OM VERMA ASSISTANT PROFESSOR GRACIOUS COLLEGE OF NURSING( C.G)

1. CHEST TRAUMA

2. PRESENTED BY
MR.OM VERMA
ASSISTANT PROFESSOR
RELIANCE INSTITUTE OF
NURSING

3. INTRODUCTION:
 The chest is a large exposure part of the
body that is very vulnerable to impact
injuries. Because it houses the heart, lungs,
and great vessels, chest trauma frequently
produces life threatening disruption. Injury
to the thoracic case and its contraction can
restrict the hearts ability to function
properly.

5. Anatomy and Physiology of
the Thorax
 Thoracic Skeleton
– 12 Pair of C-shaped ribs
 Ribs 1-7: Join at sternum with cartilage end-points
 Ribs 8-10: Join sternum with combined cartilage at
7th rib
 Ribs 11-12: No anterior attachment
– Sternum
 Manubrium
– Joins to clavicle and 1st rib
– Jugular Notch
 Body
– Sternal angle (Angle of Louis)
 Junction of the manubrium with the sternal body
 Attachment of 2nd rib
 Xiphoid process
– Distal portion of sternum

8. DEFINITION:
Chest Trauma / Thoracic Trauma is
a serious injury of the chest. Any
trauma which leads to injury to
chest is termed as chest trauma.
According to
Brunner & Suddarth's

9.  A chest injury, also known as chest
trauma, is any form of
physical injury to the chest including
the ribs, heart and lungs. ...
Typically chest injuries are caused by
blunt mechanisms such as motor vehicle
collisions or penetrating mechanisms
such as stabbings.
according to lippencott

11. Mechanism of Injury
in Chest Trauma
 Acceleration/deceleration (motor vehicle accident)
 Body compression (crush injury)
 High-speed impact (gunshot wound)
 Miscellaneous
Low-velocity penetration
(stab wound)
Airway obstruction
(suffocation)
Caustic injury (poisoning)
Burns
Electrocution

12. Main Causes of Chest
Trauma
 Blunt Trauma- Blunt force to chest.
 Penetrating Trauma- Projectile that
enters chest causing small or large hole.
 Compression Injury- Chest is caught
between two objects and chest is
compressed.

13. Thoracic Trauma
 Blunt Trauma
– Results from kinetic energy forces
 Subdivision Mechanisms
– Blast
 Pressure wave causes tissue disruption
 Tear blood vessels & disrupt alveolar tissue
 Disruption of tracheobronchial tree
 Traumatic diaphragm rupture
– Crush (Compression)
 Body is compressed between an object and a hard surface
 Direct injury of chest wall and internal structures
– Deceleration
 Body in motion strikes a fixed object
 Blunt trauma to chest wall
 Internal structures continue in motion
– Ligamentum Arteriosum shears aorta
– Age Factors
 Pediatric Thorax: More cartilage = Absorbs forces
 Geriatric Thorax: Calcification & osteoporosis = More fractures

14. PATHOPHYSIOLOGY
CHEST INJURY
INTRAPLEURAL SPACE INCREASES
LUNG COLLAPSE
MEDIASTINUM SHIFT

15. COMPRESSION OF LARGE VEINS
DIFFICULTY IN GAS EXCHANGE
CARBON OXIDE DECREASES
CARDIAC ARRYTHMIAS
SUDDEN DEATH

16. Diagnostic Evaluation:
 HISTORY TAKING
 PHYSICAL EXAMINATION
 CHEST X- RAY
 CT SCAN
 ECHOCARDIOGRAPHY
 ABG ANALYSIS
 ANGIOGRAPHY
 BRONCHIOSCOPY
 PULSE OXIMETRY AND PFT
 URINE OUTPUT

17. TRAUMA DEATHS
EARLY
30%-35%
Within Hours (Golden
Hour)
Thoracic Trauma
Liver/Spleen Injuries
Multiple Pelvic Fractures
Others
Optimum Initial Care
IMMEDIATE
50%
Seconds or Minutes
Spinal Cord Injuries
Severe Brain Injuries
Lesions to Great
Vessels
Prevention
Optimum Prehospital
Care
LATE
15%-20%
2-3 Weeks
Sepsis
Multiple Organ Failure
Optimum Initial Care
(Future?)

18. TYPES OF CHEST TRAUMA

19. Injuries of chest
 Simple/Closed Pneumothorax
 Open Pneumothorax
 Tension Pneumothorax
 Hemothorax
 Flail Chest
 Cardiac Tamponade
 Traumatic Aortic Rupture
 Traumatic Asphyxia
 Diaphragmatic Rupture
 Ribs fracture

20. 1. Simple/Closed
Pneumothorax
o Accumulation of air in the pleural space without an
apparent antecedent event.
o Caused by rupture of small
blebs on the visceral pleural
space
o Blunt trauma is main
o May be spontaneous
o Usually self correcting

21. S/S of Simple/Closed
Pneumothorax
 Pleuritic Chest Pain
 Dyspnoea
 Tachypnea
 Decreased Breath Sounds on
Affected Side
 Hypertymphany to percussion

22. Treatment for Simple/Closed
Pneumothorax
 ABC’s with C-spine control
 Administer high concentration of oxygen to treat
hypoxia
 Remove clothing to assess injury
 Insert chest tube with connection to suction to
remove remaining air and fluid / water seal drainage
 Constant monitoring
 Opening is plugged to align it with gauze
impregnated with petroleum. A pressure dressing is
applied and secured with a circumferential strap
 Give semi- fowlers position or on injured site
 Administer Antibiotics

23. Ongoing monitoring
 Vital signs
 Level of consciousness
 Oxygen saturation
 Cardiac rhythm
 Respiratory status
 Urinary output

24. 2. Open Pneumothorax
 Opening in chest cavity
that allows air to
enter pleural cavity.
 Causes the lung to
collapse due to increased
pressure in pleural cavity.
E.g. Stab/ gunshot wounds.
 Can be life threatening and
can deteriorate rapidly

25. Open Pneumothorax

26. Open Pneumothorax
Inhale

27. Open Pneumothorax
Exhale

28. Open Pneumothorax
Inhale

29. Open Pneumothorax
Exhale

30. Open Pneumothoarx
Inhale

31. Open Pnuemothorax
Inhale

32. S/S of Open
Pneumothorax
 Dyspnea
 Sudden sharp pain
 Subcutaneous Emphysema
 Decreased lung sounds on affected
side
 Red Bubbles on Exhalation from
wound ( a.k.a. Sucking chest
wound)

33. Subcutaneous
Emphysema
 Air collects in subcutaneous fat from
pressure of air in pleural cavity
 Feels like rice crispies or bubble wrap
 Can be seen from neck to groin area

34. Sucking Chest Wound

35. Treatment for Open
Pneumothorax
 ABC’s with c-spine control as indicated
 High Flow oxygen
 Listen for decreased breath sounds on
affected side
 Apply occlusive dressing to wound
 Notify Hospital

36. Occlusive/ Vented Dressing
 Allows air to escape
from the vent and
decreases the
likelihood of tension
pneumothorax
developing

37. Occlusive Dressing
 ASHERMAN CHEST
 Seal The Asherman Chest
Seal™ is a proven treatment
for open pneumothorax and
the prevention of tension
pneumothorax
in chest injuries from gunshot,
stab wounds or other
penetrating chest injuries. The
unique one-way valve is
designed to let air and blood
escape, while keeping both out
of the pleural cavity.

38. 3. Tension Pneumothorax
 Air builds in pleural space with no
where for the air to escape
 Results in collapse of lung on affected
side that results in pressure on
mediastium,the other lung, and great
vessels

39. Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

40. Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

41. Tension Pneumothorax
Heart is being
compressed
The trachea is
pushed to
the good side

42. S/S of Tension
Pneumothorax
 Anxiety/Restlessnes
s
 Severe Dyspnea
 Absent Breath
sounds on affected
side
 Tachypnea
 Tachycardia
 Poor Color
 Accessory Muscle
Use
 JVD(JUGULAR
VENOUS
DISTENTION)
 Narrowing Pulse
Pressures
 Hypotension
 Tracheal Deviation
(late if seen at all)

43. TREATMENT
 Monitor Cardiac Rhythm
 Establish IV access and Draw Blood
Samples
 Airway control including Intubation
 Needle Decompression of Affected
Side

44. Needle Decompression
 Locate 2-3 Intercostal space midclavicular
line
 Cleanse area using aseptic technique
 Insert catheter ( 14g or larger) at least 3 in
length over the top of the 3rd rib( nerve,
artery, vein lie along bottom of rib)
 Remove Stylette and listen for rush of air
 Place Flutter valve over catheter
 Reassess for Improvement

45. Needle Decompression

46. 4. HEMOTHORAX
A hemothorax (derived from hemo- [blood] +
thorax [chest], plural hemothoraces) is an
accumulation of blood within the pleural cavity.
The symptoms of a hemothorax include chest
pain and difficulty breathing, while the clinical
signs include reduced breath sounds on the
affected side and a rapid heart rate.

47. CON…
 Occurs when pleural space fills with
blood
 Usually occurs due to lacerated blood
vessel in thorax(tear or make deep cut
in skin)
 As blood increases, it puts pressure on
heart and other vessels in chest cavity
 Each Lung can hold 1.5 liters of blood

48. Hemothorax

49. Hemothorax

50. Hemothorax

51. Hemothorax

52. Hemothorax

53. Hemothorax
May put pressure on the heart

54. Hemothorax
Lots of blood vessels
Where does the blood come from.

55. S/S of Hemothorax
 Anxiety/Restlessness
 Tachypnea
 Signs of Shock
 Frothy, Bloody Sputum
 Diminished Breath Sounds on Affected
Side
 Tachycardia
 Flat Neck Veins

56. Treatment for
Hemothorax
 ABC’s with c-spine control as indicated
 Secure Airway assist ventilation if
necessary
 General Shock Care due to Blood loss
 Consider Left Lateral Recumbent
position if not contraindicated
 RAPID TRANSPORT
 Contact Hospital

57. 5. FLAIL CHEST
 an acute chest injury in which two or
more ribs become detached from the
rest of the ribcage.
 "patients with a flail chest often
remain at risk for pneumonia"

58. Flail Chest
 The breaking of 2
or more ribs in 2
or more places

59. Flail Chest

60. S/S of Flail Chest
 Shortness of Breath, respiratory
distress, Pneumothorax
 Paradoxical Movement
 Bruising/Swelling
 Crepitus( Grinding of bone ends on
palpation)
 Hypotension

61. Treatment of Flail Chest
 Flail Chest is a True Emergency
 Ensure airway
 Administer oxygen
 Assist ventilation. Chest decompression is done for
pneumothorax.
 Establish I/V line
 Restrict fluid intake, prescribe corticosteroids and
albumin to treat pulmonary contusion
 Prepare for operative stabilization of chest wall

62. Bulky Dressing for splint
of Flail Chest
 Use Trauma
bandage and
Triangular
Bandages to splint
ribs.
 Can also place a
bag of D5W on area
and tape down.
(The only good use
of D5W I can find)

63. 6. CARDIAC TAMPONADE
cardiac tamponade, also known
as pericardial tamponade, fluid
or blood builds up between the
heart and the sac that
surrounds ..

64.  Blood and fluids
leak into the
pericardial sac
which surrounds the
heart.
 As the pericardial
sac fills, it causes
the sac to expand
until it cannot
expand anymore
pericardial sac

65. Pericardial ( CARDIAC )
Tamponade  Once the
pericardial sac
can’t expand
anymore, the
fluid starts
putting pressure
on the heart
 Now the heart
can’t fully expand
and can’t pump
effectively.

66. Pericardial ( CARDIAC )
Tamponade  With poor pumping
the blood pressure
starts to drop.
 The heart rate starts
to increase to
compensate but is
unable
 The patient’s level of
conscious drops, and
eventually the patient
goes in cardiac arrest

67. S/S of Pericardial (
CARDIAC ) Tamponade
 Distended Neck Veins
 Increased Heart Rate
 Respiratory Rate increases, cyanosis
 Anxious, confused
 Muffled heart sound
 Hypotension, pulses paradoxes
 Shock, Death

68. Treatment of Pericardial
( CARDIAC ) Tamponade
 Check for ABC
 High Flow oxygen which may include
BVM
 Treat S/S of shock
 Assist with pericardiocentesis
 Prepare for emergency thoracotomy

69. Treatment
 Cardiac Monitor
 Large Bore IV access
 Perform pericardiocentesis

70. Pericardiocentesis
 Using aseptic technique, Insert at least 3” needle at
the angle of the Xiphoid Cartilage at the 7th rib
 Advance needle at 45 degree towards the clavicle
while aspirating syringe till blood return is seen
 Continue to Aspirate till syringe is full then discard
blood and attempt again till signs of no more blood
 Closely monitor patient due to small about of blood
aspirated can cause a rapid change in blood
pressure

71. 7. TRAUMATIC AORTIC
RUPTURE
 Traumatic aortic rupture, also
called traumatic aortic
disruption or transection, is a
condition in which the aorta, the
largest artery in the body, is torn
or ruptured as a result of trauma to
the body. The condition is frequently
fatal due to the profuse bleeding that
results from the rupture.

72. TRAUMATIC AORTIC
RUPTURE
The heart, more or less, just
hangs from the aortic arch
Much like a big pendulum.
If enough motion is placed on
the heart (i.e.. Deceleration
From a motor vehicle
accident, striking a tree while
skiing etc) the heart may tear
away from the aorta.

73. Traumatic Aortic Rupture
The chances of survival are
very slim and are based on the
degree of the tear.
If there is just a small tear then
the patient may survive. If the
aorta is completely transected
then the patient will die
instantaneously

74. S/S Of Traumatic Aortic
Rupture
 Burning or Tearing Sensation in chest
or shoulder blades
 Rapidly dropping Blood Pressure
 Pulse Rapidly Increasing
 Decreased or loss of pulse or b/p on
left side compared to right side
 Rapid Loss of Consciousness

75. Treatment
 Monitor Cardiac Rhythm
 Large Bore IV therapy probably 2 and
draw blood samples
 Airway management that may include
Intubation

76. 8. TRAUMATIC ASPHYXIA
 Traumatic asphyxia, or Perthes's
syndrome, is a medical emergency
caused by an intense compression of
the thoracic cavity, causing venous
back-flow from the right side of the
heart into the veins of the neck and
the brain.

77. CON……
 Results from sudden compression
injury to chest cavity
 Can cause massive rupture of Vessels
and organs of chest cavity
 Ultimately Death

78. S/S of Traumatic
Asphyxia
 Severe Dyspnea
 Distended Neck Veins
 Bulging, Blood shot eyes
 Swollen Tounge with cyanotic lips
 Reddish-purple discoloration of face
and neck
 Petechiae

79. Treatment
 Cardiac Monitor
 Establish IV Access and draw blood
samples
 Airway control including Intubation
 Rapid transport

80. 9. DIAPHRAGMATIC
RUPTURE
 A tear in the Diaphragm that allows
the abdominal organs enter the chest
cavity
 More common on Left side due to liver
helps protect the right side of
diaphragm
 Associated with multipile injury
patients

81. CON….
 Diaphragmatic rupture (also
called diaphragmatic injury or tear)
is a tear of the diaphragm, the
muscle across the bottom of the
ribcage that plays a crucial role in
respiration. ... Diaphragmatic
rupture can result from blunt or
penetrating trauma and occurs in
about 5% of cases of severe blunt
trauma to the trunk.

82. Diaphragm Rupture

83. S/S of Diaphragmatic
Rupture
 Abdominal Pain
 Shortness of Air
 Decreased Breath Sounds on side of
rupture
 Bowel Sounds heard in chest cavity

84. Treatment
 Cardiac Monitor
 Establish IV access and draw blood samples
 Airway management including Intubation
 Observe for Pneumothorax due to
compression on lung by abdominal contents
 Possible insertion of NG tube to help
decompress the stomach to relieve pressure

85. Management of patients with
Thoracic Trauma
 The treatment of polytraumatized patient must
follow a certain protocol which includes.
– Adequate oxygenation.
– Fluid replacement.
– Surgical intervention.
– Treatment of septic complications.
– Adequate caloric and substrate(enzyme)
supplementation.
– Prevention of stress bleeding.
– Finally, be alert of possible complication (CNS, ARDS,
hepatic, renal, coagulation disorders, sepsis.

86. 10. RIB FRACTURE:
 A broken rib is a common injury that
occurs when one of the bones in rib cage
breaks or cracks. The most common
cause is chest trauma, ...

87.  SIGN AND SYMPTOMS:
 SEVERE PAIN, TENDERNESS
 MUSCLE SPASM WHICH AGGRAVATE
WITH COUGHING , DEEP BREATHING AND
MOTION
 CRACKLING SOUND WITH GRATING
 UNSTABLE RIB CAGE ON PALPATION

88. TREATMENT
 ENSURE AIRWAY AND ADMINISTER
OXYGEN
 Stabilize with hand followed by application
of large pieces of tape horizontal across
the flail segment
 GIVE ANALGESIC
 ENCOURAGE FOR DEEP BREATHING
 MAINTAIN PATENT I/V LINE

89. ASSESSMENT:
 A- AIRWAY MAINTENANCE WITH
CERVICAL SPINE PROTECTION
 B- BREATHING AND VENTILATION
 C- CIRCULATION WITH HEMORRHAGE
CONTROL
 D- DISABILITY, NEUROLOGICAL STATUS
 E- EXPOSURE/ ENVIRONMENTAL
CONTROL, PREVENT HYPOTHERMIA

90. NURSING PROCESS
 INEFFECTIVE BREATHING PATTERN RELATED TO
CHEST INJURY
 RISK FOR DEFICIENT FLUID VOLUME RELATED TO
CHEST DRAINAGE AND BLOOD LOSS
 ACUTE PAIN RELATED TO CHEST INJURY AND
PRESENCE OF DRAINAGE TUBES IN THE CHEST
 IMPAIRED PHYSICAL MOBILITY RELATED TO PAIN,
MUSCLE INJURY
 RISK FOR INEFFECTIVE INDIVIDUAL COPING
RELATED TO
TEMPORARY DEPENDENCE AND LOSS OF FULL
RESPIRATORY FUNCTION

91. COMPLICATION
 ATELECTESIS
 INFECTION
 PNEUMONIA
 RESPIRARATORY FAILURE

92.  Although there are a wide range
of complications following thoracic
trauma, respiratory failure,
pneumonia, and pleural sepsis are the
most common potentially preventable
problems. Respiratory failure and
pneumonia are directly related to the
severity of the injury and the age and
condition of the patient.

94. 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.