chest-trauma.pdf

12/02/09
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WHAT IS IT?
WHAT IS IT?
 Chest trauma is often sudden
Chest trauma is often sudden
and dramatic
and dramatic
 Accounts for 25% of all
Accounts for 25% of all
trauma deaths
trauma deaths
 2/3 of deaths occur after
2/3 of deaths occur after
reaching hospital
reaching hospital
12/02/09
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WHY DO IT OCCUR?
WHY DO IT OCCUR?
 Blunt Trauma
Blunt Trauma- Blunt force to chest. E.g.
- Blunt force to chest. E.g.
automobile crashes and falls.
automobile crashes and falls.
 Penetrating Trauma
Penetrating Trauma- Projectile that
- Projectile that
enters chest causing small or large hole.
enters chest causing small or large hole.
E.g. gun shot and stabbing.
E.g. gun shot and stabbing.
 Compression Injury
Compression Injury- Chest is caught
- Chest is caught
between two objects and chest is
between two objects and chest is
compressed.
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12/02/09

WHAT DOES IT DO?
WHAT DOES IT DO?
 Rib fractures
Rib fractures
 Flail chest
Flail chest
 Pulmonary contusion
Pulmonary contusion
 Pneumothorax
Pneumothorax
 Haemothorax
Haemothorax
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Rib Fracture
Rib Fracture
 A rib fracture is a break in a rib bone.
A rib fracture is a break in a rib bone.
 Cause is blunt chest trauma (fall, blow to the chest,
Cause is blunt chest trauma (fall, blow to the chest,
etc).
etc).
 Symptoms
Symptoms
 Localized pain
Localized pain
 Tenderness over the fractured area on inspiration and
Tenderness over the fractured area on inspiration and
palpation
palpation
 Shallow respiration atelectasis & pneumonia
Shallow respiration atelectasis & pneumonia
 Pain when coughing
Pain when coughing
 Swelling and bruising in the fracture area
Swelling and bruising in the fracture area
 Internal bleeding
Internal bleeding
 Pneumothorax or heamothorax
Pneumothorax or heamothorax
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12/02/09

HOW TO DIAGNOSE?
HOW TO DIAGNOSE?
CHEST XRAY
CHEST XRAY
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MANAGEMENT
MANAGEMENT
 Most rib fracture heals in 3 – 6 weeks.
Most rib fracture heals in 3 – 6 weeks.
 Generally treated conservatively with rest, local
Generally treated conservatively with rest, local
heat and analgesics.
heat and analgesics.
 Monitor for the sign of associated injuries.
Monitor for the sign of associated injuries.
 Rest and do not do physical activity.
Rest and do not do physical activity.
 Adequate pain relief
Adequate pain relief
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FLIAL CHEST
FLIAL CHEST
The breaking of
The breaking of
2 or more ribs in
2 or more ribs in
2 or more
2 or more
places, resulting
places, resulting
in free- floating
in free- floating
rib segments.
rib segments.
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The flail segment has no bony or cartilaginous
The flail segment has no bony or cartilaginous
connection
connection
Moves independently of the chest wall
Moves independently of the chest wall
Paradoxical chest movement
Paradoxical chest movement
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PARADOXICAL
PARADOXICAL
MOVEMENT
MOVEMENT
The flail portion of
the chest is
• sucked in with
inspiration, instead of
expanding outward
• Ballooned out with
expiration instead of
collapsing inward
•Hypoventilation and
hypoxemia
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S/S OF FLAIL CHEST
S/S OF FLAIL CHEST
 Shortness of Breath
Shortness of Breath
 Paradoxical Movement
Paradoxical Movement
 Bruising/Swelling
Bruising/Swelling
 Crepitus (Grinding of bone ends on
Crepitus (Grinding of bone ends on
palpation)
palpation)
 Tachycardia
Tachycardia
 Hypotension
Hypotension
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Complication:
Complication:
 Hypoventilation
Hypoventilation
 Atelectasis
Atelectasis
 Mediastinal flutter (mediastinal structures tend
Mediastinal flutter (mediastinal structures tend
to swing back n forth)
to swing back n forth)
Diagnosis:
Diagnosis:
 Palpation : crepitus and tenderness near
Palpation : crepitus and tenderness near
fractured ribs.
fractured ribs.
 chest x-ray
chest x-ray
 ABGs
ABGs
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PULMONARY CONTUSION
PULMONARY CONTUSION
 It is damage to the lung tissues resulting in
It is damage to the lung tissues resulting in
hemorrhage and localized edema.
hemorrhage and localized edema.
 Ecchymosis at the site of the damage
Ecchymosis at the site of the damage
 Crackels
Crackels
 Cough may be present with blood-tinged
Cough may be present with blood-tinged
sputum.
sputum.
 Pulmonary contusions tend to worsen over a 24–
Pulmonary contusions tend to worsen over a 24–
to 48–hour period and then slowly resolve unless
to 48–hour period and then slowly resolve unless
complications occur (infection, ARDS).
complications occur (infection, ARDS).
 Patients with severe contusions may require
Patients with severe contusions may require
endotracheal intubation and mechanical
endotracheal intubation and mechanical
ventilation
ventilation
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12/02/09

NURSING IMPLICATION
NURSING IMPLICATION
NURSING DIAGNOSIS
NURSING DIAGNOSIS
 Ineffective Airway Clearance
Ineffective Airway Clearance
 Ineffective Breathing Pattern
Ineffective Breathing Pattern
 Impaired Gas Exchange
Impaired Gas Exchange
 Pain
Pain
 Risk for Infection
Risk for Infection
 Activity Intolerance
Activity Intolerance
 Anxiety
Anxiety
 Decreased Cardiac output
Decreased Cardiac output
 Impaired tissue perfusion
Impaired tissue perfusion
 Ineffective individual coping
Ineffective individual coping
 Altered health maintenance
Altered health maintenance
12/02/09
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NURSING IMPLICATION
NURSING IMPLICATION
INTERVENTION:
INTERVENTION:
 Frequent and prompt Respiratory assessment
Frequent and prompt Respiratory assessment
 Adequate oxygenation
Adequate oxygenation
 Analgesia to improve ventilation.
Analgesia to improve ventilation.
 Clearing secretion
Clearing secretion
 Stabilize the thoracic cage
Stabilize the thoracic cage
 Deep breathing exercises
Deep breathing exercises
 Intubation and mechanical ventilation may be
Intubation and mechanical ventilation may be
required to prevent further hypoxia
required to prevent further hypoxia
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NURSING IMPLICATION
NURSING IMPLICATION
 Pain Control
Pain Control
 Alternative to relieve pain:
Alternative to relieve pain:
1.
1. Intercostal Nerve Blocks
Intercostal Nerve Blocks
2.
2. Epidural Anesthesia.
Epidural Anesthesia.
3.
3. Wearing a chest binder
Wearing a chest binder
 Maintain IV flow rates
Maintain IV flow rates
 Monitor S/S of adequate tissue perfusion
Monitor S/S of adequate tissue perfusion
 Anxiety reducing techniques
Anxiety reducing techniques
 Coping mechanism
Coping mechanism
 Heath education/teaching
Heath education/teaching
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COMPLICATIONS
COMPLICATIONS
 Pneumonia
Pneumonia
 ARDS
ARDS
 Lung abscess
Lung abscess
 Emphysema
Emphysema
 Pulmonary embolism.
Pulmonary embolism.
12/02/09
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PNEUMOTHORAX
PNEUMOTHORAX
 Pneumothorax is a pocket of air
Pneumothorax is a pocket of air
between the two layers of pleura
between the two layers of pleura
(parietal or visceral), resulting in
(parietal or visceral), resulting in
collapse of the lung.
collapse of the lung.
 TYPES :
TYPES :
 Open Pneumothorax
Open Pneumothorax
 Tension Pneumothorax
Tension Pneumothorax
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Types
Types
 Open Laceration in the
Open Laceration in the
parietal pleura that allows
parietal pleura that allows
atmospheric air to enter
atmospheric air to enter
the pleural space; occurs
as a result of penetrating
as a result of penetrating
chest trauma
chest trauma
 Closed Laceration in the
Closed Laceration in the
visceral pleura that allows
visceral pleura that allows
air from the lung to enter
air from the lung to enter
as a result of blunt chest
as a result of blunt chest
trauma
trauma
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Open Pneumothorax
Open Pneumothorax
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Open Pneumothorax
Open Pneumothorax
Inhale
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Open Pneumothorax
Open Pneumothorax
Exhale
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Open Pneumothoarx
Open Pneumothoarx
Inhale
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12/02/09
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Open Pnuemothorax
Open Pnuemothorax
Inhale
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Pathophysiology
Pathophysiology
Air enters the pleural space, the affected
Air enters the pleural space, the affected
lung
lung becomes compressed.
becomes compressed.
As the lung collapses, the alveoli become
As the lung collapses, the alveoli become
underventilated,
underventilated,
Causing V/Q mismatching and
Causing V/Q mismatching and
intrapulmonary
intrapulmonary shunting.
shunting.
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CONT..
CONT..
If the pneumothorax is large, hypoxemia ensues
If the pneumothorax is large, hypoxemia ensues
and acute respiratory failure quickly develops.
and acute respiratory failure quickly develops.
In addition, increased pressure within the chest
In addition, increased pressure within the chest
can lead to shifting of the mediastinum,
can lead to shifting of the mediastinum,
compression of the great vessels, and
compression of the great vessels, and
decreased cardiac output
decreased cardiac output
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Occurs when air is allowed to
Occurs when air is allowed to
enter the pleural space but
enter the pleural space but
not exit it; as pressure
not exit it; as pressure
increases inside the pleural
increases inside the pleural
space, the lung collapses and
space, the lung collapses and
the mediastinum shifts to the
the mediastinum shifts to the
unaffected side; may be a
unaffected side; may be a
result of a spontaneous or
result of a spontaneous or
traumatic pneumothorax.
traumatic pneumothorax.
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Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
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Heart is being
compressed
The trachea is
pushed to
the good side
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S/S OF TENSION
S/S OF TENSION
PNEUMOTHORAX
PNEUMOTHORAX
 Anxiety/Restlessness
Anxiety/Restlessness
 Severe Dyspnea
Severe Dyspnea
 Absent Breath sounds
Absent Breath sounds
on affected side
on affected side
 Tachypnea
Tachypnea
 Tachycardia
Tachycardia
 Poor Color
Poor Color
 Accessory Muscle Use
Accessory Muscle Use
 Hypotension
Hypotension
 Tracheal Deviation
Tracheal Deviation
(late if seen at all)
(late if seen at all)
 Hyperresonance to
Hyperresonance to
percussion
percussion
.
.
12/02/09
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Assessment and
Assessment and
Diagnosis
Diagnosis
 Depend on the degree of lung collapse.
Depend on the degree of lung collapse.
 When a pneumothorax is large, decreased respiratory
When a pneumothorax is large, decreased respiratory
excursion on the affected side may be noticed, along
excursion on the affected side may be noticed, along
with bulging intercostal muscles. The trachea may
with bulging intercostal muscles. The trachea may
deviate away from the affected side.
deviate away from the affected side.
 Percussion reveals hyperresonance with decreased or
Percussion reveals hyperresonance with decreased or
absent breath sounds over the affected area.
absent breath sounds over the affected area.
 ABGs will demonstrate hypoxemia and hypercapnia.
ABGs will demonstrate hypoxemia and hypercapnia.
 A chest x-ray film will confirm the pneumothorax with
A chest x-ray film will confirm the pneumothorax with
increased translucency evident on the affected side
increased translucency evident on the affected side
12/02/09
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MEDICAL MANAGEMENT
MEDICAL MANAGEMENT
 Depending on the severity of the specific
Depending on the severity of the specific
disorder.
disorder.
 At times requires only supplemental oxygen
At times requires only supplemental oxygen
administration, unless complications occur
administration, unless complications occur
or underlying lung disease or injury is
or underlying lung disease or injury is
present.
present.
 At times urgently require intervention to
At times urgently require intervention to
evacuate the air from the pleural space and
evacuate the air from the pleural space and
facilitate re expansion of the collapsed lung.
facilitate re expansion of the collapsed lung.
12/02/09
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Treatment
Treatment
 Administering supplemental oxygen
Administering supplemental oxygen
 Inserting a large-bore needle or catheter into
Inserting a large-bore needle or catheter into
the second intercostal space at the
the second intercostal space at the
midclavicular line of the affected side. This
midclavicular line of the affected side. This
action relieves the pressure within the chest.
action relieves the pressure within the chest.
The needle should remain in place until the
The needle should remain in place until the
patient is stabilized and a chest tube is inserted
patient is stabilized and a chest tube is inserted
 Chest tube insertion
Chest tube insertion
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Needle Decompression
 Locate 2-3 Intercostal space midclavicular line
Locate 2-3 Intercostal space midclavicular line
 Cleanse area using aseptic technique
Cleanse area using aseptic technique
 Insert catheter ( 14g or larger) at least 3” in
Insert catheter ( 14g or larger) at least 3” in
length over the top of the 3
length over the top of the 3rd
rd
rib( nerve, artery,
rib( nerve, artery,
vein lie along bottom of rib)
vein lie along bottom of rib)
 Remove Stylette and listen for rush of air
Remove Stylette and listen for rush of air
 Place Flutter valve over catheter
Place Flutter valve over catheter
 Reassess for Improvement
Reassess for Improvement
12/02/09
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12/02/09
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Nursing Diagnosis
Nursing Diagnosis
 Impaired Gas Exchange related to ventilation/
Impaired Gas Exchange related to ventilation/
perfusion mismatching or intrapulmonary shunting
perfusion mismatching or intrapulmonary shunting
 Ineffective Breathing Pattern related to decreased
Ineffective Breathing Pattern related to decreased
lung expansion
lung expansion
 Acute Pain related to transmission and perception of
Acute Pain related to transmission and perception of
cutaneous, visceral, muscular, or ischemic impulses
cutaneous, visceral, muscular, or ischemic impulses
 Anxiety related to threat to biologic, psychologic, and/
Anxiety related to threat to biologic, psychologic, and/
or social integrity
or social integrity
 Disturbed Body Image related to actual change in
Disturbed Body Image related to actual change in
body structures, function, or appearance
body structures, function, or appearance
 Compromised Family Coping related to critically ill
Compromised Family Coping related to critically ill
family member
family member
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NURSING INTERVENTIONS
NURSING INTERVENTIONS
 Continuous and vigilant respiratory
Continuous and vigilant respiratory
assessment
assessment
 Optimizing oxygenation and ventilation,
Optimizing oxygenation and ventilation,
 Maintaining the chest tube system
Maintaining the chest tube system
 Providing comfort and emotional support
Providing comfort and emotional support
 Maintaining surveillance for complications.
Maintaining surveillance for complications.
12/02/09
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Hemothorax
Hemothorax
 Occurs when pleural space fills with blood
Occurs when pleural space fills with blood
 Usually occurs due to lacerated blood
Usually occurs due to lacerated blood
vessel in thorax
vessel in thorax
 As blood increases, it puts pressure on
As blood increases, it puts pressure on
heart and other vessels in chest cavity
heart and other vessels in chest cavity
 Each Lung can hold 1.5 liters of blood
Each Lung can hold 1.5 liters of blood
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Hemothorax
Hemothorax
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Hemothorax
Hemothorax
May put pressure on the heart
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Hemothorax
Hemothorax
Lots of blood vessels
Where does the blood come from.
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12/02/09

S/S of Hemothorax
S/S of Hemothorax
 Anxiety/Restlessness
Anxiety/Restlessness
 Tachypnea
Tachypnea
 Signs of Shock
Signs of Shock
 Frothy, Bloody Sputum
Frothy, Bloody Sputum
 Diminished Breath Sounds on Affected
Diminished Breath Sounds on Affected
Side
Side
 Tachycardia
Tachycardia
 Flat Neck Veins
Flat Neck Veins
12/02/09
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Treatment for Hemothorax
Treatment for Hemothorax
 ABC’s
ABC’s
 Secure Airway assist ventilation if
Secure Airway assist ventilation if
necessary
necessary
 General Shock Care due to Blood loss
General Shock Care due to Blood loss
 RAPID TRANSPORT to hospital.
RAPID TRANSPORT to hospital.
12/02/09
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Summary
Summary
Chest Injuries are common and often life
Chest Injuries are common and often life
threatening in trauma patients. So, Rapid
threatening in trauma patients. So, Rapid
identification and treatment of these patients is
identification and treatment of these patients is
paramount to patient survival. Airway
paramount to patient survival. Airway
management is very important and aggressive
management is very important and aggressive
management is sometimes needed for proper
management is sometimes needed for proper
management of most chest injuries.
management of most chest injuries.
12/02/09
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chest-trauma.pdf

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