Chest

.
NURSING IMPLICATION <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Ineffective Airway Clearance

</li></ul><ul><li>Ineffective Breathing Pattern </li></ul><ul><li>Impaired Gas Exchange
</li></ul><ul><li>Pain </li></ul><ul><li>Risk for Infection </li></ul><ul><li>Activity Intolerance
</li></ul><ul><li>Anxiety </li></ul><ul><li>Decreased Cardiac output </li></ul><ul><li>Impaired tissue
perfusion </li></ul><ul><li>Ineffective individual coping </li></ul><ul><li>Altered health maintenance
</li></ul>06/07/09 www.health-nurses-doctors.blogspot.com
. 15. NURSING IMPLICATION <ul><li>INTERVENTION: </li></ul><ul><li>Frequent and prompt Respiratory
assessment </li></ul><ul><li>Adequate oxygenation </li></ul><ul><li>Analgesia to improve ventilation.
</li></ul><ul><li>Clearing secretion </li></ul><ul><li>Stabilize the thoracic cage </li></ul><ul><li>Deep
breathing exercises </li></ul><ul><li>Intubation and mechanical ventilation may be required to prevent
further hypoxia </li></ul>06/07/09 www.health-nurses-doctors.blogspot.com
. 16. NURSING IMPLICATION <ul><li>Pain Control </li></ul><ul><li>Alternative to relieve pain:
</li></ul><ul><ul><li>Intercostal Nerve Blocks </li></ul></ul><ul><ul><li>Epidural Anesthesia.
</li></ul></ul><ul><ul><li>Wearing a chest binder </li></ul></ul><ul><li>Maintain IV flow rates
</li></ul><ul><li>Monitor S/S of adequate tissue perfusion </li></ul><ul><li>Anxiety reducing techniques
</li></ul><ul><li>Coping mechanism </li></ul><ul><li>Heath education/teaching </li></ul>06/07/09
www.health-nurses-doctors.blogspot.com
. 17. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>ARDS
</li></ul></ul><ul><ul><li>Lung abscess </li></ul></ul><ul><ul><li>Emphysema
</li></ul></ul><ul><ul><li>Pulmonary embolism. </li></ul></ul>06/07/09
. 18. PNEUMOTHORAX <ul><li>Pneumothorax is a pocket of air between the two layers of pleura (parietal or
visceral), resulting in collapse of the lung. </li></ul><ul><li>TYPES : </li></ul><ul><li>Open Pneumothorax
</li></ul><ul><li>Tension Pneumothorax </li></ul>06/07/09 www.health-nurses-doctors.blogspot.com
. 19. Types <ul><li>Open Laceration in the parietal pleura that allows atmospheric air to enter the pleural
space; occurs as a result of penetrating chest trauma </li></ul><ul><li>Closed Laceration in the visceral
pleura that allows air from the lung to enter the pleural space; occurs as a result of blunt chest trauma
. Nursing Diagnosis <ul><li> Impaired Gas Exchange related to ventilation/ perfusion mismatching or
intrapulmonary shunting </li></ul><ul><li>Ineffective Breathing Pattern related to decreased lung
expansion </li></ul><ul><li>Acute Pain related to transmission and perception of cutaneous, visceral,
muscular, or ischemic impulses </li></ul><ul><li>Anxiety related to threat to biologic, psychologic, and/or
social integrity </li></ul><ul><li>Disturbed Body Image related to actual change in body structures, function,
or appearance </li></ul><ul><li>Compromised Family Coping related to critically ill family member
. 41. NURSING INTERVENTIONS <ul><li>Continuous and vigilant respiratory assessment
</li></ul><ul><li>Optimizing oxygenation and ventilation, </li></ul><ul><li>Maintaining the chest tube
system </li></ul><ul><li>Providing comfort and emotional support </li></ul><ul><li>Maintaining surveillance
for complications. </li></ul>06/07/09 www.health-nurses-doctors.blogspot.com
. 42. Hemothorax <ul><li>Occurs when pleural space fills with blood </li></ul><ul><li>Usually occurs due to
lacerated blood vessel in thorax </li></ul><ul><li>As blood increases, it puts pressure on heart and other
vessels in chest cavity </li></ul><ul><li>Each Lung can hold 1.5 liters of blood </li></ul>06/07/09
. 43. Hemothorax 06/07/09 www.health-nurses-doctors.blogspot.com
. 48. Hemothorax May put pressure on the heart 06/07/09 www.health-nurses-doctors.blogspot.com
. 49. Hemothorax Lots of blood vessels Where does the blood come from. 06/07/09
. 50. S/S of Hemothorax <ul><li>Anxiety/Restlessness </li></ul><ul><li>Tachypnea </li></ul><ul><li>Signs
of Shock </li></ul><ul><li>Frothy, Bloody Sputum </li></ul><ul><li>Diminished Breath Sounds on Affected
Side </li></ul><ul><li>Tachycardia </li></ul><ul><li>Flat Neck Veins </li></ul>06/07/09
. 51. Treatment for Hemothorax <ul><li>ABC’s </li></ul><ul><li>Secure Airway assist ventilation if necessary
</li></ul><ul><li>General Shock Care due to Blood loss </li></ul><ul><li>RAPI
Introduction: Traumatic injuries to the chest contribute to 75% of all
traumatic deaths. Thoracic injuries range from simple rib fractures
to complex life-threatening rupture of organs. The mechanisms of
injuries causing chest trauma are separated into two categories: blunt
trauma and penetrating trauma.
4. Chest injuries are potentially life-threatening because of immediate

disturbances of cardiorespiratory physiology and haemorrhage and later
developments of infection, damaged lung and thoracic cage.
5. Definition
6. Definition: A chest injury is define as, “it is a form of injury

to the chest including the ribs, heart and lungs, great vessels, trachea
and esophagus.”
7. Incidence
8. Incidence: 25% of all death form traumatic injury.
9. Causes
10. Causes: BLUNT INJURY CAUSES PENETRATING INJURY CAUSES
11. BLUNT INJURY CAUSES: Motor vehicle accident Pedestrian

accident Fall Sports injury Assault with blunt object or
Altercations Crush injury Explosion
12. PENETRATING INJURY CAUSES: Knife Gunshot Stick Arrow

Occupational injury
13. Types of chest injuries
14. Types of chest injuries Rib Fracture Hemothorax Flail Chest Pulmonary
Contusion Cardiac Tamponade
15. Rib Fracture: Most common chest injury. May interfere with
ventilation and may lacerate underlying lung.
16. Hemothorax: Blood in pleural space as a result of penetrating or

blunt chest trauma. Accompanies a high percentage of chest injuries.
Can result in hidden blood loss.
17. Flail Chest: Loss of stability of chest wall as a result of multiple

rib fractures, or combined rib and sternum fractures. When this occurs,
one portion of the chest has lost its bony connection to the rest of the
rib cage.
18. During respiration, the detached part of the chest will be pulled
in on inspiration and blown out on expiration (PARADOXICAL MOVEMENT)
Normal mechanics of breathing are impaired to a degree that seriously
jeopardizes ventilation, causing dyspnea and cyanosis.
19. Pulmonary Contusion: Bruise of the lung parenchyma those results

in leakage of blood and edema fluid into the alveolar and interstitial
spaces of the lung. May not be fully developed for 24 to 72 hours.
20. Cardiac Tamponade: Compression of the heart as a result of

accumulation of fluid within the pericardial space. Caused by
penetrating injuries, metastasis, and other disorders.
21. Clinical manifestation:
22. Respiratory Dyspnea, respiratory distress Cough with or without

haemoptysis Cyanosis of mouth, face, nail beds, mucous membranes
Tracheal deviation Audible air escaping from chest wound Decreased
breath sounds on side of injury Decreased O2 saturation Frothy
secretions
23. Cardiovascular Rapid, thready pulse Decreased BP Narrowed

pulse pressure Asymmetric BP values in arms Distended neck veins
Muffled heart sounds
24. Chest pain Crunching sound synchronous with heart sounds

Dysrhythmias
25. Surface Findings Bruising Abrasions Open chest wound

Asymmetric chest movement Subcutaneous emphysema
26. Diagnostic evaluation
27. History collection Physical examination While doing physical

examination assess for abdominal tenderness, chest tenderness, chest
bruising, chest swelling, decrease lung sound, wheezing, rapid pulse and
rapid breathing, chest crepitation, cyanosis, dyspnea. X- Ray CT Scan
and MRI
28. Management
29. The goal is to restore normal cardiorespiratory function as quickly

as possible. This is accomplished by, Performing effective
resuscitation While simultaneously assessing the patient, Restoring
chest wall integrity, Reexpanding the lung.
30. Assist with intercostal nerve block to relieve pain so coughing
and deep breathing may be accomplished. An intercostal nerve block is the
injection of a local anesthetic into the area around the intercostal
nerves to relieve pain temporarily after rib fractures, chest wall injury,
or thoracotomy. For multiple rib fractures, epidural anesthesia may
be used.
31. Rib Fracture: Give analgesics (usually nonopioid) to assist in

effective coughing and deep breathing. Encourage deep breathing with
strong inspiration; give local support to injured area by splinting with
hands.
32. Hemothorax: Assist with thoracentesis to aspirate blood from

pleural space, if being done before a chest tube insertion. Assist with
chest tube insertion and set up drainage system for complete and
continuous removal of blood and air. Auscultate lungs and monitor for
relief of dyspnea. Monitor amount of blood loss in drainage. Replace
volume with I.V. fluids or blood products.
33. Flail Chest: Stabilize the flail portion of the chest with hands;
apply a pressure dressing and turn the patient on injured side, or place
10-lb sandbag at site of flail. Thoracic epidural analgesia may be used
for some patients to relieve pain and improve ventilation.
34. Pulmonary Contusion: Employ mechanical ventilation to keep lungs

inflated. Administer diuretics to reduce edema. Correct metabolic
acidosis with I.V. sodium bicarbonate. Use PAP monitoring. Monitor
for development of pneumonia.
35. If respiratory failure is present, prepare for immediate ET

intubation and mechanical ventilation treats underlying pulmonary
contusion and serves to stabilize the thoracic cage for healing of
fractures, improves alveolar ventilation, and restores thoracic cage
stability and intrathoracic volume by decreasing work of breathing.
Prepare for operative stabilization of chest wall in select patients.
36. Cardiac Tamponade: Assist with pericardiocentesis to provide

emergency relief and improve hemodynamic function until surgery can be
undertaken. Prepare for emergency thoracotomy to control bleeding and
to repair cardiac injury.
37. ADDITIONAL RESPONSIBILITIES: Secure and support the airway as

indicated.
38. Prepare for tracheostomy if indicated. Tracheostomy helps to clear
tracheobronchial tree, helps the patient breathe with less effort,
decreases the amount of dead airspace in the respiratory tree, and helps
reduce paradoxical motion. When used with mechanical ventilation,
provides a closed system and stabilizes the chest.
39. Secure one or more I.V. lines for fluid replacement, and obtain
blood for baseline studies, such as hemoglobin level and hematocrit.
Monitor serial CVP readings to prevent hypovolemia and circulatory
overload. Monitor ABG/Spo2 results to determine need for supplemental
oxygen, mechanical ventilation.
40. Obtain urinary output hourly to evaluate tissue perfusion.

Continue to monitor thoracic drainage to provide information about rate
of blood loss, whether bleeding has stopped, whether surgical
intervention is necessary.
41. Institute ECG monitoring for early detection and treatment of

cardiac dysrhythmias (dysrhythmias are a frequent cause of death in chest
trauma).
42. Maintain ongoing surveillance for complications: Aspiration

Atelectasis Pneumonia Mediastinal/subcutaneous emphysema
Respiratory failure
43. Patient education and health maintenance: Instruct patient in

splinting techniques. Make sure patient is aware of importance of
automobile seat belt use to reduce serious chest injuries caused by
automobile accidents. Teach patient to report signs of complications
increasing dyspnea, fever, and cough.
44. Summary Introduction Definition Incidence Causes Types

Clinical manifestation Diagnostic evaluation Management
45. › What is the definition of chest injury? › What are the causes of
chest injury? › What are the types of chest injury? › What are the
diagnostic evaluation for chest injury? Feedback questions:
: DEFINITION – CHEST TRAUMA A chest trauma is any form of physical injury

to the chest including the heart and lungs. Chest injuries account for
25% of all deaths from traumatic injury. Feliciano 2012
Chest cavity: Chest cavity Lungs Heart Great vessels D iaphragm Oesophagus
Ribs Sternum Clavicle Tracheo -bronchial tree
History of chest trauma – From 1600 BC: History of chest trauma – From
1600 BC
INCIDENCE OF CHEST TRAUMA : INCIDENCE OF CHEST TRAUMA Thoracic trauma is

responsible for over 70% of all deaths in RTA. Blunt trauma to chest is
fatal- 10% of cases and the mortality increases to 30% if other injuries
are present U.S – 16000 Deaths per year due to chest injuries. Statistics
from India is not available but expected to be more (V.K.Arora,2006)
CAUSES OF CHEST TRAUMA: CAUSES OF CHEST TRAUMA MVA / RTA Stab wound Gun
shot Blast Fall from height Crush
MECHANISMS OF CHEST TRAUMA: MECHANISMS OF CHEST TRAUMA Blunt Trauma

PenetratingTrauma
Assessment : Assessment Primary Survey ABCDE s of trauma care A - Airway

B - Breathing C - Circulation D - Disability E – Exposure Secondary Survey
AMPLE history Physical exam Reassessment of vitals Diagnostic studies
Diagnostic Aids: Diagnostic Aids Standard trauma labs ABG , CBC,

Electrolytes PTT , Blood Glucose CT/ MRI Chest radiographs ECG and ECHO
FAST scans TEE Aortography
LIFE THREATENING CHEST INJURY : LIFE THREATENING CHEST INJURY
AIRWAY OBSTRUCTION: AIRWAY OBSTRUCTION An airway obstruction is a

blockage in the airway. CAUSES U nconscious patient . Dentures, teeth,
secretions and blood Bilateral mandibular fracture Expanding neck
haematoma . M echanical compression of the trachea.
SIGNS AND SYMPTOMS: SIGNS AND SYMPTOMS A gitation C yanosis
(bluish-colored skin) Confusion D ifficulty in breathing B reathing
noises such as wheezing U nconsciousness
Tension Pneumothorax: Tension Pneumothorax Air enters the pleural space

during inspiration and unable to escape during exhalation . Results in
collapse of lung on affected side that results in pressure on mediastinum,
the other lung, and great vessels
Tension Pneumothorax: Tension Pneumothorax Each time we inhale, the lung

collapses further. There is no place for the air to escape.
Tension Pneumothorax: Tension Pneumothorax Each time we inhale, the lung

collapses further. There is no place for the air to escape.
Tension Pneumothorax: Tension Pneumothorax Heart is being compressed The

trachea is pushed to the unaffected side
Signs and Symptoms: Signs and Symptoms Anxiety Severe Dyspnea Absent
Breath sounds on affected side Tachypnea Signs and symptoms of decreased
cardiac output Accessory Muscle Use JVD Narrowing Pulse Pressures
Tracheal Deviation
Pericardial Tamponade Collection of blood or blood clots in the

pericardial sac : Pericardial Tamponade Collection of blood or blood clots
in the pericardial sac Pericardial sac
Pericardial Tamponade: Pericardial Tamponade Accumulating pressure on

the heart, limiting Ventricular filling and decreasing output.
Pericardial Tamponade: Pericardial Tamponade Decreased cardiac function .

The patient’s level of conscious drops, and eventually the patient goes
in cardiac arrest
PowerPoint Presentation: Chest pain Tachycardia ,Tachypnoea , Dyspnoea
Altered mental status Pulsus paradoxus Poor skin color Beck’s Triad-
Hypotension, Distended Neck Veins , Muffled or distant heart sounds Signs
and symptoms
Open Pneumothorax: Open Pneumothorax Penetrating trauma opens the pleural

space, causing a pneumothorax and a ‘ sucking ’ chest wound
Open Pneumothorax: Open Pneumothorax Inhale
Open Pneumothorax: Open Pneumothorax Exhale
Open Pneumothorax: Open Pneumothorax Inhale
Open Pneumothorax: Open Pneumothorax Exhale
Open Pneumothoarx: Open Pneumothoarx Inhale
Open Pnuemothorax: Open Pnuemothorax Inhale
Signs and symptoms of Open pneumothorax: Signs and symptoms of Open

pneumothorax Respiratory Distress Subcutaneous emphysema Asymmetrical
chest expansion Tracheal deviation Hyper-resonant to percussion
Diminished or absent breath sounds “Bubbling” of blood at the wound site
Hemothorax - Accumulation of blood in the pleural cavity caused by

bleeding from chest wall, lung parenchyma or major thoracic vessels. . :
Hemothorax - Accumulation of blood in the pleural cavity caused by
bleeding from chest wall, lung parenchyma or major thoracic vessels. .
Hemothorax: Hemothorax
Hemothorax: Hemothorax May put pressure on the heart
Signs and Symptoms of Hemothorax: Signs and Symptoms of Hemothorax Pain

on inspiration Asymmetric chest wall movement Signs of Shock Frothy,
Bloody Sputum Diminished Breath Sounds on Affected Side Dullness on
percussion Flat Neck Veins
FLIAL CHEST: FLIAL CHEST It is the breaking of 2 or more ribs in 2 or more

places, resulting in free floating rib segments.
Signs and symptoms of Flail chest: Signs and symptoms of Flail chest
Shortness of Breath Paradoxical Movement Respiratory distress
Bruising/Swelling Subcutaneous emphysema Crepitus( Grinding of bone ends
on palpation )
Aortic Injuries: Aortic Injuries Injuries to the aorta can vary from a
small intimal tear to complete aortic rupture (mortality rate 60%-90%)
Signs and symptoms Loud murmur Signs of respiratory distress Rapid LOC
Burning or Tearing Sensation Chest pain. Unequal BP in upper extremities,
Hypotension
Tracheobronchial injuries : Tracheobronchial injuries Traumatic

disruption of the tracheo bronchial tree is rare. Signs and symptoms Signs
of airway obstruction, Hoarseness, Hemoptysis Subcutaneous emphysema
Hamman’s Sign- Crunching or bubbling sound, synchronous with the heart
beat Persistent air leakage in chest drainage system
Myocardial contusion Cardiac contusion usually occurs due to severe

direct blunt trauma to the anterior chest. It is caused by rapid
deceleration injury .Shearing forces cause bleeding and bruising within
the myocardium : Myocardial contusion Cardiac contusion usually occurs
due to severe direct blunt trauma to the anterior chest. It is caused by
rapid deceleration injury .Shearing forces cause bleeding and bruising
within the myocardium Signs and symptoms Ventricular dysrhythmias Chest
pain
Rupture of diaphragm : Rupture of diaphragm It can occur from penetrating

trauma A rupture or tear in the diaphragm allows the abdominal contents
to herniate into the chest cavity.
Signs and symptoms: Signs and symptoms Often asymptomatic, Blood loss
Cardiopulmonary distress Difficulty in swallowing Bowel sounds in
thoracic cavity Undigested food in the chest tube drainage Kehr’s sign-
Abdominal pain radiate to the left shoulder.
Oesophageal injury : Oesophageal injury Oesophageal injury during trauma

is rare. It is associated with first and second rib fracture Signs and
Symptoms Sudden onset of severe chest or neck pain Tachypnea, Dyspnea,
Stridor Dysphagia , Intra abdominal free air Hamman’s sign Gastric
contents or bile in chest tube drainage. Subcutaneous emphysema
Pulmonary contusion: Pulmonary contusion An injury to lung parenchyma

secondary to blunt trauma .It can lead to V/P mismatch which evolves over
a period of 24hrs. Signs and symptoms Respiratory distress symptoms
Ineffective cough and Hemoptysis Pain Presence of other severe chest
injuries
Management : Management Airway obstruction Simultaneous protection of the

C-spine . ETT or Nasotracheal tube intubation Tracheostomy and
Cricothyrotomy Epinephrine administration Cardiopulmonary resuscitation
(CPR) Pericardial Tamponade Rapid infusion of IV fluids to increase
cardiac filling pressures. Needle pericardiocentesis
Needle pericardiocentesis : Needle pericardiocentesis
PowerPoint Presentation: Tension Pneumothorax Needle decompression Place

Flutter valve Prepare for chest tube insertion . Surgical management –
Thoracotomy
PowerPoint Presentation: Open Pnuemo - thorax Observe for the development

of tension pneumothorax Cover the wound with an 3 sided occlusive dressing
Asherman Chest seal
PowerPoint Presentation: Hemo -thorax Insertion of ICD . Maintenance of

circulating volume , Auto transfusion Flial Chest ET intubation with Mech.
ventilator Pain control Chest tube insertion Correct Hypovolemia Don’t
use sand bags Use Trauma bandage and Triangular Bandages . Surgical
management
PowerPoint Presentation: Aortic Injuries Volume resuscitation with

colloids and blood products. Administer short acting B- Blockers
Endovascular stent placement Open surgery with CABG. Tracheo - bronchial
injuries Maintaining patent airway with high flow oxygen Place the client
in Semi-fowler’s position. Chest tube insertion and mediastinal tube
placement
PowerPoint Presentation: Rupture of diaphragm Nasogastric tube or

orogastric tube to decompress the stomach Emergency surgical management
Myocardial contusion Symptomatic Management
PowerPoint Presentation: Pulmonary contusion High flow supplemental

oxygen Advanced airway management Be cautious with fluid resuscitation
Non invasive Ventilator support Pain management Oesophageal injury IV
Fluid administration Surgical repair
PowerPoint Presentation: Nursing Management- Assessment Breathing

Unlaboured No breathing Laboured Beware Chest injury Pneumothorax
Contusion Flial chest Head injury Spinal injury Drugs
Nursing management – NANDA Diagnosis : Nursing management – NANDA

Diagnosis Acute pain Deficient Fluid volume Decreased cardiac output
Inability to sustain spontaneous ventilation Ineffective breathing
pattern Impaired gas exchange Impaired tissue perfusion
Nursing Management in Chest Trauma: Nursing Management in Chest Trauma

AMPLE History and Physical examination Maintain ABC Respiratory support-
Oxygen administration ICD care- FOCA assessment Follow aseptic
precautions Clearence of secretions Pain management Breathing exercises
PAIN MANAGEMENT IN CHEST TRAUMA: PAIN MANAGEMENT IN CHEST TRAUMA
PowerPoint Presentation: Traumatised tissue releases variety of pain

producing substances such as Serotonine Bradykinins Prostaglandins
Principles of pain management Pain can and should be anticipated
Prevention is better than attempting to catch up. Pain relief at cough
is necessary not just at rest
Causes of pain in thoracic Trauma: Causes of pain in thoracic Trauma
Importance of pain management : Importance of pain management Active pain

management is important to Limit depth of ventilatory excursions Improve
coughing and deep inspiration Prevent Atelectasis Avoid Retention of
secretions Perform chest physiotherapy To improve lung function
Pain management methods : Pain management methods

Intra pleural analgesia : Intra pleural analgesia It is useful in Chest
injury and thorocotomy C atheter is inserted between the parietal and
visceral pleura Drugs Bubivocaine 0.5% with or without epinephrine .
Duration of analgesia is 4-8 hours If local anaesthetic drug is given clamp
the chest tube drains for 30 mts to prevent draining of medicine
Patient controlled analgesia : Patient controlled analgesia More

effective pain relief than interval analgesic dosing provided as needed
when requested by the patient or initiated by nursing staff among patients
with postoperative pain. Drugs Morphine 1mg Bolus 1-3 mg then with
maintenance
Epidural analgesia: It is done through cannula inserted to the epidural

space Analgesia may be achieved by intermittent boluses or continous
infusion of opioids, local anaesthetics or both Drugs Bubivocaine 0.125%
Morphine Fentanyl – 5-10 µg/ml Epidural analgesia
Intercostal Nerve Block : Intercostal Nerve Block Intercostal is a simple

technique used for patients with chest injury, surgical procedures,
multiple –Rib fractures. Drugs Bubivocaine (3-5ml) Epinephrine
Non steroidal anti inflammatory drugs : Non steroidal anti inflammatory

drugs It is helpful in chest wall injuries It exerts their effort in
inhibition of peripheral prostaglandin system Ex… Paracetamol ,
Ketoroloc , Aspirin, Ibuprofen
Conclusion: Conclusion Chest Injuries are common and often life

threatening in trauma patients. So, Rapid identification and treatment
of these patients is paramount to patient survival. Airway management is
very important and aggressive management is sometimes needed for proper
management of most chest injuries.
Bibliography: Bibliography Sheey’s Emergency care , 7 th ed, Elsevier

Rosen’s Emergency Medicine Concepts and Clinical Practice, 5 th edition.
Emergency Medicine A Comprehensive Study Guide, 5 th edition S.P. Agarwal,
Practical approach to critical respiratory medicine –Sleep disorders and
fibro-optic bronchoscopy, Jaypee, Newdelhi,2006. Thoracic surgery
clinics- Thoracic trauma Scott.R. Karlen, Initial management of the
trauma patient Chest surgery clinics of North america- Anesthetic
considerations in chest trauma Civetta, Critical care, Lippincott, 2009
POLICY A. Function: To facilitate and guide the Registered Nurse (RN) in

the assessment and treatment of patients with chest trauma. B.
Circumstances under which the RN may perform: 1. Setting: Triage and
treatment area. 2. Supervision: None required. II. PROTOCOL A. Definition:
This protocol covers the assessment and treatment of patients presenting
with penetrating or blunt injury to the chest. B. Subjective: 1. Chief
complaint (document in the patient’s own words). 2. Precipitating event.
3. Date, time, and location of injury. 4. Mechanism of injury (e.g., weapon,
or blunt trauma). 5. Pain (location, intensity, quality, and radiating
characteristics). 6. Shortness of breath. 7. Allergies. 8. Current
medications and last dose taken. 9. Tetanus immunization status
(penetrating trauma only). C. Objective: 1. Vital signs and pulse oximeter
reading. 2. Observe and document the following: a. Assess airway,
breathing and circulation. b. Dyspnea. c. Shortness of breath. d. Skin
color and temperature. e. Restlessness. f. Distended neck veins. g.
Tracheal deviation. h. Chest depressions or bulges. i. Asymmetrical or
paradoxical chest wall movement. j. Entrance and exit wounds; wound size
and estimated blood loss. 3. Palpate chest wall for crepitus, swelling,
and tenderness. 4. Percuss for hyperresonance. 5. Auscultate breath
sounds bilaterally (clear, wheezes, crackles, diminished, absent).
D. Assessment: Impaired gas exchange related to/evidenced by:

Ineffective breathing pattern related to/evidenced by: Fluid volume
deficit related to/evidenced by: E. Plan: 1. Contact physician STAT. 2.
Maintain airway, breathing, and circulation. 3. For non-penetrating
trauma, immobilize the cervical/thoracic/lumbar spine with the patient
secured to a backboard. Note: Thoracic trauma, in the absence of altered
level of consciousness, neck tenderness, or signs and symptoms of neck
trauma, does not require a backboard, which may interfere with evaluation,
management, and patients comfort. 4. Control hemorrhage. 5. Administer
supplemental oxygen via non-rebreather mask to maintain O2 saturation
above 90%. 6. Start an intravenous line and infuse Sodium Chloride
Intravenous Solution (0.9%). Adjust rate to keep systolic blood pressure >
90 mm Hg. Do not start an IV if vital signs are normal and the trauma is
non-penetrating, non-vehicular or involves a fall less than ten (10) feet.
7. DO NOT remove impaled object unless object interferes with
cardiopulmonary resuscitation. 8. Cover (do not stuff) open chest wound
with dry sterile gauze and occlusive tape. Apply occlusive dressing at
the end of expiration and tape dressing on three sides only to allow air
to escape. Continuously evaluate patient for development of pneumothorax.
Remove dressing if tension pneumothorax develops. 9. For paradoxical
chest movement, immobilize the flail segment of the chest by stabilizing
it with sandbags or bags of IV solution taped securely to the flail segment.
This improves the patient’s comfort and willingness to take a deep breath.
Note: Paradoxical movement in itself rarely causes respiratory compromise;
it is the underlying lung injury that creates the problem. 10. Place
patient on injured side to ensure the injury is compressed. 11. Obtain
EKG if blunt cardiac trauma is suspected. 12. Keep patient NPO. 13.
Continue to monitor airway, breathing, circulation, vital signs, oxygen
saturation, and neurologic status every 15 minutes. 14. Prepare to
transfer patient to outside facility or admit to a facility capable of
providing a higher level of care. 15. Fax a copy of the relevant progress
notes, physician orders, and emergency care flow sheet to receiving
facility.
Patient Education: 1. Assess patient's potential for understanding the

health information to be provided. 2. Provide patient education
consistent with the assessment of the condition. 3. Document the education
provided and the patient’s level of understanding on the emergency care
flow sheet. 4. Refer patient to other resources as needed. Document all
referrals on the emergency care flow sheet. G. Documentation: All
information related to the patient’s complaint shall be documented on
the emergency care flow sheet. The flow sheet shall be filed in the
patient’s unit health record. III. REQUIREMENTS FOR RN A.
Education/Training: The Registered Nurse shall attend an in-service on
the assessment and management of chest trauma and achieve a minimum score
of 80% on the written posttest examination. B. Experience: None. C.
Certification: None D. Initial Evaluation: Initial competence will be
validated onsite through simulated exercises, mock scenarios, and return
demonstration. The Registered Nurse must satisfactorily demonstrate all
critical behaviors identified on the Competence Validation Tool to be
considered competent to perform standardized procedure functions. A
written performance appraisal shall be performed by the Supervising
Registered Nurse or designee six months after initial competence has been
validated. Methods to evaluate performance shall include, but not be
limited to direct observation, feedback from colleagues and physicians,
and chart review. E. Ongoing Evaluation: Ongoing competence will be
validated annually using case study analysis, written examination, and
return demonstrations where appropriate. IV. REGISTERED NURSES
AUTHORIZED TO PERFORM THIS PROCEDURE A current list of all Registered
Nurses authorized to perform this procedure shall be maintained on file
in the Office of the Director of Nursing.
Classified as either: Blunt or Penetrating Trauma
Blunt Trauma • Most Common Causes: • MVA (Seatbelt, wheel) • Falls •

Bicycle Crashes • Generalized Symptoms: • Hypoxemia • Hypovolemia •
Cardiac Failure • Mechanisms of Blunt Chest Trauma: • Acceleration –
moving object impacts chest • Deceleration – sudden decrease in
speed/velocity (MVA) • Shearing – stretching forces to areas of chest
• Compression – direct blow to the chest
Penetrating Trauma Most Common Causes: • Gunshot • Stab Wound Classified

By: Velocity: Stab Wound Low Gunshot High
Initial Assessment of Suspected Chest Trauma VITALS & LOC Temperature,

Pulse, RR, BP, SPO2 & PAIN Inspect Respirations Effort & Depth; Chest Wall
Symmetry. Paradoxical Chest Wall Motion; Bruising ; Penetrating Wounds
Palpate Trachea for deviation; Adequate and Equal Chest Wall Movement;
Chest wall tenderness; Rib 'crunching' indicating rib fractures Percuss
Percuss Both Sides of the Chest Looking for Dullness or Resonance
Auscultate Normal & Equal Breath Sounds (Brown et al., 2009)
Initial Assessment of Suspected Chest Trauma (Trauma. Org, 2004)
Secondary Assessment of Chest Trauma • Gather history of event from family,

client, and EHS. • Chief complaint • In depth medical history • Allergies
• Pain assessment
Complications Of Chest Trauma • Pneumothoraxes • Simple • Traumatic • Open

• Hemothorax • Tension Pneumothorax • Pleural Effusion • Sternal and Rib
Fractures • Flail Chest • Pulmonary Contusion • Cardiac Tamponade •
Pulmonary Embolism *
Pneumothorax defined & types individually discuss • Three Types: • Simple

• Traumatic • Open • Hemothorax • Tension (Day et al., 2010)
Tension Pneumothorax • Air is drawn into the pleural space from a

laceration. • Air that enters becomes trapped • Increased positive
pressure • Lung collapses and causes a mediastinal shift away from the
affected lung (Day et al., 2010)
Hemothorax 40% of the circulating blood volume can accumulate A small

amount of blood (<300) in the pleural space may cause no clinical
manifestations and may require no intervention (blood is reabsorbed
spontaneously). Massive HTX results from a rapid accumulation of more than
1500cc of blood in the chest cavity. This may be life threatening because
of resultant hypovolemia and tension Rib fractures and pulmonary
parenchyma disruption are the most common causes
Pneumothorax-Manifestations Simple/Uncomplicated • Sudden onset of pain

• ↓ Tactile Fremitis • Absent breath sounds • Hyperresonant Percussion
• Minimal respiratory distress Large/Tension • Air hungry, anxious,
dyspnea, diaphoresis, hypotension, tachycardia • Central cyanosis may re
from severe hypoxemia • Acute Respiratory Distress—lung collapses
totally
Pleural Effusion Pleural = Pleural Cavity Effusion = abnormal, excessive

collection of this fluid
Pleural Effusion • Abnormal buildup of fluid between linings of the lung

and chest wall • result of a disease process or inflammation • Normally
5 to 10 mL of serous fluid in the visceral and parietal pleura. • Any more
can cause great changes in intrathoracic pressure.
Signs and Symptoms • Pleural effusion in itself does not cause symptoms.
• If effusion expands and presses on lung, patient may develop • sharp,
localized pain that worsens with coughing, or deep breathing. • Dyspnea
• non-productive cough.
Signs and Symptoms cont... • Early signs include decreased or bronchial

breath sounds on the affected side, dullness to percussion, and decreased
fremitus over area of fluid accumulation • Auscultation: EGOPHONY • Hear
“A” over fluid accumulation when patient speaks “E”.
Complications of Pleural Effusion • Respiratory compromise and distress

from fluid compressing lung. • Infection in pleural
space---Sepsis/Empyema • Fistulas in bronchi or chest wall •
Inflammation/infection in pleural space leads to increased potential for
adhesions. Adhesions isolate effusion to one lung and complicates
treatment.
Sternal & Rib Fractures Rib Fractures are the most common type of Chest
Trauma (60%) Sternal Fractures are most common in MVCs Fractures to the
5th-9th Rib are most common site of fracture (Day et al., 2010)
Sternal & Rib Fractures Manifestations • Chest Pain • Ecchymosis •

Crepitus • Swelling • Chest Wall Deformities Interventions: • Pain Control
• Deep Breathing and Coughing • Surgery is Rarely Necessary Patient Must
Be Closely Monitored for Underlying Cardiac Injuries!!
Caused by Blunt trauma Flail Chest

http://www.youtube.com/watch?v=uJHfX1RFkF0
Flail chest trauma
Damage to the lung tissues resulting in hemorrhage and localized edema.

The client is unable to clear secretions effectively, and the work of
breathing is significantly increased Primary defect is the abnormal
accumulation of fluid Pulmonary Contusion (Day et al., 2010)
Pulmonary Contusion Moderate Pulmonary Contusion: Mucous, Serum and Frank

Blood in the Tracheobroncial Tree Persistent Unproductive Cough Severe
Pulmonary Contusion Central Cyanosis, Agitation, Combativeness
Productive Cough with Frothy Bloody Secretions Treatment priorities are
to maintain airway, provide oxygenation and pain management Day et al.,
2010
Cardiac Tamponade • Compression of the heart as a result of fluid within

the pericardial sac • Usually due to chest trauma • Manifestations •
Hypotension • Jugular-venous distention • Muffled heart sounds •
Periocardiocentesis to remove fluid from pericardial sac
Pulmonary Embolism • Pulmonary embolism occurs when a blood clot becomes

lodged in a lung artery, blocking blood flow to lung tissue. Blood clots
often originate in the legs.
Pulmonary Embolism • Blockage makes it more difficult for the heart to

pump blood through lungs. As a result, less oxygen is available to the
rest of the body. If the blockage is large enough, tissue death (infarction)
occurs in the lung area cut off from circulation. Pulmonary embolisms are
commonly misdiagnosed. Nurses need to watch for it!
Misdiagnosed Why? Easily attributed to other conditions and vary with the
size and number of clots. • Such as a heart attack • Pneumonia •
Hyperventilation • Congestive heart failure • Panic attacks. Misdiagnosed
for
Who is at risk? • Immobilization — Being immobilized puts a strain on

the circulatory system. Although the heart acts as the body’s main pump,
movement also assists in keeping blood circulating properly. • Long
periods of inactivity may increase risk of blood clots. Examples include
lengthy road trips or flights, or bed rest due to illness or surgery. •
Blood abnormalities — Some people are born with blood that’s more prone
to clotting & those dehydrated, septic, have Ca, those giving birth.
Other Risk Factors for Pulmonary Embolism • Advanced age (especially over
age 70) • Significantly overweight • Birth control pills, HRT drugs & the
osteoporosis drug raloxifene (Evista) are examples of drugs that list a
small risk of developing blood clots.
About 90 % of Pulmonary Emboli Result When a Clot Travels from a Leg to

a Lung - often no symptoms • Blood tests, a chest X-ray, an
electrocardiogram — to help rule out other possible reasons for symptoms.
• Sometimes a leg blood clot may cause redness, swelling and pain in the
calf muscle area. Refer to a physician promptly. • A pulmonary angiogram
is a more definitive test, although it involves some risk and is more
expensive. • the CT scan (computed tomography scan) — instead of lung
scan or pulmonary angiogram. CT scan is a less invasive test that provides
fast and accurate results.
Nursing Diagnosis for Chest Traumas Impaired Gas Exchange Ineffective

Airway Clearance Ineffective Breathing Patterns Imbalanced Fluid Volume
Decreased Cardiac Output Decreased tissue perfusion Acute Pain Anxiety
PC: Bleeding Risk for infection
Chest Tubes Chest Tube
What are Chest Tubes • A chest tube is a large catheter inserted through
the thorax to remove air, blood, pus or lymph • Small Bore (12-20 Fr) •
Large Bore (24-32 Fr) Perry & Potter, 2010)
Indications for Use (Briggs, 2010) Pneumothorax Tension Pneumothorax

Bilateral Pneumothoraces Hemothorax Post-Operatively (Cardiac Surgery)
Pleural Effusion Empyema Chylothorax Esophageal Rupture with Gastric
Contents in Pleural Space
Equipment Required • Chest tube of appropriate size • Underwater seal
drainage system • Sterile gloves, gown and drapes • Local anesthetic •
Skin Prep solution • Chest Tube Tray • Dressing Material • Chest tube
clamps (Briggs, 2010)
Chest Tubes Continued There are two types of Chest tubes: Pleural
Mediastinal
Pleural Chest Tube Durai, et al., 2010; Perry & Potter, 2010
Mediastinal Chest Tubes Perry & Potter, 2010
Pre-Insertion of Chest Tubes * MD responsible for admin of analgesic

(Durai, 2010) • Nurse prepares sterile table scalpel, local anesthetic
(such as lidocaine), thick silk or polypropylene suture on a cutting
needle, a chest tube of appropriate size and the underwater seal with
sterile water filled to the mark • Opens drain package and prepares drain
as per manufacturers instructions • Nurse Positions Patient for Procedure
• Explain Procedure and assure patient • Monitor Vital Signs and for
Discomfort
Methods for Insertion Durai, 2010 Two Methods for Tube Insertion Trocar
based (i.e. the Seldinger technique) Allows for easier insertion Greater
Risk Less Painful Blunt dissection More painful for the patient Safest
Method
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: \u2212 Hypoxemia from disruption of the airway; injury to the
lung Parenchyma, rib cage, and respiratory musculature; massive
hemorrhage; collapsed lung; and pneumothorax \u2212 Hypovolemia from
massive fluid loss from the great vessels, cardiac rupture, or hemothorax
\u2212 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
intrapleuralpressure 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.
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
intrapleuralpressure 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
ERNAL 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.
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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
usuallyin 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.
Chest Tube Insertion
ICROBIAL KERATITIS • BACTERIAL INFECTIONBACTERIAL INFECTION • FUNGALE

INFECTIONFUNGALE INFECTION • VIRAL INFECTIONVIRAL INFECTION • PARASITIC
INFECTIONPARASITIC INFECTION
12. BACTERIAL INFECTIONBACTERIAL INFECTION Most common microorganism/ •

Staphylococci G+ - aureus - epidemidis • streptococci G+ - pneumoniae -
pyogenes • Pseudomonas aeruginosa • Neisseria
13. Signs and symptoms painful red eye with a localised abscess in the
cornea accompanied by stromal ulceration should arouse clinical
suspicion. There may be an acute uveitis with hypopyon. Photophobia.
14. Diagnosis Clinical history. Physical examination. Cultures of

corneal scrapings (for identification the organism) Corneal biopsy .
15. Treatment Hospitalization Topical administration (rout of choice)

Subconjuntival injection . I.V antibiotic . Oral antibiotics (low
efficacy)
16. FUNGALE INFECTIONFUNGALE INFECTION A fungal keratitis is an

inflammation of the eye's cornea that results from infection by a fungal
organism.
17. Symptoms of Fungal Keratitis Symptoms of fungal keratitis include:

Eye pain and redness Blurred vision Sensitivity to light Excessive
tearing or discharge If you experience any of these symptoms, remove your
contact lenses (if you wear them) and call your eye doctor right away.
Fungal keratitis is a very rare condition, but if left untreated, it can
become serious and result in vision loss or blindness.
. Maintain standard precautions Consider all blood and bodily fluids to be contaminated Avoid
contaminating outside of container when collecting specimens Do not recap needles and syringes Clean up spills of blood and body fluid
immediately Follow CDC recommendations for immunization of health care workers 
. CD4 (T4) malfunctions, suppressing the entire immune system Results: Lymphocytopenia Abnormal T-cell function Increased production of incomplete and nonfunctional antibodies Abnormally functioning macrophages 
. Providing care can evoke complex personal issues for nurses Acknowledge your own fear Acknowledge any negative attitudes regarding possible lifestyles contributing to HIV infection Practice appropriate infection control techniques always Provide compassionate, nonjudgmental
care 
. 41. ASSESSMENT 
. 42. History Age, gender, occupation and residence Thoroughly assess current
complaint/illness Ask when HIV was diagnosed and what symptoms led to that diagnosis Chronology of infections/clinical problems since diagnosis 
. 43. History Health history (any blood transfusions 1978-1985?) History of STDs, infectious
diseases Clotting factors, if hemophiliac Assess client’s level of knowledge 
. 44. Physical Assessment Possible signs/symptoms: Cough Fever Night sweats Fatigue 
. 45. Physical Assessment Possible signs/symptoms: N/V Weight loss Lymphodenopathy Diarrhea 
. 46. Physical Assessment Possible signs/symptoms: Visual changes Headache Memory loss Confusion Seizures Personality changes 
. 47. Physical Assessment Possible signs/symptoms: Dry skin Rashes Skin lesions Pain Discomfort 
. 48. Physical Assessment 
. 49. Physical Assessment – Opportunistic Infections Protozoal Infections Pneumocystis carinii
pneumonia (PNP) – fatigue, weight loss; crackles on auscultation Toxoplasmosis encephalitis – sudden
mental, neurological changes Cryptosporidosis – mild to severe diarrhea with wasting, electrolyte
imbalance 
. 50. Physical Assessment – Opportunistic Infections Fungal Infections Candida
stomatitis/esophagitis – mouth/retrosternal pain; cottage cheese plaques; (vaginal candidiasis – plaques,
pruritis, discharge, perineal irritation) Cryptococcosis – meningitis (fever, headache, n/v, nuchal rigidity,
mental/neurological changes) Histoplasmosis – respiratory infection (dyspnea, fever, cough, weight
loss) 
. 51. Physical Assessment – Opportunistic Infections Bacterial Infections MAC syndrome
(systemic mycobacterium infections of respiratory and/or gastrointestinal tracts; tuberculosis) – fever, weight
loss, debility; lymphadenopathy, organ disease Recurrent pneumonia – chest pain, productive cough,
fever, dyspnea 
. 52. Physical Assessment – Opportunistic Infections Viral Infections Cytomegalovirus (CMV) –
eyes, respiratory/ gastrointestinal tracts, central nervous system Herpes simplex virus (HSV) – painful
lesions/ulcers, fever, pain, bleeding and lymph node enlargement Varicella zoster (VZ) – shingles (pain,
burning along dermatome nerve tracts, headache, low grade fever, large painful vesicles 
. 53. Physical Assessment – Malignancies Kaposi’s sarcoma Malignant lymphomas 
. 54. Physical Assessment – Other Clinical Manifestations AIDS Dementia Complex Wasting
Syndrome Integumentary changes 
. 55. Laboratory Assessment Lymphocyte counts CD4/CD8 counts Antibody tests –
enzyme-linked immunosorbent assay (ELISA); Western blot test Viral culture Viral load testing –
measures RNA or viral protein in client’s blood 
. 56. Psychosocial Assessment Ask about client’s support system – family, SOs, friends Protect
confidentiality Activities of daily living Employment Assess client’s levels of anxiety, self
esteem Assess changes in body image Coping strategies, strengths 
. 57. NURSING DIAGNOSES 
. 58. Risk of infection related to immunodeficiency Impaired gas exchange related to anemia, respiratory
infection or malignancy, anemia, fatigue or pain Acute pain or chronic pain related to neuropathy,
myelopathy, malignancy or infection 
. 59. Imbalanced nutrition: less than body requirements related to high metabolic need, n/v, diarrhea, difficulty
chewing/swallowing, or anorexia Diarrhea related to infection, food intolerance or medications 
. 60. Impaired skin integrity related to KS, infections, altered nutritional state, incontinence, immobility,
hyperthermia or malignancy Disturbed thought processes related to AIDS dementia complex, central
nervous system infection or malignancy 
. 61. Situational low self-esteem or chronic low self-esteem related to changes in body image, decreased
self-esteem, or helplessness Social isolation related to stigma, virus transmissibility, infection control
practices or fear 
. 62. PLANNING/IMPLEMENTATION 
. 63. Risk of Infection Expected outcome: The client is expected to remain free of opportunistic
diseases Interventions: Drug therapy – antiretrovirals only inhibit viral replication; they do not kill
the virus Immune enhancement – bone marrow transplant; lymphocyte transfusion; lymphokines Alternative therapy – vitamins, shark cartilage; botanicals Health promotion – the nurse teaches client
to avoid exposure to infection See Iggy, Chart 22-8, p. 378 
. 64. Impaired Gas Exchange Expected outcome: The client is expected to maintain adequate
oxygenation and perfusion, and experience minimal dyspnea and discomfort Interventions: Drug
therapy Respiratory support and maintenance Comfort Rest and activity 
. 65. Imbalance nutrition: less than body requirements Expected outcome: The client is expected to
maintain optimal weight through adequate nutrition and hydration Interventions: Drug therapy Diet therapy Mouth care 
. 66. Diarrhea Expected outcome: The client is expected to experience decreased diarrhea; maintain
fluid, electrolyte and nutritional status; and minimize incontinence Interventions: Drug therapy Diet therapy Bedside commode The nurse provides privacy, support and understanding 
. 67. Impaired Skin Integrity Expected outcome: The client is expected to have healing of any existing
lesions and avoid increased skin breakdown or secondary infection Interventions: Chemotherapy Drug therapy Wound care Make-up, concealers 
. 68. Disturbed Thought Processes Expected outcome: The client is expected to demonstrate improved
mental status and sustain no injury Interventions: Orientation Drug therapy Safety
measures Support 
. 69. Situational Low Self-Esteem Expected outcome: The client is expected to identify positive aspects
of himself or herself and accept himself or herself Interventions: The nurse allows for privacy, but
does not avoid, isolate the client Promote self care, independence, control and decision-making Complementary alternative therapies 
. 70. Social Isolation Expected outcome: The client is expected to identify behaviors that cause social
isolation and demonstrate behaviors that reduce social isolation Interventions: Promotion of
interaction Education 
. 71. EVALUATION 
. 72. Outcomes: Expected outcomes include that the client will Not develop opportunistic infections Demonstrate adequate respiratory function Achieve and acceptable level of physical comfort Attain adequate weight, nutritional and fluid status 
. 73. Maintain skin integrity Remain oriented and/or in a safe environment Maintain self-esteem Maintain a support system and involvement with others Comply with the appropriate and available
therapy 
. 74. Other Immunodeficiencies Therapy-induced Immunodeficiencies Drug-induced
Immunodeficiencies Cytotoxic drugs Corticosteroids Cyclosporine Radiation-induced
Immunodeficiencies – Collaborative management 
. 75. REFERENCES All Refer (2009). Cancer. Retrieved October 25, 2009, from
http://health.allrefer.com/health/cancer-lymphoma-malignant-ct-scan.html BBC (2008). US set to
spend $50bn against HIV. Retrieved October 25, 2009, from http://news.bbc.co.uk/2/hi/7327694.stm Both Teams Play Hard (n.d.). . Retrieved October 25, 2009, from
http://www.bothteamsplayedhard.net/wp-content/uploads/2008/10/magazines-time-magicjohnson.jpg Council Rock School District (2005). STDs, HIV & AIDS Outline. Retrieved October 25, 2009, from
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NURSING IMPLICATION <ul><li>NURSING DIAGNOSIS </li></ul><ul><li>Ineffective Airway Clearance

4. Chest injuries are potentially life-threatening because of immediate

6. Definition: A chest injury is define as, “it is a form of injury

8. Incidence: 25% of all death form traumatic injury.

10. Causes: BLUNT INJURY CAUSES PENETRATING INJURY CAUSES

11. BLUNT INJURY CAUSES: Motor vehicle accident Pedestrian

12. PENETRATING INJURY CAUSES: Knife Gunshot Stick Arrow

13. Types of chest injuries

16. Hemothorax: Blood in pleural space as a result of penetrating or

17. Flail Chest: Loss of stability of chest wall as a result of multiple

19. Pulmonary Contusion: Bruise of the lung parenchyma those results

20. Cardiac Tamponade: Compression of the heart as a result of

21. Clinical manifestation:

22. Respiratory Dyspnea, respiratory distress Cough with or without

23. Cardiovascular Rapid, thready pulse Decreased BP Narrowed

24. Chest pain Crunching sound synchronous with heart sounds

25. Surface Findings Bruising Abrasions Open chest wound

26. Diagnostic evaluation

27. History collection Physical examination While doing physical

29. The goal is to restore normal cardiorespiratory function as quickly

31. Rib Fracture: Give analgesics (usually nonopioid) to assist in

32. Hemothorax: Assist with thoracentesis to aspirate blood from

34. Pulmonary Contusion: Employ mechanical ventilation to keep lungs

35. If respiratory failure is present, prepare for immediate ET

36. Cardiac Tamponade: Assist with pericardiocentesis to provide

37. ADDITIONAL RESPONSIBILITIES: Secure and support the airway as

40. Obtain urinary output hourly to evaluate tissue perfusion.

41. Institute ECG monitoring for early detection and treatment of

42. Maintain ongoing surveillance for complications: Aspiration

43. Patient education and health maintenance: Instruct patient in

44. Summary Introduction Definition Incidence Causes Types

: DEFINITION – CHEST TRAUMA A chest trauma is any form of physical injury

INCIDENCE OF CHEST TRAUMA : INCIDENCE OF CHEST TRAUMA Thoracic trauma is

MECHANISMS OF CHEST TRAUMA: MECHANISMS OF CHEST TRAUMA Blunt Trauma

Assessment : Assessment Primary Survey ABCDE s of trauma care A - Airway

Diagnostic Aids: Diagnostic Aids Standard trauma labs ABG , CBC,

LIFE THREATENING CHEST INJURY : LIFE THREATENING CHEST INJURY

AIRWAY OBSTRUCTION: AIRWAY OBSTRUCTION An airway obstruction is a

Tension Pneumothorax: Tension Pneumothorax Air enters the pleural space

Tension Pneumothorax: Tension Pneumothorax Each time we inhale, the lung

Tension Pneumothorax: Tension Pneumothorax Each time we inhale, the lung

Tension Pneumothorax: Tension Pneumothorax Heart is being compressed The

Pericardial Tamponade Collection of blood or blood clots in the

Pericardial Tamponade: Pericardial Tamponade Accumulating pressure on

Pericardial Tamponade: Pericardial Tamponade Decreased cardiac function .

Open Pneumothorax: Open Pneumothorax Penetrating trauma opens the pleural

Open Pneumothorax: Open Pneumothorax Inhale

Open Pneumothorax: Open Pneumothorax Exhale

Open Pneumothorax: Open Pneumothorax Inhale

Open Pneumothorax: Open Pneumothorax Exhale

Open Pneumothoarx: Open Pneumothoarx Inhale

Open Pnuemothorax: Open Pnuemothorax Inhale

Signs and symptoms of Open pneumothorax: Signs and symptoms of Open

Hemothorax - Accumulation of blood in the pleural cavity caused by

Hemothorax: Hemothorax May put pressure on the heart

Signs and Symptoms of Hemothorax: Signs and Symptoms of Hemothorax Pain

FLIAL CHEST: FLIAL CHEST It is the breaking of 2 or more ribs in 2 or more

Tracheobronchial injuries : Tracheobronchial injuries Traumatic

Myocardial contusion Cardiac contusion usually occurs due to severe

Rupture of diaphragm : Rupture of diaphragm It can occur from penetrating

Oesophageal injury : Oesophageal injury Oesophageal injury during trauma

Pulmonary contusion: Pulmonary contusion An injury to lung parenchyma