Asuhan Keperawatan Klien dengan Trauma dada Tuti Herawati, SKp, MN

Introduction Struktur Organ: Jantung, pembuluh darah besar, esofagus, trakeobronkial dan paru -paru 25% of kematian akibat KLL disebabkan karena trauma dada Trauma abdomen um umnya disertai dengan trauma dada Penyebab: trauma tumpul dan trauma tajam Fokus pencegahan Sistem yang memperbaiki keselamatan penumpang seperti airbags, safet y belt

Anatomi & Fisiologi Thorax Tulang dinding thorax 12 pasang tulang-tulang iga yang berbentuk C Ribs 1-7: Join at sternum with cartilage end-points Ribs 8-10: Join sternum with combined cartilage at 7 th 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 A ttachment of 2nd rib Xiphoid process Distal portion of sternum

PENYEBAB TRAUMA DADA Trauma Tajam Panah, pisau, handguns, Shotguns, tergantung jarak dengan senjata dan kaliber. Type I: >7 meters: injuri jaringan lunak Type II: 3-7 meters : penetrasi ke fasc ia dan organ internal Type III: <3 meters: kerusakan jaringan yang hebat. Trauma.org

Penyebab Trauma dada Trauma Tumpul

Injuri yang menyertai trauma pada dada Closed pneumothorax Open pneumothorax (including sucking chest wound) Tension pn eumothorax Pneumomediastinum Hemothorax Hemopneumothorax Laceration of vascular structures Tracheobronchial tree lacerations Esophageal lacerations Penetrating cardiac injuries Pericardial tamponade Spinal cord injuries Diaphragm trauma Int ra-abdominal penetration with associated organ injury

Dinding dada Contusion Umumnya disebabkan trauma tumpul Signs & Symptoms Erythema Ecchymosis DYSPNEA Nyeri saat bernafas Suara nafas yang menurun Limi breath sounds HYPOVENTILAsi (nyeri saat bernafas) Crepitus Gerakan dinding dada paradox

Dinding dada Fraktur Iga >50% trauma dada disebabkan oleh trauma tumpul Compressional forces flex and fra cture ribs at weakest points Iga 1-3 diperlukan kekauatan yang besar bila terjad i fraktur, dapat menuebabkan injuri paru Iga 4-9 tempat yang paling umum terjadi farktur Iga 9-12 jarang terjadi fraktur Transmisikan energy trauma ke organ internal Bila fraktur, curigai adanya injuri hepar dan limpa Hypoventilasi umum terjadi karena nyeri

Dinding dada Sternal Fracture & Dislocation Associated with severe blunt anterior trauma Typical MOI Direct Blow (i.e. Steering wheel) Incidence: 5-8% Mortality: 25-45% Myocardial contusion Pericardial tamponade Cardiac rupture Pulmonary contusion Dislocation uncommon but same MOI as fracture Tracheal depression if posterior

Dinding dada Flail Chest Segment of the chest that becomes free to move with the pressure changes of resp iration Three or more adjacent rib fracture in two or more places Serious chest wall injury with underlying pulmonary injury Reduces volume of respiration Adds to increased mortality Paradoxical flail segment movement Positive pressure ventilation can restore tid al volume

Paradoxical chest wall movement

The point of insertion in the chest most commonly occurs on the side (lateral th orax), at a line drawn from the armpit (anterior axillary line) to the side (lat eral) of the nipple in males, or to the side (about 2 in [5 cm]) above the stern oxiphoid junction (lower junction of the sternum, or chest bone) in females.

Injury Paru-Paru Simple Pneumothorax Closed Pneumothorax Progresses into Tension Pneumothorax Occurs when lung tissue is disrupted and air leaks into the pleural space Progressive Pathology Air accumulates in pleural space Lung collapses Alveoli collapse (atelectasis) R educed oxygen and carbon dioxide exchange Increased ventilation but no alveolar perfusion Reduced respiratory efficiency r esults in HYPOXIA Ventilation/Perfusion Mismatch

Injury Paru-Paru Open Pneumothorax Free passage of air between atmosphere and pleural space Air replaces lung tissu e Mediastinum shifts to uninjured side Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger Signs & Symptoms Penetrating chest trauma Sucking chest wound Frothy blood at wound site Severe D yspnea Hypovolemia

Injuri Paru-paru Tension Pneumothorax Buildup of air under pressure in the thorax. Excessive pressure reduces effectiv eness of respiration Air is unable to escape from inside the pleural space Progr ession of Simple or Open Pneumothorax

Pulmonary Injuries Tension Pneumothorax Signs & Symptoms Dyspnea Tachypnea at first Progressive ventilation/perfusion mismatch Atelectasi s on uninjured side Hypoxemia Hyperinflation of injured side of chest Hyperreson ance of injured side of chest Diminished then absent breath sounds on injured si de Cyanosis Diaphoresis JVD Hypotension Hypovolemia Tracheal Shifting LATE SIGN

Injuri Paru-Paru Hemothorax Accumulation of blood in the pleural space Serious hemorrhage may accumulate 1,5 00 mL of blood Mortality rate of 75% Each side of thorax may hold up to 3,000 mL Blood loss in thorax causes a decrease in tidal volume Ventilation/Perfusion Mismatch & Shock Typically accompanies pneumothorax Hemopneumothorax

Hemothorax sign & symptoms Blunt or penetrating chest trauma Shock Dyspnea Tachycardia Tachypnea Diaphoresis Hypotension Dull to percussion over injured side

Pulmonary Injury Pulmonary Contusion Soft tissue contusion of the lung 30-75% of patients with significant blunt ches t trauma Frequently associated with rib fracture Typical MOI Deceleration Chest impact on steering wheel Bullet Cavitation High velocity ammunition Microhemorrhage may account for 1- 1 L of blood loss in alveolar tissue Progressive deterioration of ventilatory status Hemoptysis typically present

Cardiovascular injury Myocardial Contusion Occurs in 76% of patients with severe blunt chest trauma Right Atrium and Ventri cle is commonly injured Injury may reduce strength of cardiac contractions Reduced cardiac output Electrical Disturbances due to irritability of damaged myocardial cells Progress ive Problems Hematoma Hemopericard Myocardial necrosis Dysrhythmias CHF & or Cardiogenic shoc k

Myocardial contusion sign & symptom Bruising of chest wall Tachycardia and/or irregular rhythm Retrosternal pain sim ilar to MI Associated injuries Rib/Sternal fractures Chest pain unrelieved by oxygen May be relieved with rest THIS IS TRAUMA-RELATED PAIN Similar signs and symptoms of medical chest pain

Cardiovascular injury Pericardial Tamponade Restriction to cardiac filling caused by blood or other fluid within the pericar dium Occurs in <2% of all serious chest trauma However, very high mortality Results from tear in the coronary artery or penetration of myocardium Blood seeps into pericardium and is unable to escape 200-300 ml of blood can res trict effectiveness of cardiac contractions Removing as little as 20 ml can provide relief

Pericardial Tamponade Signs & Symptoms Dyspnea Possible cyanosis Becks Triad JVD Distant heart tones Hypotension or narrowing pulse pressure Weak, thready pulse Shock Kussmauls sign Decrease or absence of JVD during inspiration Pulsus Paradoxus Dro p in SBP >10 during inspiration Due to increase in CO2 during inspiration Electr ical Alterans P, QRS, & T amplitude changes in every other cardiac cycle PEA

Cardiovascular injury Traumatic Aneurysm or Aortic Rupture Aorta most commonly injured in severe blunt or penetrating trauma 85-95% mortality Typically patients will survive the initial injury insult 30% mortality in 6 hrs 50% mortality in 24 hrs 70% mortality in 1 week Injury may be confined to areas of aorta attachment Signs & Symptoms Rapid and deterioration of vitals Pulse deficit between right and left upper or lower extremities

Assessment of the Thoracic Trauma Patient Scene Size-up Initial Assessment Rapid Trauma Assessment Observe JVD, SQ Emphysema, Expansion of chest Palpate Auscultate Percuss Blunt T rauma Assessment Penetrating Trauma Assessment Ongoing Assessment

General Management of the Chest Injury Patient Ensure ABCs High flow O2 via NRB Intubate if indicated Consider overdrive ventilation If tidal volume less than 6,000 mL BVM at a rate of 12-16 May be beneficial for chest contusion and rib fractures Promotes oxygen perfusio n of alveoli and prevents atelectasis Anticipate Myocardial Compromise Shock Management Fluid Bolus: 20 mL/kg AUSCULTATE! AUSCULATE! AUSCULATE!

Management of the Chest Injury Patient Rib Fractures Consider analgesics for pain and to improve chest excursion Morphine Sulfate CONTRAINDICATION Nitrous Oxide May migrate into pleural or mediastinal space and worsen condition

Management of the Chest Injury Patient Sternoclavicular Dislocation Supportive O2 therapy Evaluate for concomitant inju ry Flail Chest Place patient on side of injury ONLY if spinal injury is NOT suspected Expose injury site Dress with bulky bandage against flail segment Stabilizes fracture site High flow O2 Consider PPV or ET if decreasing respiratory status DO NOT USE SANDBAGS TO STABILIZE FX

Trauma.org

Management of the Chest Injury Patient Open Pneumothorax High flow O2 Cover site with sterile occlusive dressing taped on three sides Pro gressive airway management if indicated

Management of the Chest Injury Patient Tension Pneumothorax Confirmation Auscultaton & Percussion Pleural Decompression 2nd intercostal space in mid-clavicular line TOP OF RIB Consider multiple decompression sites if patient remains symptomatic Large over the needle catheter: 14ga

Management of the Chest Injury Patient Hemothorax High flow O2 2 large bore IVs Maintain SBP of 90-100 EVALUATE BREATH SOUNDS for fluid overload Myocardial Contusion Monitor ECG Alert for dysrhythmias IV if antidysrhythmics are needed

Management of the Chest Injury Patient Pericardial Tamponade High flow O2 IV therapy Consider pericardiocentesis; rapidly deteriorating patie nt Aortic Aneurysm AVOID jarring or rough handling Initiate IV therapy enroute Mild hypotension may be protective Rapid fluid bolus if aneurysm ruptures Keep patient calm

Diagnosa keperawatan 1. Ketidakefektifan pola pernapasan berhubungan dengan ekpansi paru yang tidak m aksimal karena akumulasi udara/cairan. 2. Inefektif bersihan jalan napas berhubu ngan dengan peningkatan sekresi sekret dan penurunan batuk sekunder akibat nyeri dan keletihan. 3. Perubahan kenyamanan : Nyeri akut berhubungan dengan trauma jaringan dan refl ek spasme otot sekunder. 4. Kerusakan integritas kulit berhubungan dengan trauma mekanik terpasang bullow drainage. 5. Hambatan mobilitas fisik berhubungan deng an ketidakcukupan kekuatan dan ketahanan untuk ambulasi dengan alat eksternal. 6 . Risiko terhadap infeksi berhubungan dengan tempat masuknya organisme sekunder terhadap trauma.

Ketidakefektifan pola pernapasan berhubungan dengan ekspansi paru yang tidak mak simal karena trauma. Tujuan : Pola pernapasan efektive. Kriteria hasil : o Memperlihatkan frekuensi p ernapasan yang efektive. o Mengalami perbaikan pertukaran gas-gas pada paru. o A daptive mengatasi faktor-faktor penyebab. Intervensi : Berikan posisi yang nyama n, biasanya dnegan peninggian kepala tempat tidur. Balik ke sisi yang sakit. Dor ong klien untuk duduk sebanyak mungkin. Observasi fungsi pernapasan, catat freku ensi pernapasan, dispnea atau perubahan tanda-tanda vital. Jelaskan pada klien b ahwa tindakan tersebut dilakukan untuk menjamin keamanan

Intervensi Jelaskan pada klien tentang etiologi/faktor pencetus adanya sesak atau kolaps pa ru-paru. Pertahankan perilaku tenang, bantu pasien untuk kontrol diri dnegan men ggunakan pernapasan lebih lambat dan dalam. Perhatikan alat chest drainase berfu ngsi baik, cek setiap 1 2 jam Periksa pengontrol penghisap untuk jumlah hisapan yang benar. Periksa batas cairan pada botol penghisap, pertahankan pada batas ya ng ditentukan. Observasi gelembung udara botol penampung. Posisikan sistem drain age slang untuk fungsi optimal, yakinkan slang tidak terlipat, atau menggantung di bawah saluran masuknya ke tempat drainage. Alirkan akumulasi drainase bila pe rlu. Catat karakter/jumlah drainage selang dada. Kolaborasi dengan tim kesehatan lain Pemberian analgetika. Konsul photo toraks.

Inefektif bersihan jalan napas berhubungan dengan peningkatan sekresi sekret dan penurunan batuk sekunder akibat nyeri dan keletihan. Tujuan : Jalan napas lanca r/normal Kriteria hasil : Menunjukkan batuk yang efektif. Tidak ada lagi penumpu kan sekret di sal. pernapasan. Klien nyaman. Intervensi : Jelaskan klien tentang kegunaan batuk yang efektif dan mengapa terdapat penumpukan sekret di saluran p ernapasan. Ajarkan latihan pernapasan dan batuk efektif Auskultasi paru sebelum dan sesudah klien batuk. Ajarkan mempertahankan hidrasi yang adekuat; meningkatkan masukan cairan 1000 sampai 1500 cc/hari bila tidak ko ntraindikasi. Dorong atau berikan perawatan mulut yang baik setelah batuk. Lakukan penghisapan lendir jika diperlukan Kolaborasi dengan tim kesehatan lain : Pemberian expectoran, pemberian analgesik ,