CHEST TRAUMA

- occur as the result of an accidental or deliberate penetration of a foreign

object into the chest.
- It accounts around 25% to 50% in the mortality rates
- CLASSIFICATION:

1. BLUNT TRAUMA
 Responsible for the 20-25% of trauma deaths
 Symptoms are generalizes and vague
 Most common causes is MOTOR VEHICLE ACCIDENTS, FALLS
and BICYCLE CRASHES
 Injuries are life threatening and result to the following:
a. HYPOXEMIA- from disruption of the airway;injury to the lung
parenchyma, rib cage and respiratory muscles; massive
haemorrhage; collapsed lungs and pneumothorax
b. HYPOVOLEMIA- from massive fluid loss from the great blood
vessels, cardiac rupture, or hemothorax
c. CARDIAC FAILURE – from cardiac tamponade, cardiac
contusion or increased intrathoracic pressure.
 TYPES: chest wall fractures, dislocations and barotrauma
 ASSESSMENT:
a. To be assess IMMEDIATELY:
 TIME ELAPSED since injury occurred
 MECHANISM OF INJURY
 LEVEL OF RESPONSIVENESS
 SPECIFIC INJURIES
 ESTIMATED BLOOD LOSS
 RECENT DRUG AND ALCOHOL USE
 PREHOSPITAL TREATMENT
b. INITIAL ASSESSMENT- life threatening and requires
immediate treatment
 Assessment of airway obstruction
 Tension pneumothorax
 Open pneumothorax
 Massive hemothorax
 Flail chest
 Cardiac tamponade
c. SECONDARY ASSESSMENT
 Assessment of simple pneumothorax
 Hemothorax
 Pulmonary contusion
 Traumatic aortic rupture
 Tracheobrachial disruption
 Esophageal perforation
 Traumatic diaphragmatic injury
 Penetrating wounds in the mediastinum

 PHYSICAL EXAMINATION:
 INSPECTION OF THE THORAX, NECK VEINS AND
DIFFICULTY OF BREATHING
 ASSESS RATE AND DEPTH OF BREATHING
 ASSESS THE CHEST FOR SYMMETRIC MOVEMENT,
SYMMETRY OF BREATH SOUNDS, OPEN CHEST WOUNDS
ENTRANCE AND EXIT WOUNDS IMPALED OBJECTS,
TRACHEAL SHIFT, DISTENDED NECK VEINS,
 SUBCUTANEOUS EMPHYSEMA AND PARADOXICAL CHEST
WALL MOTION.
 PALPITATION OF THORAX FOR TENDERNESS AND
CREPITUS

 DIAGNOSTICS:

 CHEST XRAY
 CT SCAN
 CBC
 CLOTTING STUDIES
 BLOOD TYPING AND CROSSMATCHING- in case of blood
loss
 ELECTROLYTES
 ABG ANALYSIS
 ECG
 OXYGEN SATURATION

 MEDICAL MANAGEMENT
GOALS: evaluate the patient’s condition and to initiate
aggressive resuscitation.
OXYGEN THERAPY/ SUPPORT- should established
immediately
Ensure adequate airway and ventilation
Stabilizing and re-establishing chest wall integrity
Draining and removing any air or fluid from the thorax to
relieve pneumothorax, hemothorax and cardiac tamponade

STERNAL AND RIB FRACTURES

 common in motor vehicle crashes with a direct blow to the sternum
(60% of blunt chest injury)
 Fractures of the 1st 3 ribs:
 Rare but can result in high mortality rate because they are assoc. With
laceration of the subclavian artery or vein.
 Fx of the 5th-9th rib:
 Most common sites of fx; assoc with injury to the spleen & liver w/c may
be lacerated by fragmented sections of the rib.

 S/sx:
1.Sternal fractures
◦ Ant. chest pain

◦ Overlying tenderness
◦ Ecchymosis

◦ Crepitus
◦ Swelling
◦ Potential of a chest wall deformity
2. Rib fractures

◦ Severe pain
◦ Point tenderness

◦ Muscle spasm aggravated by coughing, deep breathing & mov’t

◦ Bruises

◦ Shallow respirationimpaired ventilation atelectasis  ARF

◦ Chest splinting
Assessment & Dx findings
 Auscultation-
 Chest x-ray -
 ECG
 Pulse oximetry
 ABG
Medical Mgmt:
A. Sternal fracture- goal is directed towords:
◦ Control of pain, avoid excessive activity & tx of assoc. injuries

◦ Surgical fixation – rarely necessary (unless grossly displaced)

◦ PAIN- SUBSIDES IN 5 TO 7 DAYS

◦ HEALING- 3 TO 6 WEEKS (RIBS REUNITE SPONTANEOUSLY)

B. Rib fracture
 Control pain, detect & treat the injury
 MANAGEMENT (RIB & STERNAL FRACTURE)
Relieve pain and encourage deep breathing exercises
1. HIG FOWLER’S POSITION
2. INTERCOSTAL NERVE BLOCK
3. ICE/ COLD COMPRESS
4. CHEST BINDER
5. EPIDURAL ANESTHESIA
6. PCA
7. NON-OPOID ANALGESIC
8. SEDATION (with caution)

FLAIL CHEST
 -occurs when 3 or more adjacent ribs are fractured at 2 or more sites,
resulting in free-floating rib segments
  - is a blunt chest trauma associated with accidents, which may result in
hemothorax and rib fracture
 -loose segment of the chest wall becomes paradoxical to the expansion
and contraction of the rest of the chest wall
 -inward movement of a segment of the thorax during
____________________ and outward movement during_____________
Pathophysiology
Pendelluft/ Paradoxical Movement of the chest
 During inhalation: the flail rib is sucked inward & the mediastinal
structures shift to the unaffected side. The amount of air drawn into the
affected lung is reduced.
 On expiration: the flail segment bulges outward & the mediatinal
structures shift back to the affected side.
Signs and Symptoms
 Severe pain in the chest
 Dyspnea
 Cyanosis
 Tachycardia
 Hypotension
 Tachypnea, shallow respiration
 Diminished breath sounds

Medical Mgmt:
 Ventilatory support
 Clearing secretions from the lungs
 Controlling pain

Objectives:
 To clear the airway –
 To relieve pain –
 For mild to moderate flail chest
 Monitor fld intake & appropriate fld replacement
 Relieve chest pain
 Pulmonary Physiotherapy

For severe flail chest

 ET intubation & mechanical ventilation
 Surgery
Management:
  High fowlers
 Humidified O2
 Monitor increase respiratory distress
 Encourage DBE & coughing
 Pain meds
 Maintain bed rest & limit activity
 Prepare intubation with mech. Ventilation with PEEP (severe flail chest)

PULMONARY CONTUSION
 damage to the lung tissues resulting in hemorrhage & localized edema
 Pathophysiology:
Injury to lung parenchyma and capillary

Leakage of serum CHON & plasma

Entry to the lung & accumulate in the bronchioles & alveolar space

Impaired gas exchange

Hypoxemia/ Hypercapnia

S/Sx:
 Tachypnea, tachycardia, pleuritic chest pain, hypoxemia & blood-tinged
secretions
 Severe tachypnea, tachycardia, crackles, frank bleeding, severe
hyproxemia & resp. Acidosis
 Changes in sensorium
 Large amount of mucus, serum & frank blood
 S/sx of ARDS

 Dyspnea
 Hypoxemia
 Increased bronchial secretions
 Hemoptysis
 Restlessness
 Decreased breath sound
 Crackles/ wheezes
 Moderate to severe pulmonary contusion
 SIGNS OF PULMONARY CONTUSION: moderate - severe
 Central cyanosis
 Agitation
 Combativeness
 Productive cough, bloody secretions
Assessment & Dx findings
 Pulse oximetry & ABG
 Chest x-ray
Management
A. MILD:
 Adequate hydration – IV fluids & oral intake
 Volume expansion techniques – postural drainage, CPT, coughing,
suctioning
 Pain – intercostal nerve block, opioids,
 Antimicrobials- damaged lungs are susceptible to infection
 02 – mask, cannula – for 24 – 36 hrs
B.MODERATE:
 Bronchoscopy- ________________
 Intubation and mechanical ventilation with PEEP- __________
 Diuretics - _____________________
 NGT- to relieve GIT distention
C. SEVERE: may develop RESPIRATORY FAILURE
-aggressive treatment with ET intubation and ventilation, diuretics, fluid
restrictions
-Colloids and crystalloids – to treat hypovolemia

PENETRATING TRAUMA: GUNSHOT & STAB WOUND

Stab wounds- generally considerd of low velocity; DECEPTIVE
 Eg.
Gunshot wounds- low medium or high velocity; depends on the
1. distance from w/c the gun was fired,
2. caliber of the gun
3. construction & size of the bullet
DIAGNOSTIC TEST:
 X-ray
 ABG, pulse oximetry, ECG
 CBC, crossmatching –
 IFC- u.O
  NGT (low suction)—to decompress GIT
Medical Mgmt:
GOAL: to restore & maintain cardiopulmonary function
1. establish airway, assess for shock, & intrathoracic, intraabdominal
injuries
2. do not miss additional injuries- Undress the patient
3. supportive care – injuries from the 5th ICS – may be assoc. With
intraabdominal injuries
DEATH – due to hemorrhage

Management:
 Treat shock – colloid, albumin
 Chest tube- reexpansion of the lung, to evacuate blood and air
 Surgical intervention- if wound in the great vessels, esophagus,
traheobronchial tree

PNEUMOTHORAX
 TYPES:
a.SIMPLE/ SPONTANEOUS- when air enters the pleural space through
a breach of either the parietal or visceral pleura

b.TRAUMATIC- when air escapes from a laceration in the lung itself and
enters the pleural space or through a wound in the chest wall
EX. Blunt trauma
 Open- when wound is large; allow air to pass freely in and out of the
thoracic cavity with each respiration.
 Tension- air is drawn into the pleural space from a small opening or
wound in the chest wall
-air is trapped and cannot be expelled
Signs and Symptoms
 Sharp pain on the chest (movement)
 Restlessness, anxiety
 Dyspnea
 Cough
 Cessation of normal movements on affected side
 Absence of breath sounds (affected side)
 Cyanosis
 Tracheal deviation on the unaffected side
 CXR: air in pleural space; mediastinal shift to
unaffected side
MANAGEMENT
 Provide emergency first aid management:
 Place sterile occlusive gauze dressing over wound
 Tape dressing on 3 sides to allow air to escape during
expiration
 Position the patient Fowler’s to promote respirations.
 O2 therapy as ordered.
 Encourage slow breathing to improve gas exchange.
 Careful administration of narcotics to prevent respiratory
depression. (Avoid morphine).
 Prepare patient and assist in the insertion of chest tube drainage, if
indicated