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Chest injury
1.
2.
At the end of class students will be able to-
Define chest injuries.
Explain classification of chest injuries.
Enlist causes of different chest injuries.
Discuss pathophysiology of chest injuries.
Enumerate clinical manifestations of chest injuries.
Explain management of chest injuries.
Objectives
3. Chest is large exposed portion of the body that is vulnerable to
impact injuries.
Because chest houses heart, lungs, and great vessels chest
trauma is frequently life threatening .
Injuries to thoracic cage and its content can restrict the hearts
ability to pump blood or lungs ability to exchange air and
oxygenated blood.
Major danger with chest injuries is internal bleeding and organ
puncture
Introduction
4.
Trauma is the leading cause of death, morbidity, hospitalization, and
disability.
It constitutes a major health care problem.
According to the Centers for Disease Control and Prevention, 126-
438 deaths occurred from unintentional injury to chest in 2014.
Morbidity and mortality
5.
Trauma is responsible for more than 100,000 deaths annually in the
United States.
Approximately 33% of these injuries necessitate hospital admission.
Overall, blunt thoracic injuries are directly responsible for 20-25% of
all deaths.
Frequency
6.
Definition
Chest injury is any form of
physical injury to the chest
including the ribs, heart, and
lungs.
Major chest injuries may occur
alone or multiple other injuries .
12.
Blunt trauma occurs when body is struck by a blunt object,
such as a steering wheel. The external injury may appear
minor, but the impact may cause severe, life threatening
internal injuries, such as ruptured spleen. It is difficult to
identify the extent of damage because the symptoms may
be generalized.
Blunt trauma
15. Injury resulting from collision between a body part and another object
or body part while both are in motion.
MECHANISM
Acceleration-A head suddenly accelerates (e.g., a blow to the head)
and the stationary brain is struck by the accelerated cranium at the site
of the blow.
Deceleration- a rapidly moving skull is abruptly stopped (e.g., an
auto accident), while the brain continues forward and impacts directly
below the site where the skull stops.
Acceleration-deceleration
injury
16. Due to etiology (motor vehicle accident, fall from height etc)
Blunt chest injuries occurs due to mechanism of acceleration deceleration, shearing,
and compression
Hypoxia occurs due to disruption of the airway, injuries to lung parenchyma, rib cage
and respiratory muscle
Hypovolemia from massive fluid loss from great vessels, cardiac rupture, and
hemothorex
These pathogenic states frequently causes impaired ventilation and perfusion leading to
acute renal failure and Hypovolemic shock and at last death if not treated properly
Pathophysiology
18.
An airway is immediately established with oxygen support &
in some cases, intubation & ventilatory support.
Reestablishing fluid volume & negative intrapleural pressure
& draining intrapleural fluid & blood are essential.
Medical management
19.
Sternal & Rib fractures are
common chest injuries
Fracture of Ribs 1 & 2 are
called the “Hallmark of severe
trauma”
5th and 9th ribs are commonly
affected.
Specific chest injuries
20. STERNAL
FRACTURE
RIB
FRACTURE
1. Anterior chest pain
2. over lying tenderness
3. Ecchymosis, crepitus
4. Swelling & possible
chest wall deformity
1. Pain at the site of injury
2.Shallow breathing
3.Localized tenderness &
crepitus on palpation and
auscultation.
4.Splinting of the chest
Clinical manifestations
24. Fractured ribs are generally treated conservatively with
good pulmonary physiotherapy, rapid mobilization, and
proper pain management.
Sedation is used to relieve the pain and allow deep
breathing and coughing.
Alternative strategies to relieve pain include an intercostals
nerve block and ice over the fracture site.
Usually pain relieve within 5 to 7 days, Most of rib
fractures heal in 3 to 6 weeks.
Medical management
25.
26.
It usually occurs when three or more
adjacent ribs are fractured at two or more
sites, resulting in free floating rib
segments. .
This produces paradoxical chest wall
movement in the flail segment.
There is associated respiratory distress
from the paradoxical chest wall
movement, associated pulmonary
contusions and painful rib fractures
causing voluntary and involuntary chest
splinting.
Flail chest
27.
Flail chest injury & breathing in
paradoxical manner
Increased dead space, a reduction in
alveolar ventilation & decreased
compliance.
Retained airway secretions & atelectasis,
hypoxemia & if gas exchange is greatly
compromised, respiratory acidosis as a
result of carbon dioxide retention.
Pathophysiology
28. Rapid , shallow respirations
Tachycardia
Movement of the thorax is asymmetric
and uncoordinated
During inspiration the affected portion is
sucked in, and during expiration it
bulged out.
Chest pain
Dyspnea
Clinical manifestations
30.
Airway management
Administration of IV fluids
Pain control
Mechanical ventilation.
Clear the secretions from lungs
through suctioning
Pulmonary physiotherapy
Medical management
31.
In rare circumstances surgery may be
required (patients who are difficult to
ventilate)
Regardless the type of treatment , the
patient is fully monitored by serial
chest x-rays, ABG analysis, pulse rate
and bed side pulmonary function
monitoring
Medical management cont…
33. Is a common thoracic injury
Associated with flail chest.
Defined as damage to the lung tissues resulting in
hemorrhage and localizes edema.
Characterized by development of infiltrates and various
degree of respiratory dysfunction
May not evident initially on examination but develops
in post traumatic period.
Introduction
34. A pulmonary contusion (or lung contusion) is a bruise
of the lung, caused by chest trauma.
As a result of damage to capillaries blood and other
fluids accumulated in the lung tissue.
The excess fluid interferes with gas exchange,
potentially leading to inadequate oxygen levels
(hypoxia).
Definition
35.
Due to injury to lung parenchyma and its
capillary network results in leakage of serum
protein and plasma
Abnormal accumulation of fluid in the
interstitial and intra-alveolar space
This fluid exerts an osmotic pressure that
enhances loss of fluids from capillaries
Blood and cellular debris (from cellular
response to injury) enters the lung and
accumulate in bronchioles and alveoli
Pathophysiology
36.
In bronchioles and alveoli they
interfere with gas exchange
As result, patient has hypoxemia
and carbon dioxide retention
Symptoms of pulmonary
contusion occur
Pathophysiology
42.
Bronchoscopy may be required to
remove secretions.
Diuretics to reduce edema
A nasogastric tube to relieve gastro
intestinal distention
In severe cases E.T intubation and
ventilator support may be necessary.
Colloids and crystalloids solution may
be used to treat Hypovolemia
44.
Definition
It is defined as when a
foreign body passes
through the body tissues
(e.g. gun shot wounds,
stabbing)
45. It is the most common cause of penetrating
trauma.
Knives and switch blades cause most stab
wounds.
The appearance of the external wound may
be deceptive, because pneumothrax,
hemothorax, lung contusion, cardiac
temponade, ,along with severe and
continuing hemorrhage, can occur from any
small wound.
Gunshot and stab wounds
47. Restore and maintain cardiopulmonary functions.
Adequate airway ventilation.
examination for shock and intra abdominal
injuries
After peripheral pulse status assessed a large bore
I.V line is inserted
Medical management
48. An indwelling catheter.
Nasogastric tube is inserted and
connected to low suction to prevent
aspiration.
Shock is treated simultaneously with
colloid solutions, crystalloids or
blood as indicated by patients
condition.
Medical management
49.
A chest tube is inserted into pleural space
in most patients with penetrating wound of
chest to achieve continuing re-expansion
of lungs.
The insertion of chest tube frequently
results in complete evacuation of blood
and air.
Medical management
51. It is presence of air in pleural
space, there is partial or
complete collapse of the lungs.
This condition should be
suspected after any blunt
trauma to the chest wall, there
are various types of
pneumothrax
Pneumothorax
54.
Closed pneumothorax
has no associated external wound.
most common form is spontaneous pneumothrax, which is
accumulation of air in the pleural space without an
apparent antecedent event.
is caused by rupture of small belbs on the visceral pleural
space.
this condition occur most commonly in underweight male
cigarette smokers between 20 to 40 year of age
55.
Open pneumothorax
It occurs when air enters the pleural space through an
opening in the chest wall, like stab or gunshot injuries. it
should be covered with vented dressing.
This allows air to escape from the lungs and decreases the
likelihood of tension pneumothrax developing
The abnormal movement of air through the chest wound
produces sucking noise that is audible in quiet
environment
56.
Accidental injuries or surgical trauma (like if
chest drainage tube accidentally pulled out , the
remaining puncture incision in the chest wall
may became sucking wound)
Causes
57. Immediately cover the wound securely, do not
waste time looking for sterile gauze .
If the client is conscious and cooperative ask the
client to take deep breath and try to blow it out
while keeping the mouth and nose closed.
This pushing effort against the closed glottis
helps push air out through chest wound and re-
expand the lungs
Chest tubes are inserted on the affected side
away from the open wound .surgical closure of
the wound may follow.
Supplemental high-flow oxygen should be
administered
Management
58.
Tension pneumothorax
It is a pneumothrax with rapid
accumulation of air in the pleural
space from a lacerated lung or through
a small opening or wound on the chest
wall.
May be complication of other types of
pneumothrax.
In contrast to open pneumothrax, the
air that enters the chest cavity with
each inspiration is trapped; it cannot
expelled during expiration through the
air passages or the opening in the
chest wall.
59.
Tension pneumothorax
This cause lungs to collapse and the heart, great vessels and
trachea to shift towards unaffected side of the chest.
Both respiratory and circulatory functions are compromised
In extreme cases , the pulse may be undetected this is called
Pulse Less Electrical Activity
60.
Hemothorax
It is accumulation of
blood into plural space.
It frequently found in
association with open
pneumothrax and is often
called as
Hemopneumothorax,
causes may be include
chest trauma and lung
malignancy.
61.
Chylothorax
It is lymphatic fluid In the pleural space
due to leak in the thoracic ducts
Causes include trauma, surgical procedure
and malignancy.
The thoracic duct is disrupted and the
chylous fluid, milky white with high lipid
content, fills the pleural space.
Total lymphatic flow through the thoracic
duct is 1500 to 2400 ml/day.
50% cases will heal with conservative
management like chest drainage and
parenteral nutrition.
62.
Dyspnea
Sudden sharp pain on affected side
Difficult coughing
Asymmetrical chest expansion
Clinical manifestations
65. Mild pneumothrax subsides automatically.
For moderate cases insert chest tube
immediately into the pleural space via 4th
intercostals space at midaxillary or anterior
axillary line, it is connected through closed
chest drainage.
The catheter permits continuous escape of
air and blood from pleural spaces.
The goal of treatment is to evacuate the air
or blood from the pleural space
Management
66.
When the chest tubes are inserted and suction is
applied(20 mm/hg), effective decompression of
pleural cavity occurs.
If an excessive amount of blood enters the chest tube in
relatively short period , an auto transfusion may
require.
Management
67. In such an emergency anything can be used
that is large enough to fill the chest wound.
In hospitals the opening is covered with
gauze impregnated with petroleum. A
pressure dressing is applied antibiotics are
usually applied to combat with infection.
The lung is then re-expand resume the
function of gas exchange. If there is more
then 1500 ml blood aspirated initially by
thoracentasis, the chest wall opens surgically
(thoracotomy).
Management
69.
Definition
Cardiac temponade is compression of
the heart resulting from fluid and
blood with in the pericardial sac.
Usually it is caused by blunt and
penetrating trauma to chest.
Cardiac temponade may also occurs
due to diagnostic cardiac
catheterization, angiographic
procedure, and pacemaker insertion,
which can produce perforation to heart
and great vessels
71.
Other possible causes
Heart tumors
Kidney failure
Leukemia
Placement of central lines
Radiation therapy to the chest
Recent invasive heart procedures
Recent open heart surgery
Systemic lupus erythematosus
72. Feeling of fullness in chest
Prominent neck veins
Shortness of breath
Hypotension
Narrowing the pulse pressure
Anxiety, restlessness
Chest pain Radiating to the neck, shoulder,
back, or abdomen
Clinical manifestation
73.
Difficulty breathing
Discomfort, sometimes relieved by sitting
upright or leaning forward
Fainting, light-headedness
Pale, gray, or blue skin
Palpitations
Rapid breathing
Swelling of the abdomen or other areas
Clinical manifestation
75. Cardiac temponade is an emergency condition
that requires hospitalization.
The fluid around the heart must be drained as
quickly as possible.
Pericardiocentesis is a procedure that uses a
needle to remove fluid from the pericardial
sac, the tissue that surrounds the heart.
A procedure to cut and remove part of the
pericardium (surgical pericardiectomy or
pericardial window) may also be done.
Medical management
76. Fluids are given to maintain normal blood
pressure until pericardiocentesis can be
performed.
Medications that increase blood pressure
may also help sustain the patient's life until
the fluid is drained.
The patient may be given oxygen. This
reduces the workload on the heart by
decreasing tissue demands for blood flow.
Medical management
77. INITIAL
Ensure patent airway of the patients
Place patient in semi fowler position
Administer high flow oxygen to the patient
Administer fluid to the patient through iv line
Remove clothing to assess the injury
Cover sucking chest wound with non porous dressing taped on
three sides
Stabilize flail rib segment with hand followed by application of
large pieces of tape horizontal across the flail segment
Emergency management of chest
injuries
78.
ONGOING MONITORING
Monitor vital signs, level of consciousness, oxygen
saturation, respiratory status and urinary output
Anticipate intubation for respiratory distress
Release dressing if tension pneumothrax develops after
sucking chest wound is covered
Emergency management of chest
injuries
79. ASSESSMENT
Assess the patient for :
RESPIRATORY-
Dyspnea
Respiratory distress
Cyanosis of mouth, face, nail beds
Tracheal deviation
Audible air escaping from chest wound
Decreased breath sound on the side of injury
Decreased oxygen saturation
Frothy secretions
Nursing management
81.
1. Impaired gas exchange related to air or fluid
collection in the pleural space and lungs as
evidenced by drainage from chest tube,
decreased breath sound and abnormal pulse-
oximetry
EXPECTED OUTCOME-
To maintain patients gas exchange and breathing pattern
INTERVENTIONS-
Monitor respiratory and oxygenation status of the patient to any
significant change in respiratory function
Provide oxygen therapy to the patient to treat hypoxemia
Provide semi-fowlers position to the patient to prevent from dyspnea
Ensure that all tabbing connections are properly attached
Maintain intake and output of the patients
Keep the drainage container below chest level to prevent from tension
pneumothrax
82.
2.Ineffective breathing pattern related to pain and position as
evidenced by shortness of breath and shallow respiration
EXPECTED OUTCOME-
To maintain the normal respiratory pattern of the patient
INTERVENTIONS-
Assess the patient rate , rhythm, and depth of respiration
Provide suctioning if needed
Provide proper position to the patient to treat dyspnea
Provide oxygen to the patient
Provide prescribed analgesics to the patient to promote deep
breathing and coughing
Assist the patient with intensive spirometry
83.
3. Acute pain related to trauma as evidenced by facial
expressions of the patient.
EXPECTED OUTCOME-
to relieve the pain of the patient
INTERVENTIONS-
Assess the pain level of the patient
Provide proper position to the patient in which in which he feels
comfortable
Provide comfort devices to the patient
Provide analgesics to the patient if prescribed by doctor
84.
4. Immobility related to pain as evidenced by
inability to move purposefully with in physical
environment
EXPECTED OUTCOME-
Patient performs physical activity independently or with assistive
devices as needed
INTERVENTIONS-
Assess patients dependency level
Encourage and facilitate early ambulation
Provide positive reinforcement during activity
Allow patient to perform tasks at his or her own, do not rush the patient
Keep side rails up and bed in low position
Turn and position every two hours as needed
Use incentive spirometer to increase lung expansion
Teach energy saving technique
Assist patient in accepting limitation
85.
5. Risk of infection related to inadequate primary
defenses: broken skin, injured tissue, body fluid stasis
EXPECTED OUTCOME:-
Patient remains free of infection , as evidenced by normal vital signs
and absence of purulent drainage from wound
INTERVENTIONS:-
Wash hands before and after before and after contact with patient, and
teach other caregivers and patient attendant to wash hand before
contact with patient
Maintain asepsis for dressing change and wound care.
Encourage to intake of protein and calorie rich diet.
Teach the use of antimicrobial drugs as ordered.
Place the patient in protective isolation room if patient is at very high
risk.
Encourage the patient for coughing and deep breathing exercises
86.
6. Self care deficit related to inability to perform bath
and groom self independently
EXPECTED OUTCOME:
Patient safely perform self care activities
INTERVENTIONS
Assist patient in accepting necessary amount of dependence
Set short range goal with patient
Encourage independence, but intervene when patient can not
perform
Provide adequate time to patient to perform task
Provide positive reinforcement for all
87.
Conclusion
Mostly chest injuries are not life threatening and can be
manage with proper and timely management. Chest
injuries mainly affects respiratory system so it is important
to monitor respiratory system and manage it properly
88.
INTRODUCTION
MORBIDITY AND MORTALITY
FREQUENCY
DEFINITION
CAUSES
TYPES
PATHOPHYSIOLOGY
MECHANISM
SPECIFIC CHEST INJURIES
SPECIFIC PULMONARY INJURIES
MANAGEMENT
NURSING MANAGEMENT
Summarization
90.
Joyce m. black, Jane hokanson,medical surgical sursing clinical
management for positive outcome, first edition:2009.elsevier
India private limited page no 1657-1663
Brunner and suddarth’s, textbook of medical surgical nursing,
first edition 2011.wolters kluwer publishers pvtltd page no 593-
599
Lewis heitkemper et all, medical surgical nursing assessment
and management of clinical problems edition :seventh 2009,
evolve publishers page no-585-593
http://www.ncbi.nlm.nih.gov/pubmed/25207119
http://www.ncbi.nlm.nih.gov/pubmed/26358517
References
