hmela chest trauma

8/6/2019 Hmela Chest Trauma

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Chest Trauma

Is it considered a medical emergency?

& life threatening?



Chest Trauma

� Precisely, because the chest houses the heart,

the lungs, & great vessels

� Therefore

chest trauma frequently produces life-

threatening disruptions of cardiopulmonaryfunction.



Chest Traumas

Causes:

� Falls

� Use of machinery� Employment of lethal weapons

� Motor vehicle crashes



Chest Traumas

Classifications:

� Penetrating Chest Injury

»Non-Penetrating Chest Injury



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.



Penetrating Chest Traumas

may seriously damage the lungs,heart & other thoracic structures



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



Assessment of & Therapeutic

Intervention for the Chest Trauma Victim

Maintain

Airway,

Breathing,

& Circulation!



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?



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?



Perform a quick (1-minute) evaluation

� for SOB & cyanosis

� VS

� skin color & temperature� wound size & location

� for paradoxical chest movement

� distended neck veins




� Listen for respiratory stridor.

� Listen for breath sounds.

� Look for epigastric & supravicular indrawing.� Give rough estimate of tidal volume.

� for tracheal deviation.




� Assess intercostal muscle use.

� Assess accessory muscle use.

� Check for subcutaneous emphysema.� Look & listen for sucking chest sounds.

� Listen to heart sounds.



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



Provide Therapeutic Intervention

� Initiate IV line

� Do pericardiocentesis, if indicated.� Get CXR

� Frequently recheck VS

� Monitor for dysrhythmias



Complications

� Pneumothorax

� Tension pneumothorax & mediastinal shift

� Open pneumothorax & mediastinal flutter� Hemothorax

� Fractured ribs

� Fractured sternum� Flail chest



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



What are the possible causes?

± Open chest wound

±

Rupture of an emphysematous vesicle ± Severe bout of coughing




Types of Pneumothorax

� Tension Pneumothorax

»Open Pneumothorax




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




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




Great vessel compression

Impairment of blood return in the heart

Decrease in CO & BP




Tracheal deviation

Airway obstruction




Clinical Manifestations

� Marked, severe dyspnea

� Tachypnea� Crepitus

� Progressive cyanosis

� Acute pleuritic chest pain� Hyperresonance (on percussion)





� Tachycardia

� Assymetric chest wall movement� Diminished or absent breath sounds (on

affected side)

� Extreme restlessness/agitation





(Other)

� Neck vein distention

� Laryngealt/ tracheal deviation� Feeling of tightness/pressure w/n the chest

� PMI shift laterally/ medially

� Severe hypotension




Diagnostic Exams

� X-ray study

� ABGs




Medical Management

� *Immediate intervention is to convert tension

pneumothorax into open pneumothorax

�

Prompt thoracenteis� Insertion of water-seal drainage system (CTT)


!Nursing Alert

Relief of tension pneumothorax is considered an emergency

measure



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.





3. Provide relief/control of pain.

� a. Administer narcotics/analgesics/sedatives

as ordered and monitor effects.� b. Position client in high-Fowler¶s position.




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




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




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.




Management

� Provide supplemental O2

� Prompt thoracentesis

� Insertion of water-seal drainage system (CTT)




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



Diagnostic Exam/s

� CXR




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




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



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



Diagnostic Exams

� CXR

� ABG Analysis

� Pulse Oxymetry� Pulmonary Fxn Monitoring



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



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



Management

� Pain Management thru¶ Drug therapy

-narcotics

-sedatives

-muscle relaxants/musculoskeletal

paralyzing agents (pancuronium bromide)




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



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)



General Classification

� Transudative effusion

� Exudative effusion



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



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.



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)



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.



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.



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



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



Treatment Modalities



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



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



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)



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



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



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



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



Thoracentecis



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



Thoracentecis

� The pleural fluid is evaluated for gross

appearance; CHON; LDH; glucose; Gram stain

& bacteriologic cultures; M. Tuberculosis &

fungus; cytology; CEA levels;



Contraindications

� Patients w/ significant

thrombocytopenia



Potential Complications

� Pneumothorax

� Interpleural Bleeding

�

Hemoptysis� Reflex bradycardia & HPN

� Pulmonary Edema

� Seeding of the needle tract w/ tumor� Subcutaneous Emphysema



Thoracentecis

� No more than 1000 ml of fluid should beremoved at a time; fluid withdrawn should besent to the laboratory for culture andsensitivity tests



Procedure & Patient Care



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



Patient Care: During

� The patient is usually placed in an upright

position w/ the arms & shoulders raised &

supported on an padded overhead table.



Position




� 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.




� 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.



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



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



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.

hmela chest trauma

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