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Chest/Thoracic trauma

Blunt: < 10% Penetrating: 15 30% Most life-threatening injuries identified in primary survey

Anatomy
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Chest X-ray
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Parietal Pleura This lines the chest wall

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Pleural Space
4 cc

Visceral Pleura

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Assessment
- Patients airway - Air movement - Breathing pattern - Breath sounds - Life-threatening injuries - Use of intercostal & accessory muscles - Circulation & hemodynamic status

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Diagnosis
- Mechanism of injury - Clinical observations - Chest x-ray - Arterial oxygen saturation O2 sat - Arterial blood gas ABG - Electrocardiogram ECG

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Immediate life-threatening injuries in chest

Airway obstruction Tension pneumothorax Flail chest Open pneumothorax Massive hemothorax Cardiac tamponade

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Laryngeal injury

Rare Causing Airway Obstruction Hoarseness/ Subcutaneous emphysema Treatment - Intubate cautiously - Tracheostomy

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Tension Pneumothorax

can lead to cardiovascular collapsepulseless electrical activity (PEA).-

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Tension pneumothorax

Distended neck veins Respiratory distress Unilateral in breath Sounds Hyperresonance Cyanosis (late)

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Tension pneumothorax

Hx. chest injury Chest pain, air hunger, respiratory distress Tachycardia, hypotension, tracheal deviation, neck vein distension, unilateral absent breath sound

Tension pneumothorax
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: Immediate decompression (14G) ICS 2 midclavicular line - Intercostal drainage (ICD) tube

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Immediate decompression

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Open Pneumothorax

(Large defects of chest wall, which remain open)

OPEN PNEUMOTHORAX SUCKING CHEST WALL

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Diameter 2/3 >trachea


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Flail Chest

a segment of the thoracic wall becomes unattached from the rest of the chest wall - there are two or more ribs fractured

Flail Chest

Paradoxical chest movement

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Flail Chest
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Asymmetry chest movement

Flail Chest
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- Paradoxical motion Hypoventilation - Dyspnea - Guarding - Self-Splinting - Bony Crepitus (grating or crackling sound from broken bones rubbing) - Tachycardia - Excruciating pain upon movement

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Flail Chest / Pulmonary Contusion

Oxygenation O2 Reexpand lung Fluid resuscitation Intubate as indicated Adequate pain control

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Massive hemothorax

Massive bleeding in pleural cavity - 1500 cc - 1/3 total blood volume - Continuous bleeding 200 cc/hr for 2-4 hrs - ICD into 5th ICS anterior to mid axillary line - Thoracotomy

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Rt. Lung Hazy

Lt. Lung clear

Mediastinal shift

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Massive hemothorax

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Cardiac Tamponade
Becks Triad : venous pressure elevation : decline in arterial pressure (BP drop) : muffled heart tones

FAST

CXR for cardiac tamponade

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Fast
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VDO 2

Secondary Survey
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Eight lethal injuries are considered:

1. simple pneumothorax 2. Hemothorax 3. Pulmonary contusion 4. Tracheobronchial tree injuries 5. Blunt cardiac injury 6. Traumatic aortic disruption 7. Traumatic diaphragmatic injury 8. Mediastinal traversing wounds

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Pneumothorax

CXR
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 pneumothorax
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Pneumothorax
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- Pleuritic chest pain sharp pain on inspiration) - Increased heart rate - Anxiety - Decreased breath sounds/chest expansion on the affected side - Increased oxygen demand ( O2 sat )

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Pulmonary Contusion

Pulmonary Contusion
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- Pulmonary edema - Interstitial hemorrhage - Atelectasis - Airway obstruction - Increased pulmonary vascular resistance (PVR) - Intra-alveolar hemorrhage alveoli

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Aortic Rupture

bleeding either into or around (or both) the wall of the aorta. Aorta

Aortic Rupture
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- Chest Pain (sudden, sharp, stabbing, radiating to shoulder neck and jaw) - Decreased sensation - Anxiety - Pallor - Dry skin (dry mouth, thirst) - Nausea and Vomiting, Dizziness - Shortness of Breath (Dyspnea, Tachypnea)

Mediastinal traversing wounds

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Mediastinal traversing wounds

Bilat. thoracotomy

Mediastinal traversing wounds

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Other manifestation of chest injuries

A. Subcutaneous emphysema B. Crushing injury to chest wall C. Rib, sternum, Scapular Fracture D. Blunt esophageal rupture

Chest wall wound

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Axillary a.

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Fracture Pathophysiology Sternum, Scapular, and Rib

Pain Associated injuries Complications Atelectasis Pneumonia

Fracture Pathophysiology
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Associated Injuries
Sternum, Scapular, and Rib Ribs 1-3 - Severe force - Associated injuries Ribs 4-9: Pulmonary contusion and pneumothorax Ribs 10-12: Suspect abdominal injury

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Treatment Options for Pleural Disruption (Pneumo/Hemo/Tension) includes:

Chest Tube
4 - 5 mid-axillary line

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ICD

ICD
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ICD

ICD

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Pre Insertion Care includes:

- Gathering the necessary equipment - Instructing the patient on the procedure and expected outcome - Checking for allergies and giving ordered analgesic and sedation - Properly positioning patient for insertion - Assisting physician with creating a sterile field - Assisting physician with insertion

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Post Insertion Care includes:

Assessment (immediately after and q 4 hours): :- Fluctuations in the air leak indicator :- Air bubbles in the air leak indicator:- Suction set at ordered level :- Comfort level

Post Insertion Care includes:

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- Breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and (V/S) - O2 saturation - Drainage for amount, color and consistency (Depending on situation, usually > then 100ml/hour needs to be reported, check specific order) chest drain - Dressing for occlusiveness and drainage from insertion site - Chest wall at insertion site for subcutaneous emphysema - Mark volume of drainage on Pleur-evac (date, time and initial) record

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Nursing Interventions post insertion include: - Assure chest x-ray is obtained post insertion ? - Verify that patient understands and reports potential complications such as dyspnea, hemoptysis or severe pain - Verify that patient understands mobility restraints - Position drainage system in an upright position and below the level of the heart - Turn patient q 2 hours ? - Change dressing per policy or more frequently if needed Bottle of sterile NS Vaseline Gauze 4x4 gauze
Tape and non-toothed padded clamps

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Note: The only time a chest tube should be momentarily clamped is when changing the system or assessing for location of an air leak.

underwater seal 2 cm

 ( )
suction air fluid

Fluid clear effusion

suction pressure pressure

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