Reported by : Jazon, Gabriel Liberon P.

Mr. Ivan T. Pacatang, RN-MN Clinical Instructor NCM104-C2 JUNE 19, 2010

II. Introduction
y Records describing chest trauma and its treatment

date to antiquity y . An ancient Egyptian treatise (the Edwin Smith Surgical Papyrus [circa 3000-1600 BC]) and Hippocrates' writings in the 5th century contain a series of trauma case reports, including thoracic injuries.

y Estimates of thoracic trauma frequency indicate that

injuries occur in 12 persons per million populations per day y Approximately 33% of these injuries require hospital admission. y By far, the most important cause of significant blunt chest trauma is motor vehicle accidents y MVAs account for 70-80% of such injuries.

III. Definition of Terms .

_____ y having an edge or point that is not sharp .

such as in cardiac tamponade. ._________ y stoppage of the blood flow to an organ or a part of the body by pressure or the compression of a part by an accumulation of fluid.

__________ The tissue characteristic of an organ. as distinguished from associated connective or supporting tissues. .

. it is the angle where the diaphragm meet the ribs.____________ _____ y In anatomy.

_________ _____ y is an exaggeration of the normal variation during the inspiratory phase of respiration. in which the blood pressure declines as one inhales and increases as one exhales. .

IV. Etiology y motor vehicular accidents .

y Stabs or gun shot wounds .

y blasts or explosions

y falls from great heights

y Chest injuries result from blunt or penetrating trauma

and range from mild to severe.
y The injuries may involve the chest wall pleura,

parenchyma, or heart and great vessels ruptured aorta and surrounding structures
y Because of the number of vital structures contained

within the chest, trauma to this area is particularly hazardous and often life threatening.

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Blunt Chest Trauma y The most common causes of blunt chest trauma are MVA crashes. . ruptures. y deceleration -sudden decrease in rate of speed or velocity. Mechanisms of blunt chest trauma include: y acceleration -moving object hitting the chest or patient being thrown into an object. falls.A. such as a motor vehicle crash. or dissections. y shearing -stretching forces to areas of the chest causing tears. and bicycle crashes.

such as a crush injury.y compression -direct blow to the chest. Injuries to the chest are often lifethreatening and result in one or more of the following pathologic states: Hypoxemia Hypovolemia Cardiac failure .

It is essential to assess the patient immediately to determine the following:  Time elapsed since injury occurred  Mechanism of injury  Level of consciousness  Specific Injuries  Estimated blood loss  Recent drug or alcohol use  Prehospital treatment .Assessment y Time is critical in treating chest trauma.

and draining .Medical Management y The goals of treatment are to evaluate the patient s condition and to initiate aggressive resuscitation. open pneumothorax. y Strategies to restore and maintain cardiopulmonary function include ensuring an adequate airway and ventilation. stabilizing and re-establishing chest wall integrity.

B. y Knives and switchtables cause most stab wounds y Gunshot wounds maybe classified as low. or high velocity . Penetrating Chest Trauma y Gunshot and stab wounds are the most common causes of penetrating chest trauma y Stab wounds are generally considered low-velocity trauma because the weapon destroys a small area around the wound. medium.

as indicated by the patient s condition . crystalloids. or blood.  The patient s blood is typed and cross-matched in case blood transfusion is required.‡Medical Management  After an adequate airway is ensured and ventilation is established. examination for shock and intrathoracic injuries should be done.  Shock is treated with colloid solutions.

‡Medical Management y A chest tube is inserted into the pleural space in most patients with penetrating wounds of the chest to achieve rapid and continuing reexpansion of the lungs y If the patient has a wound on the heart or great vessels. esophagus or the tracheobronchial tree. surgical intervention is required. .

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ib Fractures .Fracture of rib at point of impact by blunt or penetrating trauma .

low PaO2. Chest X-ray: vertical fracture line or non-union of rib .Assessment for Rib Fractures y Pain on palpation y Pain on inspiration y vascular injury with fracture of ribs 1 and 2 y underlying lung injury with fracture of ribs 3-9. y y y y abdominal or liver injury with fracture of lower ribs ineffective ventilation secretion retention ABGs: normal. low PaCO2.

Interventions y Analgesia y Intercostal nerve block with local anesthetic y epidural catheter with analgesia or anesthetic no constrictive appliances y incentive spirometry y chest physical therapy y Ortho-thoracic Surgery .

Fracture of two or more ribs on both sides of the point of impact produces unstable rib cage . .Heals in 6 weeks.Flail segment responds to changes in intrapleural pressure. leading to atelectasis and hypoxemia .Flail Chest . .prevents full lung expansion.

Assessment for Flail Chest
y Pain on palpation y pain on inspiration y paradoxical movement of flail segment y lowered tidal volumes y increased respiratory effort y dyspnea y ABGs: low PaO2, high PaCO2 y Chest X-ray: multiple adjacent rib fractures

Interventions
y Patent airway y analgesia: intravenous PCA, y transcutaneous electric nerve stimulation y intercostals nerve block y external splinting, oxygen, mechanical ventilation y Positive end- expiratory pressure y surgical fixation y chest physical therapy & incentive spirometry.

preventing lung expansion and compromising gas exchange.Pneumot orax . normal negative intrathoracic pressure is lost.air collects in pleural cavity. all or part of the lung collapses .Perforation of lung by fractured rib or penetrating trauma .

decreased lung volume . high PaCO2 y chest x-ray film: air in pleural space.Assessment for Pneumothorax y Chest pain y Dyspnea y asymmetrical lung expansion y diminished or absent breath sounds on affected side y hyperresonance and crepitus y ABGs: normal. low PaO2.

Interventions y Cook catheter with Heimlich valve y small-bore chest tube second intercostals space y y y y midclavicular line to water seal suctioning watch for tension pneumothorax Oxygen therapy analgesia .

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compromising gas exchange.hemothorax may also result from lacerated liver or perforated diaphragm .Hemothorax . .Perforation of blood vessel and internal mammary artery by rib fracture or penetrating trauma . part of lung tissue on affected side is compressed.causes collection of blood between pleural layers.

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Assessment for Hemothorax y Chest pain y Dyspnea y asymmetrical lung expansion y diminished or absent breath sounds on affected side y dullness or flatness over blood collection y ABGs: normal. high PaCO2 y chest x-ray: pleural effusion on upright film. 1000 ml extends 5 cm above diaphragms . 300 ml blunts costophrenic angle. low PaO2.

Interventions y Large-bone chest tube fifth intercostals space midaxillary line to water seal or suction y oxygen therapy y excessive blood loss (1000ml immediate or 200500ml/hr) is an indication for surgery y analgesia .

and left-sided heart is usual target .Perforated Diaphragm y Blunt or more commonly penetrating trauma as high as T4 tears diagphragm y predominant incidence involves left hemidiaphragm because most assailants are right handed y right side is protected by liver.

Assessment for Perforated Diaphragm y Decreased breath sounds y decreased respiratory excursion y decreased diaphragmatic excursion y shortness of breath and chest pain y persistent air leak in chest tube tachypnea y bowel sounds in chest cavity .

or elevated hemidiaphragm . bowel herniated into chest cavity.Assessment for Perforated Diaphragm y tympany to percussion y difficulty in passing nasogastric tube with herniated bowel y mediastinal shift to opposite side y chest x-ray film: normal.

Intervention: Surgical repair .

Tension Pneumothorax y Air in pleural cavity. trapped without exit may result from primary traumatic injury or be delayed y pressure collapses lung y pushes mediastinum to opposite side compromising contralateral lung y venous return is impaired as mediastinal shift distorts vena cava and air increases intrathoracic pressure .

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hyperresonance or tympany to percussion .Assessment for Tension Pneumothorax y Severe respiratory distress y trachea deviated to opposite side y asymmetrical chest movement y distended neck veins y absent or diminished breath sounds on affected side y chest pain.

high PaCO2 y chest x-ray: collapsed lung on affected side.y Tachycardia y Hypotension y Cyanosis y extreme agitation y decreased cardiac output y ABGs: low PaO2 and SaO2. mediastinum and trachea shifted to opposite side .

Interventions y Oxygen y needle decompression (16-18G). second intercostals space midclavicular line y small-bore chest tube to water seal or suction .

Cardiac contusion y Myocardial contusion is similar to myocardial infarction and frequently results from blunt chest wall injuries. including fracture of ribs and sternum .

Assessment for Cardiac contusion y Dysrhythmias especially for 48-72 hours y ECG: similar to ischemia y premature atrial and ventricular contractions y ventricular tachycardia y decreased or normal cardiac output y chest pain y elevated cardiac enzymes .

Interventions y Continous assessment of rhythm and hemodynamics y normal fluid balance y inotropic agents y decreased stressors y decreased oxygen consumption .

Cardiac Tamponade y Life threatening accumulation of blood in the pericardial sac y usually the result of blunt injury or puncture wound to heart y patient develops cardiogenic shock as cardiac output falls with increased intrapericardial pressure.volume of fluid varies y usually is greater than 50-100mL symptoms and treatment depend on rapidity of accumulation .

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dyspnea.Assessment Cardiac Tamponade y Midthoracic pain especially in second to seventh y y y y y intercostals spaces left of sternum distant. muffled heart sounds hypotension. narrow pulse pressure. distended neck veins. . elevated central venous pressure decreased cardiac output. tachycardia. pulsus paradoxus greater than 15 mmHg.

Interventions y Pericardiocentesis with large-bore long needle below y y y y or along left xiphoid process aspirated blood should not clot. since it is defibrinated by cardiac motion in pericardium pericaridial catheter surgery observe for recurrence .

most common site is distal to left subclavian artery on descending thoracic aorta. y On deceleration. long-term survival is 6%-8%. and other sites include ascending aorta at pericardial sac and at diaphragm. 90% die at scene of injury. intima and media tear and adventitia balloons into pseudoaneurysm.Ruptured Aorta y Complete or partial dissection of aorta y usually from deceleration injury y tears occur at points of anatomical fixation. .

.Ruptured Aorta y 1st or 2nd rib fractured. high sterna fracture. or left clavicular fracture is often associated with aortic injury.

Assessment for ruptured aorta y Sternal or interscapular back pain y upper extremity hypertension y absent or delayed femoral or radial pulse y hypovolemic shock. dyspnea. hypotension. y precordial or interscapular murmur caused by turbulence across disrupted area y hoarseness caused by hematoma pressure around aortic arch y tachypnea .

entire left side may be opacified y tracheal and esophageal deviation to the right . low or high PaCO2 y chest x-ray: widened mediastinum on upright film.y Cyanosis y lower extremity neuromuscular or sensory deficit y cardiopulmonary arrest y low haemoglobin and hematocrit y ABGs: low PaO2. low SaO2. Massive pleural effusion more commonly on left.

Reparative surgery sedatives antihypertensives antibiotics .Interventions y Fluid resuscitation y large-bore chest tube to gravity or suction drainage y y y y with blood salvaging device although this may provide route for exsanguinations by eliminating tamponade effect.

Interventions y surgery for bowel ischemia y CPR .

Pulmonary Contusion y Compression or decompression injury that ruptures lung tissue small airways and alveoli y Interstitial and alveolar edema accompanied by inflammation. bruising may be accompanied by pulmonary laceration or tear y more common in thin chest walls and young people with compliant chest walls .

Pulmonary Contusion y Ventilation-perfusion abnormalities and shunt present in damaged or collapsed gas exchanging units. y Atelectasis and secretion retention problems y older individuals usually have more fractures but fewer contusions y may be unilateral or bilateral .

low PaCO2. dyspnea. y Chest x-ray: focal area of infiltrate usually within 6-24 hours. and hemoptysis y Increased peak ventilating pressures. .Assessment for Pulmonary Contusion y Tachypnea .crackles and wheezes. y ABGs: low PaO2. decreased lung compliance. low SaO2.

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Interventions y Oxygen Therapy y Intubation and mechanical ventilation with PEEP y jet ventilation y suctioning with lavage y chest physical therapy y rotokinetic therapy y Analgesia/sedation y pharmacological paralysis y normal fluid balance y observe for trauma and infection .

Ruptured Trachea or Bronchus y Usually caused by blunt forces y suspect with fracture of first to 5th ribs y typical site within 1 inch of the carina frequently incomplete and circumferential y may result in tracheal stenosis or tracheal malacia. .

Assessment for Ruptured Trachea or Bronchus y Dyspnea y hemoptysis y difficulty in intubating y persistent pneumothorax y early atelectasis from secretions or blood clot y subcutaneous emphysema y signs of air embolus .

Interventions y Patent airway y careful suctioning y careful neck positioning y double lumen Endotracheal tube y chest tube y bronchoscopy y surgical repair .

y Penetrating trauma more frequently associated with ruptured esophagus. .Ruptured Esophagus y Deceleration injury tears esophagus at one of three areas of narrowing. cricoids cartilage. or diagphragm. arch of aorta. y corrosion of mediastinal structures by digestive juices and bacterial contamination are major concerns.

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Ruptured Esophagus y most common complications are: Mediastinitis periesophageal abscess empyema esophageal fistula Peritonitis y mortality is reported to be 19%-27% .

shoulders.Assessment for Ruptured Esophagus y Pain may radiate to neck chest. or abdomen y Resistance of neck to passive range of motion y peritoneal signs y dyspnea y hoarseness or cough y stridor y bleeding from mouth or nasogastric tube .

Assessment for Ruptured Esophagus y fever y Dysphagia y crepitus y pneumothorax y hest x-ray shows normal. mediastinal or pleural air (esophagoscopy or esophagogram to confirm) .

Interventions y Surgical repair may include closure of esophagus and y y y y y mucous fistula gastric decompression antibiotics wound drainage skin care nutritional support .

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Laboratory Studies y Complete Blood Count y Arterial Blood Gas y Serum Profile y Coagulation Profile y Troponin Levels y Lactate Levels y Blood Type MATCH THAT TEST .

Imaging Studies y Chest Radiographs y Chest CT Scan y Aortogram y Thoracic Ultrasound y Electrocardiogram y Flexible or rigid Esophagoscopy y Fiberoptic or Rigid Bronchoscopy .

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Pre-Operative Nursing Management y Improving Airway Clearance y Teaching the Patient y Relieving Anxiety .

the head of the bed maybe elevated 30-45° y The nurse assesses for signs of complications. dyspnea.Post-Operative Nursing Management y and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary edema y After the patient is conscious and the vital signs have stabilized. including cyanosis. and acute chest pain .

Chest Physical Therapy y Positioning /Postural Drainage y Percussion/Vibration y Coughing y Breathing and Incentive Therapy y Oxygen Therapy y Adjuncts to Physical Therapy .

Invasive Techniques y AMBU Bag .a valve mask that is used to help a person breathe who is not breathing or is breathing inadequately on his own .can also be attached to oxygen devices to provide 100 percent oxygen to a patient .

thyroid gland. inability to clear secretions or inadequate minute ventilation . or esophagus .endotracheal tube is inserted because of lower airway obstruction.Invasive Techniques y Intubation .risks for this procedure include trauma to the voice box (larynx). vocal cords and trachea (windpipe).

the opening that is created during a tracheostomy allows them to breathe freely. .Tracheostomy y A tracheostomy tube is inserted through the opening and into the trachea y a tracheostomy can also be used to remove unwanted fluids produced by the lungs or throat y If a person s airway is blocked or unusable.

Bronchoscopy y is a small flexible tube containing fieberoptics y the physician can see the inside of the nose. or larger airways y begin by withholding food and oral fluids for at least 3 to 6 hours. larynx. trachea. depending on the patient and the physician y Orals fluids are also withheld for at least 2 hours or until gag reflex returns to normal after the procedure .

. advantage of a decreased potential for sinus infections y As a general rule to prevent aspiration.Feeding Tubesthe oral route may have the y For trauma patients. patients should not be positioned head-down for up to 30 minutes after the bolus gastric feeding y Continuous gastric feeding pumps should be stopped before chest physical therapy is begun.

Thoracentesis y is a procedure used to obtain a sample of fluid from the space around the lungs y Assist the patient throughout the procedure by holding his shoulders or sides and reassuring him. y Monitor the patient every 15 minutes during the first hour after the procedure. then as often as his condition warrants .

.Chest Tubes y The tube is placed between the ribs and into the pleural space y inserted through an incision between the ribs into the chest and is connected to a bottle or canister that contains sterile water y Suction is attached to the system for drainage. A stitch (suture) and adhesive tape keep the tube in place.

Pleurodesis y used to prevent recurrence of a pneumothorax or pleural effusion y the irritant causes a local reaction that encourages adherence of the parietal and visceral pleura y A successful procedure prevents recurrent pneumothorax and reaccumulation of pleural fluid. .

fluid. and blood y Placement of a chest tube in the pleural space restores the negative intrathoracic pressure needed for lung reexpansion following surgery or trauma.Drainage Systems y are used to re-expand the involved lung and to remove excess air. .

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are usually connected to a chest drainage system to collect any pleural fluid and monitor for air .Two types of chest tubes: y Small-bore catheters (7F to 12F) have a one-way valve apparatus to prevent air from moving back into the patient y Large-bore catheters. which range in size up to 40F.

Cardiothoracic Surgeries y Coronary Bypass Surgery y Cardiopulmonary Bypass y Hypothermia .

Patient and Family Teaching Guide Following Surgery from Chest Trauma y The nurse needs to be familiar with the full range of lung surgery which a client may undergo y Demonstration of this knowledge by the nurse gives the patient more confidence in the nurse s ability as an effective educator y A holistic approach is definitely called for one that recognizes that the patient is a complex human being .

The objective of the nurse s teaching efforts is to have the patient become a proficient and independent in performing the postoperative exercises as his or her overall life situation .

Teaching Session y PACU room y Turning . Splinting y Diaphragmatic Breathing y Coughing y Exercise y Huffing y Postural Drainage CHECK YOUR CHAIRS!!! .

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One consideration in teaching the patient and family regarding post-op care for chest trauma. 3. 2. 4. Used to prevent recurrence of a pneumothorax or pleural effusion Fracture of two or more ribs on both sides of the point of impact produces unstable rib cage Give at least two etiological factors for chest trauma Differentiate Pneumothorax from tension pneumothorax. .QUESTIONS 1. 5.

B. Medical-Surgical Nursing. CA: y y y y y y y y Pearson Education. Louis. EN.com/article/blunt tissue trauma Dettenmeier.). (1988). Black J. St. (2004). Singapore: Pearson Education. MO 63146 Smeltzer S..A. J. and practice (7th ed). USA: Lippincott Williams & Wilkins. http://emedicine. al. (2004).D. (1996). (2005). process.S. E. M. Connecticut 06855 Irwin. S. & Tecklin. Fundamentals of nursing: concepts. Pulmonary Care: A Guide for Patient Education . Missouri. (1992). USA:Elsevier. PA. Essentials of human anatomy and physiology.Mosby-Year Book.Appleton-CenturyCrofts. & Bare B. Kozier. Burns. Medical-Surgical Nursing. Louis. (2004). & Hawks J. St. MO 63146 . Pulmonary Nursing Care Mosby-Year Book. P. Inc. et.medscape. San Francisco. Cardiopulmonary physical therapy (3rd ed. Inc.BIBLIOGRAPHY y Marieb. Inc.medscape.com/article/penetrating/traum http://emedicine. Inc.

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