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Sujitha .

E,
Lecturer,
Faculty of Nursing,
Sri Ramachandra University, Porur
Chest cavity
Soft tissues
 Lungs
 Heart
 Great vessels
 diaphragm
 oesophagus
Bony areas
 Ribs
 Sternum
 Clavicle
 Tracheo broncheal
tree
Classification
Blunt injuries Penetrating injuries
Etiology
 Motor vehicle
accidents
 Fall from height
 Violence
 Iatrogenic
Mechanisms involved
 Acceleration force
 Deceleration force
 Transmission of blunt internal force to
force to structures
 Direct trauma
 Compression
Chest trauma
 Chest wall injuries  Pneumothorax
 Sternal fractures  Hemothorax
 Flail chest  Mediastinal injuries
 Pulmonary and  cardiac injuries
pleural injuries  Great vessel injuries
 Traumatic asphyxia  Diaphragmatic
 Tracheo bronchial injuries
injuries  Oesophageal injuries
From history (King Tut 1341 BC – 1323 BC)
Pulmonary injuries
Pneumothorax
 Collection of air
in the space
between the
parietal and
visceral pleura
Tension pneumothorax
An expanding collection of intra pleural air
without communication with external
environment
Clinical manifestations
 Distended neck veins
 Hypotension/hypoperfusion
 Absent breath sounds on affected side
 Tracheal deviation to contra lateral side
Management
 Immediate needle aspiration
 14 gauge IV needle of length more than 4.5
cm and catheter into pleural space through
chest wall in MCL at second intercostal
space(temporary measure)
 Large bore chest tube thoracostomy
Open pneumothorax
(sucking chest wound)
A communication between the pleural
space and surrounding atmospheric
pressure
Respiration is the function of negative
pressure inside the thoracic cavity ,
positive atmospheric pressure and
elastic recoil of lungs
Pneumothorax
Clinical manifestations
•Air entry and breath sounds
diminished in the affected side
•Impaired chest wall motion
Pathophysiology
Negative intrapleural pressure during
inspiration

Air leak into the pleural cavity

Increased intra thoracic pressure

Reduced vital capacity and venous return


Pneumothorax
Diagnosis
 Chest radiography(double pleural markings)
 Ultrasound
Management
 Cover the wound with a three sided dressing
 Air can escape during expiration but do not enter
during inspiration(one way valve)
 Chest tube insertion
Pneumothorax
Open pneumothorax
3-side dressing Asherman chest seal
Massive hemothorax
Accumulation of at least 1500 ml or two
thirds of the available hemithorax in an
adult
Hemothorax
Life threatening by three mechanisms
 Acute hypovolemia causing decreased
preload
 Collapsed lung promoting hypoxia
 Hemothorax compressing venacava
 impairing preload
Hemothorax
Clinical manifestations
Abnormal vital signs
Dullness to percussion
Diminished breath sounds
Diagnosis
Plain chest radiography completely opacified
hemithorax
Ultrasonography-fluid between chest wall and
lung
Management
Chest tube insertion
Care of chest tube
 Position-last hole 2.5-5 cm inside chest wall
 Suction chamber with 20-30 cm of water
 Never clamp the tubes
 Bottle at 1-2 ft lower than patient’s chest
 Left in place for 24 hrs after leak has stopped
Flail chest
 Free floating lung segment that is no
longer connected to the rest of the
thorax
Cause
 Segmental rib fractures in two or more
locations of the same rib of three or
more adjacent ribs
Flail chest
 Clinical manifestations
 Paradoxical
inward movement
of the involved
portion of the
chest wall during
inspiration and
outward
movement during
expiration
Pathophysiology-flail chest
Decreased ventilatory efficiency

Increased work of breathing

Hypoxemia

Sudden respiratory arrest


Management-Flail chest
 Analgesics
 Ventilator
support
 stabilization
Diaphragmatic injury
 Often unnoticed if not very big defect
 Causes referred shoulder pain
 Respiratory distress (herniation of abdominal
contents into the thorax)
Diagnosis
 Decreased breath sounds
 Auscultation of bowel sounds in the chest
 Tension viscero thorax
 Bowel obstruction and strangulation
Management- Repair of diaphragm
Cardiac injuries
Cardiac tamponade
 Accumulation of blood in the pericardial cavity
under pressure
 Common causes are gunshot wounds and stabs
Clinical features
 Tachycardia
 Narrow pulse pressure
 Elevated CVP Becks
triad
 Hypotension
Cardiac tamponade
 Pathophysiology

Elevated intra cardiac pressure

Decreased right and left ventricular filling

Decreased cardiac output


Management-Pericardiocentesis
Great vessel injuries
The main vessels
 Aorta
 Brachio cephalic
branches
 Pulmonary arteries and
veins
 Venae cavae
 Thoracic duct
Aortic injury
 Commonly injured part is proximal descending aorta
 Clinical manifestations
 Hypo tension
 hypertension in upper extremity& hypotension in lower
extremities
 Intra capsular murmurs or bruits
 Diagnosis
 Chest radiograph
 TEECHO
 Aortography
Aortic rupture
Management
 Pharmacologic control of heart rate and blood
pressure(around 60/mt and 100-120 mmHg systolic)
 Hemodynamic monitoring (pul.catheter)
 Sedatives
 Analgesics
 Vasodilators (sodium nitroprusside)
 β –blockers (esmolol)
 Auto transfusion
 Surgical repair
Nursing diagnoses
 Acute pain
 Fluid volume deficit
 Decreased cardiac output
 Inability to sustain spontaneous ventilation
 Ineffective breathing pattern
 Impaired gas exchange
 Impaired tissue perfusion
Other investigations
 CT
 Bronchoscopy
 Oesophagoscopy
 Oesophagography
 Angiography
Airway management-
 Indications for mechanical ventilation
o Altered mental status
o Excessive secretions
o Associated face and neck injuries
o Impending respiratory failure
o Cardiopulmonary collapse
o Significant co morbidities
o Advanced age
o ABG abnormalities
Fluid resuscitation
Goal: to stabilize the intravascular volume sufficiently
to provide time to manage hemorrhage
 Insert at least two large bore IV
catheters
 Central/femoral/subclavian/IJV
access
 Control hemorrhage and then replace
 Consider auto transfusion