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CHEST TRAUMA
- 1. Mrs.JEEVA.D NURSING TUTOR, GANGA COLLEGEOF NURSING, COIMBATORE.
- 3. INTRODUCTION ANATOMY DEFITION TYPES CAUSES SYMPTOMS MANAGEMENT COMPLICATION
- 4. Second leadingcause of trauma deaths Around 65 -70% of chest injuries are due to RTAs Approx. 25% of deaths are due to chest injuries 50 % of patients who die from poly trauma have significant chest injuries.
- 7. Thoracic Inlet.. Connects thoracic cavity to the root of the Neck. • Thoracic Outlet… Connects thoracic cavity with the Abdomen. Closed by Diaphragm. Thoracic Wall Posteriorly… Thoracic vertebrae 12. Anteriorly… Sternum and Costal Cartilages. Laterally… Ribs and Intercostal spaces.
- 8. • Trachea • Bronchi •Lungs • Heart • Great Vessels. • Oesophagus
- 9. CHEST TRAUMA/ INJURY : It is any form of physical injury to the chest including ribs, heart and lungs. Thoracic injury… 25% of all injuries. In another 25%, its contributor to other injuries. Major Cause of death…. Hemorrhage.
- 10. • 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.
- 11. BLUNT –This type of injury is caused by coming into contact with some solid object that causes increased intra thoracic or chest cavity pressure. Penetrating – A penetrating injury is one that involves piercing of the chest cavity by foreign object.
- 12. Blast –These types of injuries are associated with explosions. Inhalation – An inhalation chest injury is one caused by gases, fumes, dusts, or even liquids entering the lungs.
- 13. IMMEDIATE • Within secondsto minutes • Disruption of heart or great vessels injury EARLY • Within few minutes to hours • Airway obstruction, tension pneumothorax, pulmonary contusion or cardiac tamponade LATE • Within few days to weeks • Pulmonary complications, sepsis and missed injuries
- 14. Immediately Life threatening • Airwayobstruction • Simple / Closed Pneumothorax • Open Pnuemothorax • Tension Pneumothorax • Massive Hemothorax • Flail Chest • Cardiac Tamponade Potentially life Threatening • Cardiac Contusion • Aortic Disruption • Diaphragmatic rupture • Esophageal Injury • Pulmonary Contusion • Tracheo bronchial injury
- 15. Low velocitypenetration Knife (stab wound) Airway Obstruction Caustic Injury (Poisoning) Burns Electrocution Acceleration / deceleration (RTA) Body compression (crush injury) High speed impact (gunshot wound) Miscellaneous
- 16. Chest Injury Intra PluralSpace Increases Lung Collapse Mediastinum Shift
- 17. Compression of LargeVeins Carbon Oxide Decreases Cardiac Arrythmias Sudden Death
- 19. SIMPLE /CLOSED PNEUMOTHORAX - Defined as accumulation of air within the pleural space producing a collapsed lung. Air leak is secondary to a fractured rib penetrating the lung or stab wound through the parietal & visceral pleura. Symptoms – chest pain, shortness of breath, coughing, rapid breathing, an abnormal breathing movemnt On percussion : Hyper resonance on the affected side On Auscultation : Decreased breath sounds on affected side.
- 20. ABC’s withC-spine control Chest tube placement Airway Assistance as needed Provide supportive care Usually small and self limiting. Monitor for Development of Tension Pneumothorax
- 22. Open Pneumothorax -itoccurs when air accumualtes between the chest wall and the lung as the result of an open chest wound or other physical defect. The larger opening, the greater degree of lung collapse and difficulty of breathing. On exam : Obvious chest wall defect On auscultation : Complete or near complete loss of breath sounds Diagnosis : Physical exam and CXR
- 23. Dyspnea Suddensharp pain Subcutaneous Emphysema Decreased breath sounds on affected side Hyper-resonance Red Bubbles on Exhalation from wound (a.k.a. Sucking chest wound) DIAGNOSTIC EVALUATION CHEST X-RAY Standing. Smaller pneumothorax may need Expiration CXR or CT
- 24. Sucking chestwound : Placing a three way occlusive dressing. Intent is to prevent the rise of intrathoracic pressures in the affected hemothorax A chest tube is then placed. Afterinitial stabilization, definitive chest wall closure is planned Observation…. Small pneumothorax, Asymtomatic. Aspiration. Chest Intubation…Gold standard, Pleurectomy Pleurodesis…. Sclerosig agents… Doxy, Bleomycin, talc. Surgery…needed in less than 20%...Thoracotomy.
- 26. Develops whena lung or chest wall injury is such that it allows air into the pleural space but not out of it ( a one way valve) As a result, air accumulates & compresses the lung, resulting into : - Shifting of mediastinum -Compression of contralateral lung Symptoms :Sharp & stabbing chest pain, dyspnea, cyanosis, sweating ,fainting
- 27. Symptoms -Distended neck veins Hypotension or evidence of hypo perfusion, Diminished or absent breath sounds on affected side, Tracheal deviation to the contralateral side Diagnosis : Clinically before the CXR is obtained. Immediate needle decompression of the chest with a 16G in 2nd intercostal space, midclavicular space. Once accomplished, a chest tube is placed.
- 28. Hemothorax followinga blunt/ penetrating wound to the chest can be caused by bleeding from any structure in the thorax : the intercostal arteries,lung, great vessels or heart. On percussion : Diminished breath sounds & dullness to percussion over affected hemi thorax Massive hemothorax can produce significant hemodynamic instability secondary to hemorrhagic shock.
- 29. Anxiety/Restlessness Tachypnea Signs of Shock Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side Dull percussion note… maybe resonant in supine position. Tachycardia Flat Neck Veins
- 30. ABC’s withc-spine control as indicated General Shock Care due to Blood loss Chest intubation Thoracotomy… If more than 1500 ml blood drains initially, or ongoing hemorrhage of more than 200 ml/ hr over 3-4 hrs.
- 31. A flail chestoccurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. This is usually defined as at least two fractures per rib (producing a free segment), in at least two ribs. some definitions require three or more ribs in two or more places
- 32. Respiratory distress– mc initial presentation Dyspnea, tachycardia, tachypnea, pain & tenderness usually present. On auscultation : Decreased breath sounds over the affected area. DIAGNOSIS : Physical examination & CXR CT: identification of early pulmonary contusion
- 33. Treatment modalitiesfor patients with chest wall fractures are appropriate for flail chest Pain control, pulmonary toilet, Oxygen : Primary therapy for pulmonary contusion Severity of flail injuries & associated contusions may require endotracheal intubation & IPPV Optimal ventilatory management is crucial
- 34. Use Traumabandage 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)
- 35. Life threatening complicationcaused by excessive accumulation of fluid in the pericardium leading to : Compression of cardiac chamber Impaired cardiac filling Reduction in stroke volume
- 36. Distended NeckVeins Increased Heart Rate Muffled heart sound Respiratory Rate increases Poor skin color Hypotension Death Beck’s Triad… Low BP, Raise venous pressure, Muffled Heart sounds.
- 37. CHEST X-RAYenlarged Globular heart shadow. Echo…. Fluid in pericardial sac. Central venous pressure… high CT scan TREATMENT ABC’s with c-spine control as indicated High Flow oxygen. Treat S/S of shock • Rapid Transport What patient needs is Pericardiocentesis
- 39. It isa bruise of the heart muscle, which can occur with serious bodily injury, caused by Road tracffic accident Falling from height Chest compressions Symptoms – pain above the ribs, tachycardia, fatigue, shortness of breath, light headedness, nausea vomiting and weakness.
- 40. Chest X-Ray CT scan of chest Echocardiogram & CBC TREATMENT Chest tube placement Placement of pacemaker Surgical repair of blood vessels.
- 42. It isacondition in which the aorta is torn or ruptured as aresult of trauma to the body. Most common cause of sudden death after MVA or fall from height Relatively fixed distal to the origin of Left subclavian artery. The heart, more or less, just hangs from the aortic arch much like a big pendulum. Deceleration Injury If Intima and media are disrupted, but Adventitia is intact……. Pt may be Stable.
- 43. Burning orTearing Sensation in chest or shoulder blades Rapidly dropping Blood Pressure Pulse Rapidly Increasing Asymmetry of both upper limbs, or upper and lower limbs Blood Pressure. Widened Pulse Pressure. Chest wall contusions Rapid Loss of Consciousness.
- 44. CHEST X-RAYErect…. Widened Mediastinum Aortogram. CT with Contrast. Trans-esophageal echo. TREATMENT ABC’s with c-spine control as indicated High Flow oxygen. Treatment for Shock Control of systolic B.P to less than 100mmHg. Stenting. Direct repair Excision and grafting using a Dacron graft.
- 46. A tearof the diaphragm, the muscle across the bottom of the ribcage that palys a crucial role in inspiration. Most commonly acquired by physical trauma. A tear in the Diaphragm that allows the abdominal organs enter the chest cavity. Any penetrating injury to or below 5th intercostal space can cause diaphragmatic penetration & abdominal injury. usually large, with herniation of the abdominal contents into the chest.
- 47. Abdominal Pain Shortness of Air Decreased Breath Sounds on side of rupture Bowel Sounds heard in chest cavity DIAGNOSTIC EVALUATION - Chest radiography after placement of a nasogastric tube, Contrast studies of the upper or lower gastrointestinal tract, CT scan & diagnostic peritoneal lavage. Most accurate evaluation is by video-assisted thoracoscopy (VATS) or laparoscopy.
- 48. .Operative Repair. Penetrating diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out penetrating hollow viscus injury. Laproscopy can be done.
- 50. Results frompenetrating trauma; blunt injury is rare Patient can present with odynophagia, subcutaneous or mediastinal emphysema, pleural effusion, air in the retro-oesophageal space and unexplained fever within 24 hours of injury Combination of oesophagogram and oesophagoscopy confirm diagnosis CT can be done Treatment is operative repair and drainage Mid-oesophageal injury => Right thoracotomy. Distal oesophageal injury => Left thoracotomy.
- 51. Entry into cervicalor mediastinal fascial planes of: Air Gastric juice Bacteria and Saliva Sepsis Pneumo nia CV Collapse
- 53. Crushing andbruising of the lung parenchyma. Sudden blow or blunt injury to the chest => compression of thoracic cavity and lung followed by an equally sudden decompression. Concussive and compressive force is most important cause. The natural progression of pulmonary contusion is worsening hypoxemia for the first 24 to 48 hours. X-ray findings not significant initially. CT with contrast is confirmatory.
- 54. Hemoptysis Dyspnea Cough Chest wall abrasion Echymosis. TREATMENT Oxygen administration Pul. Toilet Mechanical ventilation => in severe case
- 56. Blunt andpenetrating trauma Presented as hoarseness, SCE. Dyspnea , Pneumothorax , hemoptysis , Mediastinal crunch {Hamman’s Sign}, Intercostal retractions, Respiratory distress , Stridor. Chest drain will reveal a large air leak and the collapsed lung may fail to re-expand. • Diagnosis => Bronchoscopy TREATMENT Surgical repair : standard of care In case of airway compromise, endotracheal intubation should be done. Flexible bronchoscopy permits the tube to guide distal to the site of injury
- 57. Begin withCPR Cover an Open Wound Stop bleeding Position the person to make breath Easier Monitor Breathing Follow up Management
- 58. CAB INTERCOSTAL DRAINGE PERICARDIOCENTHESIS SURGICAL REPAIR
- 59. • A. Airway Assessfor airway patency and air exchange - listen at nose & mouth Assess for intercostal and supraclavicular muscle retractions Assess oropharynx for foreign body obstruction Continue it till it come 100-120 compression • B. Breathing Assess respiratory movements of respirations - look, listen, feel and give 2 breath. • C. Circulation Skin - look and feel for color, temperature, capillary refill- Look for cyanosis. Assess pulses for quality, rate, regularity Look at neck veins - flat vs. distended-fluid Deficit or decreased supply to body from heart due to compression. Assess the Blood Pressure.
- 60. It isa flexible plastic tube that is inserted through the chest wall into the plural space. INDICATIONS -Pneumothorax: Tension Spontaneous Iatrogenic Hemothorax Traumatic hemopneumothorax Empyema Chylothorax Bronchopleural fistula
- 61. Skin preparation& marking Administration of anesthetic agent Positioning the patient Skin incision Blunt dissection down to the intercostal muscle Digital examination along the tract into pleural space Withdrawal of central trochar & positioning of drain Suture taken to secure chest tube to skin CXR to ensure correct positioning of the chest tube & to look for lung re expansion.
- 62. CONTRA INDICATION Absolute…. Need for emrgency Thoracotomy Relatives are Bleeding Diathesis Anti-coagulation &Adhesions Loculations & Pulmonarybullae COMPLICATION Hemorrhage Infection Trauma to the Liver, spleen, Diaphragm, Aorta, Heart. Minor complications like, Subcut hematoma, Cough, dyspnea, Improper placement
- 64. Using aseptictechnique, 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 amout of blood aspirated can cause a rapid change in blood pressure
- 65. THORACOTOMY –It is a surgery to open your chest. During the procedure, a surgeon makes an incision in the chest wall between your ribs, usually to operate lungs. INDICATION Post-traumatic cardiovascular collapse Pericardial tamponade Vascular injury to the thoracic outlet Control of Hge from lung injury Massive Air leak Proved tracheobronchial injury Internal cardiac massage
- 66. Emergency /Resuscitative Thoracotomy. For bleeding control. Planned Thoracotomy. For repair of specific injury
- 67. Pain Dyspnea Infection Bleeding Pneumothorax Respiratory Failure Death
- 68. Chest Injuriesare 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.
- 69.