Chest Trauma: Assessment and Treatment

Chest Trauma

• Chest trauma can be caused by blunt trauma, pneumothorax, or cardiac tamponade

Blunt Trauma

• Common causes include motor vehicle accidents, falls, and cycling accidents
• It is often life-threatening and can result in hypoxemia from damage to the airway, lung tissue, ribs, chest muscles, massive hemorrhage, collapsed lung, or pneumothorax

Blunt Chest Trauma: Assessment and Treatment

• Assessment includes evaluating the airway, mechanism of injury, LOC, blood loss, and specific injuries to the chest
• Treatment goals are to support the airway/O2, fluid volume resuscitation, reestablish negative chest pressures, and potentially emergent surgery

Flail Chest

• Occurs when three or more adjacent ribs are fractured, resulting in paradoxical chest movement
• A patient becomes hypoxic, which is easily followed by respiratory acidosis (hypercarbia/hypercapnia)
• It often results in hypotension and inadequate tissue perfusion
• Treatment involves airway and O2 management, pain management, and sometimes surgery

Pneumothorax

• Traumatic pneumothorax occurs when air escapes from a laceration in the lung or chest wall and enters the pleural space
• Can be caused by blunt trauma (rib fractures), penetrating wounds, or thoracic procedures like central line insertion, thoracentesis, and chest surgery
• Open/sucking chest wound is a large, open chest wound that allows air to be sucked into the chest cavity, resulting in mediastinal shift

Tension Pneumothorax

• Air is drawn into the pleural space from a lacerated lung or a small opening/wound in the chest wall
• May be a complication of other kinds of pneumothorax
• Air entering the chest can't be expelled
• Pressure/tension increases with each breath, causing the lung on the affected side to collapse
• Trachea, heart, and great vessels shift to the opposite side of the chest (mediastinal shift)
• Respiratory and circulatory compromise may occur (usually arrest)
• Treatment involves restoring negative pressure to the chest cavity, managing cardiopulmonary compromise, and managing pain
• it is a medical emergency

Cardiac Tamponade

• It is the compression of the heart due to fluid or blood in the pericardium
• Can be caused by post-cath, pacemaker insertion, blunt or penetrating injury to the chest, or pericardial effusions that develop in relationship to illness (cancer, renal failure)
• Leads to cardiac arrhythmias or cardiac arrest if not treated
• It is a medical emergency

Other Ventilatory Disorders

• Two other ventilatory disorders are pulmonary hypertension and pulmonary embolism

Pulmonary Hypertension

• Characterized by elevated pulmonary arterial pressure
• It leads to secondary right ventricular heart failure, also known as cor pulmonale
• Cor refers to the heart
• Pulmonale refers to the lungs
• It is a heart problem caused by a lung problem
• Can be acute with an acute pulmonary embolus
• Can be chronic, as in some COPD patients

Pulmonary Hypertension: Clinical Manifestations and Collaborative Care

• Manifestations include dyspnea and signs/symptoms of right heart failure (with cor pulmonale)
• Collaborative care includes pharmacologic interventions, oxygen, lung transplantation (often heart-lung), emotional support, and education about medications, lifestyle adaptation, and treatment options
• Pharmacologic interventions include vasodilators like prostanoids, calcium channel blockers, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors

Cor Pulmonale: Causes

• Causes include COPD, pulmonary embolism, pulmonary fibrosis, sleep apnea, myasthenia gravis, and poliomyelitis
• Can result in right ventricular dilation and right ventricular hypertrophy

Pulmonary Embolism

• Obstruction of the pulmonary artery or one of its branches by a thrombus originating in the venous system (DVT) or right side of the heart
• The triad of risk, known as Virchow's Triad, includes hypercoagulability, venous stasis, and vessel injury
• Portions of the lung receive little or no perfusion, impairing gas exchange
• It may result in pulmonary infarction/tissue death

Pulmonary Embolism

• It is a PERFUSION problem that leads to a VENTILATION problem

Pulmonary Embolism: Manifestations and Diagnostics

• Manifestations include shortness of breath, anxiety, chest pain, and hemoptysis
• Large PE or in patients with comorbidities, it may result in cardiopulmonary distress and/or arrest
• Diagnostics include VQ scan, CT scan, D-dimer, and pulmonary angiography

Pulmonary Embolism: Collaborative Care

• Focus on prevention, including SCDs
• Pharmacologic interventions include Subcutaneous heparin/enoxaparin in hospitalized patients and Anticoagulant/antiplatelet drugs (minimum 3 - 6 months post PE; maybe long term)
• Optimize activity level both inpatient and outpatient
• Requires flexing feet and moving arms
• Hydration and stopping smoking
• Other collaborative care includes supporting respiratory status and thrombolytic therapy
• Heparin infusion and in some cases surgery and IVC filters

Acute Respiratory Failure

• Sit the patient up and put them on O2
• It is a sudden and life-threatening deterioration of the gas exchange function of the lung
• The lungs fail to provide adequate oxygenation or ventilation for the blood
• Some patients with chronic lung disorders may meet the terms (such as blood gases) for respiratory failure but have developed compensatory mechanisms that enable them to tolerate these abnormalities and are considered to be in chronic respiratory failure, not acute

Acute Respiratory Failure: Pathophysiology

• Pathophysiology includes Ventilatory failure (high CO2) and Oxygenation failure (low O₂)
• Causes of ventilatory failure include impaired CNS (opiates, head injury or infection), neuromuscular disorders (spinal cord trauma, myasthenia gravis), musculoskeletal dysfunction (chest trauma, malnutrition, kyphosis), pulmonary dysfunction (COPD, asthma, cystic fibrosis), and early postop chest or abdominal surgery (pain, opiates, anesthesia)
• Causes of oxygenation failure include pneumonia, ARDS, heart failure, pulmonary embolism, restrictive lung diseases (diseases that reduce lung volumes), and postop pain (especially abdominal or chest surgeries)

Acute Respiratory Failure: Oxygen Failure and Manifestations

• Hypoxemia - the amount of O2 in the arterial blood is less than the normal value (less than 80)
• Hypoxia - when pO2 falls enough to cause signs and symptoms of inadequate oxygenation
• Hypoxemia, if not treated, may lead to hypoxia

Acute Respiratory Failure: Hypoxia Symptoms

• Early symptoms are apprehension, restlessness, irritability, confusion, tachypnea, orthopnea, dyspnea on exertion, tachycardia, mild HTN, arrhythmias, diaphoresis, and increased work of breathing

Acute Respiratory Failure: Late Symptoms

• Late symptoms include confusion, lethargy, combative behavior, coma, dyspnea at rest, accessory muscle use, retractions, one-word sentences, dysrhythmias, hypotension, cyanosis, cool clammy skin, diaphoresis, decreased urine output, and fatigue

Acute Respiratory Failure: Hypercarbia or Hypercapnia - Narcosis (Ventilation Failure)

• It is assoicated with narcotic administration
• The body has too much CO2, usually above 45 mmHg
• Some references say the level should be higher than 50 mmHg
• Symptoms include lethargy, confusion, reduction in RR, coma, and respiratory arrest

Acute Respiratory Failure: Hypoxemic vs Hypercarbic

• In hypoxemic oxygen failure cases, pO2 is less than or equal to 60 mmHg, and symptoms include agitation, anxiety, confusion, belligerence, cyanosis decreased pulse ox, tachycardia, and tachypnea
• In hypercarbic/hypercapneic/narcosis ventilatory failure cases, pCO2 is greater than 45 mmHg and pH is < 7.35, and symptoms include decreasing LOC, sleepiness, difficult to arouse, confused, and decreased RR

Causes of Respiratory Failure

• Hypoxemic causes include ARDS, restrictive lung diseases (sarcoidosis), pneumonia, pulmonary embolism, and acute asthma attack
• Hypercapnic causes include major abdominal or thoracic surgery
• Neuromuscular disorders such as spinal cord injury
• Pulmonary disorders such as chest trauma, and COPD

Acute Respiratory Failure: Treatment

• Treatment includes noninvasive methods like BiPAP and invasive methods like mechanical ventilation

Acute Respiratory Failure: Key Interventions

• Treat the underlying cause
• Ensure adequate oxygenation/ventilation
• Use BIPAP or mechanical ventilator
• Provide pharmacologic interventions like bronchodilators, anti-inflammatory agents, treat pulmonary congestion/edema (diuretics), antibiotics, as indicated, and comfort (anxiety, pain)
• Provide nutritional therapy and ensure proper fluid balance
• Mobilize secretions through hydration, medications (guaifenesin), activity (passive, if needed), and airway suctioning (as needed)

Acute Respiratory Distress Syndrome (ARDS)

• Characterized by a severe inflammatory process causing diffuse alveolar damage
• This results in sudden and progressive pulmonary edema after injury, increasing bilateral infiltrates on CXR
• Includes hypoxemia unresponsive to oxygen supplementation, regardless of level of PEEP
• Reduced lung compliance

ARDS: Clinical Manifestations

• Rapidly progressing hypoxemia refractory to aggressive oxygenation
• Widespread alveolar collapse
• White-out on CXR
• Lungs are difficult to ventilate because lungs are noncompliant/stiff

ARDS: Complications

• Complications include VAP, barotrauma, volutrauma (trauma to alveoli due to increased mechanical ventilation volume)
• Development of stress ulcers and renal failure, and long term pulmonary fibrosis

ARDS: Collaborative Care

• Collaborative care includes identification and treatment of precipitating factors, aggressive support of the respiratory system; treat carefully if systemic hypotension occurs, and other pharmacologic treatment
• Provide Nitric oxide (inhaled vasodilators that may help with oxygenation)
• Steroids may be used
• Nutrition is usually enteral; parenteral can be used

Management of Patients With Chronic Pulmonary Disease

• This includes patients with chronic obstructive pulmonary disease (COPD) and asthma

COPD

• COPD includes chronic bronchitis and emphysema
• Most patients have components of both disorders
• COPD is a progressive, preventable damage
• It is the third leading cause of death in US among lower respiratory disorders
• Factors include exposure to noxious particles or gases (smoking, environmental exposure

COPD: Primary Process

• The primary process is inflammation from inhalation of noxious particles
• Mediators are released, causing damage to lung tissue

COPD: Chronic Bronchitis

• Characterized by cough and sputum production for at least 3 months in 2 consecutive years
• Inflammation and hypersecretion of mucus
• Thickened bronchial walls
• Damaged alveoli resulting in diminished alveolar macrophage action, increasing susceptibility to infection

COPD: Emphysema

• Overdistended alveoli is caused by walls that are destroyed
• Decreased elasticity and trapped CO2 results
• Hyperinflated chest (increased compliance)
• Reduced alveolar/capillary interface

COPD: Diagnostics and Manifestations

• Pulmonary function tests (PFTs)
• Arterial blood gases (ABGs)
• Activity Intolerance
• Chest X-rays
• H&P (Cough, sputum production, Dyspnea, Exposure to risk factors)

COPD :Clinical Manifestations and Presentation

• Manifestations include chronic cough, sputum production, dyspnea, weight loss (burn calories with work of breathing), barrel chest, clubbing of fingers (chronic hypoxia), and accessory muscle use
• The typical presentation is a middle-aged or older man with a history of smoking

COPD: Complications

• Respiratory insufficiency or failure
• Pneumonia and Chronic atelectasis
• Pneumothorax
• Pulmonary hypertension with or without cor pulmonale

COPD: Management

• Smoking cessation/reduction to environmental toxins
• Medication such as bronchodilators and corticosteroids
• Oxygen (dosing is critical!)
• Nutrition and pulmonary rehabilitation
• Bullectomy: removal of enlarged air spaces, in hopes of reducing dyspnea and improving lung function
• Lung volume reduction: palliative procedure for patient's with disease in one area, may decrease dyspnea, improve lung function and exercise, and better quality of life
• Lung transplant

COPD: Patient Education

• Teach pursed lip breathing, it increases airway resistance prolonging expiratory stage
• Teach tripod position, increasing “space” to breathe
• These techniques are also breathing techniques to help expel CO2

Asthma

• A chronic airway inflammation that can occur at any age
• The death rate continues to rise
• Allergy is the strongest predisposing factor
• Exposure to irritants over time leads to irreversible changes in the lungs

Asthma: Clinical Manifestations and Diagnostics

• Manifestations include Cough, Dyspnea, Wheezing, Chest tightness,Hypoxemia, Hypocapnia, Normalizing or rising CO2 may signal respiratory failure
• Diagnostics include History and physical, Pulmonary function tests ( Peak flow, FVC, FEV1), CXR Changes over time), ABGs (Hypoxemia) and Sputum culture (Diagnose possible infection)

Asthma: Complications

• Complications may include Status asthmaticus, Pneumonia, Respiratory failure, and Atelectasis

Asthma: Pharmacologic Treatment

• Inhalers
  • Albuterol (bronchodilator), SABA
  • Ipraptropium (bronchodilator, anticholinergic)
  • Budesonide (anti-inflammatory)
• Oral
• Intravenous- Methylprednisolone
• Know the action of these drugs

Asthma: Patient Education

• Identification of triggers and avoidance of triggers
• Use peak flow meter
• No smoking!
• Teach right way to administer drugs
• Quality of life is adherence to treatment plan

Asthma: Peak Flow Meter

• Peak flow results - Green Zone Usually, 80 to 100% of personal best Remain on medications
• Peak flow results - Yellow Zone -Usually 50-80% of personal best -Indicates caution -Something is triggering asthma
• Peak flow results - Red Zone -50% or less of personal best-Indicates serious problem -Definitive action must be taken with health care provider