Chest Trauma and it's management

1. Ms. Revathy.A

2. INTRODU
CTION
 Chest is large exposed portion of the body that is
vulnerable to impact injuries.
 Because chest houses heart, lungs, and great vessels
chest trauma is frequently life threatening .
 Injuries to thoracic cage and its content can restrict the
hearts ability to pump blood or lungs ability to exchange
air and oxygenated blood.
 Major danger with chest injuries is internal bleeding and
organ puncture

4. DEFINITION
 Chest injury is any form of
physical injury to the chest
including the ribs, heart, and
lungs.
 Major chest injuries may
occur alone or multiple other
injuries.

5. EPIDEMIOL
OGY
The number of accidental deaths
in India is even higher than in
the Western World.
Thoracic trauma contributes
heavily to these figures besides
head injury, abdominal injury
and orthopedic injuries.
Approximately one quarter of
civilian trauma deaths are caused
by thoracic trauma

8.  A rib fracture is a break in a rib bone.
 Rib fractures occur when a significant enough
force directed at the rib causes a break.
 Any rib fracture should warrant a thorough
evaluation of any concomitant injury, including
lungs, heart, kidney, spleen, liver, and neuro-
vasculature.
 Ribs 1 through 3 are the hardest to break and
signify a significant degree of trauma if fractured.
Ribs 4 through 10 are typically the most
vulnerable while ribs 11 through 12 are more
mobile and therefore more difficult to break

9.  .

10.  Tenderness on palpation.
 Chest wall deformity.
 Paradoxical/ abnormal chest
movement.
 Ventilatory insufficiency –
tachycardia, Cyanosis.
 Anxiety & distress.

11.  For simple, isolated rib fractures, conservative therapy is usually
adequate which includes appropriate analgesia, rest, and ice.
 The use of an incentive spirometer should be encouraged to prevent
pulmonary atelectasis and splinting.
 Intercostal nerve blocks can also be applied to aid in pain control.
 When conservative management fails or for more severe rib
fractures, surgical stabilization can be an option.

12.  The nurse instructs the patient to use an incentive spirometer every hour.
 Provide rest and avoid sternuous activities for several days.
 Assess the respiratory patterns every hour for several days.

14.  Flail chest is a life-threatening medical condition
that occurs when a segment of the rib cage breaks
due to trauma and becomes detached from the rest
of the chest wall.
 Flail chest is a thoracic injury resulting in
paradoxical motion of the chestwall segment.
 Flail chest is a traumatic condition of the thorax. It
may occur when 3 or more ribs are broken in at
least 2 places.
 A flail chest arises when these injuries cause a
segment of the chest wall to move independently of
the rest of the chest wall.
 A flail chest can create a significant disturbance to
respiratory physiology. This disturbance in
respiratory function is important in patients who are
older or who have chronic lung disease.
 Flail chest is an important injury with significant
complications.

16. The normal mechanics of respiration.
As the (intact) chest wall expands outward
under the influence of the respiratory
muscles (including the intercostal muscles),
the diaphragm contracts and lowers,
creating a negative intrathoracic pressure,
and in response air enters through the upper
respiratory system. In expiration, the
process is reversed

17. A flail segment of the chest wall will
negatively affect respiration in three ways:
 ineffective ventilation,
 pulmonary contusion, and
 hypoventilation with atelectasis.

20. Clinical
examination for
bruises, paradoxical
movement of flail
segment.
Chest X – Ray
Computed
Tomography

21. Analgesia.
Intubation and Ventilation.
Chest Tube Insertion
 Rib Fracture Fixation

24. Chest Tube Insertion

26. 3. PNEUMOTHORAX

27. A pneumothorax is an abnormal collection
of air in the pleural space between
the lung and the chest wall.
A pneumothorax is defined as a collection
of air outside the lung but within the
pleural cavity.
It occurs when air accumulates between
the parietal and visceral pleurae inside
the chest.
The air accumulation can apply pressure
on the lung and make it collapse.
The degree of collapse determines the
clinical presentation of pneumothorax.

28. Spontaneous pneumothorax/
Closed pneumothorax
Iatrogenic Pneumothorax /
Open Pneumothorax
Tension Pneumothorax

31.  Thoracenthesis
 Pacemaker insertion
 Bronchoscopy
 CPR
 Lung biopsy
 Barotrauma

33. Small Pneumothorax
Large Pneumothorax

34. The definition of large vs. small
pneumothorax is by the
distance between the lung margin
and chest wall:
 Small pneumothorax: the
presence of a visible rim of less
than 2 cm between the lung margin
and the chest wall
 Large pneumothorax: the
presence of a visible rim of greater
than 2 cm between the lung margin
and the chest wall

38. Chest pain – severe, sharp/stabbing,
pleuritic and radiates to ipsilateral
shoulder/arm.
Shortness of breath (64 to 85%).
Anxiety and cough
Absent breath sounds on the
affected side.

40. The management is guided by the etiology, clinical presentation,
and risk stratification.
The principles of treatment of pneumothorax are :
1. air elimination,
2. reduction of air leakage,
3. healing of pleural fistula, promoting re-expansion of the lung,
4. prevention of future recurrences.

41. Chest tube.
A chest tube, also known as a thoracostomy
tube, is a flexible tube that can be inserted
through the chest wall between the ribs into
the pleural space.
Thoracostomy tubes are commonly made
from PVC or silicone.
They range in from 6 French to 40 French.
The majority are fenestrated along the sides
of the insertion end, and the tubes have a
radiopaque stripe.
 After placement, the distal end of the tube is
connected to a pleura-evac system.

42.  A thoracostomy tube is usually
placed between the mid to
anterior axillary line in the
fourth or fifth intercostal space
tracking above the rib so as not
to injure the intercostal bundle
(artery, vein, nerve).

43. Maintain a closed chest drainage system.
Be sure to tape all connections, and secure the tube carefully
at the insertion site with adhesive bandages.
Regulate suction according to the chest tube system
directions; generally, suction does not exceed 20 to 25 cm
H2O negative pressure

44. Autotransfusion.
Autotransfusion involves taking the patient’s own blood that
has been drained from the chest, filtering it, and then
transfusing it back into the vascular system.
Antibiotics.
Antibiotics are usually prescribed to combat infection from
contamination.
Oxygen therapy.
The patient with possible tension pneumothorax should
immediately be given a high concentration of supplemental
oxygen to treat the hypoxemia.

45. 4.
HEAMOTHORA
X

46. Haemothorax is an
accumulation of blood in the
intrapleural space.
It is frequently found in
association with Open
pneumothorax and is then
called a haemopneumothorax.

47. CAUSES
Chest trauma. – Blunt/ Penetrating.
Tuberculosis
Malignancy – Lungs/ pleural
Pulmonary Embolism
Hemophilia
Use of anticoagulant drugs
Pulmonary Infraction
Hypertension
Malignant pleural effusion
Ehlers-Danlos syndrome (EDS)
Thoracic surgeries.

48. Bullous empyema
Pulmonary arteriovenous
fistulae
Spleenic artery anurysm.

51. respiratory
distress,
tachypnea,
decreased or
absent breath
sounds,
dullness to
percussion,
chest wall
asymmetry,
tracheal
deviation,
hypoxia,
narrow pulse
pressure,
hypotension.

52. DIAGNOSTI
C
MEASURES
History & Physical examination
Thoracic CT.
Chest x-ray.
CBC
Coagulation Profile
ABG

53. Perform initial resuscitation and management of a trauma patient.
Every patient should have two large bore IVs access
Connect to 12 lead ECG
Decompression needle thoracostomy, and/or emergent tube thoracostomy

54. Thrombolytic
agents
Oxygen
administration
Chest tube
drainage.

57.  To perform tube thoracostomy, a
large-bore tube (32F to 40F) should
be placed in the 4th or 5th intercostal
space at the anterior axillary line,
and connected to water seal and
suction (20-30 mL H20).
 Re-expansion of the lung
parenchyma and resolution of the
hemothorax should be monitored
with serial CXRs.

59. Pain management
Epidural analgesia
Systemic analgesics
Intrapleural
Other techniques
Management of fluid electrolytes
Intercostal catheter
Physiotherapy & Early ambulation
DVT prophylaxis.

60. NURSING ASSESSMENT
The nurse should assess the following:
Tracheal alignment.
Expansion of the chest.
Breath sounds.
Percussion of the chest.

62. Hemodynamic
instability
Shock
Hypoxia
Death