Chest Trauma Is it considered a medical emergency? & life threatening?
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Chest Trauma
Is it considered a medical emergency?
& life threatening?
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Chest Trauma
� Precisely, because the chest houses the heart,
the lungs, & great vessels
� Therefore
chest trauma frequently produces life-
threatening disruptions of cardiopulmonaryfunction.
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Chest Traumas
Causes:
� Falls
� Use of machinery� Employment of lethal weapons
� Motor vehicle crashes
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Chest Traumas
Classifications:
� Penetrating Chest Injury
»Non-Penetrating Chest Injury
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Penetrating Chest Traumas
-involves break in the skin, chest wall, &
pleural cavity
-often result from bullets, knives, impaled
objects, or flying shrapnel or splinters.
-may cause an open chest wound,
disrupting the normal ventilation mechanism.
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Penetrating Chest Traumas
may seriously damage the lungs,heart & other thoracic structures
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Non-Penetrating Chest Injury
-AKA Blunt Injuries
-are not as obvious as penetratingwounds & may, therefore, be more difficult to
diagnose.
-most commonly are deceleration
injuries associated w/ motor vehicle crashes
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Assessment of & Therapeutic
Intervention for the Chest Trauma Victim
Maintain
Airway,
Breathing,
& Circulation!
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Obtain a quick history
� What happened?
� What was the mechanism of injury?
� How long ago did it happen?
� Where is the pain? Does it radiate?
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Obtain a quick history
� Is there anything that makes the pain better orworse?
� What does the pain feel like?
� How severe is the pain on scale of 1-10?
� Is there any medical history?
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Perform a quick (1-minute) evaluation
� for SOB & cyanosis
� VS
� skin color & temperature� wound size & location
� for paradoxical chest movement
� distended neck veins
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Perform a quick (1-minute) evaluation
� Listen for respiratory stridor.
� Listen for breath sounds.
� Look for epigastric & supravicular indrawing.� Give rough estimate of tidal volume.
� for tracheal deviation.
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Perform a quick (1-minute) evaluation
� Assess intercostal muscle use.
� Assess accessory muscle use.
� Check for subcutaneous emphysema.� Look & listen for sucking chest sounds.
� Listen to heart sounds.
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Provide Therapeutic Intervention
� Maintain airway
� Ensure adequate air movement
� Administer O2� Cover any chest wound
� Control flail segment
� Insert needles or chest tube into anteriorchest wall if tension Pneumothorax is present
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Provide Therapeutic Intervention
� Initiate IV line
� Do pericardiocentesis, if indicated.� Get CXR
� Frequently recheck VS
� Monitor for dysrhythmias
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Complications
� Pneumothorax
� Tension pneumothorax & mediastinal shift
� Open pneumothorax & mediastinal flutter� Hemothorax
� Fractured ribs
� Fractured sternum� Flail chest
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Pneumothorax
� Presence of air or gas in the pleural space,
causing a lung to collapse.
� Occurs when the parietal or visceral pleura is
breached & the pleural space is exposed to
positive atmospheric pressure
Pneumothorax Pneumothorax
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What are the possible causes?
± Open chest wound
±
Rupture of an emphysematous vesicle ± Severe bout of coughing
Pneumothorax Pneumothorax
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Types of Pneumothorax
� Tension Pneumothorax
»Open Pneumothorax
Pneumothorax Pneumothorax
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Tension Pneumothorax
� Air that enters the pleural space w/ each
inspiration, becomes trapped, & is not
expelled during expiration (one-way valve
effect).
� Most commonly occurs w/ blunt traumatic
injuries
Pneumothorax Pneumothorax
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Air enters the pleural space during inspiration
Air Trapped
Air is not expelled during expiration
Air pressure build-up in the pleural space
Lung collapse
Mediastinal shift
heart lung great vessels trachealCompression compression compression deviation
Cardiac insufficiency respiratory collapse
Pneumothorax Pneumothorax
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Great vessel compression
Impairment of blood return in the heart
Decrease in CO & BP
Pneumothorax Pneumothorax
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Tracheal deviation
Airway obstruction
Pneumothorax Pneumothorax
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Clinical Manifestations
� Marked, severe dyspnea
� Tachypnea� Crepitus
� Progressive cyanosis
� Acute pleuritic chest pain� Hyperresonance (on percussion)
Pneumothorax Pneumothorax
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Clinical Manifestations
� Tachycardia
� Assymetric chest wall movement� Diminished or absent breath sounds (on
affected side)
� Extreme restlessness/agitation
Pneumothorax Pneumothorax
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Clinical Manifestations
(Other)
� Neck vein distention
� Laryngealt/ tracheal deviation� Feeling of tightness/pressure w/n the chest
� PMI shift laterally/ medially
� Severe hypotension
Pneumothorax Pneumothorax
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Diagnostic Exams
� X-ray study
� ABGs
Pneumothorax Pneumothorax
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Medical Management
� *Immediate intervention is to convert tension
pneumothorax into open pneumothorax
�
Prompt thoracenteis� Insertion of water-seal drainage system (CTT)
Pneumothorax Pneumothorax
!Nursing Alert
Relief of tension pneumothorax is considered an emergency
measure
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Nursing interventions
Restore/promote adequate respiratory function.
� Give supplementary O2
� Assist with thoracentesis and provide appropriate
nursing care.
� b. Assist with insertion of a chest tube to water-
seal drainage and provide appropriate nursing care.
� c. Continuously evaluate respiratory patterns andreport any changes.
Pneumothorax Pneumothorax
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Nursing interventions
3. Provide relief/control of pain.
� a. Administer narcotics/analgesics/sedatives
as ordered and monitor effects.� b. Position client in high-Fowler¶s position.
Pneumothorax Pneumothorax
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Open Pneumothorax
� Occurs w/ sucking chest wound/ penetrating
chest trauma
� A traumatic opening in the chest wall is large
enough for air to move freely in & out of the
chest cavity during ventilation
Pneumothorax Pneumothorax
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Penetrating chest trauma
Opening on the pleura
Air move freely in & out the chest cavity
Mediastinal flutter
Fluttering back-&-forth of the mediastinal structures &
collapsed lung w/ each inspiration & expiration
Severe cardiopulmonary embarassment
Pneumothorax Pneumothorax
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Management
� Immediately cover the wound w/ anything
available. (Ideally: sterile gauze petrolatum
dressing)
� Ask to perform valsavas maneuver
� Assess carefully for presence of tension
pneumothorax & mediastinal shift.
Pneumothorax Pneumothorax
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Management
� Provide supplemental O2
� Prompt thoracentesis
� Insertion of water-seal drainage system (CTT)
Pneumothorax Pneumothorax
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Hemothorax
� An accumulation of blood & fluid in the
pleural cavity, usually the result of trauma
� Also may be caused by the rupture of small
blood vessels that results from inflammation.
HemothoraxHemothorax
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Diagnostic Exam/s
� CXR
HemothoraxHemothorax
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Management
� Aspiration of blood in the pleural space
(thoracentesis )
�
Insertion of water-seal drainage system (CTT)� Thoracotomy (if there is a large amount of
drainage *200ml or more per hour)
� Provide supplemental O2
� WOF development of hypovolemic shock
HemothoraxHemothorax
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Flail Chest
� Consists of fractures of two or more adjacent
ribs (multiple-contiguous ribs) are fractured at
two or more sites, resulting in free-floating rib
segments.
� Frequently, a complication of blunt chest
trauma/
Flail Chest Flail Chest
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Blunt chest trauma
Rib fracture
Tearing of the pleura flail segment
& lung surface
paradoxical movement of the thorax
Hemopneumothorax
dead space compliance chest pain
Hypoxemia hypoventilation
Respiratory Acidosis Flail Chest Flail Chest
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Diagnostic Exams
� CXR
� ABG Analysis
� Pulse Oxymetry� Pulmonary Fxn Monitoring
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Assessment findings
1. Severe dyspnea; rapid, shallow, grunty breathing;paradoxical chest motion. The chest will move
INWARDS on inhalation and OUTWARDS on
exhalation.
2. Cyanosis, possible neck vein distension, tachycardia,hypotension
3. Excruciating Pain
4. Diagnostic tests reveals
±a. PO2 decreased
± b. pCO2 elevated
± c. pH decreased
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Management
it includes:
� Providing ventilatory support
- endotracheal intubation
-mechanical ventilationPurposes:
-restore adequate ventilation
-paradoxical motion thru the use of +pressure to
stabilize chest wall internally-relieve pain by decreasing movement of the fxd ribs
-provide an avenue for secretion removal
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Management
� Pain Management thru¶ Drug therapy
-narcotics
-sedatives
-muscle relaxants/musculoskeletal
paralyzing agents (pancuronium bromide)
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Nursing interventions
1. Maintain an open airway: suction secretions,blood from nose, throat, mouth, and viaendotracheal tube; note changes in amount,
color, and characteristics.2. Monitor mechanical ventilation
3. Encourage turning, coughing, and deep
breathing.4. Monitor for signs of shock: HYPOTENSION,
TACHYCARDIA
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Pleural Effusion
� Defined broadly as a collection of fluid in the pleural
space
� A symptom, not a disease; may be produced by
numerous conditions:
Complication of heart failure
TB, Pneumonia, pulmonary infectionsNephrotic syndrome
Neoplastic tumors (bronchogenic ca)
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General Classification
� Transudative effusion
� Exudative effusion
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Transudative effusion
-are substances that have passed thru
a membrane or tissue surface
-occur w/ conditions w/ CHON loss &low CHON content (cirrhosis,
nephrosis)
-also referred as hydrothorax
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Exudative effusion
� Substances that have escaped from
blood vessels.
� They contain an accumulation of cells,have high specific gravity, high LDH
� May occur in response to malignancies,
infections, or inflammatory processes.
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Assessment findings
� 1. Dyspnea, dullness over affected area upon
percussion, absent or decreased breath
sounds over affected area, pleural pain, dry
cough, pleural friction rub
� 2. Pallor, fatigue, fever, and night sweats
(with empyema)
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Diagnostic tests
� a. Chest x-ray positive if greater than 250cc pleural fluid
� b. Pleural biopsy may reveal bronchogeniccarcinoma
� c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or
tuberculosis; positive for specific organismin empyema.
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Nursing interventions: In general:
� 1. Assist with repeated thoracentesis.
� 2. Administer narcotics/sedatives as ordered to
decrease pain.
� 3. Assist with instillation of medication into pleuralspace (reposition client every 15 minutes to
distribute the drug within the pleurae).`Pleurodesis
� 4. Place client in high-Fowler¶s position to promote
ventilation.
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Medical management
1. Identification and treatment of the Underlyingcause
2. Thoracentesis
� 3. Drug therapy ± a. Antibiotics: either systemic or inserted directly into
pleural space
± b. Fibrinolytic enzymes: trypsin, streptokinase-.streptodornase to decrease thickness of pus and dissolvefibrin clots
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Medical management
4.pleurectomy (pleural stripping)
5. pleurodesis- installation of sclerosing
substance(unbuffered tetracycline, nitrogen
mustard, & talc.) into the pleural space.
6. Closed chest drainage
7. Surgery: open drainage
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Treatment Modalities
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Chest Tubes
Definition
1. Use of tubes and suction to return negative pressure
to the intrapleural space; a water seal maintains a
closed system2. To drain air from the intrapleural space, the chest
tube is placed in the second or third intercostal
space; to drain blood or fluid, the catheter would be
placed at a lower site, usually the eighth or ninth
intercostal space
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Chest Tubes: Purposes
� Foster & permit the drainage of air & orserosanuineous fluid form the pleural space &to prevent their reflux
� Help reexpand the the lung tissue byreestablishing normal negative pressure in thepleural space
� Prevent mediastinal shift & lung tissuecollapse by equalizing pressures on both sidesof the thoracic cavity
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Types of drainage systems
1. One, Two, Three-chamber system: includes onechamber that serves to collect drainage, one thatacts as a water-seal, and one that has levels of waterto control the amount of suction regardless of theamount of negative pressure applied
2. Commercially prepared plastic unit designed forclosed chest suction: combines the features of theother systems and may or may not be attached to
suction (e.g., PleurEvac)
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Nursing care
1. Ensure that the tubing is not kinked; tape allconnections to prevent separation
2. Gently milk the tubing, if ordered, in the direction of the drainage system to maintain patency; milking can
cause a pneumothorax3. Maintain the drainage system below the level of the
chest; mark and monitor drainage
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Nursing care
4. Turn the client frequently, making sure thechest tubes are not compressed
5. Report drainage on dressing immediately,
because this is not a normal occurrence6. Observe for fluctuation of fluid in tube; the
level will rise on inhalation and fall onexhalation; if there are no fluctuations, either
the lung has expanded fully or the chest tubeis clogged
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Nursing care
� 7. Palpate the area around the chest tube insertion sitefor subcutaneous emphysema or crepitus, whichindicates that air is leaking into the subcutaneous tissue
�
8. Situate the drainage system to avoid breakage
� 9. Place two clamps at the bedside for use if theunderwater-seal bottle is broken; clamp the chest tubeimmediately to prevent air from entering the
intrapleural space, which would cause pneumothoraxto occur or extend; clamps are used judiciously andonly in emergency situations
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Nursing care
10. Encourage coughing and deep breathing every 2 hours,splinting the area as needed
11. After lung reexpansion is verified by chest x-ray, instruct theclient to exhale or strain (Valsalva's maneuver) as the tube is
withdrawn by the physician; apply a gauze dressingimmediately and firmly secure with tape to make an airtightdressing
12. Encourage movement of the arm on the affected side
13. Evaluate client's response to procedure; length of time for
lung expansion depends on etiology
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Thoracentecis
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Thoracentecis
� Invasive procedure that entails the insertion of otrocar into the pleural space for removal of fluid orair
� Done for both diagnostic & therapeutic purposes.
±Therapeutically, it is done to relieve pain, DOB, & other sxof pleural pressure.
± Diagnostically, performed whenever pleural effusion of unknown etiology is recognized
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Thoracentecis
� The pleural fluid is evaluated for gross
appearance; CHON; LDH; glucose; Gram stain
& bacteriologic cultures; M. Tuberculosis &
fungus; cytology; CEA levels;
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Contraindications
� Patients w/ significant
thrombocytopenia
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Potential Complications
� Pneumothorax
� Interpleural Bleeding
�
Hemoptysis� Reflex bradycardia & HPN
� Pulmonary Edema
� Seeding of the needle tract w/ tumor� Subcutaneous Emphysema
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Thoracentecis
� No more than 1000 ml of fluid should beremoved at a time; fluid withdrawn should besent to the laboratory for culture andsensitivity tests
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Procedure & Patient Care
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Patient Care: Before
� Explain procedure to the client
� Obtain an informed consent
� Ensure that chest x-ray examination is donebefore and after the procedure
� Inform the patient that movement orcoughing should be minimized
� Administer coughed suppressant before theprocedure in occureence of troublesomecough
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Patient Care: During
� The patient is usually placed in an upright
position w/ the arms & shoulders raised &
supported on an padded overhead table.
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Position
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Patient Care: During
� Pts. Who cannot sit upright are placed in a
sidelying position on the unaffected side w/
the to be tapped uppermost.
� It is performed under strict sterile technique
� The needle insertion site is aseptically
cleansed & anesthetized locally.
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Patient Care: During
� Also, large volumes of fluid may be collected
by connecting the catheter to a gravity-
drainage system
� Monitor the patients pulse for reflex
bradycardia, & evaluate the pt. for diaphoresis
& the feeling of faintness during the
procedure.
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Patient Care: After
� Place a small bandage over the needle site.
� Place the client on opposite side for
approximately 1 hour to prevent leakage of
fluid through the thoracentesis site
� After the procedure, label and send specimens
for laboratory tests
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Patient Care: After
� Note and record the amount, color, and clarity
of the fluid withdrawn
� Observe the client for coughing, bloody
sputum, and rapid pulse rate and report their
occurrence immediately
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Patient Care: After
� Obtain CXR study as indicated to check for the
complication of pneumothorax
� Evaluate the patient for s/sx of pneumothroax,
tension pneumothorax, SQ emphysema, &
pyogenic infection
� If pt. has no complaints of DOB, normal acts.
Can be resumed after 1 hr.