Chest Trauma


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Chest Trauma

  1. 1. Chest Trauma 06/07/09
  2. 2. WHAT IS IT? <ul><li>Chest trauma is often sudden </li></ul><ul><li>and dramatic </li></ul><ul><li>Accounts for 25% of all </li></ul><ul><li>trauma deaths </li></ul><ul><li>2/3 of deaths occur after </li></ul><ul><li> reaching hospital </li></ul>06/07/09
  3. 3. WHY DO IT OCCUR? <ul><li>Blunt Trauma - Blunt force to chest. E.g. automobile crashes and falls. </li></ul><ul><li>Penetrating Trauma - Projectile that enters chest causing small or large hole. E.g. gun shot and stabbing. </li></ul><ul><li>Compression Injury - Chest is caught between two objects and chest is compressed. </li></ul>06/07/09
  4. 4. WHAT DOES IT DO? <ul><li>Rib fractures </li></ul><ul><li>Flail chest </li></ul><ul><li>Pulmonary contusion </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Haemothorax </li></ul>06/07/09
  5. 5. Rib Fracture <ul><li>A rib fracture is a break in a rib bone. </li></ul><ul><li>Cause is blunt chest trauma (fall, blow to the chest, etc). </li></ul><ul><li>Symptoms </li></ul><ul><li>Localized pain </li></ul><ul><li>Tenderness over the fractured area on inspiration and palpation </li></ul><ul><li>Shallow respiration atelectasis & pneumonia </li></ul><ul><li>Pain when coughing </li></ul><ul><li>Swelling and bruising in the fracture area </li></ul><ul><li>Internal bleeding </li></ul><ul><li>Pneumothorax or heamothorax </li></ul>06/07/09
  6. 6. HOW TO DIAGNOSE? <ul><li>CHEST XRAY </li></ul>06/07/09
  7. 7. MANAGEMENT <ul><li>  </li></ul><ul><li>Most rib fracture heals in 3 – 6 weeks. </li></ul><ul><li>Generally treated conservatively with rest, local heat and analgesics. </li></ul><ul><li>Monitor for the sign of associated injuries. </li></ul><ul><li>Rest and do not do physical activity. </li></ul><ul><li>Adequate pain relief </li></ul>06/07/09
  8. 8. FLIAL CHEST The breaking of 2 or more ribs in 2 or more places, resulting in free- floating rib segments. 06/07/09
  9. 9. <ul><li>The flail segment has no bony or cartilaginous connection </li></ul><ul><li>Moves independently of the chest wall </li></ul><ul><li>Paradoxical chest movement </li></ul>06/07/09
  10. 10. <ul><li>PARADOXICAL </li></ul><ul><li>MOVEMENT </li></ul><ul><li>The flail portion of the chest is </li></ul><ul><li>sucked in with inspiration, instead of expanding outward </li></ul><ul><li>Ballooned out with expiration instead of collapsing inward </li></ul><ul><li>Hypoventilation and hypoxemia </li></ul>06/07/09
  11. 11. S/S OF FLAIL CHEST <ul><li>Shortness of Breath </li></ul><ul><li>Paradoxical Movement </li></ul><ul><li>Bruising/Swelling </li></ul><ul><li>Crepitus (Grinding of bone ends on palpation) </li></ul><ul><li>Tachycardia </li></ul><ul><li>Hypotension </li></ul>06/07/09
  12. 12. <ul><li>Complication: </li></ul><ul><li>Hypoventilation </li></ul><ul><li>Atelectasis </li></ul><ul><li>Mediastinal flutter (mediastinal structures tend to swing back n forth) </li></ul><ul><li>Diagnosis: </li></ul><ul><li>Palpation : crepitus and tenderness near fractured ribs. </li></ul><ul><li>chest x-ray </li></ul><ul><li>ABGs </li></ul>06/07/09
  13. 13. PULMONARY CONTUSION <ul><li>It is damage to the lung tissues resulting in hemorrhage and localized edema. </li></ul><ul><li>Ecchymosis at the site of the damage </li></ul><ul><li>Crackels </li></ul><ul><li>Cough may be present with blood-tinged sputum. </li></ul><ul><li>Pulmonary contusions tend to worsen over a 24– to 48–hour period and then slowly resolve unless complications occur (infection, ARDS). </li></ul><ul><li>Patients with severe contusions may require endotracheal intubation and mechanical ventilation </li></ul>06/07/09
  14. 14. NURSING IMPLICATION <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Ineffective Airway Clearance </li></ul><ul><li>Ineffective Breathing Pattern </li></ul><ul><li>Impaired Gas Exchange </li></ul><ul><li>Pain </li></ul><ul><li>Risk for Infection </li></ul><ul><li>Activity Intolerance </li></ul><ul><li>Anxiety </li></ul><ul><li>Decreased Cardiac output </li></ul><ul><li>Impaired tissue perfusion </li></ul><ul><li>Ineffective individual coping </li></ul><ul><li>Altered health maintenance </li></ul>06/07/09
  15. 15. NURSING IMPLICATION <ul><li>INTERVENTION: </li></ul><ul><li>Frequent and prompt Respiratory assessment </li></ul><ul><li>Adequate oxygenation </li></ul><ul><li>Analgesia to improve ventilation. </li></ul><ul><li>Clearing secretion </li></ul><ul><li>Stabilize the thoracic cage </li></ul><ul><li>Deep breathing exercises </li></ul><ul><li>Intubation and mechanical ventilation may be required to prevent further hypoxia </li></ul>06/07/09
  16. 16. NURSING IMPLICATION <ul><li>Pain Control </li></ul><ul><li>Alternative to relieve pain: </li></ul><ul><ul><li>Intercostal Nerve Blocks </li></ul></ul><ul><ul><li>Epidural Anesthesia. </li></ul></ul><ul><ul><li>Wearing a chest binder </li></ul></ul><ul><li>Maintain IV flow rates </li></ul><ul><li>Monitor S/S of adequate tissue perfusion </li></ul><ul><li>Anxiety reducing techniques </li></ul><ul><li>Coping mechanism </li></ul><ul><li>Heath education/teaching </li></ul>06/07/09
  17. 17. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>ARDS </li></ul></ul><ul><ul><li>Lung abscess </li></ul></ul><ul><ul><li>Emphysema </li></ul></ul><ul><ul><li>Pulmonary embolism. </li></ul></ul>06/07/09
  18. 18. PNEUMOTHORAX <ul><li>Pneumothorax is a pocket of air between the two layers of pleura (parietal or visceral), resulting in collapse of the lung. </li></ul><ul><li>TYPES : </li></ul><ul><li>Open Pneumothorax </li></ul><ul><li>Tension Pneumothorax </li></ul>06/07/09
  19. 19. Types <ul><li>Open Laceration in the parietal pleura that allows atmospheric air to enter the pleural space; occurs as a result of penetrating chest trauma </li></ul><ul><li>Closed Laceration in the visceral pleura that allows air from the lung to enter the pleural space; occurs as a result of blunt chest trauma </li></ul>06/07/09
  20. 20. Open Pneumothorax 06/07/09
  21. 21. Open Pneumothorax Inhale 06/07/09
  22. 22. Open Pneumothorax Exhale 06/07/09
  23. 23. Open Pneumothorax Inhale 06/07/09
  24. 24. Open Pneumothorax Exhale 06/07/09
  25. 25. Open Pneumothoarx Inhale 06/07/09
  26. 26. Open Pnuemothorax Inhale 06/07/09
  27. 27. Pathophysiology <ul><li>Air enters the pleural space, the affected lung becomes compressed. </li></ul><ul><li>As the lung collapses, the alveoli become underventilated, </li></ul><ul><li>Causing V/Q mismatching and intrapulmonary shunting. </li></ul>06/07/09
  28. 28. CONT.. <ul><li>If the pneumothorax is large, hypoxemia ensues and acute respiratory failure quickly develops. </li></ul><ul><li>In addition, increased pressure within the chest can lead to shifting of the mediastinum, compression of the great vessels, and decreased cardiac output </li></ul>06/07/09
  29. 29. Tension Pneumothorax <ul><li>Occurs when air is allowed to enter the pleural space but not exit it; as pressure increases inside the pleural space, the lung collapses and the mediastinum shifts to the unaffected side; may be a result of a spontaneous or traumatic pneumothorax. </li></ul>06/07/09
  30. 30. Tension Pneumothorax Each time we inhale, the lung collapses further. There is no place for the air to escape.. 06/07/09
  31. 31. Tension Pneumothorax Each time we inhale, the lung collapses further. There is no place for the air to escape.. 06/07/09
  32. 32. Tension Pneumothorax Heart is being compressed The trachea is pushed to the good side 06/07/09
  33. 33. 06/07/09
  34. 34. S/S OF TENSION PNEUMOTHORAX <ul><li>Anxiety/Restlessness </li></ul><ul><li>Severe Dyspnea </li></ul><ul><li>Absent Breath sounds on affected side </li></ul><ul><li>Tachypnea </li></ul><ul><li>Tachycardia </li></ul><ul><li>Poor Color </li></ul><ul><li>Accessory Muscle Use </li></ul><ul><li>Hypotension </li></ul><ul><li>Tracheal Deviation </li></ul><ul><li>(late if seen at all) </li></ul><ul><li>Hyperresonance to percussion </li></ul>. 06/07/09
  35. 35. Assessment and Diagnosis <ul><li>Depend on the degree of lung collapse. </li></ul><ul><li>When a pneumothorax is large, decreased respiratory excursion on the affected side may be noticed, along with bulging intercostal muscles. The trachea may deviate away from the affected side. </li></ul><ul><li>Percussion reveals hyperresonance with decreased or absent breath sounds over the affected area. </li></ul><ul><li>ABGs will demonstrate hypoxemia and hypercapnia. </li></ul><ul><li>A chest x-ray film will confirm the pneumothorax with increased translucency evident on the affected side </li></ul>06/07/09
  36. 36. MEDICAL MANAGEMENT <ul><li>Depending on the severity of the specific disorder. </li></ul><ul><li>At times requires only supplemental oxygen administration, unless complications occur or underlying lung disease or injury is present. </li></ul><ul><li>At times urgently require intervention to evacuate the air from the pleural space and facilitate re expansion of the collapsed lung. </li></ul>06/07/09
  37. 37. Treatment <ul><li>Administering supplemental oxygen </li></ul><ul><li>Inserting a large-bore needle or catheter into the second intercostal space at the midclavicular line of the affected side. This action relieves the pressure within the chest. The needle should remain in place until the patient is stabilized and a chest tube is inserted </li></ul><ul><li>Chest tube insertion </li></ul>06/07/09
  38. 38. Needle Decompression <ul><li>Locate 2-3 Intercostal space midclavicular line </li></ul><ul><li>Cleanse area using aseptic technique </li></ul><ul><li>Insert catheter ( 14g or larger) at least 3” in length over the top of the 3 rd rib( nerve, artery, vein lie along bottom of rib) </li></ul><ul><li>Remove Stylette and listen for rush of air </li></ul><ul><li>Place Flutter valve over catheter </li></ul><ul><li>Reassess for Improvement </li></ul>06/07/09
  39. 39. Needle Decompression 06/07/09
  40. 40. Nursing Diagnosis <ul><li>  Impaired Gas Exchange related to ventilation/ perfusion mismatching or intrapulmonary shunting   </li></ul><ul><li>Ineffective Breathing Pattern related to decreased lung expansion </li></ul><ul><li>Acute Pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses </li></ul><ul><li>Anxiety related to threat to biologic, psychologic, and/or social integrity </li></ul><ul><li>Disturbed Body Image related to actual change in body structures, function, or appearance </li></ul><ul><li>Compromised Family Coping related to critically ill family member </li></ul>06/07/09
  41. 41. NURSING INTERVENTIONS <ul><li>Continuous and vigilant respiratory assessment </li></ul><ul><li>Optimizing oxygenation and ventilation, </li></ul><ul><li>Maintaining the chest tube system </li></ul><ul><li>Providing comfort and emotional support </li></ul><ul><li>Maintaining surveillance for complications. </li></ul>06/07/09
  42. 42. Hemothorax <ul><li>Occurs when pleural space fills with blood </li></ul><ul><li>Usually occurs due to lacerated blood vessel in thorax </li></ul><ul><li>As blood increases, it puts pressure on heart and other vessels in chest cavity </li></ul><ul><li>Each Lung can hold 1.5 liters of blood </li></ul>06/07/09
  43. 43. Hemothorax 06/07/09
  44. 44. Hemothorax 06/07/09
  45. 45. Hemothorax 06/07/09
  46. 46. Hemothorax 06/07/09
  47. 47. Hemothorax 06/07/09
  48. 48. Hemothorax May put pressure on the heart 06/07/09
  49. 49. Hemothorax Lots of blood vessels Where does the blood come from. 06/07/09
  50. 50. S/S of Hemothorax <ul><li>Anxiety/Restlessness </li></ul><ul><li>Tachypnea </li></ul><ul><li>Signs of Shock </li></ul><ul><li>Frothy, Bloody Sputum </li></ul><ul><li>Diminished Breath Sounds on Affected Side </li></ul><ul><li>Tachycardia </li></ul><ul><li>Flat Neck Veins </li></ul>06/07/09
  51. 51. Treatment for Hemothorax <ul><li>ABC’s </li></ul><ul><li>Secure Airway assist ventilation if necessary </li></ul><ul><li>General Shock Care due to Blood loss </li></ul><ul><li>RAPID TRANSPORT to hospital. </li></ul>06/07/09
  52. 52. Summary Chest Injuries are common and often life threatening in trauma patients. So, Rapid identification and treatment of these patients is paramount to patient survival. Airway management is very important and aggressive management is sometimes needed for proper management of most chest injuries. 06/07/09