Comprehensive Care of Chest Injuries: Rapid Review

1. 2ND ANNUAL RAPID REVIEW 12.O3.12CARE OF PATIENT WITH CHEST INJURIES Sujitha .E, Lecturer, Faculty of Nursing, Sri Ramachandra University, Porur

2. Chest cavity Soft tissues • Lungs • Heart • Great vessels • diaphragm • oesophagus

3. Bony areas • Ribs • Sternum • Clavicle • Tracheo broncheal tree

4. Classification Blunt injuries Penetrating injuries

5. Etiology • Motor vehicle accidents • Fall from height • Violence • Iatrogenic

6. Mechanisms involved • Acceleration force • Deceleration force • Transmission of blunt internal force to force to structures • Direct trauma • Compression

7. Chest trauma • Chest wall injuries • Sternal fractures • Flail chest • Pulmonary and pleural injuries • Traumatic asphyxia • Tracheo bronchial injuries • Pneumothorax • Hemothorax • Mediastinal injuries • cardiac injuries • Great vessel injuries • Diaphragmatic injuries • Oesophageal injuries

8. From history (King Tut 1341 BC – 1323 BC)

9. Pulmonary injuries Pneumothorax • Collection of air in the space between the parietal and visceral pleura

10. Tension pneumothorax An expanding collection of intra pleural air without communication with external environment • Clinical manifestations • Distended neck veins • Hypotension/hypoperfusion • Absent breath sounds on affected side • Tracheal deviation to contra lateral side

11. Management • Immediate needle aspiration • 14 gauge IV needle of length more than 4.5 cm and catheter into pleural space through chest wall in MCL at second intercostal space(temporary measure) • Large bore chest tube thoracostomy

13. Open pneumothorax (sucking chest wound) A communication between the pleural space and surrounding atmospheric pressure Respiration is the function of negative pressure inside the thoracic cavity , positive atmospheric pressure and elastic recoil of lungs

14. Pneumothorax • Clinical manifestations • Air entry and breath sounds diminished in the affected side • Impaired chest wall motion

15. Pathophysiology Negative intrapleural pressure during inspiration Air leak into the pleural cavity Increased intra thoracic pressure Reduced vital capacity and venous return

16. Pneumothorax • Diagnosis • Chest radiography(double pleural markings) • Ultrasound • Management • Cover the wound with a three sided dressing • Air can escape during expiration but do not enter during inspiration(one way valve) • Chest tube insertion

17. Pneumothorax

18. Open pneumothorax 3-side dressing Asherman chest seal

19. Massive hemothorax Accumulation of at least 1500 ml or two thirds of the available hemithorax in an adult

20. Hemothorax • Life threatening by three mechanisms • Acute hypovolemia causing decreased preload • Collapsed lung promoting hypoxia • Hemothorax compressing venacava • impairing preload

21. Hemothorax • Clinical manifestations Abnormal vital signs Dullness to percussion Diminished breath sounds • Diagnosis Plain chest radiography completely opacifiedhemithorax Ultrasonography-fluid between chest wall and lung

22. Management • Chest tube insertion Care of chest tube • Position-last hole 2.5-5 cm inside chest wall • Suction chamber with 20-30 cm of water • Never clamp the tubes • Bottle at 1-2 ft lower than patient’s chest • Left in place for 24 hrs after leak has stopped

25. Flail chest • Free floating lung segment that is no longer connected to the rest of the thorax • Cause • Segmental rib fractures in two or more locations of the same rib of three or more adjacent ribs

26. Flail chest • Clinical manifestations • Paradoxical inward movement of the involved portion of the chest wall during inspiration and outward movement during expiration

27. Pathophysiology-flail chest Decreased ventilatory efficiency Increased work of breathing Hypoxemia Sudden respiratory arrest

29. Management-Flail chest • Analgesics • Ventilator support • stabilization

30. Diaphragmatic injury • Often unnoticed if not very big defect • Causes referred shoulder pain • Respiratory distress (herniation of abdominal contents into the thorax) Diagnosis • Decreased breath sounds • Auscultation of bowel sounds in the chest • Tension viscero thorax • Bowel obstruction and strangulation

31. Management- Repair of diaphragm

32. Cardiac injuries

33. Cardiac tamponade • Accumulation of blood in the pericardial cavity under pressure • Common causes are gunshot wounds and stabs • Clinical features • Tachycardia • Narrow pulse pressure • Elevated CVP • Hypotension Becks triad

34. Cardiac tamponade • Pathophysiology • Elevated intra cardiac pressure • Decreased right and left ventricular filling • Decreased cardiac output

35. Management-Pericardiocentesis

36. Great vessel injuries • The main vessels • Aorta • Brachio cephalic branches • Pulmonary arteries and veins • Venae cavae • Thoracic duct

37. Aortic injury • Commonly injured part is proximal descending aorta • Clinical manifestations • Hypo tension • hypertension in upper extremity& hypotension in lower extremities • Intra capsular murmurs or bruits • Diagnosis • Chest radiograph • TEECHO • Aortography

38. Aortic rupture

39. Management • Pharmacologic control of heart rate and blood pressure(around 60/mt and 100-120 mmHg systolic) • Hemodynamic monitoring (pul.catheter) • Sedatives • Analgesics • Vasodilators (sodium nitroprusside) • β –blockers (esmolol) • Auto transfusion • Surgical repair

40. Nursing diagnoses • Acute pain • Fluid volume deficit • Decreased cardiac output • Inability to sustain spontaneous ventilation • Ineffective breathing pattern • Impaired gas exchange • Impaired tissue perfusion

42. Try with this • acidosis • Respiratory • & Metabolic

43. Other investigations • CT • Bronchoscopy • Oesophagoscopy • Oesophagography • Angiography

44. Airway management- • Indications for mechanical ventilation • Altered mental status • Excessive secretions • Associated face and neck injuries • Impending respiratory failure • Cardiopulmonary collapse • Significant co morbidities • Advanced age • ABG abnormalities

45. Fluid resuscitation Goal: to stabilize the intravascular volume sufficiently to provide time to manage hemorrhage • Insert at least two large bore IV catheters • Central/femoral/subclavian/IJV access • Control hemorrhage and then replace • Consider auto transfusion

46. Thank you