Chest Trauma And Thoracic Injuries PDF

CHEST TRAUMA AND THORACIC INJURIES  AMIE S. PEREZ, RN CLINICAL INSTRUCTOR  to: 1. Identify causes of chest and OBJECTIVES thoracic injuries. 2. Differentiate blunt t...

CHEST TRAUMA AND THORACIC INJURIES  AMIE S. PEREZ, RN CLINICAL INSTRUCTOR  to: 1. Identify causes of chest and OBJECTIVES thoracic injuries. 2. Differentiate blunt trauma and penetrating trauma. https://youtu.be/q48PNEaa38M At the end of the lesson, you will be able 3. Recognizethe pathophysiology, assessment, diagnostic test and medical management for blunt trauma. 4. Identify cases that falls under blunt trauma such as sternal and rib fracture, flail chest and pulmonary contusion including their assessment, diagnostic test and medical management. 5. Identify cases that falls under penetrating trauma such as gun shot wound and stab wound that result to pneumothorax and cardiac tamponade. 6. Discuss what is pneumothorax and cardiac tamponade including its assessment, diagnostic test and management. CHEST TRAUMA AND THORACIC INJURIES https://youtu.be/scjXSb6fhQs The external injury may appear minor, but internally organs may have been severely  damaged. Rib and sternal fractures can lacerate lung tissue. In a high-velocity impact, shearing forces can result in laceration or tearing of the aorta. Compression of the chest may result in contusion, crush injury, and organ rupture. The primary mechanisms of injury responsible for chest trauma as either blunt trauma or penetrating trauma BLAUNT CHEST TRAUMA https://youtu.be/bgsIHnZ6Rsc BLUNT CHEST TRAUMA Blunt chest trauma results from sudden compression or positive pressure inflicted to the chest wall. Motor vehicle crashes (trauma due to  steering wheel, seat belt), falls, and bicycle crashes (trauma due to handlebars) are the most common causes of blunt chest trauma. PATHOPHYSIOLOGY Injuries to the chest are often life-threatening and result in one or more of the following pathologic mechanisms: Hypoxemia from disruption of the airway; injury to the lung parenchyma, rib cage, and respiratory musculature; massive hemorrhage; collapsed lung; and pneumothorax Hypovolemia from massive fluid loss from the great vessels, cardiac rupture, or hemothorax Cardiac failure from cardiac tamponade, cardiac contusion, or increased intrathoracic pressure These mechanisms frequently result in impaired ventilation and perfusion leading to ARF, hypovolemic shock, and death. Time is critical in treating chest trauma. Therefore, it is essential to assess the patient immediately to determine the following: ❖ When the injury occurred ❖ Mechanism of injury ❖ Level of responsiveness ❖ Specific injuries ❖ Estimated blood loss ❖ Recent drug or alcohol use ❖ Pre hospital treatment INITIAL ASSESSMENT includes: ❖ Airway obstruction ❖ Tension pneumothorax ❖ Open pneumothorax ❖ Massive hemothorax ❖ Flail chest ❖ Cardiac tamponade SECONDARY ASSESSMENT would include: ✔ simple pneumothorax ✔ hemothorax ✔ pulmonary contusion ✔ traumatic aortic rupture ✔ tracheobronchial disruption ✔ esophageal perforation ✔ traumatic diaphragmatic injury ✔ penetrating wounds to the mediastinum ASSESSMENT Inspection of the airway, thorax, neck veins, and breathing difficulty. ✔ Assessing the rate and depth of breathing for abnormalities, such as stridor, cyanosis, nasal flaring, use of accessory muscles, drooling, and overt trauma to the face, mouth, or neck The chest should be assessed for: ✔ symmetric movement, ✔ symmetry of breath sounds, ✔ open chest wounds, ✔ entrance or exit wounds, ✔ impaled objects, tracheal shift, ✔ distended neck veins, ✔ subcutaneous emphysema, ✔ paradoxical chest wall motion. ASSESSMENT The chest wall should be assessed for: ✔ Bruising ✔ Petechiae ✔ Lacerations ✔ Burns The vital signs and skin color are assessed for signs of shock. The thorax is palpated for tenderness and crepitus; the position of the trachea is also assessed. DIAGNOSTIC TEST The initial diagnostic workup includes: ✔ Chest x-ray ✔ CT scan ✔ Complete blood count ✔ Clotting studies ✔ Type and cross-match ✔ Electrolytes ✔ Oxygen saturation ✔ Arterial blood gas analysis ✔ ECG  MEDICAL MANAGEMENT ▪ The goals of treatment are to evaluate the patient’s condition and to initiate intubation and ventilatory support. aggressive resuscitation. ▪ Re-establishing fluid volume and ▪ An airway is immediately established negative intrapleural pressure and with oxygen support and, in some cases, draining intrapleural fluid and blood are  Strategies to restore and maintain ▪ occluding any opening into the chest cardiopulmonary function: (open pneumothorax), ▪ include ensuring an adequate airway ▪ draining or removing any air or fluid and ventilation, from the thorax to relieve pneumothorax, ▪ stabilizing and re-establishing chest hemothorax, or cardiac tamponade. wall integrity, essential.  https://youtu.be/5Mh_w0JP1Rc https://youtu.be/FI8TnsQkQG8 https://youtu.be/R0to_qtq2Ks STERNAL AND RIB FRACTURES  Sternal fractures are most common in motor vehicle crashes with a direct blow to the sternum via the steering wheel and are most common in women, patients over age 50, and those using shoulder restraints. RIB FRACTURE Rib fractures are the most common type of chest trauma. Fractures of the first three ribs are rare  but can result in a high mortality rate because they are associated with laceration of the subclavian artery or 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 the rib CLINICAL MANIFESTATION  STERNAL FRACTURE RIB FRACTURE ✔ Anterior chest pain ✔ Overlying tenderness, ✔ Ecchymosis, ✔ Crepitus, ✔ Swelling, ✔ Potential of a chest wall deformity ✔ Severe pain, ✔ Point tenderness,  ✔ Muscle spasm over the movement area of the fracture, ✔ The area which is aggravated by Around the fracture may be coughing, deep bruised. breathing, and ASSESSMENT AND DIAGNOSTIC FINDINGS ASSESSMENT A crackling, grating sound in the thorax (subcutaneous crepitus) may be detected Closely evaluated for with auscultation. underlying cardiac DIAGNOSTIC TEST injuries  ECG Chest x-ray Continuous pulse oximetry Rib films of a specific area Arterial blood gas analysis  Medical management of the patient with a sternal fracture is directed toward controlling pain, avoiding excessive activity, and treating any associated injuries. Surgical fixation is rarely necessary unless fragments are grossly displaced and pose a potential for further injury In most cases, a broken sternum will heal on its own. It can take 3 months or longer for the pain to go away.  Sedation is used to relieve pain and to allow deep breathing and coughing. Care must be taken to avoid over sedation and suppression of the respiratory drive. Alternative strategies to relieve pain include an intercostal nerve block and ice over the fracture site; a chest binder may decrease pain on movement. Usually the pain abates in 5 to 7 days, and discomfort can be controlled with epidural analgesia, patient-controlled analgesia, or non opioid analgesia. Most rib fractures heal in 3 to 6 weeks. https://youtu.be/5QiQj8cBsAA CHEST https://youtu.be/RcPSK1Okbls FLAIL 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 (multiple contiguous ribs) are fractured at two or more sites, resulting in free-floating rib segments. It may also result as a combination fracture of ribs and costal cartilages or sternum As a result, the chest wall loses stability and there is subsequent respiratory impairment and usually severe respiratory distress. PATHOPHYSIOLOGY During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled 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 patient’s ability to exhale. The mediastinum then shifts back to the affected side PATHOPHYSIOLOGY  This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance. The patient has hypoxemia, and if gas exchange is greatly compromised, respiratory acidosis develops as a result of CO2 retention. Hypotension, inadequate tissue perfusion, and metabolic acidosis often follow as the paradoxical motion of the mediastinum decreases cardiac output. MEDICAL MANAGEMENT Treatment of flail chest is usually supportive. Management includes: ❖ Providing ventilatory support ❖ Clearing secretions from the lungs ❖ Controlling pain If only a small segment of the chest is involved, the objectives are to clear the airway through: ❖ Positioning ❖ Coughing ❖ Deep breathing ❖ Suctioning ❖ Relieve pain MEDICAL MANAGEMENT MILD / MODERATE SEVERE ✔ Monitoring fluid intake performed ✔ Appropriate fluid ✔ Monitored for further replacement respiratory compromise. ✔ Relieving chest pain Endotracheal intubation and mechanical ventilation are required. ✔ Pulmonary physiotherapy are  Surgery may be required to more quickly stabilize the flail segment. This may be used in the patient who is difficult to ventilate or the high-risk patient with underlying lung disease who may be difficult to wean from mechanical ventilation. Regardless of the type of treatment, the patient is carefully monitored by serial chest x-rays, arterial blood gas analysis, pulse oximetry, and bedside pulmonary function monitoring. Pain management is key to successful treatment.  PULMONARY CONTUSION PULMONARY  CONTUSION It is defined as damage to the lung tissues resulting in hemorrhage and localized edema. It is associated with chest trauma when there is rapid compression and decompression to the chest wall (i.e., blunt trauma). It may not be evident initially on examination but will develop in the posttraumatic period. https://youtu.be/wv8aoJP-q98 The primary pathologic defect is an abnormal accumulation of fluid in the interstitial and intra-alveolar spaces. It is thought that injury to the lung parenchyma 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 (from cellular response to injury) enter the lung and accumulate in the bronchioles and alveolar surface, where they interfere with gas exchange. An increase in pulmonary vascular resistance and pulmonary artery pressure occurs. The patient has hypoxemia and carbon dioxide retention. CLINICAL MANIFESTATION Pulmonary contusion may be mild, moderate, or severe.  The clinical manifestations vary from :. MILD / MODERATE SEVERE ✔ tachycardia ✔ tachypnea ✔ crackles ✔ tachycardia ✔ frank bleeding ✔ pleuritic chest pain ✔ severe hypoxemia ✔ hypoxemia ✔ respiratory acidosis ✔ blood-tinged secretions ✔ the signs and symptoms of ARDS ✔ The patient with moderate pulmonary contusion has a large amount of mucus, Changes in sensorium, including increased serum, and frank blood in the agitation or combative irrational behavior, may tracheobronchial tree be signs of hypoxemia. ✔ more severe tachypnea ASSESSMENT AND DIAGNOSTIC  FINDINGS The efficiency of gas exchange is determined by pulse oximetry and arterial blood gas measurements. Pulse oximetry is also used to measure oxygen saturation continuously. The chest x-ray may show pulmonary infiltration. The initial chest x-ray may show no changes; in fact, changes may not appear for 1 or 2 days after the injury MANAGEMENT: MILD PULMONARY CONTUSION Maintaining the airway Providing adequate oxygenation - supplemental oxygen is usually given by mask or cannula for 24 to 36 hours Controlling pain - managed by intercostal nerve blocks or by opioids via patient-controlled analgesia Intravenous fluids and oral intake Volume expansion techniques, postural drainage, physiotherapy including coughing, and endotracheal suctioning Antimicrobial therapy MEDICAL MANAGEMENT:  MODERATE PULMONARY CONTUSION Bronchoscopy to remove secretions; Intubation and mechanical ventilation with PEEP Diuretics. Nasogastric tube insertion MEDICAL MANAGEMENT:  MODERATE PULMONARY CONTUSION Bronchoscopy to remove secretions; Intubation and mechanical ventilation with PEEP Diuretics. Nasogastric tube insertion MEDICAL MANAGEMENT:  SEVERE PULMONARY CONTUSION Endotracheal intubation and ventilatory support, Diuretics Fluid restriction Colloids and crystalloid solutions Antimicrobial medications PENETRATING CHEST TRAUMA Gunshot and stab wounds are the most common types of penetrating chest trauma  Foreign object impales or passes through the body tissues, creating an open wound PENETRATING CHEST TRAUMA GUNSHOT AND STAB WOUNDS STAB WOUNDS GUNSHOT WOUNDS ✔ Low velocity with severe and continuing hemorrhage, ✔ Knives and switchblades cause most can occur from any small wound, even one stab wounds. caused by a small-diameter instrument ✔ The appearance of the external wound such as an ice pick may be very deceptive, because ✔ May be classified as of low, medium, pneumothorax, hemothorax, lung or high velocity. contusion, and cardiac tamponade, along ✔ A bullet can cause damage at the site of penetration and along its pathway. ✔ ✔ If the diaphragm is involved in either It also may ricochet off bony structures a gunshot wound or a stab wound, and damage the chest organs and great injury to the chest cavity must be vessels. considered  CHEST X-RAY CHEMISTRY PROFILE ARTERIAL BLOOD GAS ANALYSIS PULSE OXIMETRY ECG CBC BLOOD TYPING CROSS-MATCHING CT SCAN OF THE CHEST FLAT PLATE X-RAY OF THE ABDOMEN Objective of immediate management is to restore and maintain cardiopulmonary function. ✔ Adequate airway and ventilation ✔ Examine for shock and intrathoracic and intra-abdominal injuries. ✔ Undressed the patient completely ✔ IV therapy with colloids, crystalloids and blood ✔ Insert indwelling catheter ✔ Insert NGT ✔ Insert chest tube ✔ If the patient has a penetrating wound of the heart and great vessels, the esophagus, or the tracheobronchial tree, surgical intervention is required PNEUMOTHORAX https://youtu.be/DgU1HE_6ueI https://youtu.be/4rbE6irzlW8 ➔ Occurs when the parietal or visceral pleura is breached and the pleural space is exposed to positive atmospheric pressure. ➔ Normally the pressure in the pleural space is negative or subatmospheric compared to atmospheric pressure; this negative pressure is required to maintain lung inflation. ➔ When either pleura is breached, air enters the pleural space, and the lung or a portion of it collapses.  emphysema. Types of TRAUMATIC PNEUMOTHORAX PNEUMOTHORAX ➔ Occurs when air escapes from a laceration in the lung itself and enters SIMPLE PNEUMOTHORAX the pleural space or enters the pleural space through a wound in the chest ➔ A simple, or spontaneous, wall. pneumothorax occurs when air ➔ Blunt trauma,penetrating chest trauma enters the pleural space through a or even abdominal trauma breach of either the parietal or ➔ Traumatic pneumothorax may occur visceral pleura. with invasive thoracic procedures (ie, ➔ Most commonly this occurs as air thoracentesis) enters the pleural space through the ➔ Hemothorax - collection of blood in the rupture of a bleb or a pleural space resulting from torn bronchopleural fistula. intercostal vessels, lacerations of the ➔ It may be associated with diffuse great vessels, and lacerations of the interstitial lung disease and severe lungs  OTHER TYPES OF PNEUMOTHORAX HEMOTHORAX CHYLOTHORAX ▣ is an accumulation of blood in  the pleural space from injury to hemothorax needs immediate the chest wall, diaphragm, lung, insertion of a chest tube for blood vessels, or mediastinum. ▣ evacuation of the blood. When it occurs with ✔ is the presence of lymphatic pneumothorax, it is called a fluid in the pleural space. ✔ hemopneumothorax. thoracic duct is disrupted either ▣ The patient with a traumatic traumatically or from cancer,  ✔ allowing lymphatic fluid to fill the pleural space. CLINICAL MANIFESTATIONS The signs and symptoms associated with pneumothorax depend on its If the pneumothorax is large and the size and cause. lung collapses totally: Severe chest pain may occur, accompanied by tachypnea Acute respiratory distress Anxious Dyspnea Air hunger Increased use of the accessory muscles May develop central cyanosis from severe hypoxemia  uncomplicated pneumothorax: Minimal respiratory distress Slight chest discomfort Tachypnea decreased movement of the affected side of the thorax a tympanic sound on percussion of the chest wall decreased or absent breath sounds and tactile fremitus on the affected side. For small simple or MEDICAL MANAGEMENT ★ A small chest tube (28 French) is inserted near the second intercostal space ★ If with hemothorax, a large-diameter chest tube (32 French or greater) is inserted, usually in the fourth or fifth intercostal space at the midaxillary line. ★ Autotransfusion ★ Chest tube connected to water-seal drainage ★ Antibiotics https://youtu.be/rhN_QgKvTkE The goal of treatment is to evacuate the air or blood from the pleural space https://youtu.be/WR7S-yQKvIY TENSION  PNEUMOTHORAX ➔ Occurs when air is drawn into the pleural space from a lacerated lung or through a small hole in the chest wall ➔ Causes the lung to collapse and the heart ➔ Increased intrathoracic pressure decreases venous return to the heart, causing decreased cardiac output and impairment of peripheral circulation ➔ PEA (Pulseless Electrical Activity) CLINICAL MANIFESTATION ★ air hunger ➔ High concentration of supplemental oxygen ★ agitation ➔ In emergency situation, inserting a ★ increasing large-bore needle (14-gauge) at the hypoxemia ★ central second intercostal space, midclavicular line on the affected cyanosis side. ★ Hypotension ➔ A chest tube is then inserted and connected to suction to remove the ★ Tachycardia remaining air and fluid, re-establish ★ profuse diaphoresis the negative pressure, and re MEDICAL MANAGEMENT expand the lung. CARDIAC TAMPONADE https://youtu.be/zFxYDVfFouQ ❖ Cardiac tamponade is a rapid, unchecked increase in pressure in the pericardial sac. ❖ The increased pressure compresses the heart, impairs diastolic filling, and reduces cardiac output. ❖ The increase in pressure usually results from blood or fluid accumulation in the pericardial sac. ❖ Even a small amount of fluid (50 to 100 mL) can cause a serious tamponade if it accumulates rapidly CARDIAC TAMPONADE CAUSES  Viralor post irradiation pericarditis Acute MI Chronic renal failure requiring dialysis Connective tissue disorders Effusion Hemorrhage due to nontraumatic causes Hemorrhage due to trauma Idiopathic causes (such as Dressler syndrome) Drug reaction from procainamide, hydralazine, minoxidil (rogaine), isoniazid, penicillin, or daunorubicin (daunoxome). PATHOPHYSIOLOGY ASSESSMENT accumulation of fluid in In cardiac tamponade, the pericardial sac causes  compression of the heart chambers. The compression obstructs blood flow into the ventricles and reduces the amount of blood that can be pumped out of the heart with each contraction. Three (3))classic features known as the Beck triad:  diaphoresis elevated CVP with jugular vein orthopnea distention muffled heart sounds decreased arterial pressure pulsus paradoxus decreased systolic blood pressure Other signs include: restlessness narrow pulse pressure tachycardia anxiety weak, thready pulse. cold, clammy skin cyanosis  Chest X-ray shows a slightly widened mediastinum and an enlarged cardiac silhouette. ECG may show a low-amplitude QRS complex and electrical alternans or an alternating beat-to beat change in amplitude of the P wave, QRS complex, and T wave. Generalized ST segment elevation is noted in all leads. Echocardiography may reveal pericardial effusion with signs of right ventricular and atrial compression. CT scan or MRI may be used to identify pericardial effusions or pericardial thickening caused by constrictive pericarditis. MEDICAL / SURGICAL TREATMENT The goal of treatment is to relieve intrapericardial pressure and cardiac compression by removing accumulated blood or fluid, which can be done in three different ways: 1. Pericardiocentesis (needle aspiration of the pericardial cavity) 2. Insertion of a drain into the pericardial sac to drain the effusion 3. Surgical creation of an opening called a pericardial window HYPOTENSIVE PATIENT: ✔ Trial volume loading with crystalloids ✔ Inotropic drugs Additional treatment may be necessary, depending on the cause. Examples of such causes and treatments are: heparin-induced tamponade—administration of the heparin antagonist protamine sulfate traumatic injury—blood transfusion or a thoracotomy to drain reaccumulating fluid or repair bleeding sites warfarin-induced tamponade—vitamin K administration. Monitor the patient’s cardiovascular status frequently, at least every hour, noting the extent of jugular vein distention, quality of heart sounds, and blood pressure. Assess hemodynamic status, including CVP, right atrial pressure and determine cardiac output. Monitor for pulsus paradoxus. Be alert for ST segment and T wave changes on the ECG. Note rate and rhythm, and report evidence of arrhythmias. NURSING RESPONSIBILITY  Watch closely for signs of increasing tamponade, increasing dyspnea, and arrhythmias; report them immediately. Infuse IV solutions and inotropic drugs, such as dopamine, as ordered to maintain the patient’s blood pressure. Administer oxygen therapy as needed and assess oxygen saturation levels. Monitor the patient’s respiratory status for signs of respiratory distress, such as severe tachypnea and changes in the patient’s LOC. Anticipate the need for ET intubation and mechanical ventilation if the patient’s respiratory status deteriorates. Prepare the patient for pericardiocentesis or thoracotomy. NURSING RESPONSIBILITY  If the patient has trauma-induced including the use of colloids, crystalloids, and tamponade, assess for other signs of blood component therapy trauma and institute appropriate care, Assess renal function status closely, monitoring urine output every hour and notifying the practitioner if output is less than 0.5 mg/kg/hour. Monitor capillary refill time, LOC, peripheral pulses, and skin temperature for evidence of diminished tissue perfusion. Anticipate transfer of the patient to a CCU when appropriate. https://youtu.be/4VCBrwUyLqQ https://youtu.be/qe-WYYJpBmI THANK YOU! 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