RESPIRATORY DISORDER

CHEST TRAUMA

CHEST TRAUMA HYPOVOLEMIA

- from massive fluid loss from the great
vessels, cardiac rupture or hemothorax
BLUNT TRAUMA
- results from sudden compression or positive CARDIAC FAILURE
presence of infliction to the chest wall - from cardiac tamponade, cardiac contusion or
- more common; difficult to identify the extent of increased intrathoracic pressure
damage because the symptoms may be
generalized & vague. (Injury depends on the
velocity) ASSESSMENT AND DX FINDINGS
- Pt’s may not seek immediate medical attention,
which may complicate the problem (Assess the ff immediately:)
E.g., Motor vehicle crashes, falls & bicycle crashes • When the injury occurred
• Mechanism of injury
• Level of responsiveness
PENETRATING TRAUMA • Specific injuries
- Occurs when a foreign object penetrates the • Estimated blood loss
chest wall. • Recent drug or alcohol use
E.g., Gunshot wounds & stabbings • Prehospital tx

MECHANISM OF BLUNT TRAUMA INITIAL ASSESSMENT

1. ACCELERATION 1. Check for airway obstruction

2. Pneumothorax
- refers to moving object hitting the patient’s
3. Hemothorax
chest
4. FLAIL CHEST
5. Cardiac tamponade
2. DECELERATION
- decrease in the rate of speed of velocity SECONDARY ASSESSMENT
3. SHEARING • Simple pneumothorax
- causing tears, ruptures/ dissection of • Hemothorax
organs • Pulmonary contusion
• Traumatic aortic rupture
4. COMPRESSION • Tracheobronchial disruption
- direct blow to the chest (crash injury) • Esophageal perforation
• Traumatic diaphragmatic injury
• Penetrating wounds to the mediastinum
RESULT TO:
ONGOING ASSESSMENT
Impaired ventilation (V/Q mismatch)
↓ PHYSICAL EXAMINATION:
ARF and Hypovolemic shock a. inspection of the airway, thorax, neck veins and
breathing difficulty
↓ b. assess for rate & depth of breathing for
DEATH abnormalities such as stridor, cyanosis, nasal
flaring, use of accessory muscles, drooling &
PATHOLOGICAL MECHANISMS overt trauma to the face, mouth, or neck
c. V/S & skin color –SIGNS OF SHOCK
HYPOXEMIA d. Palpate thorax for tenderness & crepitus
e. SYMMETRICAL MOV’T OF THE CHEST or
- from disruption of the airway; injury to the lung Breath Sound
parenchyma, rib cage & respiratory f. ENTRANCE AND EXIT OF WOUNDS
musculature; massive hemorrhage; collapsed
g. TRACHEAL DEVIATION
lung; pneumothorax

RESPIRATORY DISORDER, TCGGUILLERMO

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 DIAGNOSTIIC TEST • Pulse oximetry
• ABG
1. Chest X-ray
2. CT scan
3. CBC – MEDICAL MANAGEMENT
4. Electrolytes, O2 sat, ABG & ECG
5. UNDRESS PATIENT 1. STERNAL FRACTURE
- goal is directed towards:
MEDICAL MANAGEMENT - Control of pain, avoid excessive activity & tx
of assoc. injuries
1. O2 therapy – intubation & ventilatory support - Surgical fixation – rarely necessary (unless
2. Re-establish fluid volume (hypovolemia/ shock) & grossly displaced)
(-) intra pleural pressure (pneumothorax)
3. Restore & maintain cardiopulmonary function 2. RIB FRACTURE
4. To control hemorrhage
- Control pain, detect & treat the injury

GENERAL MANAGEMENT (RIB & STERNAL FRACTURE)

COMPLICATIONS OF BLUNT TRAUMA
Relieve pain and encourage DBCE thru:
1. High fowler’s position
A. STERNAL AND RIB FRACTURES 2. Intercostal nerve block
3. Ice/ cold compress
4. Chest binder
FRACTURE OF THE 1ST 3 RIBS: 5. Epidural anesthesia
6. PCA
- Rare but can result in high mortality rate
7. Non-opioid analgesic
because they are assoc. With laceration of the
8. Sedation (with caution)
subclavian artery or vein.

FX OF THE 5TH-9TH RIB: B. FLAIL CHEST

- Most common sites of fracture associated with - occurs when 3 or more adjacent ribs are
injury to the spleen & liver w/c may be fractured at 2 or more sites, resulting in free-
lacerated by fragmented sections of the rib. floating rib segments
- is a blunt chest trauma associated with
SIGNS AND SYMPTOMS accidents, which may result in hemothorax and
rib fracture
- loose segment of the chest wall becomes
1. STERNAL FRACTURES paradoxical to the expansion and contraction of
- Ant. chest pain the rest of the chest wall
- Overlying tenderness - inward movement of a segment of the thorax
- Ecchymosis during ____________________ and outward
- Crepitus movement during _____________
- Swelling
- Potential of a chest wall deformity
PATHOPHYSIOLOGY
2. RIB FRACTURES
- Severe pain - Pendelluft/ Paradoxical Movement of the chest
- Point tenderness (over the fractured area)
- Muscle spasm aggravated by coughing, deep • During inhalation: the flail rib is sucked inward
breathing & movement & the mediastinal structures shift to the
- Bruises unaffected side. The amount of air drawn into
- Shallow respiration the affected lung is reduced.
o Impaired ventilation • On expiration: the flail segment bulges
o Atelectasis outward & the mediastinal structures shift back
o ARF to the affected side.

ASSESSMENT AND DX FINDINGS SIGNS AND SYMPTOMS

• Auscultation • Severe pain in the chest
• Chest x-ray • Dyspnea
• ECG

RESPIRATORY DISORDER, TCGGUILLERMO

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 • Cyanosis SIGNS AND SYMPTOMS
• Tachycardia (Can be mild to moderate- severe)
• Hypotension
• Tachypnea, shallow respiration 1. Tachypnea, tachycardia, pleuritic chest pain,
• Diminished breath sounds hypoxemia & blood-tinged secretions
2. Severe tachypnea, tachycardia, crackles, frank
MEDICAL MANAGEMENT bleeding, severe hypoxemia & resp. Acidosis
• Ventilatory support 3. Changes in sensorium (earliest)
• Clearing secretions from the 4. Large amount of mucus, serum & frank blood
5. S/sx of ARDS (severe PC)
• lungs
• Controlling pain
X: SIGNS AND SYMPTOMS
X: MANAGEMENT
• Dyspnea
• High fowlers
• Hypoxemia
• Humidified O2
• Increased bronchial secretions
• Monitor increase respiratory distress
• Hemoptysis
• Encourage DBE & coughing
• Restlessness
• Pain meds
• Decreased breath sound
• Maintain bed rest & limit activity
• Crackles/ wheezes
• Prepare intubation with mech. Ventilation with
• Moderate to severe pulmonary contusion
• PEEP (severe flail chest)

OBJECTIVES: SIGNS OF PULMONARY CONTUSION

1. To clear the airway
2. To relieve pain (Moderate- severe)
• Central cyanosis
❖ For MILD TO MODERATE flail chest • Agitation
1. Monitor fld intake & appropriate fld replacement • Combativeness
2. Relieve chest pain • Productive cough, bloody secretions
3. Pulmonary Physiotherapy
ASSESSMENT AND DIAGNOSTIC FINDINGS
❖ For SEVERE flail chest
1. ET intubation & mechanical ventilation (PEEP)
2. BED REST and activity LIMITATION 1. PULSE OXIMETRY & ABG
3. Surgery - measures efficiency of gas exchange (result:
Respi. ACIDOSIS)

C. PULMONARY CONTUSION 2. Chest x-ray

- damage to the lung tissues resulting in alveolar - may show NO changes initially, but after 1-2
hemorrhage, localized edema, and decreased days there’s (+) infiltrates
pulmonary compliance
- Major complication: ARDS
MEDICAL MANAGEMENT
PATHOPHYSIOLOGY
Injury to lung parenchyma and capillary
MILD:
• Adequate hydration – IV fluids & oral intake
↓ • Volume expansion techniques – postural
drainage, CPT, coughing, suctioning
Leakage of serum CHON & plasma
• Pain – intercostal nerve block, opioids,
↓ • Antimicrobials- damaged lungs are susceptible
to infection
Entry to the lung & accumulate in the bronchioles & • 02 – mask, cannula (for 24 – 36 hrs)
↓
MODERATE:
alveolar space 1. Bronchoscopy: localisation of the bleeding and
disclosure of central airway injury is mandatory
↓ 2. Intubation and mechanical ventilation with PEEP
3. Diuretics: to reduce pulmonary venous
Impaired gas exchange
resistance and pulmonary capillary hydrostatic
↓ pressure NGT- to relieve GIT distention
HYPOXEMIA/ HYPERCAPNIA

RESPIRATORY DISORDER, TCGGUILLERMO

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SEVERE TRAUMATIC
- when air escapes from a laceration in the lung
- may develop RESPIRATORY FAILURE
itself and enter the pleural space or through a
• aggressive treatment with ET intubation and
wound in the chest wall
ventilation, diuretics, fluid restrictions
Ex. Blunt trauma (rib fx) and penetrating trauma
• Colloids and crystalloids – to treat hypovolemia (GSW)

PENETRATING TRAUMA: GUNSHOT AND STAB TYPES OF TRAUMTIC PNEUMOTHORAX:

WOUND
A. OPEN
STAB WOUNDS - when wound is large; allow air to pass freely in
and out of the thoracic cavity with each
- generally, considered of low velocity; DECEPTIVE
respiration.

GUNSHOT WOUNDS B. TENSION

- air is drawn into the pleural space from a small
- low medium or high velocity; depends on the:
opening or wound in the chest wall
1. distance from w/c the gun was fired,
- air is trapped and cannot be expelled
2. caliber of the gun
3. construction & size of the bullet
X: signs and symptoms

DIAGNOSTIC TEST • Sharp pain on the chest (movement)

• X-ray
• ABG, pulse oximetry, ECG
• CBC, crossmatching –
• IFC- u.O
• NGT (low suction)—to
• decompress GIT
MEDICAL MANAGEMENT
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
GENERAL MANAGEMENT
1. Treat shock – colloid, albumin
2. Chest tube
3. Surgical intervention- if with trauma/wound in
the heart, great vessels, esophagus,
tracheobronchial tree.
• 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
X: MANAGEMENT
1. Provide emergency first aid management:
• Place sterile occlusive gauze dressing over
wound
• Tape dressing on 3 sides to allow air to
escape during expiration
2. Position the patient HIGH Fowler’s to promote
respirations.
3. Careful administration of narcotics (opioids) to
prevent respiratory depression.
4. Prepare patient and assist in the insertion of
chest tube drainage, if indicated

PNEUMOTHORAX
- Presence or air in the lung cavity

types

SIMPLE/ SPONTANEOUS
when air enters the pleural space through a
-
breach of either the parietal or visceral pleura
Ex. Rupture of bleb

RESPIRATORY DISORDER, TCGGUILLERMO