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Chest TraumaChest Trauma

Qutaibah oudatQutaibah oudat

jordanjordan

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IntroductionIntroduction

Chest trauma is often sudden and Chest trauma is often sudden and dramaticdramatic

Accounts for 25% of all trauma deathsAccounts for 25% of all trauma deaths 2/3 of deaths occur after reaching 2/3 of deaths occur after reaching

hospital.hospital. Associated with high mortality rate.Associated with high mortality rate. Serious pathological consequnces:Serious pathological consequnces: --

hypoxia, hypovolemia, myocardialhypoxia, hypovolemia, myocardial failure. failure.

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Mechanism of InjuryMechanism of InjuryPenetrating injuriesPenetrating injuries E.g. stab wounds etc.E.g. stab wounds etc. HaemothoraxHaemothorax PneumothoraxPneumothorax Cardiac, great vessel or oesophageal injury.Cardiac, great vessel or oesophageal injury. Great vessel injuries leads to death.Great vessel injuries leads to death. Early deaths occur (30 min-3 hrs after Early deaths occur (30 min-3 hrs after

trauma.trauma. Blunt injuries EitherBlunt injuries Either::

- direct blow (e.g. rib fracture). - direct blow (e.g. rib fracture). - compression injury.- compression injury.

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Chest Wall Injuries Chest Wall Injuries

Rib fractures Rib fractures

Flail chestFlail chest

Open pneumothoraxOpen pneumothorax

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Rib fracture is the most common Rib fracture is the most common

significant 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. 11stst-2nd rib # suggests massive force -2nd rib # suggests massive force

of injury or trauma.of injury or trauma.

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Rib FractureRib Fracture

33rdrd-9-9thth ribs associated with : ribs associated with :

a.a. Blunt trauma.Blunt trauma.

b.b. Underlying lung injury.Underlying lung injury. Lower ribs associated with:Lower ribs associated with:

a.a. Injury to liver.Injury to liver.

b.b. Injury to abdomen.Injury to abdomen. Upper ribs, clavicle or scapula Upper ribs, clavicle or scapula

fracture: suspect vascular injuryfracture: suspect vascular injury

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Rib fracturesRib fracturesSigns & Symptoms:Signs & Symptoms: Localised pain, tenderness, crepitusLocalised pain, tenderness, crepitusDiagnostic Procedure:Diagnostic Procedure: CXR to exclude other injuriesCXR to exclude other injuriesManagementManagement::a.a. Air way management.Air way management.b.b. Pain management (analgesia & avoid Pain management (analgesia & avoid

taping).taping). Nurse must consider underlying Nurse must consider underlying

structure and injury to them.structure and injury to them.

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Flail chestFlail chest Multiple rib fractures produce a mobile Multiple rib fractures produce a mobile

fragment which moves paradoxically with fragment which moves paradoxically with respiration.respiration.

Significant force required to cause # of Significant force required to cause # of multiple ribs.multiple ribs.

usually Sternal # is present.usually Sternal # is present. Usually diagnosed clinicallyUsually diagnosed clinicallyRxRx: : ABCABC .. Analgesia.Analgesia. Turn pt from side to side down to improve Turn pt from side to side down to improve

oxygenation .oxygenation . Internal splitting used.Internal splitting used.

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Flail chestFlail chest

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Flail Chest - detail

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Lung injuryLung injury

Pneumothorax Pneumothorax HaemothoraxHaemothorax Trachea and bronchial injuriesTrachea and bronchial injuries PneumomediastinumPneumomediastinum

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PneumothoraxPneumothorax

accumulation of Air or Gas between the accumulation of Air or Gas between the (pleural cavity) parietal and visceral (pleural cavity) parietal and visceral pleurae, leading to lung collapse. pleurae, leading to lung collapse.

Blunt or penetrating injury that disrupts Blunt or penetrating injury that disrupts the parietal or visceral pleura.the parietal or visceral pleura.

Degree of lung collapse determined by Degree of lung collapse determined by amount of trapped air or gas.amount of trapped air or gas.

Most common types: open, closed, and Most common types: open, closed, and tension.tension.

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CausesCauses

Closed pneumothorax:Closed pneumothorax:

a.a. barotrauma.barotrauma.

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S & SS & S

Unilateral signs:Unilateral signs:

a.a.movement and breath sounds,movement and breath sounds,

b. resonant to percussionb. resonant to percussion

Diagnostic Procedure:Diagnostic Procedure:

Confirmed by CXRConfirmed by CXR

Rx:Rx:

chest drainchest drain

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PneumothoraxPneumothorax

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Open PneumothoraxOpen Pneumothorax Defect in chest wall provides a direct communication Defect in chest wall provides a direct communication

between the pleural space and the environmentbetween the pleural space and the environment Lung collapse and paroxysmal shifting of Lung collapse and paroxysmal shifting of

mediastinum with each respiratory effort ± tension mediastinum with each respiratory effort ± tension pneumothoraxpneumothorax..

Causes:Causes: Central venous catheter insertion.Central venous catheter insertion. Chest surgery.Chest surgery. Penetrating chest injury.Penetrating chest injury. Thoracentesis. Thoracentesis. Percutaneous Lung BiopsyPercutaneous Lung BiopsyRx:Rx: ABCs.ABCs. closure of wound.closure of wound. chest drain.chest drain.

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Tension Pneumothorax Tension Pneumothorax

Air accumulates intrapleurally and Air accumulates intrapleurally and can’t escape.can’t escape.

Air enters pleural space and cannot Air enters pleural space and cannot escape.escape.

On Inspiration:On Inspiration:

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

On Expiration:On Expiration:

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

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

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Causes of Causes of Tension Tension PneumothoraxPneumothorax

Chest tube occlusion or malfunction.Chest tube occlusion or malfunction. High positive end-expiratory pressures, High positive end-expiratory pressures,

causing rupture of alveolar blebs.causing rupture of alveolar blebs. Lung or airway puncture from positive-Lung or airway puncture from positive-

pressure ventilation.pressure ventilation. Mechanical ventilation after chest Mechanical ventilation after chest

injury.injury. Penetrating chest wound.Penetrating chest wound.

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Continue…..Continue…..

P/C:P/C: chest pain.chest pain. dyspnoeadyspnoeaDx:Dx: Respiratory distress symptoms. Respiratory distress symptoms. Tracheal deviation (away)Tracheal deviation (away) Absence of breath soundsAbsence of breath sounds Distended neck veinsDistended neck veins HypotensionHypotension

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Surgical emergencySurgical emergency

Rx: emergency decompression Rx: emergency decompression

before CXRbefore CXR

Either large bore cannula in 2nd Either large bore cannula in 2nd

ICS, MCL or insert chest tubeICS, MCL or insert chest tube

CXR to confirm site of insertionCXR to confirm site of insertion

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HaemothoraxHaemothorax

Blunt or penetrating traumaBlunt or penetrating trauma Requires rapid decompression and Requires rapid decompression and

fluid resuscitationfluid resuscitation May require surgical interventionMay require surgical intervention Clinically: hypovolaemiaClinically: hypovolaemia

absence of breath sounds absence of breath sounds dullness to percussion dullness to percussion

CXR may be confused with collapseCXR may be confused with collapse

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Chest trauma: summaryChest trauma: summary CommonCommon SeriousSerious Primary goal is to provide oxygen Primary goal is to provide oxygen

to vital organsto vital organs RememberRemember

AAirwayirwayBBreathingreathing

CCirculationirculation Be alert to change in clinical Be alert to change in clinical

condition condition

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Continue…..Continue…..

ALERT If the patient’s chest tube ALERT If the patient’s chest tube dislodges, immediately place a dislodges, immediately place a petroleum gauze dressing over the petroleum gauze dressing over the opening.opening.

ALERT Watch for signs and symptoms of ALERT Watch for signs and symptoms of tension pneumothorax, which can be tension pneumothorax, which can be fatal. these include anxiety, fatal. these include anxiety, hypotension, tachycardia, tachypnea, hypotension, tachycardia, tachypnea, and cyanosis. and cyanosis.

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