Poran\u011bn\u00ed a n\u00e1hl\u00e9 p\u0159\u00edhody hrudn\u00ed"},"content":{"rendered":"<h3>6.1 Anatomie hrudn\u00ed st\u011bny a br\u00e1nice<\/h3>\n<p style=\"text-align: justify;\">Hrudn\u00edk m\u00e1 tvar komol\u00e9ho ku\u017eele ohrani\u010den\u00e9ho horn\u00ed hrudn\u00ed aperturou, muskuloskelet\u00e1ln\u00edmi komponentami hrudn\u00edho ko\u0161e a doln\u00ed hrudn\u00ed aperturou. Horn\u00ed hrudn\u00ed apertura topograficky odd\u011bluje kr\u010dn\u00ed prostor od hrudn\u00edku, m\u00e1 ledvinovit\u00fd tvar, tvo\u0159\u00ed ji manubrium sterna, kostoklavikul\u00e1rn\u00ed sklouben\u00ed, prvn\u00ed dv\u011b \u017eebra a t\u011blo 1. hrudn\u00edho obratle. Horn\u00ed hrudn\u00ed aperturou prob\u00edh\u00e1 \u0159ada d\u016fle\u017eit\u00fdch struktur (j\u00edcen, trachea, tepny oblouku aorty, p\u0159\u00edtoky horn\u00ed dut\u00e9 \u017e\u00edly, br\u00e1ni\u010dn\u00ed, bloudiv\u00e9 a zvratn\u00e9 nervy). Kupula pleur\u00e1ln\u00ed a apex pl\u00edce na obou stran\u00e1ch dosahuj\u00ed nad \u00farove\u0148 horn\u00ed hrudn\u00ed apertury, jsou kryty \u010d\u00e1st\u00ed hlubok\u00e9 kr\u010dn\u00ed fascie (suprapleur\u00e1ln\u00ed, Sibsonovy). Kost\u011bn\u00e1 \u010d\u00e1st hrudn\u00edho ko\u0161e je tvo\u0159ena hrudn\u00ed kost\u00ed, kter\u00e1 se skl\u00e1d\u00e1 z rukojeti, t\u011bla a me\u010d\u00edku. Rukoje\u0165 (manubrium sterni) je skloubena s kl\u00ed\u010dky a chrupavkami prvn\u00edch \u017eeber. T\u011blo (corpus) hrudn\u00ed kosti artikuluje se 2.\u20137. \u017eebrem. Me\u010d\u00edk (proc. xiphoideus) je chrupav\u010dit\u00fd, osifikuje po 30. roce \u017eivota. Nikdy neosifikuj\u00edc\u00ed osteochondr\u00e1ln\u00ed junkce (a kostovertebr\u00e1ln\u00ed klouby) dovoluj\u00ed ventila\u010dn\u00ed pohyby hrudn\u00ed st\u011bny. Prvn\u00edch 7 p\u00e1r\u016f \u017eeber naz\u00fdv\u00e1me prav\u00fdmi, proto\u017ee jsou skloubeny p\u0159\u00edmo se sternem. Osm\u00e1, dev\u00e1t\u00e1 a des\u00e1t\u00e1 \u017eebra ozna\u010dujeme jako neprav\u00e1, proto\u017ee jejich chrupavky spoluutv\u00e1\u0159ej\u00ed \u017eebern\u00ed oblouk, na sternum se neup\u00ednaj\u00ed. 11. a 12. p\u00e1r \u017eeber je voln\u00fd, tato \u017eebra maj\u00ed klouby pouze k p\u0159\u00edslu\u0161n\u00fdm obratl\u016fm. Doln\u00ed hrudn\u00ed apertura br\u00e1nic\u00ed odd\u011bluje hrudn\u00edk od b\u0159i\u0161n\u00ed dutiny na \u00farovni me\u010d\u00edku, \u017eebern\u00edho oblouku, 12. p\u00e1ru \u017eeber a 12. obratle. P\u0159es br\u00e1nici cestou hiatus aorticus a h. oesophagei vystupuje z hrudn\u00edku aorta, j\u00edcen a bloudiv\u00e9 nervy. Naopak skrze br\u00e1nici do hrudn\u00edku vstupuje doln\u00ed dut\u00e1 \u017e\u00edla a ductus thoracicus, kter\u00fd \u00fast\u00ed do lev\u00e9ho ven\u00f3zn\u00edho \u00fahlu. Nejv\u011bt\u0161\u00ed objem obou hrudn\u00edch dutin, kter\u00e9 jsou od sebe odd\u011bleny mezihrud\u00edm, vypl\u0148uj\u00ed pl\u00edce. V mediastinu je ulo\u017eeno srdce, velk\u00e9 c\u00e9vy, trachea a jej\u00ed bifurkace, j\u00edcen, ductus thoracicus, bloudiv\u00e9 a br\u00e1ni\u010dn\u00ed nervy. V horn\u00edm mediastinu jsou ulo\u017eeny velk\u00e9 c\u00e9vy, trachea a j\u00edcen za sebou, ve st\u0159edn\u00edm mediastinu je j\u00edcen vpravo od descendentn\u00ed aorty, klade se za lev\u00fd hlavn\u00ed bronchus, aby v doln\u00edm mediastinu p\u0159ek\u0159\u00ed\u017eil aortu doleva ventr\u00e1ln\u011b do j\u00edcnov\u00e9ho hiatu.<\/p>\n<h3>6.2 Tup\u00e9 poran\u011bn\u00ed hrudn\u00edku<\/h3>\n<p style=\"text-align: justify;\">Hrudn\u00edk m\u016f\u017ee b\u00fdt poran\u011bn v \u0161irok\u00e9 \u0161k\u00e1le od nez\u00e1va\u017en\u00fdch zhmo\u017ed\u011bn\u00ed hrudn\u00ed st\u011bny p\u0159es zlomeniny hrudn\u00edho skeletu a\u017e po z\u00e1va\u017en\u00e1, \u017eivot ohro\u017euj\u00edc\u00ed poran\u011bn\u00ed nitrohrudn\u00edch org\u00e1n\u016f. Vzhledem k d\u016fle\u017eit\u00fdm struktur\u00e1m zde ulo\u017een\u00fdm determinuje poran\u011bn\u00ed hrudn\u00edku spolu s kraniocerebr\u00e1ln\u00edm faktorem progn\u00f3zu polytraumatizovan\u00fdch nemocn\u00fdch. Naprost\u00e1 v\u011bt\u0161ina \u00faraz\u016f je dopravn\u00edch (70\u201380 %), tup\u00e9 poran\u011bn\u00ed hrudn\u00edku je p\u0159\u00ed\u010dinou smrti asi \u010dtvrtiny hospitalizovan\u00fdch nemocn\u00fdch.<\/p>\n<h4>6.2.1 Patofyziologie<\/h4>\n<p style=\"text-align: justify;\">D\u016fsledky tup\u00e9ho traumatu hrudn\u00edku jsou z\u00e1visl\u00e9 na energii \u00farazu. Z\u00e1va\u017enost poran\u011bn\u00ed m\u011bkk\u00fdch tk\u00e1n\u00ed hrudn\u00ed st\u011bny, bolest, fraktury skeletu a zejm\u00e9na poran\u011bn\u00ed nitrohrudn\u00edch org\u00e1n\u016f ur\u010duj\u00ed n\u00e1slednou poruchu d\u00fdch\u00e1n\u00ed a ob\u011bhu. Krom\u011b poruchy mechaniky d\u00fdch\u00e1n\u00ed, vlastn\u00edho traumatick\u00e9ho po\u0161kozen\u00ed srdce a plic jsou vit\u00e1ln\u00ed funkce d\u00e1le ohro\u017eeny hemoragick\u00fdm \u0161okem, p\u0159\u00edpadn\u00fdm pneumotoraxem \u010di hemotoraxem, posunem mediastina, zt\u00ed\u017een\u00fdm \u017eiln\u00edm n\u00e1vratem a sdru\u017een\u00fdmi poran\u011bn\u00edmi. Z\u00e1va\u017en\u00e1 poran\u011bn\u00ed hrudn\u00edku vedou k akutn\u00edmu syndromu dechov\u00e9 t\u00edsn\u011b (ARDS), poran\u011bn\u00ed j\u00edcnu indukuje septick\u00e9 komplikace. Fraktury prvn\u00edch \u017eeber nebo sterna jsou \u010dasto spojeny s v\u00e1\u017en\u00fdmi poran\u011bn\u00edmi srdce, trachey \u010di velk\u00fdch c\u00e9v, kter\u00e1 kon\u010d\u00ed v\u011bt\u0161inou exsangvinac\u00ed \u010di asfyxi\u00ed v p\u0159edhospitaliza\u010dn\u00ed dob\u011b. Zlomeniny dist\u00e1ln\u00edch \u017eeber (9.\u201311.) pak ukazuj\u00ed na mo\u017en\u00e9 poran\u011bn\u00ed jater nebo sleziny. Slou\u017e\u00ed proto jako indik\u00e1tor z\u00e1va\u017enosti \u00farazu a pravd\u011bpodobnosti sdru\u017een\u00fdch (nejen hrudn\u00edch) poran\u011bn\u00ed.<\/p>\n<h4>6.2.2 Diagnostika<\/h4>\n<p style=\"text-align: justify;\">Symptomatologie je d\u00e1na mechanismem \u00farazu, jeho energi\u00ed a formou po\u0161kozen\u00ed p\u0159edm\u011btn\u00fdch org\u00e1n\u016f, m\u016f\u017ee variovat od lehk\u00fdch poruch dechu, bolesti a\u017e po kardiorespira\u010dn\u00ed selh\u00e1n\u00ed a t\u011b\u017ek\u00fd \u0161okov\u00fd stav. Anamn\u00e9za, p\u0159\u00edpadn\u011b v\u00fdpov\u011bdi sv\u011bdk\u016f \u010di policie mohou pomoci v nasm\u011brov\u00e1n\u00ed diagnostick\u00fdch krok\u016f. P\u0159i podez\u0159en\u00ed na v\u00e1\u017enou hemoragii je prvn\u00edm krokem nak\u0159\u00ed\u017een\u00ed dostate\u010dn\u00e9ho po\u010dtu krevn\u00edch jednotek.<\/p>\n<h5>6.2.2.1 Laborato\u0159<\/h5>\n<p style=\"text-align: justify;\">Z laboratorn\u00edch vy\u0161et\u0159en\u00ed je oblig\u00e1tn\u00ed vy\u0161et\u0159en\u00ed krevn\u00edho obrazu, hladiny trombocyt\u016f a koagula\u010dn\u00edch parametr\u016f, krevn\u00edch plyn\u016f a acidobazick\u00e9 rovnov\u00e1hy a rozbor mo\u010di. P\u0159i suspekci na poran\u011bn\u00ed srdce lze odebrat kardioselektivn\u00ed enzymy, p\u0159ed angiografi\u00ed neb\u00edlkovinn\u00fd dus\u00edk, zvykem je vy\u0161et\u0159it miner\u00e1ly, event. jatern\u00ed testy. Lakt\u00e1tem lze monitorovat tk\u00e1\u0148ovou perfuzi, pomoc\u00ed CRP septick\u00e9 komplikace.<\/p>\n<h5>6.2.2.2 Zobrazovac\u00ed metody<\/h5>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1741.png\"><img decoding=\"async\" title=\"Obr. 1 \u2013 Pneumomediastinum p\u0159i traumatick\u00e9 ruptu\u0159e pr\u016fdu\u0161nice (\u0161ipka)\" alt=\"Obr. 1 \u2013 Pneumomediastinum p\u0159i traumatick\u00e9 ruptu\u0159e pr\u016fdu\u0161nice (\u0161ipka)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1741.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1<br \/>Pneumomediastinum p\u0159i traumatick\u00e9 ruptu\u0159e pr\u016fdu\u0161nice (\u0161ipka)<\/p><\/div>\n<p style=\"text-align: justify;\">Ultrasonografie je cenn\u00fdm pomocn\u00edkem l\u00e9ka\u0159\u016f urgentn\u00edch p\u0159\u00edjm\u016f, v r\u00e1mci prvotn\u00ed diagnostiky lze s vysokou spolehlivost\u00ed potvrdit \u010di vylou\u010dit v\u011bt\u0161\u00ed hemotorax, pneumotorax, stejn\u011b jako hemoperitoneum \u010di poran\u011bn\u00ed nitrob\u0159i\u0161n\u00edch parenchymat\u00f3zn\u00edch org\u00e1n\u016f.V p\u0159\u00edpad\u011b nez\u00e1va\u017en\u00fdch poran\u011bn\u00ed za\u010d\u00edn\u00e1 diagnostick\u00e9 kole\u010dko rentgenogramem se zad\u00e1n\u00edm ur\u010den\u00fdm symptomatologi\u00ed (vylou\u010den\u00ed pneumotoraxu, hemotoraxu, zlomenin skeletu hrudn\u00edku apod.). Je-li v \u00favaze mo\u017enost poran\u011bn\u00ed nitrohrudn\u00edch org\u00e1n\u016f nebo p\u0159i polytraumatu, je indikov\u00e1no CT, pokud to dovoluje stav nemocn\u00e9ho a mo\u017enosti pracovi\u0161t\u011b, nejl\u00e9pe spir\u00e1ln\u00ed a celot\u011blov\u00e9 s pod\u00e1n\u00edm kontrastn\u00ed l\u00e1tky (obr. 1). P\u0159i suspekci na poran\u011bn\u00ed srdce lze doplnit echokardiografick\u00e9 vy\u0161et\u0159en\u00ed, perforaci j\u00edcnu lze prok\u00e1zat ezofagogramem proveden\u00fdm vodn\u00fdm kontrastem.<\/p>\n<h5>6.2.2.3 Endoskopie<\/h5>\n<p style=\"text-align: justify;\">Bronchoskopie je indikov\u00e1na v p\u0159\u00edpad\u011b mediastin\u00e1ln\u00edho emfyz\u00e9mu nebo p\u0159i jin\u00fdch zn\u00e1mk\u00e1ch tracheobronchi\u00e1ln\u00edho poran\u011bn\u00ed, ezofagoskopie nen\u00ed obvykl\u00e1 v traumatologick\u00e9 indikaci, videotorakoskopie m\u00e1 v akutn\u00ed f\u00e1zi naprosto okrajov\u00fd v\u00fdznam \u2013 jako alternativa konzervativn\u00edho postupu, resp. prost\u0159edek k potvrzen\u00ed nez\u00e1va\u017enosti poran\u011bn\u00ed p\u0159i dobr\u00e9m celkov\u00e9m stavu nemocn\u00e9ho.<\/p>\n<h4>6.2.3 Indikace operace<\/h4>\n<p style=\"text-align: justify;\">Indikace chirurgick\u00e9 intervence pro poran\u011bn\u00ed hrudn\u00edku (zde rozebr\u00e1no pro tup\u00e1 i penetruj\u00edc\u00ed) byly d\u0159\u00edve pom\u011brn\u011b jasn\u00e9 a striktn\u00ed. Rychl\u00fdm rozvojem diagnostick\u00fdch a interven\u010dn\u00edch metod a tak\u00e9 pokrokem v anestezii, urgentn\u00ed medic\u00edn\u011b a intenzivn\u00ed p\u00e9\u010di byla n\u011bkter\u00e1 d\u0159\u00edve absolutn\u00ed krit\u00e9ria relativizov\u00e1na. Aktu\u00e1ln\u00ed v\u00fd\u010det indikac\u00ed a kontraindikac\u00ed\u00a0p\u0159edkl\u00e1daj\u00ed\u00a0tabulky 1, 2, 3 a 4:<\/p>\n<p>.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 1<\/span><br \/>\n<span style=\"color: #ffffff;\">Indikace emergentn\u00ed torakotomie<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Hypotenze pod 60 torr\u016f systoly nereaguj\u00edc\u00ed na adekv\u00e1tn\u00ed terapii<\/li>\n<li>Traumatick\u00e1 \u201etorakotomie\u201c<\/li>\n<li>Exsangvinuj\u00edc\u00ed krv\u00e1cen\u00ed (v\u00edce ne\u017e 1500 ml dr\u00e9nem)<\/li>\n<li>Hemoperikard nebo penetruj\u00edc\u00ed poran\u011bn\u00ed srdce<\/li>\n<li>Velk\u00e9 tracheobronchi\u00e1ln\u00ed poran\u011bn\u00ed<\/li>\n<li>Poran\u011bn\u00ed j\u00edcnu<\/li>\n<li>Traumatick\u00e1 z\u00e1stava (s d\u0159\u00edve ov\u011b\u0159enou srde\u010dn\u00ed aktivitou)<\/li>\n<li>Masivn\u00ed air leak<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 2<\/span><br \/>\n<span style=\"color: #ffffff;\">Relativn\u00ed indikace emergentn\u00ed torakotomie<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Prok\u00e1zan\u00e9 poran\u011bn\u00ed velk\u00fdch c\u00e9v (zv\u00e1\u017eit endovaskul\u00e1rn\u00ed postup)<\/li>\n<li>Traumatick\u00e1 z\u00e1stava bez d\u0159\u00edve ov\u011b\u0159en\u00e9 srde\u010dn\u00ed aktivity u penetruj\u00edc\u00edch poran\u011bn\u00ed<\/li>\n<li>P\u0159ednemocni\u010dn\u00ed resuscitace del\u0161\u00ed jak 10 minut<\/li>\n<li>Masivn\u00ed vzduchov\u00e1 embolie<\/li>\n<li>Embolizace projektilu<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p style=\"text-align: justify;\">Kontraindikace emergentn\u00ed torakotomie byly definov\u00e1ny American College of Surgeons \u2013 Committee for trauma. V podm\u00ednk\u00e1ch na\u0161eho zdravotnictv\u00ed jsou v kontextu \u010dasov\u00e9 nal\u00e9havosti v rozhodov\u00e1n\u00ed a ne v\u017edy vy\u010derparpateln\u00fdch diagnostick\u00fdch mo\u017enost\u00ed tyto kontraindikace relevantn\u00ed jen za velmi specifick\u00fdch podm\u00ednek.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 3<\/span><br \/>\n<span style=\"color: #ffffff;\">Kontraindikace emergentn\u00ed torakotomie<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Tup\u00e9 poran\u011bn\u00ed hrudn\u00edku bez d\u0159\u00edve ov\u011b\u0159en\u00e9 srde\u010dn\u00ed aktivity<\/li>\n<li>Mnoho\u010detn\u00e1 tup\u00e1 poran\u011bn\u00ed<\/li>\n<li>V\u00e1\u017en\u00e9 poran\u011bn\u00ed mozku<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 4<\/span><br \/>\n<span style=\"color: #ffffff;\">Indikace pro odlo\u017eenou torakotomii<br \/>\n(v\u010detn\u011b relativn\u00edch)<br \/>\n<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Zbytkov\u00fd koagulovan\u00fd hemotorax<\/li>\n<li>Posttraumatick\u00fd plicn\u00ed hematom, resp. absces<\/li>\n<li>Posttraumatick\u00fd plicn\u00ed empy\u00e9m<\/li>\n<li>Traumatick\u00fd defekt chlopn\u011b, septa<\/li>\n<li>Trvaj\u00edc\u00ed p\u00ed\u0161t\u011bl ductus thoracicus<\/li>\n<li>Bronchopleur\u00e1ln\u00ed, tracheoezofage\u00e1ln\u00ed p\u00ed\u0161t\u011bl<\/li>\n<li>Pseudoaneuryzma aorty, velk\u00fdch c\u00e9v (event. intravaskul\u00e1rn\u011b)<\/li>\n<li>P\u0159ehl\u00e9dnut\u00e1 tracheobronchi\u00e1ln\u00ed l\u00e9ze<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p style=\"text-align: justify;\">Tup\u00e1 poran\u011bn\u00ed hrudn\u00edku vy\u017eaduj\u00ed chirurgickou intervenci v m\u00e9n\u011b ne\u017e 10 % p\u0159\u00edpad\u016f, zbyl\u00e1 poran\u011bn\u00ed mohou b\u00fdt l\u00e9\u010dena konzervativn\u011b nebo semiinvazivn\u011b (hrudn\u00ed dren\u00e1\u017e, pneumatick\u00e1 dlaha, perikardiocent\u00e9za).<\/p>\n<h4>6.2.4 Terapie<\/h4>\n<p style=\"text-align: justify;\">U nemocn\u00fdch s poran\u011bn\u00edm hrudn\u00edku v bezprost\u0159edn\u00edm ohro\u017een\u00ed \u017eivota m\u016f\u017ee b\u00fdt chirurgick\u00e1 intervence \u017eivot zachra\u0148uj\u00edc\u00edm krokem, ke kter\u00e9mu je nutno odhodlat se i za situace, kdy nen\u00ed naprosto kompletn\u00ed diagnostick\u00fd protokol. Nutn\u00fdm po\u017eadavkem je zaji\u0161t\u011bn\u00ed d\u00fdchac\u00edch cest a dostate\u010dn\u00e9ho mno\u017estv\u00ed krevn\u00edch n\u00e1hrad a nep\u0159etr\u017eit\u00e1 monitorace \u010di podpora ob\u011bhu a ventilace. Tam, kde to stav nemocn\u00e9ho dovoluje, je vy\u010derp\u00e1n\u00ed diagnostick\u00fdch mo\u017enost\u00ed stran vlastn\u00edho poran\u011bn\u00ed, tak i mo\u017en\u00fdch sdru\u017een\u00fdch poran\u011bn\u00ed nanejv\u00fd\u0161 \u017e\u00e1douc\u00ed.<\/p>\n<h3>6.3 Poran\u011bn\u00ed hrudn\u00edho skeletu<\/h3>\n<h4>6.3.1 Fraktury \u017eeber a l\u00fdza kostochondr\u00e1ln\u00edch junkc\u00ed<\/h4>\n<p style=\"text-align: justify;\">Jsou nej\u010dast\u011bj\u0161\u00edm d\u016fsledkem tup\u00e9ho hrudn\u00edho poran\u011bn\u00ed. Fraktury jednotliv\u00fdch \u017eeber nevy\u017eaduj\u00ed chirurgickou intervenci, z\u00e1kladem terapie je dostate\u010dn\u00e1 kontrola bolesti tak, aby nebyla omezena ventilace. U v\u011bt\u0161iny nemocn\u00fdch je dostate\u010dn\u00e1 peror\u00e1ln\u00ed analgoterapie, v\u011bt\u0161inou sta\u010d\u00ed nesteroidn\u00ed antiflogistika. Pokud ale bolest limituje d\u00fdchac\u00ed pohyby a dostate\u010dnou expektoraci, je mo\u017en\u00e9 u men\u0161\u00edho po\u010dtu fraktur prov\u00e9st infiltra\u010dn\u00ed blok\u00e1du interkost\u00e1ln\u00edch nerv\u016f dlouhodob\u011b p\u016fsob\u00edc\u00edm lok\u00e1ln\u00edm anestetikem (marcain), vhodn\u00e9 je o\u0161et\u0159it tak\u00e9 jedno a\u017e dv\u011b mezi\u017eeb\u0159\u00ed nad i pod posti\u017een\u00fdm segmentem. V p\u0159\u00edpad\u011b v\u00edce\u010detn\u00fdch zlomenin je vhodn\u011bj\u0161\u00ed epidur\u00e1ln\u00ed p\u0159\u00edstup. \u010casn\u00e1 dechov\u00e1 rehabilitace a podpora expektorace zkracuj\u00ed dobu l\u00e9\u010dby a jsou prevenc\u00ed plicn\u00edch komplikac\u00ed. Chirurgick\u00e1 intervence je indikov\u00e1na jen zcela v\u00fdjime\u010dn\u011b v p\u0159\u00edpad\u011b z\u00e1va\u017en\u00e9ho krv\u00e1cen\u00ed z lacerovan\u00fdch interkost\u00e1ln\u00edch \u010di mamm\u00e1rn\u00edch c\u00e9v nebo p\u0159i poran\u011bn\u00ed pl\u00edce ostr\u00fdm \u00falomkem \u017eebra. V p\u0159\u00edpad\u011b nekomplikovan\u00e9ho poran\u011bn\u00ed prvn\u00edch \u017eeber je n\u011bkdy nezbytn\u00e9 odstran\u011bn\u00ed ostr\u00fdch fragment\u016f ohro\u017euj\u00edc\u00edch podkl\u00ed\u010dkov\u00e9 c\u00e9vy \u010di plexus brachialis.<\/p>\n<h4>6.3.2 Instabilita hrudn\u00ed st\u011bny<\/h4>\n<p style=\"text-align: justify;\">P\u0159i zlomenin\u00e1ch \u010dty\u0159 a v\u00edce sousedn\u00edch \u017eeber ve dvou lini\u00edch doch\u00e1z\u00ed k poru\u0161en\u00ed mechaniky d\u00fdch\u00e1n\u00ed vznikem voln\u00e9ho segmentu hrudn\u00ed st\u011bny, kter\u00fd p\u0159i n\u00e1dechu vpad\u00e1v\u00e1 do hrudn\u00edku a p\u0159i v\u00fddechu je vytla\u010dov\u00e1n ven (vlaj\u00edc\u00ed hrudn\u00edk \u2013 flail chest). Pokud jsou linie lomu unilater\u00e1ln\u011b, mluv\u00edme o dv\u00ed\u0159kov\u00e9 zlomenin\u011b, resp. later\u00e1ln\u00ed instabilit\u011b. Pokud jsou linie lomu bilater\u00e1ln\u011b, paradoxn\u00ed d\u00fdchac\u00ed pohyby kon\u00e1 segment p\u0159edn\u00ed hrudn\u00ed st\u011bny se sternem \u2013 p\u0159edn\u00ed instabilita. Tento typ zlomenin sv\u011bd\u010d\u00ed o vysok\u00e9 energii \u00farazu, \u010dasto je spojen s dal\u0161\u00edmi poran\u011bn\u00edmi nitrohrudn\u00edch org\u00e1n\u016f (pneumotorax, hemotorax, kontuze srdce, plic, tracheobronchi\u00e1ln\u00ed poran\u011bn\u00ed). To vede v kone\u010dn\u00e9m d\u016fsledku k respira\u010dn\u00edmu selh\u00e1n\u00ed s nutnost\u00ed artefici\u00e1ln\u00ed p\u0159etlakov\u00e9 ventilace. Tomuto zp\u016fsobu l\u00e9\u010dby se \u0159\u00edk\u00e1 pneumatick\u00e1 dlaha a je vyhrazen zejm\u00e9na pro nemocn\u00e9 s v\u00e1\u017enou komorbiditou. Pokud je vl\u00e1n\u00ed hrudn\u00edku hlavn\u00ed p\u0159\u00ed\u010dinou hrani\u010dn\u00ed dechov\u00e9 nedostate\u010dnosti nebo pokud nelze nemocn\u00e9ho odpojit od ventil\u00e1toru pouze pro velk\u00fd nestabiln\u00ed segment hrudn\u00ed st\u011bny, je indikov\u00e1na stabilizace hrudn\u00ed st\u011bny. Stabilizace hrudn\u00ed st\u011bny je samoz\u0159ejm\u011b vhodn\u00e1 i v r\u00e1mci torakotomie indikovan\u00e9 z jin\u00fdch d\u016fvod\u016f. Existuje cel\u00e1 \u0159ada zp\u016fsob\u016f stabilizace, od jednoduch\u00e9 extenze za sternum \u010di substern\u00e1ln\u00edch dlah u p\u0159edn\u00edch instabilit p\u0159es extern\u00ed dlahy u later\u00e1ln\u00edch instabilit a\u017e k osteosynt\u00e9ze \u017eeber preformovan\u00fdmi dlahami.<\/p>\n<h6>Zlomeniny sterna<\/h6>\n<p style=\"text-align: justify;\">Samotn\u00e1 fraktura sterna nen\u00ed nebezpe\u010dn\u00e1 sama o sob\u011b, ale ukazuje na mo\u017en\u00e1 sdru\u017een\u00e1 nitrohrudn\u00ed poran\u011bn\u00ed (kontuze srdce, plic, poran\u011bn\u00ed oblouku aorty a jeho v\u011btv\u00ed, l\u00e9ze trachey, j\u00edcnu). Sou\u010dasn\u011b b\u00fdvaj\u00ed diagnostikov\u00e1ny zlomeniny \u017eeber, dlouh\u00fdch kost\u00ed, p\u00e1nve, p\u00e1te\u0159e a kraniocerebr\u00e1ln\u00ed poran\u011bn\u00ed. Nedislokovan\u00e1 zlomenina m\u016f\u017ee b\u00fdt p\u0159ehl\u00e9dnuta v r\u00e1mci prim\u00e1rn\u00ed diagnostiky, dislokovan\u00e1 je dob\u0159e patrn\u00e1 na bo\u010dn\u00e9 projekci. Klinicky lze zjistit bolest v m\u00edst\u011b lomu, krepitaci, patologick\u00fd pohyb, prokrv\u00e1cen\u00ed m\u011bkk\u00fdch tk\u00e1n\u00ed. Nedislokovanou zlomeninu bez p\u0159idru\u017een\u00fdch poran\u011bn\u00ed lze l\u00e9\u010dit konzervativn\u011b, nevelk\u00fd posun je n\u011bkdy mo\u017en\u00e9 napravit v hyperlordoze. Pokud se bez chirurgick\u00e9 l\u00e9\u010dby nelze obej\u00edt, fixace kovovou (titanovou) dlahou d\u00e1v\u00e1 velmi dobr\u00e9 v\u00fdsledky.<\/p>\n<h3>6.4 Penetruj\u00edc\u00ed poran\u011bn\u00ed hrudn\u00edku<\/h3>\n<p style=\"text-align: justify;\">Problematika otev\u0159en\u00fdch poran\u011bn\u00ed je d\u00e1na anatomick\u00fdmi konsekvencemi. Krom\u011b hrudn\u00ed st\u011bny m\u016f\u017ee b\u00fdt poran\u011bn jak\u00fdkoli nitrohrudn\u00ed org\u00e1n (srdce, velk\u00e9 c\u00e9vy, velk\u00e9 d\u00fdchac\u00ed cesty, pl\u00edce, j\u00edcen, ductus thoracicus, br\u00e1nice), a to bu\u010f samostatn\u011b, nebo sou\u010dasn\u011b, a to i s kteroukoli strukturou mimo hrudn\u00edk. V t\u00e9to oblasti v\u00edce ne\u017e jinde z\u00edsk\u00e1v\u00e1 na v\u00fdznamu dokonal\u00e1 znalost topografick\u00e9 anatomie a orientace v patofyziologii \u00farazov\u00e9ho d\u011bje. Je nezbytn\u00e9 vy\u0161et\u0159it poran\u011bn\u00e9ho d\u016fkladn\u011b i v m\u00edstech, kde lze poran\u011bn\u00ed p\u0159ehl\u00e9dnout (axily). Bodn\u00e1 poran\u011bn\u00ed dist\u00e1ln\u011b od bradavek a lopatky mohou zasahovat intraabdomin\u00e1ln\u011b, proxim\u00e1ln\u011b ulo\u017een\u00e1 mohou poranit kr\u010dn\u00ed struktury. St\u0159eln\u00e1 poran\u011bn\u00ed jsou v tomto ohledu je\u0161t\u011b nevypo\u010ditateln\u011bj\u0161\u00ed, v p\u0159\u00edpad\u011b z\u00e1st\u0159elu je nutn\u00e9 po\u010d\u00edtat i s migrac\u00ed projektilu v pohrudni\u010dn\u00ed dutin\u011b \u010di intravaskul\u00e1rn\u011b. D\u00e1le je nutn\u00e9 po\u010d\u00edtat s d\u016fsledky absorbovan\u00e9 kinetick\u00e9 energie v okol\u00ed st\u0159eln\u00e9ho kan\u00e1lu.<\/p>\n<h4>6.4.1 Urgentn\u00ed opat\u0159en\u00ed<\/h4>\n<p style=\"text-align: justify;\">Symptomatologie penetruj\u00edc\u00edch poran\u011bn\u00ed m\u016f\u017ee b\u00fdt minim\u00e1ln\u00ed, ale tak\u00e9 velmi dramatick\u00e1, a posun mezi t\u011bmito krajn\u00edmi mezemi se m\u016f\u017ee odehr\u00e1t ve velmi kr\u00e1tk\u00e9m \u010dase. Urgentn\u00ed opat\u0159en\u00ed tedy sm\u011b\u0159uj\u00ed k zabr\u00e1n\u011bn\u00ed \u0161oku, k up\u0159esn\u011bn\u00ed diagn\u00f3zy a napl\u00e1nov\u00e1n\u00ed sekvence terapeutick\u00fdch \u00fakon\u016f. Je nezbytn\u00e9 zabezpe\u010dit ventilaci, intubace je indikovan\u00e1 p\u0159i apnoe, asfyxii, nedostate\u010dn\u00e9 ventilaci \u010di hlubok\u00e9m \u0161oku. V p\u0159\u00edpad\u011b klinick\u00fdch zn\u00e1mek tenzn\u00edho pneumotoraxu je nezbytn\u00e1 dekomprese, nejl\u00e9pe hrudn\u00ed dren\u00e1\u017e\u00ed, otev\u0159en\u00fd pneumotorax je t\u0159eba o\u0161et\u0159it jednocestn\u011b funguj\u00edc\u00edm obvazem nebo zadr\u00e9novat a uzav\u0159\u00edt r\u00e1nu. Hemotorax je nutn\u00e9 dr\u00e9novat \u2013 krom\u011b uvoln\u011bn\u00ed intratorak\u00e1ln\u00edho prostoru lze m\u011b\u0159en\u00edm sekrece monitorovat krevn\u00ed ztr\u00e1tu. Volumoterapie a substituce krevn\u00edch ztr\u00e1t, \u00faprava koagulopatie a p\u00e9\u010de o vnit\u0159n\u00ed prost\u0159ed\u00ed prob\u00edhaj\u00ed sou\u010dasn\u011b. Pokud se ob\u011bhov\u00e9 parametry poran\u011bn\u00e9ho nelep\u0161\u00ed navzdory proti\u0161okov\u00e9 terapii a masivn\u00edm n\u00e1hrad\u00e1m volumu a pokud jsme vylou\u010dili jin\u00e9 p\u0159\u00ed\u010diny neuspokojiv\u00e9ho pr\u016fb\u011bhu (tenzn\u00ed pneumotorax, perikardi\u00e1ln\u00ed tampon\u00e1da, intrabdomin\u00e1ln\u00ed krv\u00e1cen\u00ed), d\u00e1v\u00e1 okam\u017eit\u00e1 chirurgick\u00e1 revize a pokus o chirurgickou hemost\u00e1zu lep\u0161\u00ed \u0161ance ne\u017e dal\u0161\u00ed pokra\u010dov\u00e1n\u00ed suboptim\u00e1ln\u00ed resuscitace ob\u011bhu.<\/p>\n<h4>6.4.2 Indikace operace<\/h4>\n<p style=\"text-align: justify;\">Indikace emergentn\u00ed torakotomie jsou pon\u011bkud modifikov\u00e1ny patofyziologick\u00fdmi a klinick\u00fdmi p\u0159edpoklady u otev\u0159en\u00fdch poran\u011bn\u00ed (mo\u017en\u00fd rychlej\u0161\u00ed pr\u016fb\u011bh, \u0161ance na rychlou a zachra\u0148uj\u00edc\u00ed chirurgickou reparaci), proto je znovu up\u0159es\u0148ujeme v tabulce:<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 5<\/span><br \/>\n<span style=\"color: #ffffff;\">Indikace emergentn\u00ed torakotomie u penetruj\u00edc\u00edch poran\u011bn\u00ed hrudn\u00edku<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>Traumatick\u00e1 z\u00e1stava (intrahospitaliza\u010dn\u00ed nebo s d\u0159\u00edve ov\u011b\u0159enou srde\u010dn\u00ed aktivitou)<\/li>\n<li>Srde\u010dn\u00ed tampon\u00e1da, hemoperikard<\/li>\n<li>Prok\u00e1zan\u00e9 poran\u011bn\u00ed velk\u00fdch c\u00e9v (zv\u00e1\u017eit endovaskul\u00e1rn\u00ed postup)<\/li>\n<li>Traumatick\u00e1 \u201etorakotomie\u201c<\/li>\n<li>\u0160okov\u00fd stav, hypotenze pod 60 torr\u016f systoly nereaguj\u00edc\u00ed na adekv\u00e1tn\u00ed terapii<\/li>\n<li>Exsangvinuj\u00edc\u00ed krv\u00e1cen\u00ed (v\u00edce ne\u017e 1500 ml dr\u00e9nem)<\/li>\n<li>Prok\u00e1zan\u00e9 tracheobronchi\u00e1ln\u00ed poran\u011bn\u00ed, velk\u00fd air leak<\/li>\n<li>Prok\u00e1zan\u00e9 poran\u011bn\u00ed j\u00edcnu<\/li>\n<li>Embolizace projektilu do srdce \u010di plicnice<\/li>\n<li>Masivn\u00ed vzduchov\u00e1 embolie<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<h4>6.4.3 Terapie<\/h4>\n<p style=\"text-align: justify;\">Op\u011bt p\u0159ipom\u00edn\u00e1me, \u017ee krom\u011b hrudn\u00ed st\u011bny m\u016f\u017ee b\u00fdt poran\u011bn jak\u00fdkoli nitrohrudn\u00ed org\u00e1n (srdce, velk\u00e9 c\u00e9vy, velk\u00e9 d\u00fdchac\u00ed cesty, pl\u00edce, j\u00edcen, ductus thoracicus, br\u00e1nice), a to bu\u010f samostatn\u011b, nebo sou\u010dasn\u011b, a to i s kteroukoli strukturou mimo hrudn\u00edk. \u0158ada poran\u011bn\u00ed m\u016f\u017ee b\u00fdt l\u00e9\u010dena konzervativn\u011b, p\u0159edpokladem je minim\u00e1ln\u00ed n\u00e1lez klinick\u00fd, nerizikov\u00fd n\u00e1lez paraklinick\u00fdch vy\u0161et\u0159en\u00ed a dobr\u00fd celkov\u00fd stav. V dob\u00e1ch, kdy nebyly jin\u00e9 mo\u017enosti, jak vylou\u010dit poran\u011bn\u00ed nitrohrudn\u00edch struktur, byla exporativn\u00ed torakotomie u otev\u0159en\u00fdch poran\u011bn\u00ed hrudn\u00edku i u penetruj\u00edc\u00edch poran\u011bn\u00ed b\u0159icha nutnost\u00ed. V dne\u0161n\u00ed dob\u011b, kdy je mo\u017en\u00e9 poran\u011bn\u00e9ho pe\u010dliv\u011b monitorovat, opakovan\u011b sledovat trend v\u00fdvoje cestou zobrazovac\u00edch metod a p\u0159\u00edpadn\u011b si videotorakoskopicky ov\u011b\u0159it spr\u00e1vnost konzervativn\u00edho postupu u hemodynamicky stabiln\u00edch nemocn\u00fdch, ub\u00fdv\u00e1 zbyte\u010dn\u00fdch torakotomi\u00ed. \u0158ada nemocn\u00fdch m\u016f\u017ee b\u00fdt vy\u0159e\u0161ena pouze za pomoci hrudn\u00ed dren\u00e1\u017ee, kter\u00e1 m\u016f\u017ee naopak pomoci v indikaci torakotomie. Perikardiocent\u00e9za, event. mal\u00e1 perikardiotomie se uplatn\u00ed sp\u00ed\u0161e u tup\u00fdch \u00faraz\u016f hrudn\u00edku, tampon\u00e1da a penetruj\u00edc\u00ed poran\u011bn\u00ed indikuj\u00ed revizi. Rychl\u00fd rozvoj endovaskul\u00e1rn\u00edch technik dovoluje elektivn\u00ed o\u0161et\u0159en\u00ed v\u011bt\u0161iny poran\u011bn\u00ed v\u011bt\u0161\u00edch c\u00e9v, v \u010dasov\u00e9 t\u00edsni ale z\u00e1le\u017e\u00ed na dostupnosti p\u0159\u00edstroje, odborn\u00edka a vhodn\u00e9ho stentu, co\u017e m\u016f\u017ee b\u00fdt v dramatick\u00e9 situaci limituj\u00edc\u00ed. Proto z\u016fst\u00e1v\u00e1 chirurgick\u00e1 revize zlat\u00fdm standardem o\u0161et\u0159en\u00ed penetruj\u00edc\u00edch poran\u011bn\u00ed hrudn\u00edku odpov\u00eddaj\u00edc\u00edch v\u00fd\u0161e uveden\u00fdm indika\u010dn\u00edm kriteri\u00edm. Velk\u00e9 ztr\u00e1tov\u00e9 defekty hrudn\u00ed st\u011bny jsou ot\u00e1zkou prim\u00e1rn\u00edho uz\u00e1v\u011bru defektu i s pomoc\u00ed syntetick\u00e9ho materi\u00e1lu \u010di ko\u017en\u00edch a svalov\u00fdch lalok\u016f. Ot\u00e1zka stabilizace hrudn\u00ed st\u011bny byla prezentov\u00e1na v odpov\u00eddaj\u00edc\u00ed kapitole. L\u00e9ze jednotliv\u00fdch nitrohrudn\u00edch struktur a jejich l\u00e9\u010dba jsou ot\u00e1zky natolik speci\u00e1ln\u00ed, \u017ee budou diskutov\u00e1ny jednotliv\u011b, a to i s ohledem na tup\u00e1 poran\u011bn\u00ed hrudn\u00edku.<\/p>\n<h3>6.5 Poran\u011bn\u00ed plic<\/h3>\n<h4>6.5.1 Kontuze plic<\/h4>\n<p style=\"text-align: justify;\">Plicn\u00ed kontuze je nej\u010dast\u011bj\u0161\u00edm n\u00e1sledkem tup\u00e9ho hrudn\u00edho traumatu. M\u016f\u017ee b\u00fdt zp\u016fsobena n\u00e1sil\u00edm p\u016fsob\u00edc\u00edm p\u0159es hrudn\u00ed st\u011bnu na plicn\u00ed parenchym p\u0159\u00edmo \u010di decelerac\u00ed nebo v r\u00e1mci vysokoenergetick\u00fdch poran\u011bn\u00ed absorbc\u00ed kinetick\u00e9 energie st\u0159ely. Patofyziologick\u00fdm korel\u00e1tem kontuze je prokrv\u00e1cen\u00ed interalveol\u00e1rn\u00edch sept a n\u00e1sledn\u00fd ed\u00e9m okoln\u00ed plicn\u00ed tk\u00e1n\u011b. V klinice dominuje du\u0161nost, mohou se p\u0159idat hemopt\u00fdza, cyan\u00f3za, hypotenze. Podle z\u00e1va\u017enosti kontuze a zejm\u00e9na podle t\u00ed\u017ee sdru\u017een\u00fdch poran\u011bn\u00ed a p\u0159edopera\u010dn\u00ed morbidity stoup\u00e1 riziko syndromu syst\u00e9mov\u00e9 antiinflamatorn\u00ed odpov\u011bdi (SIRS) a n\u00e1sledn\u00e9 respira\u010dn\u00ed insuficience. Dal\u0161\u00ed v\u00fdvoj m\u016f\u017ee dosp\u011bt zejm\u00e9na u ventilovan\u00fdch nemocn\u00fdch k syndromu akutn\u00ed dechov\u00e9 nedostate\u010dnosti (ARDS) nebo k sekund\u00e1rn\u00ed pneumonii. Progn\u00f3za izolovan\u00e9 plicn\u00ed kontuze je pom\u011brn\u011b dobr\u00e1, v kombinaci se z\u00e1va\u017en\u00fdmi sdru\u017een\u00fdmi poran\u011bn\u00edmi ale dosahuje mortalita a\u017e 50 %.<\/p>\n<h4>6.5.2 Lacerace plic<\/h4>\n<p style=\"text-align: justify;\">Lacerace plic m\u016f\u017ee b\u00fdt v r\u016fzn\u00e9m rozsahu od drobn\u00fdch perifern\u00edch trhlin poplicnice \u010di p\u0159ilehl\u00e9ho parenchymu u tup\u00fdch i otev\u0159en\u00fdch \u00faraz\u016f p\u0159es nekomplikovan\u00e9 bodn\u00e9 r\u00e1ny a pr\u016fst\u0159ely a\u017e po t\u011b\u017ek\u00e9 dilacerace pl\u00edce postihuj\u00edc\u00ed plicn\u00ed hilus v r\u00e1mci vysoce energetick\u00fdch st\u0159eln\u00fdch poran\u011bn\u00ed. V diagnostice m\u00e1 vedouc\u00ed postaven\u00ed skiagram, poran\u011bn\u00ed plic se manifestuje jako pneumotorax, hemotorax \u010di hemopneumotorax. Klinicky v\u00fdznamn\u00fd pneumotorax by m\u011bl b\u00fdt na skiagramu patrn\u00fd.<\/p>\n<h4>6.5.3 Pneumotorax<\/h4>\n<p style=\"text-align: justify;\">Pokud nen\u00ed poru\u0161ena hrudn\u00ed st\u011bna, pova\u017eujeme pneumotorax za uzav\u0159en\u00fd. Penetruj\u00edc\u00ed poran\u011bn\u00ed hrudn\u00ed st\u011bny zp\u016fsobuj\u00ed pneumotorax otev\u0159en\u00fd. Pokud se l\u00e9ze v hrudn\u00ed st\u011bn\u011b, pr\u016fdu\u0161ce \u010di pl\u00edci chov\u00e1 ventilov\u00fdm zp\u016fsobem, to znamen\u00e1, \u017ee p\u0159i n\u00e1dechu se do pleur\u00e1ln\u00ed dutiny dost\u00e1v\u00e1 porce vzduchu, kter\u00e1 nem\u016f\u017ee b\u00fdt za v\u00fddechu evakuov\u00e1na, hovo\u0159\u00edme o pneumotoraxu tenzn\u00edm. Defekt hrudn\u00ed st\u011bny v\u011bt\u0161\u00ed, ne\u017e je pr\u016f\u0159ez pr\u016fdu\u0161nice, hrub\u00fdm zp\u016fsobem naru\u0161uje mechaniku d\u00fdch\u00e1n\u00ed, p\u0159i n\u00e1dechu proud\u00ed vzduch dovnit\u0159 poran\u011bn\u00e9ho hemitoraxu a zp\u016fsobuje p\u0159esun mediastina na zdravou stranu, p\u0159i v\u00fddechu je mezihrud\u00ed naopak p\u0159etla\u010dov\u00e1no na stranu poran\u011bnou. Tomuto jevu se \u0159\u00edk\u00e1 vl\u00e1n\u00ed mediastina. Pl\u00edce posti\u017een\u00e9 strany je kolabovan\u00e1, plicn\u00ed parenchym druh\u00e9 strany tak\u00e9 nepracuje, pouze neefektivn\u011b sleduje pohyby hrudn\u00ed st\u011bny a br\u00e1nice. Jedn\u00e1 se o z\u00e1va\u017en\u00fd, \u017eivot ohro\u017euj\u00edc\u00ed stav, podobn\u011b jako v p\u0159\u00edpad\u011b tenzn\u00edho pneumotoraxu. Oba tyto stavy pova\u017eujeme za n\u00e1hl\u00e9 p\u0159\u00edhody hrudn\u00ed. Zat\u00edmco hlavn\u00ed p\u0159\u00ed\u010dinou respira\u010dn\u00edho selh\u00e1n\u00ed u otev\u0159en\u00e9ho pneumotoraxu je porucha mechaniky d\u00fdch\u00e1n\u00ed, v p\u0159\u00edpad\u011b tenzn\u00edho pneumotoraxu dominuje porucha n\u00e1vratu \u017eiln\u00ed krve k srdci. Nas\u00e1v\u00e1n\u00ed a akumulace vzduchu v pohrudni\u010dn\u00ed dutin\u011b ventilem v hrudn\u00ed st\u011bn\u011b (nebo v pl\u00edci, tracheobronchi\u00e1ln\u00edm stromu) vedou k postupn\u00e9mu stla\u010den\u00ed p\u0159\u00edslu\u0161n\u00e9 pl\u00edce k hilu, kone\u010dn\u00fdm d\u016fsledkem je p\u0159etla\u010den\u00ed mediastina na prot\u011bj\u0161\u00ed stranu p\u016fsob\u00edc\u00ed \u00fatlak, resp. angulaci a za\u0161krcen\u00ed obou dut\u00fdch \u017eil, samoz\u0159ejm\u011b tak\u00e9 kompresi druh\u00e9 pl\u00edce. Prvn\u00ed pomoc\u00ed p\u0159i tenzn\u00edm pneumotoraxu je hrudn\u00ed dren\u00e1\u017e nebo alespo\u0148 p\u0159eveden\u00ed tenzn\u00edho pneumotoraxu na otev\u0159en\u00fd torakocent\u00e9zou siln\u00fdmi jehlami.<\/p>\n<h4>6.5.4 Hemotorax<\/h4>\n<p style=\"text-align: justify;\">Hemotorax (f luidotorax) se projev\u00ed p\u0159i objemu nad 250 ml. U asymptomatick\u00fdch nemocn\u00fdch s negativn\u00edm rentgenogramem se doporu\u010duje opakovat sn\u00edmek v intervalu 6\u201312 hodin. P\u0159i sporn\u00e9m n\u00e1lezu odkryje CT i minim\u00e1ln\u00ed PNO \u010di mal\u00e9 mno\u017estv\u00ed tekutiny. Revidovat r\u00e1nu se nedoporu\u010duje pro nebezpe\u010d\u00ed zp\u016fsoben\u00ed PNO a kontaminace pleur\u00e1ln\u00ed dutiny. V p\u0159\u00edpad\u011b prok\u00e1zan\u00e9ho PNO \u010di n\u00e1lezu tekutiny u penetruj\u00edc\u00edho poran\u011bn\u00ed je indikov\u00e1na hrudn\u00ed dren\u00e1\u017e. Je to nejlep\u0161\u00ed prevence rezidu\u00e1ln\u00edho hemotoraxu, kter\u00e1 dovoluje sledovat trend krv\u00e1cen\u00ed v \u010dase a p\u0159\u00edpadn\u011b indikovat revizi.Masivn\u00ed krv\u00e1cen\u00ed z hrudn\u00edho dr\u00e9nu vy\u017eaduje torakotomii, minim\u00e1ln\u00ed trvaj\u00edc\u00ed odpad z dr\u00e9nu m\u016f\u017ee b\u00fdt o\u0161et\u0159en torakoskopicky za p\u0159edpokladu hemodynamick\u00e9 stability. Indikace torakotomie ve vztahu k evakuovan\u00e9mu mno\u017estv\u00ed krve je trvale diskutov\u00e1na. Emergentn\u00ed torakotomie je obvykle indikov\u00e1na, pokud odpad krve do dr\u00e9nu p\u0159es\u00e1hne:<\/p>\n<ul>\n<li>jednor\u00e1zov\u011b 1500 ml,<\/li>\n<li>300 ml ml ve t\u0159ech hodin\u00e1ch n\u00e1sleduj\u00edc\u00edch po zaveden\u00ed dr\u00e9nu.<\/li>\n<\/ul>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1841.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 2 \u2013 Ruptura pr\u016fdu\u0161nice zp\u016fsoben\u00e1 p\u0159i intubaci v r\u00e1mci resuscitace\" alt=\"Obr. 2 \u2013 Ruptura pr\u016fdu\u0161nice zp\u016fsoben\u00e1 p\u0159i intubaci v r\u00e1mci resuscitace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1841.png\" width=\"200\" height=\"160\" \/><\/a><p class=\"wp-caption-text\">Obr. 2<br \/>Ruptura pr\u016fdu\u0161nice zp\u016fsoben\u00e1 p\u0159i intubaci v r\u00e1mci resuscitace<\/p><\/div>\n<p style=\"text-align: justify;\">P\u0159\u00edsn\u011bj\u0161\u00ed auto\u0159i dokl\u00e1daj\u00ed, \u017ee mortalita rapidn\u011b stoup\u00e1 p\u0159i celkov\u00e9 sekreci nad 1500 ml za 24 hodin, toto mno\u017estv\u00ed tedy pova\u017euj\u00ed op\u011bt za indikuj\u00edc\u00ed pro revizi.<\/p>\n<p style=\"text-align: justify;\">Naprost\u00e1 v\u011bt\u0161ina plicn\u00edch poran\u011bn\u00ed vy\u017eaduj\u00edc\u00edch torakotomii je o\u0161et\u0159iteln\u00e1 za cenu minim\u00e1ln\u00ed ztr\u00e1ty parenchymu (koagulace, p\u0159e\u0161it\u00ed, pro\u0161it\u00ed staplerem \u010di neanatomick\u00e9 plicn\u00ed resekce, tk\u00e1\u0148ov\u00e1 lepidla). Anatomick\u00e9 resekce jsou vynucen\u00e9 u t\u011b\u017ek\u00fdch lacerac\u00ed s nereparovateln\u00fdm posti\u017een\u00edm hilov\u00fdch struktur. Pneumonektomie je opr\u00e1vn\u011bn\u00e1 pouze p\u0159i vy\u010derp\u00e1n\u00ed v\u0161ech dostupn\u00fdch prost\u0159edk\u016f k z\u00e1chran\u011b pl\u00edce, jako ultimum refugium je prov\u00e1zena vysokou mortalitou.<\/p>\n<h3>6.6 Tracheobronchi\u00e1ln\u00ed poran\u011bn\u00ed<\/h3>\n<p style=\"text-align: justify;\">Tracheobronchi\u00e1ln\u00ed poran\u011bn\u00ed nejsou \u010dast\u00e1, vyskytuj\u00ed se asi u 1 % zran\u011bn\u00fdch \u010dasto sdru\u017een\u011b s l\u00e9zemi jin\u00fdch struktur. Krom\u011b\u00a0nev\u00fdznamn\u00fdch\u00a0drobn\u00fdch trhlin s \u017e\u00e1dnou nebo minim\u00e1ln\u00ed doprovodnou symptomatologi\u00ed vy\u017eaduj\u00ed oblig\u00e1tn\u011b chirurgickou reparaci. V\u00edce jak t\u0159i \u010dtvrtiny penetruj\u00edc\u00edch (v\u011bt\u0161inou bodn\u00fdch \u010di \u0159ezn\u00fdch) \u00faraz\u016f postihuj\u00ed kr\u010dn\u00ed \u00fasek pr\u016fdu\u0161nice, stejn\u00fd pod\u00edl postihuje dist\u00e1ln\u00ed tracheu nad bifurkac\u00ed u tup\u00fdch \u00faraz\u016f hrudn\u00edku. Krom\u011b direktn\u00edho mechanismu jsou \u00farazy trachey zp\u016fsobeny stla\u010den\u00edm v oblasti horn\u00ed hrudn\u00ed apertury v\u011bt\u0161inou s poran\u011bn\u00edm ostatn\u00edch zde ulo\u017een\u00fdch struktur, na srde\u010dn\u011b-plicn\u00ed stopku p\u016fsob\u00ed decelera\u010dn\u00ed s\u00edly u hyperkinetick\u00fdch nehod a typicky trhaj\u00ed pr\u016fdu\u0161nici t\u011bsn\u011b nad bifurkac\u00ed. S t\u011bmito silami spolup\u016fsob\u00ed je\u0161t\u011b vysok\u00fd tlak vzduchu ve velk\u00fdch d\u00fdchac\u00edch cest\u00e1ch.Klinicky se tyto \u00farazy projevuj\u00ed chrapotem, huh\u0148\u00e1n\u00edm, podko\u017en\u00edm emfyz\u00e9mem, hemopt\u00fdzou, pneumotoraxem, na rentgenogramu m\u016f\u017ee b\u00fdt vid\u011bt kolabovan\u00e1 pl\u00edce a\/nebo pneumomediastinum. Pokud je prok\u00e1z\u00e1n pneumotorax, z hrudn\u00edho dr\u00e9nu m\u016f\u017ee b\u00fdt masivn\u00ed \u00fanik vzduchu, to ukazuje na poran\u011bn\u00ed velk\u00fdch pr\u016fdu\u0161ek v intrapleur\u00e1ln\u00edm pr\u016fb\u011bhu. Pokud se p\u0159edpokl\u00e1d\u00e1 poran\u011bn\u00ed trachey (masivn\u00ed pneumomediastinum a podko\u017en\u00ed emfyz\u00e9m, nep\u0159\u00edtomnost air&#8211;leaku), je vhodn\u00e9 intubovat pomoc\u00ed bronchoskopu, kter\u00fdm se dokon\u010d\u00ed i definitivn\u00ed diagnostika. V p\u0159\u00edpad\u011b trache\u00e1ln\u00edch poran\u011bn\u00ed je prvn\u00ed pomoc\u00ed intubace pod m\u00edsto defektu navigovan\u00e1 bronchoskopi\u00ed. V p\u0159\u00edpad\u011b l\u00e9ze velk\u00fdch pr\u016fdu\u0161ek je nutn\u00e9 zaintubovat neporu\u0161enou pr\u016fdu\u0161ku, a lze-li, zablokovat poran\u011bnou. Stejn\u011b v\u00fdznamn\u00e9 je prov\u00e9st dokonalou toaletu d\u00fdchac\u00edch cest (obr. 2).Technika a taktika reparace po\u0161kozen\u00fdch d\u00fdchac\u00edch cest je analogick\u00e1 elektivn\u00edm operac\u00edm. P\u0159\u00edstup k horn\u00ed t\u0159etin\u011b pr\u016fdu\u0161nice je mo\u017en\u00fd z kol\u00e1rn\u00edho \u0159ezu, p\u0159\u00edpadn\u011b roz\u0161\u00ed\u0159en\u00e9ho o manubriotomii. Nutnost revize pro p\u0159idru\u017een\u00e1 poran\u011bn\u00ed okoln\u00edch struktur vy\u017eaduje sternotomii a v p\u0159\u00edpad\u011b st\u0159edn\u00edho \u00faseku trachey i transperikardi\u00e1ln\u00ed p\u0159\u00edstup. K dist\u00e1ln\u00ed pr\u016fdu\u0161nici a ob\u011bma kmenov\u00fdm pr\u016fdu\u0161k\u00e1m se lze dostat nejl\u00e9pe z pravostrann\u00e9 torakotomie. Poran\u011bn\u00ed dist\u00e1ln\u011bj\u0161\u00edch \u00fasek\u016f d\u00fdchac\u00edch cest lze \u0159e\u0161it reparac\u00ed na zp\u016fsob bronchoplastick\u00fdch operac\u00ed, n\u011bkdy jsou vynuceny anatomick\u00e9 resekce. Pneumonektomie je nutn\u00e1 naprosto raritn\u011b, s velmi \u0161patnou progn\u00f3zou. Technika je op\u011bt stejn\u00e1 jako u pl\u00e1novan\u00fdch v\u00fdkon\u016f a v onkochirurgii: prim\u00e1rn\u00ed sutura nebo resekce posti\u017een\u00e9ho (lacerovan\u00e9ho) brochu s end-to-end anastom\u00f3zou v p\u0159ijateln\u00e9m tahu za \u0161et\u0159en\u00ed c\u00e9vn\u00edho z\u00e1soben\u00ed. Stehy by m\u011bly b\u00fdt atraumatick\u00e9, vst\u0159ebateln\u00e9, uzlen\u00e9 zevn\u011b, jednotliv\u00e9 \u010di pokra\u010duj\u00edc\u00ed. Podpora sutury vit\u00e1ln\u00ed tk\u00e1n\u00ed je vhodn\u00e1. Ne v\u017edy jsou tato poran\u011bn\u00ed rozpozn\u00e1na prim\u00e1rn\u011b, k odlo\u017een\u00e9mu \u0159e\u0161en\u00ed pak vedou typick\u00e9 komplikace \u2013 striktury nebo atelekt\u00e1zy a infek\u010dn\u00ed komplikace dan\u00e9 obstrukc\u00ed.<\/p>\n<h3>6.7 Poran\u011bn\u00ed velk\u00fdch c\u00e9v<\/h3>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1861.png\"><img decoding=\"async\" title=\"Obr. 3 \u2013 Traumatick\u00e1 ruptura isthmu aorty o\u0161et\u0159en\u00e1 kr\u00e1tkou dakronovou prot\u00e9zou\" alt=\"Obr. 3 \u2013 Traumatick\u00e1 ruptura isthmu aorty o\u0161et\u0159en\u00e1 kr\u00e1tkou dakronovou prot\u00e9zou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1861.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<br \/>Traumatick\u00e1 ruptura isthmu aorty o\u0161et\u0159en\u00e1 kr\u00e1tkou dakronovou prot\u00e9zou<\/p><\/div>\n<p style=\"text-align: justify;\">Jako velk\u00e9 nitrohrudn\u00ed c\u00e9vy klasifikujeme aortu a v\u011btve oblouku, horn\u00ed dutou \u017e\u00edlu a jej\u00ed p\u0159\u00edtoky, doln\u00ed dutou \u017e\u00edlu, plicn\u00ed tepny a plicn\u00ed \u017e\u00edly. V\u00edce ne\u017e 90 % jejich poran\u011bn\u00ed je penetruj\u00edc\u00edch, v\u00e1\u017en\u00e1 poran\u011bn\u00ed velk\u00fdch tepen v\u011bt\u0161inou kon\u010d\u00ed fat\u00e1ln\u011b je\u0161t\u011b v ter\u00e9nu. \u0160ance na \u00fasp\u011b\u0161n\u00fd z\u00e1sah se po\u010d\u00edt\u00e1 na minuty, proto se diagnostika omezuje v\u011bt\u0161inou na minimum, u stabiln\u00edch nemocn\u00fdch lze stihnout RTG, CT, p\u0159\u00edpadn\u011b CTAG.<\/p>\n<p style=\"text-align: justify;\">Nemocn\u00ed v t\u011b\u017ek\u00e9m hemoragick\u00e9m \u0161oku, p\u0159\u00edpadn\u011b po inici\u00e1ln\u00ed resuscitaci sm\u011b\u0159uj\u00ed bezodkladn\u011b na s\u00e1l. Metodou volby je podle m\u00edsta poran\u011bn\u00ed okam\u017eit\u00e1 torakotomie (sternotomie), manu\u00e1ln\u00ed komprese poran\u011bn\u00ed, p\u0159\u00edpadn\u011b zasvorkov\u00e1n\u00ed krv\u00e1cej\u00edc\u00ed c\u00e9vy. V n\u011bkter\u00fdch p\u0159\u00edpadech m\u016f\u017ee pomoci intravaskul\u00e1rn\u011b zaveden\u00fd balonkov\u00fd kat\u00e9tr. Definitivn\u00ed o\u0161et\u0159en\u00ed se d\u011bje standardn\u00ed technikou. Problematick\u00e1 je volba p\u0159\u00edstupu. Ascendentn\u00ed aorta je p\u0159\u00edstupn\u00e1 ze sternotomie, descendentn\u00ed z levostrann\u00e9 torakotomie. Plicn\u00ed c\u00e9vy jsou \u0159e\u0161eny z p\u0159\u00edslu\u0161n\u00e9 torakotomie. Horn\u00ed dut\u00e1 \u017e\u00edla je dostupn\u00e1 ze sternotomie nebo pravostrann\u00e9 torakotomie, doln\u00ed ze sterno\u010di sternofrenolaparotomie. Tepny oblouku jsou p\u0159\u00edstupn\u00e9 ze supra \u010di infraklavikul\u00e1rn\u00edho p\u0159\u00edstupu, transklavikul\u00e1n\u011b, ze sternotomie, z hemiclamshell \u010di trapdoor \u0159ezu.<\/p>\n<p style=\"text-align: justify;\">Poran\u011bn\u00ed aorty kon\u010d\u00ed \u010dasto exsangvinac\u00ed. Ascendentn\u00ed aortu nelze uzav\u0159\u00edt bez mimot\u011bln\u00edho ob\u011bhu, pokud nen\u00ed k dispozici, lze n\u011bkter\u00e1 poran\u011bn\u00ed kontrolovat a definitivn\u011b o\u0161et\u0159it suturou na velk\u00fdch n\u00e1st\u011bnn\u00fdch svork\u00e1ch. Sestupn\u00e1 aorta m\u016f\u017ee b\u00fdt zasvorkov\u00e1na a o\u0161et\u0159ena suturou \u010di v p\u0159\u00edpad\u011b nutnosti interpozic\u00ed vaskul\u00e1rn\u00ed prot\u00e9zou.<\/p>\n<p style=\"text-align: justify;\">V emergentn\u00ed situaci nen\u00ed prevence ischemie m\u00edchy standardem (obr. 3). P\u0159i poran\u011bn\u00ed velk\u00fdch plicn\u00edch c\u00e9v je prvn\u00edm krokem zalo\u017een\u00ed turniketu na plicnici, plicn\u00ed \u017e\u00edly mohou b\u00fdt vyv\u011b\u0161eny podobn\u011b. Po dosa\u017een\u00ed uspokojiv\u00e9 hemost\u00e1zy n\u00e1sleduje reparace poran\u011bn\u00fdch struktur. Imperativem je vyhnout se za ka\u017edou cenu pneumonektomii.<\/p>\n<p style=\"text-align: justify;\">Poran\u011bn\u00ed dut\u00fdch \u017eil mus\u00ed b\u00fdt reparov\u00e1no se zachov\u00e1n\u00edm pr\u016fchodnosti, podvaz jedn\u00e9 nebo druh\u00e9 dut\u00e9 \u017e\u00edly je neslu\u010diteln\u00fd se \u017eivotem. Jednostrann\u00fd podvaz brachiocefalick\u00e9 \u017e\u00edly je mo\u017en\u00fd, dostate\u010dn\u00fd kolater\u00e1ln\u00ed ob\u011bh se p\u0159edpokl\u00e1d\u00e1.Poran\u011bn\u00ed tepen oblouku aorty je \u010dast\u00e9 p\u0159i bodn\u00fdch ran\u00e1ch v oblasti krku a mo\u017en\u00e9 p\u0159i tup\u00fdch \u00farazech v oblasti horn\u00ed hrudn\u00ed apertury. Principem jejich o\u0161et\u0159en\u00ed je sutura, event. rekonstrukce \u010di by-pass prot\u00e9zou nebo \u017eiln\u00edm \u0161t\u011bpem (obr. 4).<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1871.png\"><img decoding=\"async\" title=\"Obr. 4 \u2013 N\u00e1hrada truncus brachiocephalicus a sutura pr\u016fdu\u0161nice pro sdru\u017een\u00e9 poran\u011bn\u00ed\" alt=\"Obr. 4 \u2013 N\u00e1hrada truncus brachiocephalicus a sutura pr\u016fdu\u0161nice pro sdru\u017een\u00e9 poran\u011bn\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1871.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4<br \/>N\u00e1hrada truncus brachiocephalicus a sutura pr\u016fdu\u0161nice pro sdru\u017een\u00e9 poran\u011bn\u00ed<\/p><\/div>\n<p style=\"text-align: justify;\">U nemocn\u00fdch s prolongovan\u00fdm pr\u016fb\u011bhem nab\u00fdv\u00e1 na v\u00fdznamu endovaskul\u00e1rn\u00ed terapie. Z\u00e1kladn\u00edm probl\u00e9mem z\u016fst\u00e1v\u00e1 dostupnost p\u0159\u00edstroje, rentgenologa a pot\u0159ebn\u00e9ho stentgraftu v dan\u00e9m m\u00edst\u011b a v pot\u0159ebn\u00e9m \u010dase.<\/p>\n<h3>6.8 Poran\u011bn\u00ed srdce<\/h3>\n<p style=\"text-align: justify;\">Tup\u00e1 poran\u011bn\u00ed srdce prov\u00e1zej\u00ed hrudn\u00ed trauma asi ve 20% p\u0159\u00edpad\u016f. V\u011bt\u0161inou vznikaj\u00ed v d\u016fsledku dopravn\u00edch hav\u00e1ri\u00ed, n\u00e1raz hrudn\u00edku na volant je typick\u00fdm mechanismem \u00farazu, p\u0159i kter\u00e9m se uplat\u0148uje decelerace a komprese srdce mezi sternem a p\u00e1te\u0159\u00ed za p\u0159isp\u011bn\u00ed rychl\u00e9ho p\u0159epln\u011bn\u00ed srdce ven\u00f3zn\u00ed krv\u00ed p\u0159i zm\u00e1\u010dknut\u00ed doln\u00ed poloviny t\u011bla. Fraktura sterna \u010di dv\u00ed\u0159kov\u00e9 vylomen\u00ed p\u0159edn\u00edho segmentu \u017eeber s hrudn\u00ed kost\u00ed ukazuj\u00ed na pravd\u011bpodobnost poran\u011bn\u00ed srdce nebo jin\u00fdch mediastin\u00e1ln\u00edch struktur. L\u00e9\u010dbu vy\u017eaduje jen asi 10 % t\u011bch nejv\u00e1\u017en\u011bj\u0161\u00edch poran\u011bn\u00ed (ruptura komory, ruptura perikardu s herniac\u00ed srdce, levostrann\u00e9 chlop\u0148ov\u00e9 vady, poran\u011bn\u00ed koron\u00e1rn\u00edch tepen). Pro hodnocen\u00ed z\u00e1va\u017enosti tup\u00e9ho srde\u010dn\u00edho poran\u011bn\u00ed bylo vytvo\u0159eno trauma sk\u00f3re:<\/p>\n<ul>\n<li>Jeden bod:\n<ul>\n<li>Patofyziologick\u00e9 \u010di anatomick\u00e9 odchylky bez EKG projev\u016f<\/li>\n<li>EKG abnormity<\/li>\n<li>Elevace kardioselektivn\u00edch enzym\u016f<\/li>\n<\/ul>\n<\/li>\n<li>Dva body:\n<ul>\n<li>Hematom st\u011bny srde\u010dn\u00ed \u010di septa<\/li>\n<li>Defekt septa<\/li>\n<\/ul>\n<\/li>\n<li>\u010cty\u0159i body:\n<ul>\n<li>\u00darazov\u00e1 insuficience chlopn\u011b<\/li>\n<\/ul>\n<\/li>\n<li>P\u011bt bod\u016f\n<ul>\n<li>Ruptura st\u011bny srde\u010dn\u00ed<\/li>\n<li>Herniace srdce<\/li>\n<li>Poran\u011bn\u00ed koron\u00e1rn\u00edch tepen<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Diagnostika je obt\u00ed\u017en\u00e1, symptomatologie nen\u00ed specifick\u00e1, krom\u011b bolesti, tachykardie, krepitace p\u0159i fraktur\u00e1ch sterna, oslaben\u00ed ozev p\u0159i tampon\u00e1d\u011b \u010di sly\u0161iteln\u00fdch \u0161elest\u016f p\u0159i defektech septa \u010di chlopn\u00ed nen\u00ed typick\u00fdch zn\u00e1mek srde\u010dn\u00edho poran\u011bn\u00ed. Patologick\u00fd n\u00e1lez na EKG a elevace kardioselektivn\u00edch enzym\u016f (kreatinkin\u00e1za \u2013 myokardi\u00e1ln\u00ed frakce, troponiny I,T) ukazuj\u00ed bl\u00ed\u017ee na mo\u017en\u00e9 posti\u017een\u00ed myokardu. Nejp\u0159esn\u011bj\u0161\u00ed a dostupn\u00e1 diagnostika je echokardiografie (transpariet\u00e1ln\u00ed \u010di l\u00e9pe transezofage\u00e1ln\u00ed).<\/p>\n<p style=\"text-align: justify;\">Penetruj\u00edc\u00ed poran\u011bn\u00ed srdce jsou vedouc\u00ed p\u0159\u00ed\u010dinou traumatick\u00fdch \u00famrt\u00ed v p\u0159edhospitaliza\u010dn\u00ed i hospitaliza\u010dn\u00ed dob\u011b. Mohou b\u00fdt zp\u016fsobeny p\u0159\u00edmo (bodn\u00e9, st\u0159eln\u00e9 r\u00e1ny) nebo nep\u0159\u00edmo (ostr\u00fdmi \u00falomky \u017eeber \u010di sterna p\u0159i jejich zlomenin\u00e1ch). V\u00edce ne\u017e t\u0159etina poran\u011bn\u00ed postihuje pravou komoru, ve stejn\u00e9m po\u010dtu lze diagnostikovat poran\u011bn\u00ed v\u00edce srde\u010dn\u00edch odd\u00edl\u016f, asi ve \u010dtvrtin\u011b p\u0159\u00edpad\u016f je izolovan\u011b poran\u011bna lev\u00e1 komora. Zat\u00edmco u tup\u00fdch poran\u011bn\u00ed je v\u011bt\u0161inou ur\u010dit\u00fd interval mo\u017eno v\u011bnovat diagnostice, u penetruj\u00edc\u00edch poran\u011bn\u00ed hrudn\u00edku v prekordiu a v nadb\u0159i\u0161ku za ob\u011bhov\u00e9 nestability zb\u00fdvaj\u00ed pouze minuty na bezodkladnou revizi. Prvn\u00edmi p\u0159\u00edznaky tampon\u00e1dy srde\u010dn\u00ed jsou tachykardie, vysok\u00fd ven\u00f3zn\u00ed a n\u00edzk\u00fd arteri\u00e1ln\u00ed tlak a oslaben\u00e9 ozvy. Tampon\u00e1da nemus\u00ed b\u00fdt p\u0159\u00edtomna p\u0159i v\u011bt\u0161\u00edm defektu perikardu (se\u010dn\u00e9, st\u0159eln\u00e9 r\u00e1ny). Pr\u016fkaz i mal\u00e9ho mno\u017estv\u00ed tekutiny v perikardu nebo poran\u011bn\u00ed srde\u010dn\u00edch odd\u00edl\u016f je indikac\u00ed k bezodkladn\u00e9 revizi. Perikardi\u00e1ln\u00ed punkce m\u00e1 p\u0159\u00edli\u0161 vysok\u00e1 procenta fale\u0161n\u011b pozitivn\u00edch i fale\u0161n\u011b negativn\u00edch v\u00fdsledk\u016f, v akutn\u00ed f\u00e1zi se nepou\u017e\u00edv\u00e1. Perikardiotomie pod me\u010d\u00edkem m\u016f\u017ee b\u00fdt u stabiln\u00edch poran\u011bn\u00fdch rychlou diagnostickou metodou k ov\u011b\u0159en\u00ed a evakuaci hemoperikardu a k digit\u00e1ln\u00ed kontrole poran\u011bn\u00ed p\u0159i hrotu srde\u010dn\u00edm. U nemocn\u00fdch v hemoragick\u00e9m \u010di kardiogenn\u00edm \u0161oku je nezbytn\u00e1 bezodkladn\u00e1 sternotomie a revize cel\u00e9ho srdce, alternativou, zejm\u00e9na tam, kde nen\u00ed k dispozici kardiochirurgick\u00e9 vybaven\u00ed, je levostrann\u00e1 torakotomie 4. mezi\u017eeb\u0159\u00edm, kter\u00e1 dovoluje zasvorkov\u00e1n\u00ed dist\u00e1ln\u00ed aorty k centralizaci ob\u011bhu do tepen oblouku a koron\u00e1rn\u00edch, m\u016f\u017ee b\u00fdt roz\u0161\u00ed\u0159ena transstern\u00e1ln\u011b napravo.<\/p>\n<p style=\"text-align: justify;\">Minim\u00e1ln\u011b invazivn\u00ed metody nemaj\u00ed v akutn\u00ed f\u00e1zi m\u00edsto. O\u0161et\u0159en\u00ed jednotliv\u00fdch poran\u011bn\u00ed respektuje z\u00e1sady kardiochirurgie. Poran\u011bn\u00ed komor lze reparovat suturou pleten\u00fdm \u010di monofiln\u00edm vl\u00e1knem s\u00edly 2-0, 3-0 s odpov\u00eddaj\u00edc\u00ed jehlou p\u0159es teflonov\u00e9 \u010di perikardi\u00e1ln\u00ed podlo\u017eky. Doporu\u010duje se zalo\u017eit 1 a\u017e 2 siln\u00e9 hlubok\u00e9 hemostatick\u00e9 stehy ke kontrole krv\u00e1cen\u00ed, pot\u00e9 n\u00e1sleduje definitivn\u00ed reparace. Pou\u017eit\u00ed balonkov\u00e9ho kat\u00e9tru je n\u011bkter\u00fdmi autory preferov\u00e1no, jin\u00ed ho zavrhuj\u00ed pro nebezpe\u010d\u00ed vzduchov\u00e9 embolie a interference s chlopn\u011bmi a \u0161la\u0161inkami. Na p\u0159eds\u00edn\u011b lze vysta\u010dit s monofilamentn\u00edm vl\u00e1knem 3-0, 4-0, v\u011bt\u0161\u00ed defekty lze uzav\u0159\u00edt perikardem. Poran\u011bn\u00ed hlavn\u00edch kmen\u016f koron\u00e1rn\u00edch tepen m\u00e1 v\u011bt\u0161inou infaustn\u00ed pr\u016fb\u011bh, \u010dasn\u011b z d\u016fvodu exsangvinace a tampon\u00e1dy, odlo\u017een\u011b pro ischemii myokardu. P\u0159\u00edm\u00e1 sutura koron\u00e1rn\u00edch tepen na bij\u00edc\u00edm srdci je obt\u00ed\u017en\u011b provediteln\u00e1, podvaz \u010di pro\u0161it\u00ed jsou posledn\u00ed mo\u017enost\u00ed s p\u0159edpokl\u00e1dan\u00fdmi v\u00e1\u017en\u00fdmi d\u016fsledky a vysokou mortalitou. Lze je prov\u00e9st jako prvn\u00ed krok k dosa\u017een\u00ed hemost\u00e1zy jako alternativu digit\u00e1ln\u00ed kontroly p\u0159ed napojen\u00edm na mimot\u011bln\u00ed ob\u011bh. Dovoluje-li to pr\u016fb\u011bh operace a jde-li o v\u011bt\u0161\u00ed kmen, je c\u00edlem zalo\u017een\u00ed by-passu dist\u00e1ln\u011b pod m\u00edsto podvazu. Dist\u00e1ln\u00ed \u00faseky koron\u00e1rn\u00edch tepen mohou b\u00fdt ligov\u00e1ny nebo pro\u0161ity.<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1901.png\"><img decoding=\"async\" title=\"Obr. 5 \u2013 Herniace pl\u00edce defektem hrudn\u00ed st\u011bny ozna\u010dena \u0161ipkou\" alt=\"Obr. 5 \u2013 Herniace pl\u00edce defektem hrudn\u00ed st\u011bny ozna\u010dena \u0161ipkou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1901.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5<br \/>Herniace pl\u00edce defektem hrudn\u00ed st\u011bny ozna\u010dena \u0161ipkou<\/p><\/div>\n<p style=\"text-align: justify;\">Poran\u011bn\u00ed chlopn\u00ed vy\u017eaduje akutn\u00ed reparaci krom\u011b chlopn\u011b plicnice. Operace vy\u017eaduje mimot\u011bln\u00ed ob\u011bh, plastika chlopn\u011b \u010di sutura \u0161la\u0161inek je v\u00fdjime\u010dn\u00fdm krokem, v\u011bt\u0161inou je nejrychlej\u0161\u00edm \u0159e\u0161en\u00edm chlopenn\u00ed n\u00e1hrada.<\/p>\n<p style=\"text-align: justify;\">Defekty septa se v\u011bt\u0161inou\u00a0projev\u00ed a\u017e s \u010dasovou latenc\u00ed, komorov\u00e9 je nutno uzav\u0159\u00edt suturou \u010di z\u00e1platou, v\u011bt\u0161inou ve druh\u00e9 dob\u011b.<\/p>\n<p style=\"text-align: justify;\">Herniace srdce m\u016f\u017ee b\u00fdt do obou hemitorax\u016f nebo transdiafragmaticky. Pokud je branka defektu perikardu mal\u00e1, bez operace m\u00e1 stav rychl\u00fd fat\u00e1ln\u00ed pr\u016fb\u011bh. Repozice a direktn\u00ed sutura s ponech\u00e1n\u00edm mal\u00e9 fenestrace nen\u00ed slo\u017eit\u00e1, z\u00e1plata je pot\u0159ebn\u00e1 m\u00e1lokdy.<\/p>\n<p style=\"text-align: justify;\">O\u0161et\u0159en\u00ed poran\u011bn\u00ed velk\u00fdch intraperikardi\u00e1ln\u00edch c\u00e9v (aorta, plicnice, dut\u00e9 \u017e\u00edly) je nep\u0159edstaviteln\u00e9 bez mimot\u011bln\u00edho ob\u011bhu (a\u017e na v\u00fdjime\u010dn\u00e9 drobn\u00e9 lacerace dovoluj\u00edc\u00ed nalo\u017een\u00ed n\u00e1st\u011bnn\u00e9 svorky a steh). Takov\u00e1 poran\u011bn\u00ed se a\u017e na opera\u010dn\u00ed s\u00e1l dostanou naprosto raritn\u011b a i tehdy je jejich pr\u016fb\u011bh v\u011bt\u0161inou fat\u00e1ln\u00ed.<\/p>\n<p style=\"text-align: justify;\">Ciz\u00ed t\u011blesa ze srde\u010dn\u00edch odd\u00edl\u016f, zejm\u00e9na z lev\u00e9 komory, mus\u00ed b\u00fdt odstran\u011bna.<\/p>\n<h3>6.9 Komplikace<\/h3>\n<p style=\"text-align: justify;\">Komplikace specificky v\u00e1zan\u00e9 na trauma hrudn\u00edku mohou postihovat plicn\u00ed tk\u00e1\u0148, pleur\u00e1ln\u00ed prostor, c\u00e9vy, hrudn\u00ed st\u011bnu nebo mediastin\u00e1ln\u00ed struktury. V tabulce 6 je uveden p\u0159ehled nej\u010dast\u011bj\u0161\u00edch komplikac\u00ed a obr\u00e1zek 5 ilustruje jednu z nich:<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 6<\/span><br \/>\n<span style=\"color: #ffffff;\">Komplikace poran\u011bn\u00ed hrudn\u00edku<\/span><\/td>\n<\/tr>\n<tr>\n<td>\u00a0Plicn\u00ed<\/p>\n<ul>\n<li>ARDS<\/li>\n<li>Pneumonie<\/li>\n<li>Plicn\u00ed absces<\/li>\n<li>Z\u00fa\u017een\u00ed bronchu<\/li>\n<\/ul>\n<p>Pleur\u00e1ln\u00ed<\/p>\n<ul>\n<li>Empy\u00e9m<\/li>\n<li>Bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl<\/li>\n<li>Zbytkov\u00fd hemotorax<\/li>\n<li>Fibrotorax<\/li>\n<li>Chylotorax<\/li>\n<\/ul>\n<p>Mediastin\u00e1ln\u00ed<\/p>\n<ul>\n<li>Tracheoezofage\u00e1ln\u00ed p\u00ed\u0161t\u011bl<\/li>\n<li>Ezofagopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl<\/li>\n<\/ul>\n<p>Kardi\u00e1ln\u00ed<\/p>\n<ul>\n<li>Arytmie<\/li>\n<li>Perikarditida<\/li>\n<\/ul>\n<p>Vaskul\u00e1rn\u00ed<\/p>\n<ul>\n<li>C\u00e9vn\u00ed pseudoaneuryzma<\/li>\n<li>Arterioven\u00f3zn\u00ed p\u00ed\u0161t\u011bl<\/li>\n<\/ul>\n<p>Hrudn\u00ed st\u011bna<\/p>\n<ul>\n<li>Posttraumatick\u00e1 hernie<\/li>\n<li>Chronick\u00e1 bolest<\/li>\n<\/ul>\n<p>Retinovan\u00fd ciz\u00ed p\u0159edm\u011bt<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<h4>6.9.1 ARDS<\/h4>\n<p style=\"text-align: justify;\">Rozvinut\u00fd syndrom akutn\u00ed dechov\u00e9 t\u00edsn\u011b (ARDS \u2013 adult respiratory distress syndrom) je nejv\u00e1\u017en\u011bj\u0161\u00ed komplikac\u00ed \u00faraz\u016f hrudn\u00edku s mortalitou dosahuj\u00edc\u00ed 5%. Je charakterizov\u00e1n akutn\u011b vznikl\u00fdm non-hydrostatick\u00fdm plicn\u00edm ed\u00e9mem, hypoxemi\u00ed nereaguj\u00edc\u00ed na oxygenoterapii a p\u0159\u00edtomnost\u00ed difuzn\u00edch infiltr\u00e1t\u016f v plicn\u00edm parenchymu. N\u011bkte\u0159\u00ed auto\u0159i pova\u017euj\u00ed ARDS za t\u011b\u017e\u0161\u00ed formu akutn\u00edho plicn\u00edho traumatu (acute lung injury \u2013 ALI). Na jeho vzniku m\u00e1 nejv\u011bt\u0161\u00ed pod\u00edl difuzn\u00ed reakce endotelu v r\u00e1mci syst\u00e9mov\u00e9 protiz\u00e1n\u011btliv\u00e9 odpov\u011bdi (systemic inflamatory response syndrom \u2013 SIRS), kter\u00e1 zp\u016fsobuje naru\u0161en\u00ed k\u0159ehk\u00e9 rovnov\u00e1hy molekul\u00e1rn\u00edch medi\u00e1tor\u016f z\u00e1n\u011btu (interleukiny, endotelin, TNF, antiapoptotick\u00e9 faktory reguluj\u00edc\u00ed septick\u00e9 granulocyty), nadm\u011brn\u00e9 vyplaven\u00ed proz\u00e1n\u011btliv\u00fdch cytokin\u016f vede k naru\u0161en\u00ed kontraktility a permeability plicn\u00edch c\u00e9v. To m\u00e1 za n\u00e1sledek mikrotromb\u00f3zy v perifern\u00edm plicn\u00edm \u0159e\u010di\u0161ti a rozvoj interstici\u00e1ln\u00edho ed\u00e9mu. \u0158ada faktor\u016f m\u016f\u017ee tento stav iniciovat nebo prohloubit. Nejv\u00e1\u017en\u011bj\u0161\u00ed pr\u016fb\u011bh m\u00edv\u00e1 ARDS u nemocn\u00fdch s pneumoni\u00ed \u010di aspirac\u00ed, po v\u00e1\u017en\u00e9 plicn\u00ed kontuzi \u010di penetruj\u00edc\u00edm nebo inhala\u010dn\u00edm poran\u011bn\u00ed plic, v\u00fdznamn\u00fdmi negativn\u00edmi faktory jsou sepse, v\u00e1\u017en\u00e1 infekce, pop\u00e1leniny. Spolup\u016fsobit mohou srde\u010dn\u00ed nedostate\u010dnost, p\u0159echodn\u00e1 hypoxemie b\u011bhem akutn\u00ed f\u00e1ze \u00farazu, v\u011bt\u0161\u00ed krevn\u00ed ztr\u00e1ta, mechanick\u00e9 inzulty b\u011bhem operace a \u0159ada dal\u0161\u00edch faktor\u016f. ARDS m\u00e1 vysokou mortalitu, a i kdy\u017e se akutn\u00ed f\u00e1ze ARDS poda\u0159\u00ed zvl\u00e1dnout, n\u00e1sledky tohoto syndromu mohou v\u00e9st k trval\u00e9mu po\u0161kozen\u00ed plicn\u00ed tk\u00e1n\u011b v d\u016fsledku fibr\u00f3zn\u00edch reparativn\u00edch zm\u011bn intersticia. Terapie je podp\u016frn\u00e1, spo\u010d\u00edv\u00e1 v odstran\u011bn\u00ed \u010di korekci vyvol\u00e1vaj\u00edc\u00ed p\u0159\u00ed\u010diny, dokonal\u00e9 oxygenaci pomoc\u00ed vhodn\u00e9ho ventila\u010dn\u00edho re\u017eimu, v p\u00e9\u010di o rovnov\u00e1hu tekutin a dostate\u010dnou nutrici, podpo\u0159e srde\u010dn\u00ed \u010dinnosti a l\u00e9\u010db\u011b arytmi\u00ed, nemal\u00fd v\u00fdznam m\u00e1 odpov\u00eddaj\u00edc\u00ed fyzioterapie. Farmakologicky lze pou\u017e\u00edt inhalaci kysli\u010dn\u00edku dusn\u00e9ho (NO), surfaktantov\u00e9ho aerosolu, pod\u00e1n\u00ed nesteroidn\u00edch antiflogistik, monoklon\u00e1ln\u00edch protil\u00e1tek proti interleukin\u016fm a TNF, \u00faloha kortikoid\u016f v terapii ARDS je sporn\u00e1. V p\u0159\u00edpad\u011b t\u011b\u017ek\u00e9ho pr\u016fb\u011bhu refraktern\u00edho na agresivn\u00ed ventila\u010dn\u00ed re\u017eimy je mo\u017en\u00e9 aplikovat extrakorpor\u00e1ln\u00ed membr\u00e1novou oxygenaci (ECMO).<\/p>\n<h4>6.9.2 Pneumonie<\/h4>\n<p style=\"text-align: justify;\">Pneumonie je nej\u010dast\u011bj\u0161\u00ed posttraumatickou infek\u010dn\u00ed komplikac\u00ed, je p\u0159\u00ed\u010dinou 50 % \u00famrt\u00ed po \u00farazu hrudn\u00edku, je signifikantn\u011b v\u00e1z\u00e1na na dlouhodobou um\u011blou plicn\u00ed ventilaci (UPV). Prvn\u00ed p\u0159\u00edznaky se objevuj\u00ed nej\u010dast\u011bji mezi 3.\u20137. poopera\u010dn\u00edm dnem. Za predisponuj\u00edc\u00ed faktory se pova\u017euj\u00ed aspirace, preexistuj\u00edc\u00ed plicn\u00ed onemocn\u011bn\u00ed, sdru\u017een\u00e1 poran\u011bn\u00ed, kolonizace d\u00fdchac\u00edch cest p\u0159i UPV, polypragmatick\u00e1 antibioterapie selektuj\u00edc\u00ed polyrezistentn\u00ed patogeny, posttraumatick\u00e1 imunosuprese. Prevenc\u00ed t\u00e9to komplikace je operace v chr\u00e1n\u011bn\u00e9m koagulu, dob\u0159e veden\u00e1 anestezie (separace neporan\u011bn\u00e9 pl\u00edce), \u0161etrn\u00e1 opera\u010dn\u00ed technika, starost o dokonalou reexpanzi pl\u00edce a dostate\u010dnou expektoraci. L\u00e9\u010dba je pov\u011bt\u0161inou nechirurgick\u00e1 (antibiotika dle citlivosti, p\u00e9\u010de o hrudn\u00ed dr\u00e9ny, expektorancia, toaleta bronchi\u00e1ln\u00edho stromu, fyzioterapie).<\/p>\n<h4>6.9.3 Plicn\u00ed absces<\/h4>\n<p style=\"text-align: justify;\">Jde o lokalizovan\u00fd hnisav\u00fd proces v dutin\u011b vytvo\u0159en\u00e9 destrukc\u00ed parenchymu. Nej\u010dast\u011bji je d\u016fsledkem intraparenchymat\u00f3zn\u00edho hematomu, u vy\u010derpan\u00fdch nemocn\u00fdch b\u00fdv\u00e1 typickou a v\u00e1\u017enou komplikac\u00ed nekrotizuj\u00edc\u00ed pneumonie. Kultiva\u010dn\u011b lze u ventilovan\u00fdch nemocn\u00fdch v\u011bt\u0161inou prok\u00e1zat sm\u00ed\u0161enou fl\u00f3ru \u2013 <i>Staphylococcus<\/i>, <i>Klebsiella<\/i>, <i>Pseudomonas<\/i>, <i>Proteus species<\/i>, <i>Escherichia<\/i>, <i>Bacteroides<\/i>, <i>Peptococcus<\/i>, <i>Peptostreptococcus<\/i>, <i>Fusobacterium<\/i>. Diagnostika se op\u00edr\u00e1 o typick\u00e9 symptomy: febrilie, ka\u0161el s expektorac\u00ed hnisav\u00e9ho nebo a\u017e putridn\u00edho sputa, mal\u00e1tnost, \u00fanavnost, v\u00e1hov\u00fd \u00fabytek, dyspnoe, pleur\u00e1ln\u00ed bolest, v\u00fdjime\u010dn\u011b hemopt\u00fdza. Fyzik\u00e1ln\u00ed n\u00e1lez v\u0161ak v\u011bt\u0161inou b\u00fdv\u00e1 chud\u00fd. Typick\u00fd rentgenologick\u00fd obraz je infiltr\u00e1t a pozd\u011bji dutina s hladinkou. P\u0159esn\u011bj\u0161\u00ed diagnostika sporn\u00fdch infiltr\u00e1t\u016f je mo\u017en\u00e1 pomoc\u00ed CT. V laborato\u0159i lze vysledovat leukocyt\u00f3zu, elevaci CRP, anemizaci, p\u0159i teplotn\u00edch \u0161pi\u010dk\u00e1ch je vhodn\u00e9 odebrat hemokulturu. Materi\u00e1l k aerobn\u00ed i anaerobn\u00ed kultivaci lze krom\u011b sputa z\u00edskat p\u0159i bronchoskopii, kter\u00e1 je indikov\u00e1na k vylou\u010den\u00ed aspirace \u010di obstrukce ciz\u00edm t\u011blesem. L\u00e9\u010dba je antibiotick\u00e1, zprvu empirick\u00e1 a intraven\u00f3zn\u00ed (1\u20132 t\u00fddny), co nejd\u0159\u00edve \u0159\u00edzen\u00e1 dle citlivosti, po pominut\u00ed toxick\u00fdch zn\u00e1mek infekce i peror\u00e1ln\u00ed v d\u00e9lce 4\u20136 t\u00fddn\u016f. Velk\u00e9 abscesy nereaguj\u00edc\u00ed na konzervativn\u00ed terapii je n\u011bkdy nutn\u00e9 punktovat, resp. l\u00e9pe dr\u00e9novat transpariet\u00e1ln\u011b, pod skiaskopickou, sonografickou \u010di CT navigac\u00ed. Jen v naprosto v\u00fdjime\u010dn\u00fdch p\u0159\u00edpadech je nutn\u00e1 terapie chirurgick\u00e1 \u2013 dren\u00e1\u017e na zp\u016fsob kavernostomie nebo resekce pl\u00edce s abscesovou dutinou. Separace neoperovan\u00e9 pl\u00edce b\u011bhem v\u00fdkonu je velmi \u017e\u00e1douc\u00ed.<\/p>\n<h4>6.9.4 Z\u00fa\u017een\u00ed bronchu<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1931.png\"><img decoding=\"async\" title=\"Obr. 6 \u2013 Striktura hlavn\u00edch pr\u016fdu\u0161ek po rekonstrukci bifurkace\" alt=\"Obr. 6 \u2013 Striktura hlavn\u00edch pr\u016fdu\u0161ek po rekonstrukci bifurkace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1931.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6<br \/>Striktura hlavn\u00edch pr\u016fdu\u0161ek po rekonstrukci bifurkace<\/p><\/div>\n<p style=\"text-align: justify;\">Posttraumatick\u00e1 striktura bronchu (obr. 6) vznik\u00e1 nej\u010dast\u011bji jako n\u00e1sledek nepoznan\u00e9 bronchi\u00e1ln\u00ed l\u00e9ze. Manifestuje se r\u016fzn\u011b v\u00fdraznou du\u0161nost\u00ed nebo infek\u010dn\u00edmi komplikacemi z retence sekretu za z\u00fa\u017een\u00edm. Diagnostika se op\u00edr\u00e1 o bronchoskopii a CT (ev. virtu\u00e1ln\u00ed bronchoskopii). Terapie spo\u010d\u00edv\u00e1 v resekci a anastom\u00f3ze posti\u017een\u00e9 pr\u016fdu\u0161ky, pokud je striktura perifern\u011b, m\u016f\u017ee b\u00fdt \u0159e\u0161en\u00edm resekce pl\u00edce za p\u0159ek\u00e1\u017ekou. V dne\u0161n\u00ed dob\u011b nab\u00fdv\u00e1 na v\u00fdznamu endobronchi\u00e1ln\u00ed sanace, resp. stenting.<\/p>\n<h4>6.9.5 Posttraumatick\u00fd empy\u00e9m<\/h4>\n<p style=\"text-align: justify;\">Posttraumatick\u00fd empy\u00e9m je dal\u0161\u00ed \u010dastou a z\u00e1va\u017enou po\u00farazovou komplikac\u00ed. Velmi \u010dasto se vyskytuje sou\u010dasn\u011b s bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl\u00ed. V \u0159ad\u011b aspekt\u016f se li\u0161\u00ed od klasick\u00fdch parapneumonick\u00fdch afekc\u00ed. V\u011bt\u0161inou je d\u016fsledkem zbytkov\u00e9ho hemotoraxu, proto nem\u00e1 \u010dasnou exsudativn\u00ed f\u00e1zi. B\u00fdv\u00e1 dob\u0159e a pevn\u011b ohrani\u010den\u00fd, pouh\u00e1 dren\u00e1\u017e m\u00e1lokdy vede k uspokojiv\u00e9mu vyhojen\u00ed. V \u010dasn\u00e9 f\u00e1zi (7.\u201314. den) m\u016f\u017ee b\u00fdt \u00fasp\u011b\u0161n\u00e1 videotorakoskopick\u00e1 \u010di videoasistovan\u00e1 toaleta (debridement). Pokud tento postup nen\u00ed \u00fasp\u011b\u0161n\u00fd, je indikov\u00e1na torakotomie a definitivn\u00ed \u0159e\u0161en\u00ed (empy\u00e9mektomie, dekortikace, pleurektomie, fenestrace, raritn\u011b i torakoplastika).<\/p>\n<h4>6.9.6 Bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl, p\u0159etrv\u00e1vaj\u00edc\u00ed air-leak<\/h4>\n<p style=\"text-align: justify;\">Jako air-leak b\u00fdv\u00e1 ozna\u010dov\u00e1n \u00fanik vzduchu do dren\u016f trvaj\u00edc\u00ed d\u00e9le jak 7 dn\u00ed po operaci. B\u00fdv\u00e1 \u010dastou komplikac\u00ed penetruj\u00edc\u00edch poran\u011bn\u00ed. Net\u011bsnost pl\u00edce je zp\u016fsobena drobn\u00fdmi neo\u0161et\u0159en\u00fdmi pr\u016fdu\u0161inkami v lacerovan\u00e9 \u010di operovan\u00e9 pl\u00edci nebo nepoznan\u00fdm poran\u011bn\u00edm v\u011bt\u0161\u00edch pr\u016fdu\u0161ek. Masivn\u00ed \u00fanik odpov\u00eddaj\u00edc\u00ed polovin\u011b dechov\u00e9ho objemu ukazuje na v\u00e1\u017en\u00e9 poran\u011bn\u00ed velk\u00fdch pr\u016fdu\u0161ek, tedy p\u0159\u00edmou komunikaci mezi pr\u016fdu\u0161kou a pleur\u00e1ln\u00ed dutinou \u2013 bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl. Ta vy\u017eaduje neodkladnou reparaci. Men\u0161\u00ed poran\u011bn\u00ed se obvykle uzav\u0159ou slepen\u00edm p\u0159edm\u011btn\u00e9 partie pl\u00edce (a\u0165 u\u017e konvexity, b\u00e1ze \u010di interlobia) s okoln\u00edm parenchymem nebo hrudn\u00ed st\u011bnou. Tomuto procesu br\u00e1n\u00ed nedokonal\u00e1 reexpanze pl\u00edce, a\u0165 u\u017e z d\u016fvodu malfunkce hrudn\u00ed dren\u00e1\u017ee \u010di pro nepom\u011br mezi velikost\u00ed poran\u011bn\u00e9 pl\u00edce a objemem pohrudni\u010dn\u00ed dutiny. Terapie nev\u00fdznamn\u00e9ho \u00faniku je v\u011bt\u0161inou konzervativn\u00ed \u2013 d\u00e9letrvaj\u00edc\u00ed funk\u010dn\u00ed dren\u00e1\u017e, pat\u0159i\u010dn\u011b upravovan\u00e1, nebo redren\u00e1\u017e. Urychlit hojen\u00ed m\u016f\u017ee pomoci \u0161etrn\u00e1 chemick\u00e1 pleurod\u00e9za (koncentrovan\u00fd roztok gluk\u00f3zy, talek). \u00dasp\u011b\u0161n\u00fd m\u016f\u017ee b\u00fdt i miniinvazivn\u00ed p\u0159\u00edstup (pro\u0161it\u00ed m\u00edsta \u00faniku stehem \u010di endostaplerem). Pokud tyto kroky nejsou \u00fasp\u011b\u0161n\u00e9, je nutn\u00e1 operace, revize magistr\u00e1ln\u00edch pr\u016fdu\u0161ek, identifikace p\u00ed\u0161t\u011ble a jej\u00ed p\u0159e\u0161it\u00ed v n\u011bkolika vrstv\u00e1ch nebo resekce pl\u00edce dist\u00e1ln\u011b od poran\u011bn\u00ed. Neanatomick\u00e9 v\u00fdkony,staplerov\u00e9 resekce jsou v\u011bt\u0161inou dosta\u010duj\u00edc\u00ed, anatomick\u00e9 resekce jsou indikov\u00e1ny jen raritn\u011b. Dokonal\u00e9 rozvinut\u00ed zbyl\u00e9 pl\u00edce je v ka\u017ed\u00e9m p\u0159\u00edpad\u011b z\u00e1sadn\u00edm p\u0159edpokladem \u00fasp\u011bchu.<\/p>\n<h4>6.9.7 Rezidu\u00e1ln\u00ed hemotorax, fibrotorax<\/h4>\n<p style=\"text-align: justify;\">Akumulace koagulovan\u00e9 krve, kterou se nepoda\u0159ilo odstranit \u0159\u00e1dnou hrudn\u00ed dren\u00e1\u017e\u00ed, je nebezpe\u010dn\u00e1 z d\u016fvodu mo\u017en\u00e9 kontaminace a v\u00fdvoje empy\u00e9mu. Neinfikovan\u00fd koagulovan\u00fd hemotorax se v\u011bt\u0161inou neresorbuje \u00fapln\u011b, v\u011bt\u0161inou se vyvine v m\u00edst\u011b kolekce (typicky dorzobaz\u00e1ln\u011b) v\u011bt\u0161\u00ed \u010di men\u0161\u00ed fibrotorax. Nejlep\u0161\u00ed prevenc\u00ed takov\u00e9ho pr\u016fb\u011bhu je \u010dasn\u00e1 dekortikace, resp. mechanick\u00e1 toaleta (debridement) posti\u017een\u00e9 \u010d\u00e1sti pohrudni\u010dn\u00ed dutiny, kterou je mo\u017en\u00e9 prov\u00e9st podle lok\u00e1ln\u00edch pom\u011br\u016f videotorakoskopicky, videoasistovan\u011b \u010di cestou mal\u00e9 torakotomie.<\/p>\n<h4>6.9.8 Chylotorax<\/h4>\n<p style=\"text-align: justify;\">Traumatick\u00fd chylotorax je neobvyklou komplikac\u00ed a nepoznan\u00fd m\u016f\u017ee dosp\u011bt do fat\u00e1ln\u00edho konce. V souhlasu s pr\u016fb\u011bhem m\u00edzovodu se li\u0161\u00ed stranovou manifestac\u00ed. Pravostrann\u00fd chylotorax vznik\u00e1 z poran\u011bn\u00ed ductus thoracicus v doln\u00edm mediastinu po \u00farove\u0148 bifurkace, levostrann\u00fd p\u0159i l\u00e9zi hluboko pod obloukem aorty, mezi aortou a lev\u00fdm bronchem a v lev\u00e9m horn\u00edm mediastinu a\u017e po vstup do levostrann\u00e9ho angulus venosus. Nebezpe\u010d\u00ed t\u00e9to komplikace tkv\u00ed v tom, \u017ee excesivn\u00ed ztr\u00e1ta vody, miner\u00e1l\u016f, protein\u016f a tuk\u016f dok\u00e1\u017ee dov\u00e9st nemocn\u00e9ho do metabolick\u00e9ho rozvratu. Terapie m\u016f\u017ee b\u00fdt zpo\u010d\u00e1tku konzervativn\u00ed \u2013 vylou\u010den\u00ed p\u0159\u00edjmu per os, kompletn\u00ed vybalancovan\u00e1 parenter\u00e1ln\u00ed hyperalimentace, lze zkusit somatostatin nebo jeho analoga. Konzervativn\u00ed l\u00e9\u010dba m\u016f\u017ee m\u00edt nad\u011bji na \u00fasp\u011bch v p\u0159\u00edpad\u011b nekompletn\u00ed l\u00e9ze. Infek\u010dn\u00ed komplikace nehroz\u00ed, chylus obsahuje mno\u017estv\u00ed protil\u00e1tek a lymfocyt\u016f a chov\u00e1 se bakteriostaticky a\u017e baktericidn\u011b. V p\u0159\u00edpad\u011b \u00fapln\u00e9ho p\u0159eru\u0161en\u00ed ductus thoracicus, \u010demu\u017e odpov\u00eddaj\u00ed denn\u00ed ztr\u00e1ty do dr\u00e9n\u016f p\u0159esahuj\u00edc\u00ed 3000 ml, je nad\u011bje na spont\u00e1nn\u00ed \u00fapravu miziv\u00e1. P\u0159i nezhojen\u00ed do 14 dn\u016f je nutn\u00e1 opera\u010dn\u00ed revize. Jsou v podstat\u011b t\u0159i mo\u017en\u00e9 zp\u016fsoby chirurgick\u00e9 n\u00e1pravy. Je to vyhled\u00e1n\u00ed p\u0159eru\u0161en\u00e9ho duktu v opera\u010dn\u00edm poli a jeho pro\u0161it\u00ed, ev. masivn\u00ed pro\u0161it\u00ed mediastina v m\u00edst\u011b, kde je patrn\u00e1 lymfatick\u00e1 sekrece. Dal\u0161\u00ed mo\u017enost\u00ed je vypreparov\u00e1n\u00ed m\u00edzovodu nad br\u00e1nic\u00ed mezi v. azygos a j\u00edcnem a jeho selektivn\u00ed podvaz. T\u0159et\u00ed cestou je postupn\u00e1 masivn\u00ed ligatura v\u0161ech tk\u00e1n\u00ed mezi t\u0159emi v\u00fd\u0161e vyjmenovan\u00fdmi strukturami. Ductus thoracicus m\u00e1 velmi nepravideln\u00fd pr\u016fb\u011bh, \u010detn\u00e9 v\u011btven\u00ed, a\u017e v 60 % p\u0159\u00edpad\u016f b\u00fdv\u00e1 nad br\u00e1nic\u00ed zdvojen a\u017e ztrojen. Podvaz jednoho vypreparovan\u00e9ho m\u00edzovodu proto nemus\u00ed b\u00fdt \u00fasp\u011b\u0161n\u00fd. Uveden\u00e9 postupy jsou uskute\u010dniteln\u00e9 z torakotomie i miniinvazivn\u011b, v\u011bt\u0161inou zprava. Pokus o uz\u00e1v\u011br lymfatick\u00e9 p\u00ed\u0161t\u011ble m\u016f\u017ee b\u00fdt dopln\u011bn pleurod\u00e9zou.<\/p>\n<h4>6.9.9 Tracheoezofage\u00e1ln\u00ed, bronchoezofage\u00e1ln\u00ed p\u00ed\u0161t\u011bl (TEF)<\/h4>\n<p style=\"text-align: justify;\">V\u011bt\u0161ina penetruj\u00edc\u00edch poran\u011bn\u00ed v oblasti hrudn\u00ed apertury b\u00fdv\u00e1 neodkladn\u011b revidov\u00e1na a jednotliv\u00e9 struktury jsou bezprost\u0159edn\u011b o\u0161et\u0159eny. N\u00e1sledky tup\u00fdch poran\u011bn\u00ed se manifestuj\u00ed pozd\u011bji, do 10. dne od \u00farazu. Kr\u010dn\u00ed p\u00ed\u0161t\u011ble vznikaj\u00ed v d\u016fsledku komprese laryngo-trache\u00e1ln\u00edho p\u0159echodu a j\u00edcnu proti p\u00e1te\u0159i. Dal\u0161\u00ed mo\u017en\u00fd mechanismus vzniku TEF p\u0159edstavuje dekubit\u00e1ln\u00ed nekr\u00f3za st\u011bny pr\u016fdu\u0161nice a j\u00edcnu t\u011bsn\u00edc\u00ed man\u017eetou, nap\u0159. proti nazogastrick\u00e9 sond\u011b p\u0159i dlouhodob\u00e9 UPV. Mechanismus vzniku dist\u00e1ln\u00edch mediastin\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed je nejasn\u00fd, p\u0159edpokl\u00e1danou roli hraje v\u00fdznamn\u00e1 decelerace, subklinick\u00e1 lacerace membran\u00f3zn\u00ed trachey a kontuze p\u0159edn\u00ed st\u011bny j\u00edcnu. Klinicky se tato komplikace projevuje opakovan\u00fdmi aspiracemi, diagnostika je mo\u017en\u00e1 skiagraficky (ezofagogram vodn\u00fdm kontrastem), bronchoskopicky, ezofagoskopicky \u010di pomoc\u00ed CT. Prim\u00e1rn\u00ed l\u00e9\u010dba nemocn\u00fdch na ventil\u00e1toru je konzervativn\u00ed \u2013 intubace pod \u00fast\u00ed p\u00ed\u0161t\u011ble a zabezpe\u010den\u00ed v\u00fd\u017eivy enter\u00e1ln\u00ed sondou \u010di gastrostomi\u00ed. Po obnoven\u00ed spont\u00e1nn\u00ed ventilace je mo\u017en\u00e1 l\u00e9\u010dba chirurgick\u00e1. Mal\u00e9 p\u00ed\u0161t\u011ble lze po odd\u011blen\u00ed obou struktur p\u0159e\u0161\u00edt a sutury odd\u011blit interpozic\u00ed vit\u00e1ln\u00ed tk\u00e1n\u011b. Velk\u00e9 p\u00ed\u0161t\u011ble jsou \u0159e\u0161eny transtrache\u00e1ln\u00ed suturou j\u00edcnu a resekc\u00ed posti\u017een\u00e9ho \u00faseku pr\u016fdu\u0161nice rekonstrukc\u00ed end-to-end. Interpozice vit\u00e1ln\u00ed tk\u00e1n\u011b (perikard, sval) je op\u011bt \u017e\u00e1douc\u00ed. Hypoventilace, resp. nutnost reintubace znamenaj\u00ed kritick\u00e9 riziko ne\u00fasp\u011bchu. Definitivn\u00ed chirurgick\u00e1 l\u00e9\u010dba d\u00e1v\u00e1 nejlep\u0161\u00ed \u0161anci na \u00fasp\u011bch, u rizikov\u00fdch nemocn\u00fdch lze s ur\u010ditou nad\u011bj\u00ed na \u00fasp\u011bch \u0159e\u0161it tuto komplikaci obdukovan\u00fdmi trache\u00e1ln\u00edmi nebo ezofage\u00e1ln\u00edmi stenty.<\/p>\n<h4>6.9.10 Ezofagopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl<\/h4>\n<p style=\"text-align: justify;\">J\u00edcen b\u00fdv\u00e1 vzhledem k velikosti a chr\u00e1n\u011bn\u00e9mu ulo\u017een\u00ed p\u0159ed p\u00e1te\u0159\u00ed po\u0161kozen v r\u00e1mci \u00farazu jen vz\u00e1cn\u011b. Penetruj\u00edc\u00ed poran\u011bn\u00ed, je-li o\u0161et\u0159eno v\u010das (24 hodin od \u00farazu), m\u00e1 velmi dobr\u00e9 \u0161ance na zhojen\u00ed. Pozdn\u00ed n\u00e1sledky tup\u00fdch \u00faraz\u016f hrudn\u00edku jsou d\u016fsledkem kontuze st\u011bny j\u00edcnu a lok\u00e1ln\u00ed ischemie, hoj\u00ed se strikturami, kter\u00e9 jsou v\u011bt\u0161inou dilatovateln\u00e9 nebo stentovateln\u00e9. Ezofagopleur\u00e1ln\u00ed p\u00ed\u0161t\u011ble vznikaj\u00ed v\u011bt\u0161inou v d\u016fsledku nepoznan\u00e9 perforace, manifestuj\u00ed se jako empy\u00e9m. Po hrudn\u00ed dren\u00e1\u017ei ukazuje na komunikaci j\u00edcnu s pleur\u00e1ln\u00edm prostorem p\u0159\u00edm\u011bs \u017elu\u010di \u010di enter\u00e1ln\u00ed v\u00fd\u017eivy v sekretu. Pr\u016fkaz je mo\u017en\u00fd ezofagograficky, ezofagoskopie je rizikov\u00e1 z d\u016fvodu mo\u017en\u00e9ho zhor\u0161en\u00ed lok\u00e1ln\u00edho stavu. Sutura chronick\u00e9 ezofagopleur\u00e1ln\u00ed p\u00ed\u0161t\u011ble zejm\u00e9na u kritick\u00fdch nemocn\u00fdch m\u00e1 malou \u0161anci na \u00fasp\u011bch. Principem l\u00e9\u010dby je \u0159\u00e1dn\u00e1 dren\u00e1\u017e pohrudni\u010dn\u00ed dutiny, pomoci m\u016f\u017ee kr\u010dn\u00ed ezofagostomie a vnit\u0159n\u00ed dren\u00e1\u017e j\u00edcnu, v\u00fd\u017eivu je t\u0159eba zajistit jejunostomi\u00ed. Progn\u00f3za t\u00e9to komplikace je velmi nejist\u00e1, z\u00e1vis\u00ed na v\u00e1\u017enosti \u00farazu a kondici zran\u011bn\u00e9ho.<\/p>\n<h4>6.9.11 Arytmie<\/h4>\n<p style=\"text-align: justify;\">Mohou b\u00fdt nez\u00e1va\u017en\u00e9, supraventrikul\u00e1rn\u00ed, v\u011bt\u0161ina z nich se projev\u00ed v prvn\u00edch dnech po operaci, \u0159ada z nich spont\u00e1nn\u011b vymiz\u00ed. Za vyvol\u00e1vaj\u00edc\u00ed p\u0159\u00ed\u010dinu b\u00fdv\u00e1 pova\u017eov\u00e1na akutn\u00ed plicn\u00ed hypertenze z restrikce v\u00fdtokov\u00e9 mo\u017enosti prav\u00e9ho srdce p\u0159i akutn\u00edm plicn\u00edm traumatu. Fibrilace a zejm\u00e9na flutter s\u00edn\u00ed s rychlou odpov\u011bd\u00ed komor mus\u00ed b\u00fdt bedliv\u011b monitorov\u00e1ny a p\u0159\u00edpadn\u011b l\u00e9\u010deny farmakologicky. U v\u00e1\u017en\u011bj\u0161\u00edch arytmi\u00ed lze zv\u00e1\u017eit kardioverzi, pokud je v\u0161ak tachyarytmie d\u016fsledkem nastupuj\u00edc\u00edho ARDS, je nutn\u00e9 zam\u011b\u0159it l\u00e9\u010dbu t\u00edmto sm\u011brem.<\/p>\n<h4>6.9.12 Perikarditida<\/h4>\n<p style=\"text-align: justify;\">Vz\u00e1cn\u011b b\u00fdv\u00e1 popisov\u00e1na konstriktivn\u00ed perikarditida jako d\u016fsledek retinovan\u00e9ho hemoperikardu a lok\u00e1ln\u00ed posttraumatick\u00e9 reakce epikardu. Symptomatologie je dan\u00e1 rozsahem posti\u017een\u00ed, diagnostika echokardiografick\u00e1 nebo pomoc\u00ed MRI. L\u00e9\u010dbou klinicky v\u00fdznamn\u00fdch stadi\u00ed je perikardektomie.<\/p>\n<h4>6.9.13 Pseudoaneuryzma<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1971.png\"><img decoding=\"async\" title=\"Obr. 7 \u2013 Traumatick\u00e9 pseudoaneuryzma truncus brachiocephalicus\" alt=\"Obr. 7 \u2013 Traumatick\u00e9 pseudoaneuryzma truncus brachiocephalicus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1971.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7<br \/>Traumatick\u00e9 pseudoaneuryzma truncus brachiocephalicus<\/p><\/div>\n<p style=\"text-align: justify;\">Ruptura aorty je p\u0159\u00ed\u010dinou ka\u017ed\u00e9ho des\u00e1t\u00e9ho \u00famrt\u00ed souvisej\u00edc\u00edho s tup\u00fdm \u00farazem hrudn\u00edku. Pokud nekon\u010d\u00ed fat\u00e1ln\u011b a nen\u00ed rozpozn\u00e1na, m\u016f\u017ee se vyvinout do pseudoaneuryzmatu, stejn\u011b jako nepoznan\u00e9 ruptury velk\u00fdch c\u00e9v oblouku (obr. 7). Indikace k resekci b\u00fdvala oblig\u00e1tn\u00ed. B\u011bhem elektivn\u00ed operace mus\u00ed b\u00fdt preventivn\u011b minimalizov\u00e1no riziko ischemie m\u00edchy aorto-aort\u00e1ln\u00edm zkratem (Gott\u016fv shunt) nebo pomoc\u00ed extrakorpor\u00e1ln\u00ed cirkulace. V posledn\u00ed dob\u011b nab\u00fdv\u00e1 na v\u00fdznamu ve vhodn\u00fdch indikac\u00edch (stejn\u011b jako\u00a0u netraumatick\u00fdch v\u00fddut\u00ed) endovaskul\u00e1rn\u00ed terapie stentgrafty.<\/p>\n<h4>6.9.14 Hernie hrudn\u00ed st\u011bny<\/h4>\n<p style=\"text-align: justify;\">Interkost\u00e1ln\u00ed hernie je sp\u00ed\u0161e n\u00e1sledkem torakotomie ne\u017e vlastn\u00edho poran\u011bn\u00ed hrudn\u00ed st\u011bny (viz obr. 5). Mimo torakotomii pak b\u00fdv\u00e1 paravertebr\u00e1ln\u011b nebo parastern\u00e1ln\u011b. V\u011bt\u0161inou m\u00e1 minim\u00e1ln\u00ed symptomatologii. Bolest v defektu hrudn\u00ed st\u011bny sv\u011bd\u010d\u00ed sp\u00ed\u0161e pro sekund\u00e1rn\u00ed zm\u011bny herniovan\u00e9 pl\u00edce. Chirurgick\u00e1 l\u00e9\u010dba je indikovan\u00e1 u velk\u00fdch a symptomatick\u00fdch herni\u00ed. Reparace je mo\u017en\u00e1 plikac\u00ed a perikost\u00e1ln\u00ed suturou nebo pomoc\u00ed autologn\u00edho \u010di syntetick\u00e9ho materi\u00e1lu.<\/p>\n<h4>6.9.15 Chronick\u00e1 bolest<\/h4>\n<p style=\"text-align: justify;\">Chronick\u00e1 posttraumatick\u00e1 bolest postihuje a\u017e t\u0159etinu poran\u011bn\u00fdch na dobu \u0159ady m\u011bs\u00edc\u016f a\u017e let. L\u00e9\u010dba je konzervativn\u00ed, ne v\u017edy \u00fasp\u011b\u0161n\u00e1. V torpidn\u00edch p\u0159\u00edpadech z\u016fstavaj\u00ed nemocn\u00ed v p\u00e9\u010di ambulance bolesti na trval\u00e9 analgetick\u00e9 medikaci. Neurochirurgick\u00e9 metody (neuromodulace, epidur\u00e1ln\u00ed elektrostimulace, DREZ-tomie, spinotalamick\u00e1 traktotomie) maj\u00ed jen okrajov\u00fd v\u00fdznam.<\/p>\n<h3 style=\"text-align: justify;\">6. 10 Literatura<\/h3>\n<ol>\n<li style=\"text-align: justify;\">Allen GS, Coates NE. Pulmonary contusions:a collective review. Am Surg. 1996;62:895\u2013900.<\/li>\n<li style=\"text-align: justify;\">Baker SP, O\u2019Neill B, Haddon W, Long WB. Theinjury severity score: a method for describing pa-tients with multiple injuries and evaluating emer-gency care. J Trauma. 1974;14:187\u2013196.<\/li>\n<li style=\"text-align: justify;\">Bernard GR, Artigas A, Brigham KL, Carlet J, etal. The American-European Consensus Confer-ence od ARDS: definitions, mechanisms, relevantoutcomes, and clinical trial coordination. AmJ Respir Crit Care Med. 1994;149:818\u2013824.<\/li>\n<li style=\"text-align: justify;\">Bosse MJ, MacKenzie E, Riemer BL, et al. Adultrespiratory distress syndrome, pneumonia, andmortality following thoracic injury and femoralfracture treated either with intramedullary nailingwith reaming or with a plate. J Bone Joint SurgAm. 1997;79(6):799\u2013809.<\/li>\n<li style=\"text-align: justify;\">Cohn SM. Pulmonary contusion: review of clini-cal entity. J Trauma. 1997;42(5):973\u2013979.<\/li>\n<li style=\"text-align: justify;\">Clark GC, Schecter WP, Trunkey DD. Variablesaffecting outcome in blunt chest trauma: flailchest vs pulmonary contusion. J Trauma. 1988;28:298\u2013304.<\/li>\n<li style=\"text-align: justify;\">Freedland M, Wilson RF, Bender JS, Levison MA.The management of flail chest injury: factors af-fecting outcome. J Trauma. 1990;30:1460\u20131468.<\/li>\n<li style=\"text-align: justify;\">Gaillard M, Herve C, Mandin L, Raynaud P. Mor-tality prognostic factors in chest injury. J Trauma.1990;30:93\u201396.<\/li>\n<li style=\"text-align: justify;\">Greene R. Lung alternations in thoracic trauma.J Thorac Imag. 1987;2:1\u20137.<\/li>\n<li style=\"text-align: justify;\">Hoff SJ, Shotts SD, Eddy VA, Morris JA. Outcomeof isolated pulmonary contusion in blunt traumapatients. Am Rurg 1994;60:138\u2013142.<\/li>\n<li style=\"text-align: justify;\">Lee RB, Bass SM, Morris JA, Mac Kenzie EJ. Threeor more rib fracture as an indicator for transfer toa level I trauma center: a population-based study.J Trauma. 1990;30(6):689\u2013694.<\/li>\n<li style=\"text-align: justify;\">Lo Cicero J, Mattox KL. Epidemiology of chesttrauma. Surg Clin North Am. 1989;69:15\u201319.<\/li>\n<li style=\"text-align: justify;\">Pafko P. Z\u00e1klady speci\u00e1ln\u00ed chirurgie. Praha; Ga-l\u00e9n: 2008.<\/li>\n<li style=\"text-align: justify;\">Pearson GF, Cooper JD, Deslauriers J, Gins-berg RJ, Hiebert CA, Patterson GA, Urschel HC.Thoracic surgery. New York: Churchil Living-stone; 2002.<\/li>\n<li style=\"text-align: justify;\">Pichlmaier H, Schildberg FW. Thoraxchirurgie.Heidelberg: Springer; 2006.<\/li>\n<li style=\"text-align: justify;\">Price-Thomas C. C onser vative resection ofthe bronchial three. J R Coll Sulg Edinb. 1956;1:169\u2013173.<\/li>\n<li style=\"text-align: justify;\">Proch\u00e1zka J. Resekce plic. Praha. SZN; 1954.<\/li>\n<li style=\"text-align: justify;\">Regel G, Seekamp A, Aebert H, et al. Bronchos-copy in severe blunt chest trauma. Surg Endosc.1990;4:31\u201335.<\/li>\n<li style=\"text-align: justify;\">\u0158eh\u00e1k F, \u0160mat V Chirurgie plic a mediastina. Pra-ha: Avicenum; 1986.<\/li>\n<li style=\"text-align: justify;\">Sturm JA, Lewis FR, Trentz O. Cardiopulmonaryparameters and prognosis after severe multipletrauma. J Trauma. 1979;19:305\u2013317.<\/li>\n<li style=\"text-align: justify;\">Toombs BD, Sandler SV, Lester RG. Computedtomography of chest trauma. Radiology. 1981;140:733\u2013738.<\/li>\n<li style=\"text-align: justify;\">van Os JP, Roumne R, Schoots F, Heystraaten FJ, Goris RJA. Is early osteosynthesis safe in multiple trauma patients with severe thoracic trauma and pulmonar y contusions? J Trauma. 1994;36:495\u2013498.<\/li>\n<li style=\"text-align: justify;\">Wagner RB, Crawford WO jr, Schimpf PP, Jamie-son PM, Rao KC. Quantification and pattern ofparenchymal lung injury in blunt chest trauma:diagnostic and therapeutic implications. J Com-put Tomogr. 1988;12:270\u2013281.<\/li>\n<li style=\"text-align: justify;\">Wilson JM, Thomas A, Goodman P, Lewis FR.Severe chest trauma: morbidity implication offirst end second rib fractures in 120 patients. ArchSurg. 1978;113:846\u2013884.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>6.1 Anatomie hrudn\u00ed st\u011bny a br\u00e1nice Hrudn\u00edk m\u00e1 tvar komol\u00e9ho ku\u017eele ohrani\u010den\u00e9ho horn\u00ed hrudn\u00ed aperturou, muskuloskelet\u00e1ln\u00edmi komponentami hrudn\u00edho ko\u0161e a doln\u00ed hrudn\u00ed aperturou. Horn\u00ed hrudn\u00ed apertura topograficky odd\u011bluje kr\u010dn\u00ed prostor od hrudn\u00edku, m\u00e1 ledvinovit\u00fd tvar, tvo\u0159\u00ed ji manubrium sterna, kostoklavikul\u00e1rn\u00ed sklouben\u00ed, prvn\u00ed dv\u011b \u017eebra a t\u011blo 1. hrudn\u00edho obratle. Horn\u00ed hrudn\u00ed aperturou prob\u00edh\u00e1 \u0159ada d\u016fle\u017eit\u00fdch [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1347,"menu_order":30,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1560","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1560","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1560"}],"version-history":[{"count":22,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1560\/revisions"}],"predecessor-version":[{"id":1826,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1560\/revisions\/1826"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1347"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1560"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}