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CHEST TRAUMA

Chest trauma is classified as either blunt or penetrating. Blunt chest trauma results from
sudden compression or positive pressure inflicted to the chest wall. Penetrating trauma
occurs when a foreign object penetrates the chest wall.

BLUNT TRAUMA

Blunt chest trauma is more common, it is often difficult to identify the extent of the
damage because the symptoms may be generalized and vague.

PATHOPHYSIOLOGY

Injuries to the chest are often life-threatening and result in one or more of the following
pathologic mechanisms:

− Hypoxemia from disruption of the airway; injury to the lung Parenchyma, rib
cage, and respiratory musculature; massive hemorrhage; collapsed lung; and
pneumothorax
− Hypovolemia from massive fluid loss from the great vessels, cardiac rupture, or
hemothorax
− Cardiac failure from cardiac tamponade, cardiac contusion, or Increased
intrathoracic pressure

These mechanisms frequently result in impaired ventilation and perfusion leading to


hypovolemic shock, and death.
ASSESSMENT

INITIAL ASSESSMENT OF THORACIC INJURIES: Assessment for airway


obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest,
cardiac tamponade.
SECONDARY ASSESSMENT: Assessment for simple pneumothorax, hemothorax,
pulmonary contusion, traumatic aortic rupture, tracheobronchial disruption, esophageal
perforation, traumatic diaphragmatic injury, and penetrating wounds to the mediastinum.
PHYSICAL EXAMINATION: Inspection of the airway, neck veins and breathing
difficulty. The chest is assessed for symmetric movement, symmetry of breath sounds,
open chest wounds, entrance or exit wounds, impaled objects, tracheal shift, distended
neck veins, and paradoxical chest wall motion. In addition, chest wall is assessed for
bruising, petechiac, lacerations, and burns. The vital signs and skin color are assessed for
signs of shock. The thorax is palpated for tenderness and crepitus.

DIAGNOSTIC PROCEDURE

1. Chest X-ray
2. CT Scan
3. Complete blood count
4. Arterial blood gas analysis
5. ECG

MEDICAL MANAGEMENT

1. An airway is immediately establish with oxygen support and, in some cases,


intubation and ventilatory support.
2. Re-establishing fluid volume and negative intrapleural pressure and draining
intrapleural fluid and blood are essential.
3. Re-establishing chest wall integrity, occluding any opening into the chest, and
draining or removing any air or fluid from the thorax to relieve pneumothorax,
hemothorax, or cardiac tamponade.
STERNAL AND RIB FRACTURES

Sternal fractures are most common in motor vehicle crashes with a direct blow to the via
the steering wheel. Most rib fracture are benign and are treated conservatively. Fractures
of the first three ribs are rare but can result in high mortality rate because they are
associated with laceration of the subclavian artery of the vein. The fifth through ninth ribs
are the most common sites of fractures. Fractures of the lower ribs are associated with
injury to the spleen and liver, which may be lacerated by fragmented sections of rib.

SIGNS AND SYMPTOMS

STERNAL FRACTURE: Anterior chest pain, overlying tenderness, ecchymosis, crepitus,


swelling, and possible chest wall deformity.
RIB FRACTURE: Severe pain, point tenderness, and muscle spasm over the area of the
fracture that are aggravated by coughing, deep breathing and movement.

DIAGNOSTIC PROCEDURES

1. Chest X-ray
2. Rib films of a specific area
3. ECG
4. Continuous pulse oximetry
5. Arterial blood gas analysis

MEDICAL ASSESSMENT

1. Avoiding excessive activity and treating any associated injuries.


2. Surgical fixation is rarely necessary unless fragments are grossly displaced and
pose a potential for further injury.
3. Alternative strategies to relieve the pain include an intercoastal nerve block and
ice over the fracture site.
4. A chest binder may be used as supportive treatment to provide stability to the
chest wall and may decrease pain.
5. The patient is instructed to apply the binder snugly enough to provide support, but
not to impair respiratory excursion.

FLAIL CHEST

Flail chest is frequently a complication of blunt chest trauma from a steering wheel
injury. It usually occurs when three or more adjacent ribs are fractured at two or more
sites, resulting in free-floating rib segments. It may also result as a

PATHOPHYSIOLOGY

During inspiration as the chest expands, the detached part of the rib segment moves in a
paradoxical manner in that it is pull inward during inspiration, reducing the amount of air
that can be drawn into the lungs. On expiration, because the intrathoracic pressure
exceeds atmospheric pressure, the flail segment bulges outward, impairing the patients
ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical
actions results in increased dead space, a reduction in alveolar ventilation and decreased
compliance. Retained airway secretions and atelectasis frequently accompany flail chest.
Hypotension, inadequate tissue perfusion, and metabolic acidosis often follow as the
paradoxical motion of the mediastinum decreases cardiac output.

MEDICAL MANAGEMENT

1. Providing ventilatory support, clearing secretions from the lungs and controlling
pain.
2. If only a small segment of the chest is involved, the objectives are to clear the
airway through positioning, coughing, deep breathing, and suctioning to aid in the
expansion of the lung, and to relieve pain by intercostal nerve blocks, high
thoracic epidural blocks.
3. For mild to moderate flail chest injuries, the underlying pulmonary contusion is
treated by monitoring fluid intake and appropriate fluid replacement, while at the
same time relieving chest pain.
4. When a severe flail chest injury is encountered, endotracheal intubation and
mechanical ventilation are required to provide internal pneumatic stabilization of
the flail chest and to correct abnormalities in gas exchange.
5. Surgery may be required to more quickly stabilize the flail segment.

PULMONARY CONTUSION

Pulmonary contusion is defined as damage to the lung tissues resulting in hemorrhage


and localized edema.

PATHOPHYSIOLOGY

The primary pathologic defect is an abnormal accumulation of fluid in the interstitial and
intraalveolar spaces. It is though that injury to the lung paranohyma and its capillary
network results in a leakage of serum protein and plasma. The leaking serum protein
exerts an osmotic pressure that enhances loss of fluid from the capillaries. Blood, edema,
and cellular debris enter the lung and accumulate in the bronchioles and alveolar surface,
where they interfere with gas exchange. As increase in pulmonary vascular resistance and
pulmonary artery pressure occurs. The patient has hypoxemia and carbon dioxide
retention.
SIGNS AND SYMPTOMS

1. Tachypnea
2. Tacycardia
3. Pleuritic chest pain
4. Hypoxemia
5. Patient has a constant cough but cannot clear secretions.

MEDICAL MANAGEMENT

1. In mild pulmonary, contusion, adequate hydration via IV fluids and oral intake
is important to mobilize secretions, fluid intake must be closely monitored to
avoid hypervolemia.
2. In moderate pulmonary contusion may require bronchospy to remove
secretions; intubation and mechanical ventilation.
3. In severe contusion, who may develop respiratory failure, aggressive
treatment with endotracheal intubation and ventilatory support, diuretics, and
fluid restriction may be necessary.

PENETRATING TRAUMA:
GUNSHOT AND STAB WOUNDS

Gunshot and stab wounds are the most common causes of penetrating trauma, stab
wounds are generally considered low-velocity trauma because the weapon destroys a
small area around the wound. Knives and switchblades cause most stab wounds.

Gunshot wounds may be classified as low, medium, or high velocity. The factors that
determine the velocity and resulting extent damage include the distance from which the
gun was fired, the caliber of the gun and the construction and size of the bullet.
MEDICAL MANAGEMENT

1. Examination for shock and intrathoracic and intra-abdominal injuries is


necessary.
2. Shock is treated simultaneously with colloid solutions, crystalloids, or blood,
as indicated by the patients condition.
3. 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.

DIAGNOSTIC PROCEDURE

1. Chest X-ray
2. Arterial blood gas analysis
3. ECG
4. CT scans of chest or abdomen
5. Flat plate x-ray of the abdomen

PNEUMOTHORAX

Pneumothorax occurs when the parietal or visceral pleura is breached and the pleural
space is exposed to positive atmospheric pressure.

TYPES OF PNEUMOTHORAX

1. Simple Pneumothorax – occurs when air enters the pleural space through a breach
of either the parietal or visceral pleura, it may occur in an apparently
healthy person in the absence of trauma due to rapture of an air-filled bleb,
or blister, on the surface of the lung, allowing air from the airways to enter
the pleural cavity.
2. Traumatic Pneumothorax – occurs when air escapes from a laceration in the lung
itself and enters the pleural space or enters the pleural space through a
wound in the chest wall.

3. Tension Pneumothorax – occurs when air is drawn into the pleural space from a
lacerated lung or through a small opening or wound in the chest wall.

SIGNS AND SYMPTOMS

1. Pain is usually sudden and may be pleuritic.


2. Minimal respiratory distress with slight chest discomfort.
3. Tachypnea with a small simple or uncomplicated pneumothorax.

MEDICAL MANAGEMENT

1. To evacuate the air or blood from the pleural space a small chest tube is
inserted near the second intercostal space because this space is the thinnest
part of the chest wall, minimizes the danger of contracting the thoracic nerve
and leaves a less visible scar.
2. If a patient also has a hemothorax, a large diameter chest tube is inserted
usually in the fourth or fifth intercostal space at the midaxillary line, the tube
is directed posteriorly to drain the fluid and air.
3. If an excessive amount of blood enters the chest tube in a relatively short
period, an autotransfusion may be needed.
4. In such an emergency, anything may be used that is large enough to fill the
chest wound – a towel, a handkerchief or the heel of the hand.
5. The patient with a possible tension pneumothorax should be immediately be
given a high concentration of supplemental oxygen to treat the hypoxemia,
and pulse oximetry should be used to monitor oxygen saturation.
CARDIAC TAMPONADE

Cardiac tamponade is compression of the heart resulting from fluid or blood within the
pericardial sac. Usually caused by blunt or penetrating trauma to the chest.

SUBCUTANEOUS EMPHYSEMA

Subcutaneous emphysema is of itself usually not a serious complication. The


subcutaneous air is spontaneously absorbed if the underlying air leak is treated or stops
spontaneously.

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