CHEST TRAUMA

SEMINAR ON
CHEST TRAUMA

MR OM VERMA
Msc lecturer medical surgical nursing
INTRODUCTION:

 The chest is a large exposure part of the

body that is very vul-nerable to impact
injuries. Because it houses the heart, lungs,
and great vessels, chest trauma frequently
produces life threate-ning disruption. Injury
to the thoracic case and its contraction can
restrict the hearts ability to function
properly.
 Chest Injuries are broken into 2
categories:
– 1. Open chest injury-Must have opening or
break in skin.
– 2. Closed chest injury-Usually from blunt
trauma to chest cavity.
DEFINITION:

Chest Trauma / Thoracic Trauma

is a serious injury of the chest.
Any trauma which leads to injury
to chest is termed as chest
trauma.
 A CHEST INJURY IS ANY FROM OF
PHYSICAL INJURY TO THE CHEST
INCLUDING THE RIBS ,HEART,
LUNGS
 Mechanism of Injury
in Chest Trauma
 Acceleration/deceleration (motor vehicle accident)
 Body compression (crush injury)
 High-speed impact (gunshot wound)
 Miscellaneous

Low-velocity penetration
(stab wound) KNIFE
Airway obstruction
(suffocation)
Caustic injury (poisoning)
Burns
Electrocution
 Main Causes of Chest
Trauma
 Blunt Trauma - Blunt force to chest.
( gun shorts )

 Penetrating Trauma - Projectile that

enters chest causing small or large hole.

 Compression Injury - Chest is caught

between two objects and chest is
compressed.
Thoracic Trauma
 Blunt Trauma
– Results from kinetic energy forces
 Subdivision Mechanisms
– Blast
 Pressure wave causes tissue disruption
 Tear blood vessels & disrupt alveolar tissue
 Disruption of tracheobronchial tree
 Traumatic diaphragm rupture

– Crush (Compression)
 Body is compressed between an object and a hard surface
 Direct injury of chest wall and internal structures

– Deceleration
 Body in motion strikes a fixed object
 Blunt trauma to chest wall
 Internal structures continue in motion
– Ligamentum Arteriosum shears aorta
– Age Factors
 Pediatric Thorax: More cartilage = Absorbs forces
 Geriatric Thorax: Calcification & osteoporosis = More fractures
 ASSESSMENT
 A. Airway

Assess for airway patency and air

exchange - listen at nose & mouth
Assess for intercostal and
supraclavicular muscle retractions
Assess oropharynx for foreign body
obstruction
 B. Breathing
Assess respiratory movements and
quality of respirations - look, listen, feel.
Slow respirations are early indicator of
distress - cyanosis is late.
 C. Circulation

Skin - look and feel for color,

temperature, capillary refill- Look for
cyanosis.
Assess pulses for quality, rate, regularity
Look at neck veins - flat vs. distended-
fluid deficit or decreased supply to body
from heart due to compression.
Assess the B.P.
PATHOPHYSIOLOGY
CHEST INJURY

INTRAPLEURAL SPACE INCREASES

LUNG COLLAPSE

MEDIASTINUM SHIFT
 COMPRESSION OF LARGE VEINS

CARBON OXIDE DECREASES

CARDIAC ARRYTHMIAS
a condition in which the heart beats with an
irregular or abnormal rhythm.

SUDDEN DEATH
Diagnostic Evaluation:
 CHEST X- RAY
 CT SCAN
 ECHOCARDIOGRAPHY
 ABG ANALYSIS
 ANGIOGRAPHY
 BRONCHIOSCOPY
 PULSE OXIMETRY AND PFT
 URINE OUTPUT
 CHEST X- RAY
 Chest X -rays  produce images of your
heart, lungs, blood vessels, airways, and
the bones of your chest  and spine
 CT SCAN
 A chest injury  is any form of physical
injury to the chest including the ribs, heart
and lungs. ... Diagnosis of blunt injuries
may be more difficult and require
additional investigations such as CT
scanning .
 ECHOCARDIOGRAPHY
 Echocardiography  is a diagnostic test
that uses ultrasound waves to create an
image of the heart muscle, lungs .
Ultrasound the heart can show the size,
shape, and movement of the heart's
valves and chambers as well as the flow
of blood through the heart.
ABG ANALYSIS

 An arterial blood gas  (ABG ) test

measures the acidity (pH) and the
levels of oxygen and carbon dioxide in
the blood from an artery. This test is
used to check how well your lungs are
able to move oxygen into the blood
and remove carbon dioxide from the
blood.
ANGIOGRAPHY
 CT angiography  uses a CT  scanner
to produce detailed images of both
blood vessels and tissues in various
parts of the body. An iodine-rich
contrast material (dye) is usually
injected through a small catheter
placed in a vein of the arm.
Injuries of chest

 Simple/Closed Pneumothorax
 Open Pneumothorax
 Tension Pneumothorax
 Flail Chest
 Cardiac Tamponade
 Traumatic Aortic Rupture
 Traumatic Asphyxia
 Diaphragmatic Rupture
 1. Simple/Closed
Pneumothorax
o Accumulation of air in the pleural space without an
apparent antecedent event.
o Caused by rupture of small
blebs(small sac of the air ) on the visceral pleural
space
o Blunt trauma is main
o May be spontaneous
o Usually self correcting
S/S of Simple/Closed
Pneumothorax
 Pleuritic Chest Pain
 Dyspnoea
 Tachypnea ( ABNORMAL RAPID
BRATHING )
 Decreased Breath Sounds on
Affected Side
 Hypertymphany to percussion
( like sound heard over air filled
structure during the abdominal
examination
Treatment for Simple/Closed
Pneumothorax
 ABC’s with C-spine control
 Administer high concentration of oxygen to treat
hypoxia
 Remove clothing to assess injury
 Insert chest tube with connection to suction to
remove remaining air and fluid / water seal
drainage
 Constant monitoring
 Opening is plugged to align it with gauze
impregnated with petroleum. A pressure dressing
is applied and secured with a circumferential strap
 Give semi- fowlers position or on injured site
 Administer Antibiotics
Ongoing monitoring
 Vital signs
 Level of consciousness
 Oxygen saturation
 Cardiac rhythm
 Respiratory status
 Urinary output
 2. Open Pneumothorax
 Opening in chest cavity
that allows air to
enter pleural cavity.
 Causes the lung to

collapse due to increased

pressure in pleural cavity.
E.g. Stab/ gunshot wounds.
 Can be life threatening and

can deteriorate rapidly

Open Pneumothorax
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothoarx
Inhale
Open Pnuemothorax
Inhale
S/S of Open
Pneumothorax
 Dyspnea
 Sudden sharp pain
 Subcutaneous Emphysema
 Decreased lung sounds on affected
side
 Red Bubbles on Exhalation from
wound ( a.k.a. Sucking chest
wound)
Subcutaneous
Emphysema
 Air collects in subcutaneous fat from
pressure of air in pleural cavity
 Feels like rice crispies or bubble wrap
 Can be seen from neck to groin area
Sucking Chest Wound
Treatment for Open
Pneumothorax
 ABC’s with c-spine control as
indicated
 High Flow oxygen
 Listen for decreased breath sounds on
affected side
 Apply occlusive dressing to wound
 Notify Hospital
 Occlusive/ Vented Dressing

 Allows air to escape

from the vent and
decreases the
likelihood of tension
pneumothorax
developing
Occlusive Dressing
 Asherman Chest
Seal
3. Tension
Pneumothorax
 Air builds in pleural space with no
where for the air to escape
 Results in collapse of lung on affected
side that results in pressure on
mediastium,the other lung, and great
vessels
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
The trachea is
pushed to
the good side

Heart is being
compressed
S/S of Tension
Pneumothorax
 Anxiety/Restlessne  Accessory Muscle
ss Use
 Severe Dyspnea  JVD

 Absent Breath  Narrowing Pulse

sounds on affected Pressures
side  Hypotension
 Tachypnea  Tracheal Deviation
 Tachycardia (late if seen at all)
 Poor Color
TREATMENT
 Monitor Cardiac Rhythm
 Establish IV access and Draw Blood
Samples
 Airway control including Intubation
 Needle Decompression of Affected
Side
Needle Decompression
 Locate 2-3 Intercostals space midclavicular
line
 Cleanse area using aseptic technique
 Insert catheter ( 14g or larger) at least 3” in
length over the top of the 3rd rib( nerve,
artery, vein lie along bottom of rib)
 Remove Stylette ( a flexible metallic rod
inserted in the lumen of a flexible catheter )
and listen for rush of air
 Place Flutter valve over catheter
 Reassess for Improvement
Needle Decompression
4, Hemothorax
 Occurs when pleural space fills with
blood
 Usually occurs due to lacerated blood
vessel in thorax
 As blood increases, it puts pressure
on heart and other vessels in chest
cavity
 Each Lung can hold 1.5 liters of blood
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax

May put pressure on the heart

Hemothorax
Where does the blood come
from.

Lots of blood vessels

S/S of Hemothorax
 Anxiety/Restlessness
 Tachypnea
 Signs of Shock
 Frothy, Bloody Sputum
 Diminished Breath Sounds on Affected
Side
 Tachycardia
 Flat Neck Veins
Treatment for
Hemothorax
 ABC’s with c-spine control as
indicated
 Secure Airway assist ventilation if
necessary
 General Shock Care due to Blood loss
 Consider Left Lateral Recumbent
position if not contraindicated
 RAPID TRANSPORT
 Contact Hospital
5. Flail Chest

The breaking of 2
or more ribs in 2
or more places
Flail Chest
S/S of Flail Chest
 Shortness of Breath, respiratory
distress, Pneumothorax
 Paradoxical Movement
 Bruising/Swelling
 Crepitus( Grinding of bone ends on
palpation)
 Hypotension
Treatment of Flail Chest
 Flail Chest is a True Emergency
 Ensure airway
 Administer oxygen
 Assist ventilation. Chest decompression is done
for pneumothorax.
 Establish I/V line
 Restrict fluid intake, prescribe corticosteroids and
albumin to treat pulmonary contusion
 Prepare for operative stabilization of chest wall
Bulky Dressing for splint
of Flail Chest
 Use Trauma
bandage and
Triangular
Bandages to splint
ribs.
 Can also place a
bag of D5W on
area and tape
down. (The only
good use of D5W I
can find)
6. Pericardial
Tamponade Blood and fluids
leak into the
pericardial sac
which surrounds the
heart.
As the pericardial
sac fills, it causes
the sac to expand
until it cannot
pericardial sac expand anymore
Pericardial Tamponade
Once the
pericardial sac
can’t expand
anymore, the
fluid starts putting
pressure on the
heart
Now the heart
can’t fully expand
and can’t pump
effectively.
Pericardial Tamponade
With poor pumping
the blood pressure
starts to drop.
The heart rate starts
to increase to
compensate but is
unable
The patient’s level of
conscious drops, and
eventually the patient
goes in cardiac arrest
 pericardial tamponade ,
is when fluid in
the pericardium  (the sac
around the heart) builds up and
results in compression of the
heart. .
 S/S of Pericardial
Tamponade
 Distended Neck Veins
 Increased Heart Rate
 Respiratory Rate increases, cyanosis
 Anxious, confused
 Muffled heart sound
 Hypotension, pulses paradoxes
 Shock, Death
Treatment of Pericardial
Tamponade
 Check for ABC
 High Flow oxygen which may include
BVM
 Treat S/S of shock
 Assist with pericardiocentesis
 Prepare for emergency thoracotomy
Treatment
 Cardiac Monitor
 Large Bore IV access
 Perform pericardiocentesis
 Pericardiocentesis
 Using aseptic technique, Insert at least needle at
the angle of the Xiphoid Cartilage at the 7 th rib
 Advance needle at 45 degree towards the clavicle
while aspirating syringe till blood return is seen
 Continue to Aspirate till syringe is full then discard
blood and attempt again till signs of no more blood
 Closely monitor patient due to small about of blood
aspirated can cause a rapid change in blood
pressure
7. Traumatic Aortic
Rupture
The heart, more or less, just
hangs from the aortic arch
Much like a big pendulum.

If enough motion is placed on

the heart (i.e.. Deceleration
From a motor vehicle
accident, striking a tree while
skiing etc) the heart may tear
away from the aorta.
Traumatic Aortic Rupture
The chances of survival are
very slim and are based on the
degree of the tear.

If there is just a small tear then

the patient may survive. If the
aorta is completely transected
then the patient will die
instantaneously
S/S Of Traumatic Aortic
Rupture
 Burning or Tearing Sensation in chest
or shoulder blades
 Rapidly dropping Blood Pressure
 Pulse Rapidly Increasing
 Decreased or loss of pulse or b/p on
left side compared to right side
 Rapid Loss of Consciousness
Treatment
 Monitor Cardiac Rhythm
 Large Bore IV therapy probably 2 and
draw blood samples
 Airway management that may include
Intubation
8. Traumatic Asphyxia
 Results from sudden compression
injury to chest cavity
 Can cause massive rupture of Vessels
and organs of chest cavity
 Ultimately Death
S/S of Traumatic
Asphyxia
 Severe Dyspnea
 Distended Neck Veins
 Bulging, Blood shot eyes
 Swollen Tounge with cyanotic lips
 Reddish-purple discoloration of face
and neck
 Petechiae
Treatment
 Cardiac Monitor
 Establish IV Access and draw blood
samples
 Airway control including Intubation
 Rapid transport
9. Diaphragmatic
Rupture
 A tear in the Diaphragm that allows
the abdominal organs enter the chest
cavity
 More common on Left side due to liver
helps protect the right side of
diaphragm
 Associated with multipile injury
patients
Diaphragm Rupture
S/S of Diaphragmatic
Rupture
 Abdominal Pain
 Shortness of Air
 Decreased Breath Sounds on side of
rupture
 Bowel Sounds heard in chest cavity
Treatment
 Cardiac Monitor
 Establish IV access and draw blood
samples
 Airway management including Intubation
 Observe for Pneumothorax due to
compression on lung by abdominal contents
 Possible insertion of NG tube to help
decompress the stomach to relieve pressure
 Management of patients with
Thoracic Trauma
 The treatment of polytraumatized patient must
follow a certain protocol which includes.
– Adequate oxygenation.
– Fluid replacement.
– Surgical intervention.
– Treatment of septic complications.
– Adequate caloric and substrate supplementation.
– Prevention of stress bleeding.
– Finally, be alert of possible complication (CNS, ARDS,
hepatic, renal, coagulation disorders, sepsis.
RIB FRACTURE:
 SIGN AND SYMPTOMS:
 SEVERE PAIN, TENDERNESS
 MUSCLE SPASM WHICH AGGRAVATE
WITH COUGHING , DEEP BREATHING
AND MOTION
 CRACKLING SOUND WITH GRATING
 UNSTABLE RIB CAGE ON PALPATION
 TREATMENT
 ENSURE AIRWAY AND ADMINISTER
OXYGEN
 Stabilize with hand followed by application
of large pieces of tape horizontal across
the flail segment
 GIVE ANALGESIC
 ENCOURAGE FOR DEEP BREATHING
 MAINTAIN PATENT I/V LINE
 ASSESSMENT:
 A- AIRWAY MAINTENANCE WITH
CERVICAL SPINE PROTECTION
 B- BREATHING AND VENTILATION
 C- CIRCULATION WITH HEMORRHAGE
CONTROL
 D- DISABILITY, NEUROLOGICAL
STATUS
 E- EXPOSURE/ ENVIRONMENTAL
CONTROL, PREVENT HYPOTHERMIA
 NURSING PROCESS
 INEFFECTIVE BREATHING PATTERN RELATED
TO CHEST INJURY
 RISK FOR DEFICIENT FLUID VOLUME RELATED
TO CHEST DRAINAGE AND BLOOD LOSS
 ACUTE PAIN RELATED TO CHEST INJURY AND
PRESENCE OF DRAINAGE TUBES IN THE CHEST
 IMPAIRED PHYSICAL MOBILITY RELATED TO
PAIN, MUSCLE INJURY
 RISK FOR INEFFECTIVE INDIVIDUAL COPING
RELATED TO
TEMPORARY DEPENDENCE AND LOSS OF FULL
RESPIRATORY FUNCTION
COMPLICATION
 ASPIRATION
 ATELECTESIS ( collapse or closure of
a lung )
 INFECTION
 PNEUMONIA
 RESPIRARATORY FAILURE
=inadequate gas exchange by the
respiratory system
 Summary

Chest Injuries are common and often life

threatening in trauma patients. So, Rapid
identification and treatment of these patients is
paramount to patient survival. Airway
management is very important and aggressive
management is sometimes needed for proper
management of most chest injuries.