BS-CT

8/3/2019 BS-CT

1/101

8/3/2019 BS-CT

2/101

WHAT IS IT?WHAT IS IT?

Chest trauma is often suddenChest trauma is often sudden

and dramaticand dramatic

Accounts for 25% of allAccounts for 25% of alltrauma deathstrauma deaths

2/3 of deaths occur after2/3 of deaths occur after

reaching hospitalreaching hospital

8/3/2019 BS-CT

3/101

WHY DO IT OCCUR?WHY DO IT OCCUR?

Blunt TraumaBlunt Trauma-- Blunt force to chest. E.g.Blunt force to chest. E.g.automobile crashes and falls.automobile crashes and falls.

Penetrating TraumaPenetrating Trauma-- Projectile thatProjectile thatenters chest causing small or large hole.enters chest causing small or large hole.E.g. gun shot and stabbing.E.g. gun shot and stabbing.

Compression InjuryCompression Injury-- Chest is caughtChest is caughtbetween two objects and chest isbetween two objects and chest iscom ressed.com ressed.

8/3/2019 BS-CT

4/101

Chest traumaChest trauma

BLUNT TRAUMABLUNT TRAUMA

Blunt trauma is common than penetratingBlunt trauma is common than penetrating

traumatraumaCausesCauses--

Motor vehicle crashes (steeringMotor vehicle crashes (steering wheel,seatwheel,seat

belt),belt),Falls ,bicycle crash(handle bar)Falls ,bicycle crash(handle bar)

8/3/2019 BS-CT

5/101

AccelerationAcceleration moving object hitting the chest ormoving object hitting the chest orpatient thrown into an objectpatient thrown into an object

DecelerationDeceleration--sudden decrease in rate ofsudden decrease in rate ofspeed or vehicle as in motor vehicle crashspeed or vehicle as in motor vehicle crash

ShearingShearing--stretching forces to area of cheststretching forces to area of chestcausingcausing tear,rupturetear,rupture or dissectionsor dissections

CompressionCompression--direct blow to chest ,likedirect blow to chest ,likecrush injurycrush injury

8/3/2019 BS-CT

6/101

8/3/2019 BS-CT

7/101

assessmentassessment

AssessAssess

Time elapsedTime elapsed

Mechanism of injury

Mechanism of injury

Level of responsivenessLevel of responsiveness

Specific injuriesSpecific injuries

EstimatedEstimated boodbood lossloss

Recent drug or alcohol useRecent drug or alcohol use

PrehospitalPrehospital treatmenttreatment

8/3/2019 BS-CT

8/101

Initial assessmentInitial assessment

Airway obstructionAirway obstruction

TensionTension pnemothoraxpnemothorax

OpenOpen pneumothoraxpneumothorax Massive heMassive he

Flail chestFlail chest

CardiacCardiac tamponadetamponade

8/3/2019 BS-CT

9/101

Secondary assessmentSecondary assessment

SimpleSimple pnemothoraxpnemothorax

HemothoraxHemothorax

Pulmonary contusion

Pulmonary contusion

Traumatic thoracic ruptureTraumatic thoracic rupture

TracheobronchialTracheobronchial disruptiondisruption

Esophageal perforationEsophageal perforation

Trauma diaphragmatic injuryTrauma diaphragmatic injury

Penetrating wound toPenetrating wound to mediastinummediastinum

8/3/2019 BS-CT

10/101

Physical examinationPhysical examination

InspectionInspection

Airway,thorax,neckAirway,thorax,neck veins,breathingveins,breathing

difficultydifficulty Stridor,cyanosis,nasalStridor,cyanosis,nasal flaring,useflaring,use ofof

assessoryassessory muscles,droolingmuscles,drooling

Trauma toTrauma to face,mouthface,mouth or neckor neck ChestChest--symmetricalsymmetrical movement,breathmovement,breath

soundssounds symmetrical,opensymmetrical,open chestchestwound,entrancewound,entrance or exit woundor exit wound

8/3/2019 BS-CT

11/101

Tracheal shiftTracheal shift

Impaled objectImpaled object

Distended neck veinsDistended neck veins Subcutaneous emphysemaSubcutaneous emphysema

Paradoxical chest wall motionParadoxical chest wall motion

In additionIn addition

Brusing,petechiae,laceration,burnsBrusing,petechiae,laceration,burns

Vital sign and skinVital sign and skin colourcolour for sign of shockfor sign of shock

8/3/2019 BS-CT

12/101

PALPATIONPALPATION

TENDERNESS,CREPITUSTENDERNESS,CREPITUS

POSTION OF TRACHEAPOSTION OF TRACHEA

8/3/2019 BS-CT

13/101

DIAGNOSTIC MEASURESDIAGNOSTIC MEASURES

Chest xChest x--rayray

CT scanCT scan

CBCCBC

Clotting studiesClotting studies

Type andType and crossmatchingcrossmatching

Electrolytes, oxygen saturationElectrolytes, oxygen saturation

ABGABG ECGECG

AssocitedAssocited head & Abdominal injurieshead & Abdominal injuries

8/3/2019 BS-CT

14/101

Ongoing assessmentOngoing assessment

Response to treatmentResponse to treatment

Detect early sign of clinical deteriorationDetect early sign of clinical deterioration

8/3/2019 BS-CT

15/101

Medical managementMedical management

Patent airwayPatent airway OxygenOxygen Intubation & ventilatory supportIntubation & ventilatory support

reestablish fluid volume &reestablish fluid volume & --VE INTRAPLEURALVE INTRAPLEURALPRESSUREPRESSURE Restore cardiopulmonary functionRestore cardiopulmonary functionAdequate airway and ventilationAdequate airway and ventilation Reestablishing chest wall integrityReestablishing chest wall integrity Draining fluid or air to relieveDraining fluid or air to relieve

pneumothorax,hemothoraxpneumothorax,hemothorax or cardiacor cardiac tamponadetamponade CorrectCorrect hypovolemiahypovolemia ,low cardiac output,low cardiac output

8/3/2019 BS-CT

16/101

WHAT DOES IT DO?WHAT DOES IT DO?

Rib fracturesRib fractures


Pulmonary contusionPulmonary contusion

PneumothoraxPneumothorax

HaemothoraxHaemothorax

8/3/2019 BS-CT

17/101

Rib FractureRib FractureA rib fracture is a break in a rib bone.A rib fracture is a break in a rib bone.

Cause is blunt chest trauma (fall, blow to the chest,Cause is blunt chest trauma (fall, blow to the chest,etc).etc).

60% of blunt trauma60% of blunt trauma

SymptomsSymptoms Localized painLocalized pain

Tenderness over the fractured area on inspiration andTenderness over the fractured area on inspiration andpalpationpalpation

Shallow respirationShallow respiration atelectasisatelectasis & pneumonia& pneumonia

Pain when coughingPain when coughing

Swelling and bruising in the fracture areaSwelling and bruising in the fracture area

Internal bleedingInternal bleeding

PneumothoraxPneumothorax oror heamothoraxheamothorax

8/3/2019 BS-CT

18/101

8/3/2019 BS-CT

19/101

8/3/2019 BS-CT

20/101

8/3/2019 BS-CT

21/101

2121

Rib FractureRib Fracture

Most common chest wall injury fromMost common chest wall injury fromdirect traumadirect trauma

M

ore common in adults than childrenM

ore common in adults than children Especially common in elderlyEspecially common in elderly

Ribs form ringsRibs form rings

P

ossibility of break in two placesP

ossibility of break in two places Most commonly 5thMost commonly 5th -- 9th ribs9th ribs

Poor protectionPoor protection

8/3/2019 BS-CT

22/101

2222


Fractures of 1st and 2nd second requireFractures of 1st and 2nd second requirehigh forcehigh force

Frequently have injury to aorta or bronchiFrequently have injury to aorta or bronchiOccur in 90% of patients with tracheoOccur in 90% of patients with tracheo--

bronchial rupturebronchial rupture

May injure subclavian artery/veinMay injure subclavian artery/vein

May result in pneumothoraxMay result in pneumothorax

30% will die30% will die

8/3/2019 BS-CT

23/101

2323


Fractures of 10 to 12th ribs can causeFractures of 10 to 12th ribs can causedamage to underlying abdominal soliddamage to underlying abdominal solidorgans:organs:

LiverLiver

SpleenSpleen

KidneysKidneys

8/3/2019 BS-CT

24/101

2424


Assessment FindingsAssessment Findings Localized pain, tendernessLocalized pain, tenderness

Increases on palpation or when patient:Increases on palpation or when patient:

CoughsCoughsMovesMoves

Breathes deeplyBreathes deeply

Splinted RespirationsSplinted Respirations

Instability in chest wall, CrepitusInstability in chest wall, Crepitus

Deformity and discolorationDeformity and discoloration

Possible pneumo or hemothoraxPossible pneumo or hemothorax

8/3/2019 BS-CT

25/101

2525


ManagementManagementHigh concentration OHigh concentration O22 Positive pressure ventilation as neededPositive pressure ventilation as needed

Splint using pillow or swathesSplint using pillow or swathes Encourage pt to breath deeplyEncourage pt to breath deeply

NonNon--circumferential splintingcircumferential splinting

8/3/2019 BS-CT

26/101

8/3/2019 BS-CT

27/101

2727

Sternal FractureSternal Fracture

2525 -- 45% mortality due to associated45% mortality due to associatedtrauma:trauma:

Disruption of thoracic aortaDisruption of thoracic aorta

Tracheal or bronchial tearTracheal or bronchial tearDiaphragm ruptureDiaphragm rupture


Myocardial traumaMyocardial trauma High incidence of myocardial contusion,High incidence of myocardial contusion,

cardiac tamponade or pulmonary contusioncardiac tamponade or pulmonary contusion

8/3/2019 BS-CT

28/101

2828


Assessment FindingsAssessment Findings

Localized painLocalized pain

Tenderness over sternumTenderness over sternum

CrepitusCrepitus

Tachypnea, DyspneaTachypnea, Dyspnea

Hx/Mechanism of blunt chest traumaHx/Mechanism of blunt chest trauma

8/3/2019 BS-CT

29/101

2929


ManagementManagement Establish airwayEstablish airway

High concentration oxygenHigh concentration oxygen

Assist ventilations with BVM as neededAssist ventilations with BVM as needed IV NS/LRIV NS/LR

Restrict fluidsRestrict fluids

Emergent TransportEmergent Transport HospitalHospital

8/3/2019 BS-CT

30/101

FLIAL CHESTFLIAL CHEST

The breaking ofThe breaking of

2 or more ribs in2 or more ribs in2 or more2 or more

places, resultingplaces, resulting

in freein free-- floatingfloatingrib segments.rib segments.

8/3/2019 BS-CT

31/101

8/3/2019 BS-CT

32/101

PARADOXICALPARADOXICAL

MOVEMENTMOVEMENT

The flail portion ofthe chest is

sucked in with

inspiration, instead of

expanding outward

Ballooned out with

expiration instead of

collapsing inward

Hypoventilation and

hypoxemia

8/3/2019 BS-CT

33/101

8/3/2019 BS-CT

34/101

Complication:Complication:

HypoventilationHypoventilationAtelectasisAtelectasis

Mediastinal flutter (mediastinal structures tendMediastinal flutter (mediastinal structures tend

to swing back n forth)to swing back n forth)

Diagnosis:Diagnosis:

Palpation : crepitus and tenderness near

Palpation : crepitus and tenderness nearfractured ribs.fractured ribs.

chest xchest x--rayray

ABGsABGs

8/3/2019 BS-CT

35/101

Flail Chest - detail

8/3/2019 BS-CT

36/101

PULMONARY CONTUSIONPULMONARY CONTUSION It is damage to the lung tissues resulting inIt is damage to the lung tissues resulting in

hemorrhage and localized edema.hemorrhage and localized edema.

EcchymosisEcchymosis at thesite of the damageat thesite of the damage

CrackelsCrackels

Cough may be present with bloodCough may be present with blood--tingedtingedsputum.sputum.

Pulmonary contusions tend to worsen over a 24Pulmonary contusions tend to worsen over a 24

to 48to 48hour period and then slowly resolve unleshour period and then slowly resolve unlescomplications occur (infection, ARDS).complications occur (infection, ARDS).

Patients with severe contusions may requirePatients with severe contusions may requireendotrachealendotracheal intubation and mechanicalintubation and mechanical

ventilationventilation

8/3/2019 BS-CT

37/101

NURSING IMPLICATIONNURSING IMPLICATION

NURSING DIAGNOSISNURSING DIAGNOSIS Ineffective Airway ClearanceIneffective Airway Clearance Ineffective Breathing PatternIneffective Breathing Pattern Impaired Gas ExchangeImpaired Gas Exchange PainPain Risk for InfectionRisk for Infection Activity IntoleranceActivity Intolerance AnxietyAnxiety

Decreased Cardiac outputDecreased Cardiac output Impaired tissue perfusionImpaired tissue perfusion Ineffective individual copingIneffective individual coping Altered health maintenanceAltered health maintenance

8/3/2019 BS-CT

38/101


INTERVENTION:INTERVENTION:

Frequent and prompt Respiratory assessmentFrequent and prompt Respiratory assessment

Adequate oxygenationAdequate oxygenationAnalgesia to improve ventilation.Analgesia to improve ventilation. Clearing secretionClearing secretion Stabilize the thoracic cageStabilize the thoracic cage

Deep breathing exercisesDeep breathing exercises Intubation and mechanical ventilation may beIntubation and mechanical ventilation may be

required to prevent further hypoxiarequired to prevent further hypoxia

8/3/2019 BS-CT

39/101


Pain ControlPain Control

Alternative to relieve pain:Alternative to relieve pain:1.1. Intercostal Nerve BlocksIntercostal Nerve Blocks

2.2. Epidural Anesthesia.Epidural Anesthesia.3.3. Wearing a chest binderWearing a chest binder

Maintain IV flow ratesMaintain IV flow rates

Monitor S/S of adequate tissue perfusionMonitor S/S of adequate tissue perfusion

Anxiety reducing techniquesAnxiety reducing techniques Coping mechanismCoping mechanism

Heath education/teachingHeath education/teaching

8/3/2019 BS-CT

40/101

COMPLICATIONSCOMPLICATIONS PneumoniaPneumonia

ARDSARDS

Lung abscessLung abscess

EmphysemaEmphysema

Pulmonary embolism.Pulmonary embolism.

8/3/2019 BS-CT

41/101

4141

Pulmonary ContusionPulmonary Contusion

Assessment FindingsAssessment Findings Tachypnea or respiratory distressTachypnea or respiratory distress

TachycardiaTachycardia

Evidence of blunt chest traumaEvidence of blunt chest trauma Cough and/or HemoptysisCough and/or Hemoptysis

ApprehensionApprehension

CyanosisCyanosis

8/3/2019 BS-CT

42/101

8/3/2019 BS-CT

43/101

4343

Myocardial ContusionMyocardial Contusion

Assessment FindingsAssessment Findings Cardiac arrhythmias following blunt chestCardiac arrhythmias following blunt chest

traumatrauma

AnginaAngina--like pain unresponsive tolike pain unresponsive to

nitroglycerinnitroglycerin

Precordial discomfort independent ofPrecordial discomfort independent ofrespiratory movementrespiratory movement

Pericardial friction rub (late)

Pericardial friction rub (late)

8/3/2019 BS-CT

44/101

4444

Myocardial ContusionMyocardial Contusion M

anagementM

anagement Establish airwayEstablish airway

High concentration OHigh concentration O22 IV LR/NSIV LR/NS

Cautious fluid administration due to injured myocardiumCautious fluid administration due to injured myocardium

Emergent TransportEmergent Transport

HospitalHospital

8/3/2019 BS-CT

45/101

4545

Pericardial TamponadePericardial Tamponade

IncidenceIncidence Usually associated with penetrating traumaUsually associated with penetrating trauma

Rare in blunt traumaRare in blunt trauma

Occurs in < 2% of chest traumaOccurs in < 2% of chest trauma GSW wounds have higher mortality thanGSW wounds have higher mortality than

stab woundsstab wounds

Lower mortality rate if isolated tamponadeLower mortality rate if isolated tamponade

8/3/2019 BS-CT

46/101

4646


Signs and SymptomsSigns and Symptoms Becks TriadBecks Triad

Resistant hypotensionResistant hypotension

Increased central venous pressureIncreased central venous pressure(distended neck/arm veins in(distended neck/arm veins inpresence of decreased arterial BP)presence of decreased arterial BP)

Small quiet heart (decreased heartSmall quiet heart (decreased heart

sounds)sounds)

8/3/2019 BS-CT

47/101

8/3/2019 BS-CT

48/101

Cardiac tamponadeCardiac tamponade

8/3/2019 BS-CT

49/101

4949


ManagementManagement

Secure airwaySecure airway

High concentration OHigh concentration O22

PericardiocentesisPericardiocentesisOut of hospital, primarily reserved for cardiacOut of hospital, primarily reserved for cardiac

arrestarrest

Rapid transportRapid transport HospitalHospital

IVs ofLR/NSIVs ofLR/NS

8/3/2019 BS-CT

50/101

5050

Traumatic AorticTraumatic Aortic

Dissection/RuptureDissection/RuptureAssessment FindingsAssessment Findings Retrosternal or interscapular painRetrosternal or interscapular pain

Pain in lower back or one legPain in lower back or one leg

Respiratory distressRespiratory distress

Asymmetrical arm BPsAsymmetrical arm BPs

Upper extremity hypertension withUpper extremity hypertension with

Decreased femoral pulses, ORDecreased femoral pulses, ORAbsent femoral pulsesAbsent femoral pulses

DysphagiaDysphagia

8/3/2019 BS-CT

51/101

5151

Traumatic AorticTraumatic Aortic

Dissection/RuptureDissection/Rupture ManagementManagement Establish airwayEstablish airway

High concentration oxygenHigh concentration oxygen

Maintain minimal BP in dissectionMaintain minimal BP in dissection

IV LR/NS TKOIV LR/NS TKO minimize fluid administrationminimize fluid administration

Avoid PASGAvoid PASG

Emergent TransportEmergent Transport

HospitalHospital

8/3/2019 BS-CT

52/101

5252

Traumatic AsphyxiaTraumatic Asphyxia

Name given to these patientsName given to these patients

because they looked like they hadbecause they looked like they hadbeen strangled or hangedbeen strangled or hanged

8/3/2019 BS-CT

53/101

5353

Traumatic AsphyxiaTraumatic AsphyxiaAssessment FindingsAssessment Findings

PurplishPurplish--red discoloration of:red discoloration of:

Head and FaceHead and Face

NeckNeck

ShouldersShoulders

Blood shot, protruding eyesBlood shot, protruding eyes

JVDJVD

? Sternal fracture or central flail? Sternal fracture or central flail Shock when pressure releasedShock when pressure released

8/3/2019 BS-CT

54/101

5454

Traumatic AsphyxiaTraumatic Asphyxia

ManagementManagementAirway with CAirway with C--spine controlspine control

Assist ventilations with high concentrationAssist ventilations with high concentrationOO22

Spinal stabilizationSpinal stabilization

IV ofLRIV ofLR

++ MAST in severely hypotensive patients?MAST in severely hypotensive patients?

Rapid transportRapid transport HospitalHospital

8/3/2019 BS-CT

55/101

5555

Diaphragmatic RuptureDiaphragmatic Rupture

Assessment FindingsAssessment Findings

Decreased breath soundsDecreased breath sounds

Usually unilateralUsually unilateral

Dullness to percussionDullness to percussion

Dyspnea or Respiratory DistressDyspnea or Respiratory Distress

Scaphoid Abdomen (hollow appearance)Scaphoid Abdomen (hollow appearance)

Usually impossible to hear bowel soundsUsually impossible to hear bowel sounds

8/3/2019 BS-CT

56/101

5656

Diaphragmatic RuptureDiaphragmatic Rupture

Management

Management Establish airwayEstablish airway

Assist ventilations with high concentration OAssist ventilations with high concentration O22 IV ofLRIV ofLR

NG tube if possibleNG tube if possible

AvoidAvoid

MASTMAST

Trendelenburg positionTrendelenburg position

8/3/2019 BS-CT

57/101

5757

Diaphragmatic PenetrationDiaphragmatic Penetration

Suspect intraSuspect intra--abdominal trauma with anyabdominal trauma with anyinjury below 4th ICSinjury below 4th ICS

Suspect intrathoracic trauma with anySuspect intrathoracic trauma with anyabdominal injury above umbilicusabdominal injury above umbilicus

8/3/2019 BS-CT

58/101

5858

Esophageal InjuryEsophageal InjuryAssessment FindingsAssessment Findings

Pain, local tendernessPain, local tenderness

Hoarseness, DysphagiaHoarseness, Dysphagia

Respiratory distressRespiratory distress

Resistance of neck on passive motionResistance of neck on passive motion

Mediastinal esophageal perforationMediastinal esophageal perforation mediastinal emphysema / mediastinal crunchmediastinal emphysema / mediastinal crunch

mediastinitismediastinitis

SQ EmphysemaSQ Emphysema

splinting of chest wallsplinting of chest wall

ShockShock

8/3/2019 BS-CT

59/101

5959

Esophageal InjuryEsophageal Injury

ManagementManagement Establish AirwayEstablish Airway

Consider early intubation if possibleConsider early intubation if possible

IV LR/NS titrated to BP90IV LR/NS titrated to BP90--100 mm Hg100 mm Hg Emergent TransportEmergent Transport

HospitalHospital

Surgical capabilitySurgical capability

8/3/2019 BS-CT

60/101

6060

Tracheobronchial RuptureTracheobronchial Rupture

Assessment FindingsAssessment Findings Respiratory DistressRespiratory Distress

DyspneaDyspnea

TachypneaTachypnea

Obvious SQ emphysemaObvious SQ emphysema

HemoptysisHemoptysis

Especially of bright red bloodEspecially of bright red blood

Signs of tension pneumothoraxSigns of tension pneumothoraxunresponsive to needle decompressionunresponsive to needle decompression

8/3/2019 BS-CT

61/101

6161

Tracheobronchial RuptureTracheobronchial Rupture

ManagementManagement Establish airway and ventilationsEstablish airway and ventilations

Consider early intubationConsider early intubation Emergent TransportEmergent Transport

HospitalHospital

8/3/2019 BS-CT

62/101

Subcutaneous emphysemaSubcutaneous emphysema

Crackling sensation on palpationCrackling sensation on palpation

Needle decompressionNeedle decompression

SevereSeveretracheostomytracheostomy

8/3/2019 BS-CT

63/101

PNEUMOTHORAXPNEUMOTHORAX

Pneumothorax is a pocket of airPneumothorax is a pocket of airbetween the two layers of pleurabetween the two layers of pleura(parietal or visceral), resulting in(parietal or visceral), resulting in

collapse of the lung.collapse of the lung.

TYPES :TYPES :

Open PneumothoraxOpen Pneumothorax

Tension PneumothoraxTension Pneumothorax

8/3/2019 BS-CT

64/101

TypesTypes

Open Laceration in theOpen Laceration in theparietal pleura that allowsparietal pleura that allowsatmospheric air to enteratmospheric air to enterthe pleural space; occursthe pleural space; occurs

as a result of penetratingas a result of penetratingchest traumachest trauma

Closed Laceration in theClosed Laceration in thevisceral pleura that allowsvisceral pleura that allows

air from the lung to enterair from the lung to enterthe pleural space; occursthe pleural space; occursas a result of blunt chestas a result of blunt chesttraumatrauma

8/3/2019 BS-CT

65/101


8/3/2019 BS-CT

66/101


Inhale

8/3/2019 BS-CT

67/101


Exhale

8/3/2019 BS-CT

68/101


Inhale

8/3/2019 BS-CT

69/101


Exhale

8/3/2019 BS-CT

70/101

Open PneumothoarxOpen Pneumothoarx

Inhale

8/3/2019 BS-CT

71/101

Open PnuemothoraxOpen Pnuemothorax

Inhale

Pathoph siologPathoph siolog

8/3/2019 BS-CT

72/101

PathophysiologyPathophysiologyAir enters the pleural space, the affectedAir enters the pleural space, the affected

lunglung becomes compressed.becomes compressed.

As the lung collapses, the alveoli becomeAs the lung collapses, the alveoli become

underventilatedunderventilated,,

Causing V/Q mismatching andCausing V/Q mismatching and

intrapulmonaryintrapulmonary shunting.shunting.

8/3/2019 BS-CT

73/101

CONT..CONT..

If the pneumothorax is large, hypoxemia ensuesIf the pneumothorax is large, hypoxemia ensuesand acute respiratory failure quickly develops.and acute respiratory failure quickly develops.

In addition, increased pressure within the chestIn addition, increased pressure within the chestcan lead to shifting of the mediastinum,can lead to shifting of the mediastinum,compression of the great vessels, andcompression of the great vessels, and

decreased cardiac outputdecreased cardiac output

8/3/2019 BS-CT

74/101


Occurs when air is allowed toOccurs when air is allowed toenter the pleural space butenter the pleural space butnot exit it; as pressurenot exit it; as pressure

increases inside the pleuralincreases inside the pleuralspace, the lung collapses andspace, the lung collapses andthe mediastinum shifts to thethe mediastinum shifts to theunaffected side; may be aunaffected side; may be aresult of a spontaneous orresult of a spontaneous ortraumatic pneumothorax.traumatic pneumothorax.

8/3/2019 BS-CT

75/101

Tension PneumothoraxTension PneumothoraxE

ach time we inhale,the lung collapses further. There

is no place for the air to

escape..

8/3/2019 BS-CT

76/101

8/3/2019 BS-CT

77/101


Heart is being

compressed

The trachea is

pushed to

the good side

8/3/2019 BS-CT

78/101

S/S OF TENSIONS/S OF TENSION

8/3/2019 BS-CT

79/101

S/S OF TENSIONS/S OF TENSIONPNEUMOTHORAXPNEUMOTHORAX

Anxiety/RestlessnessAnxiety/Restlessness

Severe DyspneaSevere Dyspnea

AbsentBreath soundsAbsentBreath sounds

on affected sideon affected side TachypneaTachypnea


Poor ColorPoor Color

Accessory Muscle UseAccessory Muscle Use

HypotensionHypotension

Tracheal DeviationTracheal Deviation

(late if seen at all)(late if seen at all)

Hyperresonance toHyperresonance topercussionpercussion

..

Assessment andAssessment and

8/3/2019 BS-CT

80/101

Assessment andAssessment andDiagnosisDiagnosis

Depend on the degree of lung collapse.Depend on the degree of lung collapse. When a pneumothorax is large, decreased respiratoryWhen a pneumothorax is large, decreased respiratory

excursion on the affected side may be noticed, alongexcursion on the affected side may be noticed, alongwith bulging intercostal muscles. The trachea maywith bulging intercostal muscles. The trachea may

deviate away from the affected side.deviate away from the affected side. Percussion reveals hyperresonance with decreased orPercussion reveals hyperresonance with decreased or

absent breath sounds over the affected area.absent breath sounds over the affected area.

ABGs will demonstrate hypoxemia and hypercapnia.ABGs will demonstrate hypoxemia and hypercapnia.

A chest xA chest x--ray film will confirm the pneumothorax withray film will confirm the pneumothorax withincreased translucency evident on the affected sideincreased translucency evident on the affected side

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

8/3/2019 BS-CT

81/101

MEDICALMANAGEMENTMEDICALMANAGEMENT

Depending on the severity of the specificDepending on the severity of the specificdisorder.disorder.

At times requires only supplemental oxygenAt times requires only supplemental oxygenadministration, unless complications occuradministration, unless complications occur

or underlying lung disease or injury isor underlying lung disease or injury ispresent.present.

At times urgently require intervention toAt times urgently require intervention to

evacuate the air from the pleural space andevacuate the air from the pleural space andfacilitate re expansion of the collapsed lung.facilitate re expansion of the collapsed lung.

8/3/2019 BS-CT

82/101

TreatmentTreatment

Administering supplemental oxygenAdministering supplemental oxygen Inserting a largeInserting a large--bore needle or catheter intobore needle or catheter into

the second intercostal space at thethe second intercostal space at the

midclavicular line of the affected side. Thismidclavicular line of the affected side. Thisaction relieves the pressure within the chest.action relieves the pressure within the chest.The needle should remain in place until theThe needle should remain in place until thepatient is stabilized and a chest tube is insertedpatient is stabilized and a chest tube is inserted

Chest tube insertionChest tube insertion

8/3/2019 BS-CT

83/101

Needle DecompressionNeedle Decompression

Locate 2Locate 2--3 Intercostal space midclavicular line3 Intercostal space midclavicular line

Cleanse area using aseptic techniqueCleanse area using aseptic technique

Insert catheter ( 14g or larger) at least 3 inInsert catheter ( 14g or larger) at least 3 in

length over the top of the 3length over the top of the 3rdrd rib( nerve, artery,rib( nerve, artery,vein lie along bottom of rib)vein lie along bottom of rib)

Remove Stylette and listen for rush of airRemove Stylette and listen for rush of air

Place Flutter valve over catheter

Place Flutter valve over catheter

Reassess for ImprovementReassess for Improvement


8/3/2019 BS-CT

84/101


Nursing DiagnosisNursing Diagnosis

8/3/2019 BS-CT

85/101

Nursing DiagnosisNursing Diagnosis

Impaired Gas Exchange related to ventilation/Impaired Gas Exchange related to ventilation/

perfusion mismatching or intrapulmonary shuntingperfusion mismatching or intrapulmonary shunting

Ineffective Breathing Pattern related to decreasedIneffective Breathing Pattern related to decreasedlung expansionlung expansion

Acute Pain related to transmission and perception ofAcute Pain related to transmission and perception ofcutaneous, visceral, muscular, or ischemic impulsescutaneous, visceral, muscular, or ischemic impulses

Anxiety related to threat to biologic, psychologic,Anxiety related to threat to biologic, psychologic,and/or social integrityand/or social integrity

Disturbed Body Image related to actual change inDisturbed Body Image related to actual change inbody structures, function, or appearancebody structures, function, or appearance

Compromised Family Coping related to critically illCompromised Family Coping related to critically illfamily memberfamily member

NURSING INTERVENTIONSNURSING INTERVENTIONS

8/3/2019 BS-CT

86/101

Continuous and vigilant respiratoryContinuous and vigilant respiratoryassessmentassessment

Optimizing oxygenation and ventilation,Optimizing oxygenation and ventilation,

Maintaining the chest tube systemMaintaining the chest tube system

Providing comfort and emotional supportProviding comfort and emotional support

Maintaining surveillance for

Maintaining surveillance forcomplications.complications.

8/3/2019 BS-CT

87/101

PneumothoraxPneumothorax

8/3/2019 BS-CT

88/101


Occurs when pleural space fills with bloodOccurs when pleural space fills with blood

Usually occurs due to lacerated bloodUsually occurs due to lacerated bloodvessel in thoraxvessel in thorax

As blood increases, it puts pressure onAs blood increases, it puts pressure onheart and other vessels in chest cavityheart and other vessels in chest cavity

Each Lung can hold 1.5 liters of bloodEach Lung can hold 1.5 liters of blood

8/3/2019 BS-CT

89/101


8/3/2019 BS-CT

90/101


8/3/2019 BS-CT

91/101


8/3/2019 BS-CT

92/101


8/3/2019 BS-CT

93/101


8/3/2019 BS-CT

94/101


May put pressure on the heart

8/3/2019 BS-CT

95/101


Lots of blood vessels

Where does the blood come from.

8/3/2019 BS-CT

96/101

S/S of HemothoraxS/S of Hemothorax

Anxiety/RestlessnessAnxiety/Restlessness

TachypneaTachypnea

Signs of ShockSigns of Shock Frothy, Bloody SputumFrothy, Bloody Sputum

Diminished Breath Sounds on AffectedDiminished Breath Sounds on AffectedSideSide


FlatNeck VeinsFlatNeck Veins

8/3/2019 BS-CT

97/101

Treatment for HemothoraxTreatment for Hemothorax

ABCsABCs

Secure Airway assist ventilation ifSecure Airway assist ventilation ifnecessarynecessary

General Shock Care due to Blood lossGeneral Shock Care due to Blood loss

RAPID TRANSPORT to hospital.RAPID TRANSPORT to hospital.

8/3/2019 BS-CT

98/101

Iatrogenic traumaIatrogenic trauma

NG tubes:NG tubes: --coilingcoiling--endobronchial placementendobronchial placement--pneumothoraxpneumothorax

Chest tubes:Chest tubes: -- subcutaneoussubcutaneous-- intraparenchymalintraparenchymal-- intrafissuralintrafissural

Central lines:Central lines: -- neckneck-- coronary sinuscoronary sinus-- pneumothoraxpneumothorax

8/3/2019 BS-CT

99/101

Misplaced nasogastric tube

Misplaced nasogastric tube

8/3/2019 BS-CT

100/101

Chest trauma: summaryChest trauma: summary

CommonCommon

SeriousSerious

Primary goal is to provide oxygen toPrimary goal is to provide oxygen tovital organsvital organs

RememberRememberAAirwayirwayBBreathingreathingCCirculationirculation

Be alert to change in clinical conditionBe alert to change in clinical condition

SummarySummary

8/3/2019 BS-CT

101/101

SummarySummary

Chest Injuries are common and often lifeChest Injuries are common and often lifethreatening in trauma patients. So, Rapidthreatening in trauma patients. So, Rapid

identification and treatment of these patients isidentification and treatment of these patients isparamount to patient survival. Airwayparamount to patient survival. Airway

management is very important and aggressivemanagement is very important and aggressive

management is sometimes needed for propermanagement is sometimes needed for propermanagement of most chest injuries.management of most chest injuries.

Documents

BS-CT