chest_trauma -nur 415-fall 2009

8/7/2019 Chest_trauma -NUR 415-Fall 2009

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Chest TraumaChest TraumaQutaibah oudat Qutaibah oudat

jordanjordan


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IntroductionIntroductionChes t trauma i s oft en sudd en andChes t trauma i s oft en sudd en anddramaticdramaticAccount s for 25% of all trauma d eat hsAccount s for 25% of all trauma d eat hs2/3 of d eat hs occur aft e r r eaching2/3 of d eat hs occur aft e r r eachinghosp ital.hosp ital.Ass ociat ed wit h high mortality rat e .Ass ociat ed wit h high mortality rat e .Se riou s pat hological con seq unc es:Se riou s pat hological con seq unc es:

--hypoxia, hypovolemia, myocardialhypoxia, hypovolemia, myocardial

failure .failure .


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M echani sm of InjuryM echani sm of InjuryP enetrating injuries P enetrating injuries

E .g. stab wound s e tc.E .g. stab wound s e tc.

Haemot horaxHaemot horaxPneumot horaxPneumot horaxCardiac, gr eat v esse l or o es oph ag eal injury.Cardiac, gr eat v esse l or o es oph ag eal injury.Great v esse l injuri es lead s to d eat h .Great v esse l injuri es lead s to d eat h .E arly d eat hs occur (30 minE arly d eat hs occur (30 min --3 hrs aft e r trauma.3 hrs aft e r trauma.

Bl unt injuries Either Bl unt injuries Either ::-- direct blow ( e .g. rib fractur e) .direct blow ( e .g. rib fractur e) .-- com press ion injury.com press ion injury.


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Ches t Wall Injuri es Ches t Wall Injuri es

R ib fractur es R ib fractur es

Flail ches t Flail ches t

Ope n pneumot horaxOpe n pneumot horax


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Rib fracture is the most commonRib fracture is the most commonsignificant of blunt thoracic trauma:significant of blunt thoracic trauma:

a.a. Markers of serious intrathorasic &Markers of serious intrathorasic &abdominal injuries.abdominal injuries.b.b. Source of significant pain.Source of significant pain.c.c. Predictor of pulmonary deterioration.Predictor of pulmonary deterioration.

Fracture of scapula, sternum, or ribs.Fracture of scapula, sternum, or ribs.11 st st --2nd rib # suggests massive force2nd rib # suggests massive forceof injury or trauma.of injury or trauma.


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R ib Fractur eR ib Fractur e33rdrd--99 t ht h ribs ass ociat ed wit h :ribs ass ociat ed wit h :

a.a.Blunt trauma.Blunt trauma.b.b. Unde rlying lung injury.Unde rlying lung injury.Lowe r rib s ass ociat ed wit h:Lowe r rib s ass ociat ed wit h:

a.a. Injury to liv e r.Injury to liv e r.b.b. Injury to abdom en.Injury to abdom en.

Uppe r rib s, clavicl e or scapulaUppe r rib s, clavicl e or scapula

fractur e: suspe ct va scular injuryfractur e: suspe ct va scular injury


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R ib fractur esR ib fractur esSi gns & Sy mptoms:Si gns & Sy mptoms:

Localise d pain, t end e rness , cr ep itusLocalise d pain, t end e rness , cr ep itusD i agnost ic P ro c edure:D i agnost ic P ro c edure:

CX R to exclude ot he r injuri esCX R to exclude ot he r injuri esM anagement M anagement ::a.a. Air way manag ement.Air way manag ement.

b.b. Pain manag ement (analg es ia & avoidPain manag ement (analg es ia & avoidta ping).ta ping).N urse mu st con side r und e rlying structur e N urse mu st con side r und e rlying structur e and injury to t he m.and injury to t he m.


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Flail ches t Flail ches t Multiple rib fractures produce a mobile fragment Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration.which moves paradoxically with respiration.Significant force required to cause # of multipleSignificant force required to cause # of multipleribs.ribs.usually Sternal # is present.usually Sternal # is present.Usually diagnosed clinicallyUsually diagnosed clinically

RxRx::ABC ABC ..Analgesia.Analgesia.Turn pt from side to side down to improveTurn pt from side to side down to improve

oxygenation .oxygenation .

Internal splitting used.Internal splitting used.


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Flail ches t Flail ches t


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Flail Chest - detail


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Lung injuryLung injury

Pneumot horaxPneumot horaxHaemot horaxHaemot horaxTrac he a and bronc hial injuri esTrac he a and bronc hial injuri es

Pneumom ediastinumPneumom ediastinum


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Pneumot horaxPneumot horaxaccumulation of Air or Ga s be twee n t he accumulation of Air or Ga s be twee n t he

(pleural cavity ) parie tal and vi sce ral pleura e ,(pleural cavity ) parie tal and vi sce ral pleura e ,

leading to lung colla pse .leading to lung colla pse .Blunt or pe ne trating injury t hat di srupt s t he Blunt or pe ne trating injury t hat di srupt s t he parie tal or vi sce ral pleura.parie tal or vi sce ral pleura.Degree of lung colla pse de t e rmin ed byDegree of lung colla pse de t e rmin ed by

amount of tra ppe d air or ga s.amount of tra ppe d air or ga s.M ost common ty pes: ope n, clo se d, andM ost common ty pes: ope n, clo se d, andt ension.t ension.


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Cau sesCau ses

Close d pneumot horax :Close d pneumot horax :a.a. barotrauma.barotrauma.


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Pneumot horaxPneumot horax


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Tension Pn eumot horaxTension Pn eumot horaxAir accumulat es intra pleurally and can t Air accumulat es intra pleurally and can t es cape .es cape .Air ent e rs pleural sp ace and cannot Air ent e rs pleural sp ace and cannot es cape .es cape .

O n I n sp i rat i on:O n I n sp i rat i on:

Increasing intrathorasic pressure cause the mediastinum to shiftIncreasing intrathorasic pressure cause the mediastinum to shifttoward the unaffected lung, impairing ventilation.toward the unaffected lung, impairing ventilation.

O n Exp i rat i on:O n Exp i rat i on:

The mediastinal shift distorts the vena cava and reduce venousThe mediastinal shift distorts the vena cava and reduce venous

return, producing hypotension and shock.return, producing hypotension and shock.


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Cau ses of Cau ses of Tension Pn eumot horaxTension Pn eumot horax

Ches t tub e occlu sion or malfunction.Ches t tub e occlu sion or malfunction.High positive endHigh positive end --e xpiratory press ures ,expiratory press ures ,cau sing ru ptur e of alv eolar bl ebs.cau sing ru ptur e of alv eolar bl ebs.Lung or airway punctur e from positiveLung or airway punctur e from positive--press ure ventilation.press ure ventilation.M echanical v entilation aft e r c hes t injury.M echanical v entilation aft e r c hes t injury.Pene trating c hes t wound.Pene trating c hes t wound.


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C on t i n ue ..C on t i n ue ..P/ C :P/ C :

ches t pain.ches t pain.dysp noeadysp noea

D x :D x :R esp iratory di stress symptom s.R esp iratory di stress symptom s.

Trac he al d eviation (away )Trac he al d eviation (away )Abse nce of br eat h sound sAbse nce of br eat h sound sDist end ed n eck ve insDist end ed n eck ve insHypot ensionHypot ension


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S urg ic a l emerge n cy S urg ic a l emerge n cy R x: eme rgency d ecom press ion b e fore R x: eme rgency d ecom press ion b e fore CX RCX R

E it he r larg e bor e cannula in 2nd I CS,E it he r larg e bor e cannula in 2nd I CS,M

CL or in se rt c hes t tub eM

CL or in se rt c hes t tub eCX R to confirm sit e of in se rtionCX R to confirm sit e of in se rtion


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Haemot horaxHaemot horaxBlunt or pe ne trating traumaBlunt or pe ne trating traumaR eq uires ra pid d ecom press ion and fluidR eq uires ra pid d ecom press ion and fluidres uscitationres uscitationM ay r eq uire surgical int e rventionM ay r eq uire surgical int e rventionClinically: hypovola emiaClinically: hypovola emia

ab se nce of br eat h sound sab se nce of br eat h sound sdullness to pe rcu ss iondullness to pe rcu ss ion

CX R may b e confu se d wit h collapseCX R may b e confu se d wit h collapse


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Ches t trauma : summaryChes t trauma : summaryCommonCommonSe riou sSe riou s

Primary goal i s to provide oxyg en toPrimary goal i s to provide oxyg en tovital organ svital organ sR ememb e rR ememb e r

AAirwayirwayBBreat hingreat hingC C irculationirculation

Be

ale

rt to ch

ange

in clinical conditionBe

ale

rt to ch

ange

in clinical condition


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C on

t i n

ue ..C on

t i n

ue ..ALER T If t he patient s ches t tub e ALER T If t he patient s ches t tub e dislodg es , imm ediat e ly place a pe troleumdislodg es , imm ediat e ly place a pe troleumgauz e dress ing ov e r t he ope ning.gauz e dress ing ov e r t he ope ning.ALER T Watc h for signs and symptom s of ALER T Watc h for signs and symptom s of t ension pneumot horax, w hich can b e fatal.t ension pneumot horax, w hich can b e fatal.

t hese includ e anxi e ty, hypot ension,t hese includ e anxi e ty, hypot ension,tac hycardia, tac hypnea, and cyano sis.tac hycardia, tac hypnea, and cyano sis.


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chest_trauma -nur 415-fall 2009

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