2 nd annual rapid review 12.o3.12 care of patient with chest injuries
DESCRIPTION
2 ND ANNUAL RAPID REVIEW 12.O3.12 CARE OF PATIENT WITH CHEST INJURIES. Sujitha .E, Lecturer, Faculty of Nursing, Sri Ramachandra University, Porur. Chest cavity. Soft tissues Lungs Heart Great vessels diaphragm oesophagus. Bony areas. Ribs Sternum Clavicle Tracheo broncheal - PowerPoint PPT PresentationTRANSCRIPT
Sujitha .E,Lecturer,
Faculty of Nursing,Sri Ramachandra University, Porur
Chest cavitySoft tissuesLungsHeartGreat vesselsdiaphragmoesophagus
Bony areas
RibsSternumClavicleTracheo broncheal tree
ClassificationBlunt injuries Penetrating injuries
EtiologyMotor vehicle accidentsFall from heightViolenceIatrogenic
Mechanisms involvedAcceleration forceDeceleration forceTransmission of blunt internal
force to force to structuresDirect traumaCompression
Chest traumaChest wall injuriesSternal fracturesFlail chestPulmonary and
pleural injuriesTraumatic
asphyxiaTracheo bronchial
injuries
PneumothoraxHemothoraxMediastinal injuriescardiac injuriesGreat vessel
injuriesDiaphragmatic
injuriesOesophageal
injuries
From history (King Tut 1341 BC – 1323 BC)
Pulmonary injuries PneumothoraxCollection of air in the space between the parietal and visceral pleura
Tension pneumothorax
An expanding collection of intra pleural air without communication with external environment
Clinical manifestationsDistended neck veinsHypotension/hypoperfusionAbsent breath sounds on affected sideTracheal deviation to contra lateral side
ManagementImmediate needle aspiration14 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
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
PneumothoraxClinical manifestations•Air entry and breath sounds diminished in the affected side•Impaired chest wall motion
PathophysiologyNegative intrapleural pressure during
inspiration
Air leak into the pleural cavity
Increased intra thoracic pressure
Reduced vital capacity and venous return
PneumothoraxDiagnosisChest radiography(double pleural markings)UltrasoundManagementCover the wound with a three sided dressingAir can escape during expiration but do not
enter during inspiration(one way valve)Chest tube insertion
Pneumothorax
Open pneumothorax3-side dressing Asherman chest seal
Massive hemothoraxAccumulation of at least 1500 ml or
two thirds of the available hemithorax in an adult
HemothoraxLife threatening by three
mechanismsAcute hypovolemia causing
decreased preloadCollapsed lung promoting hypoxiaHemothorax compressing venacava impairing preload
HemothoraxClinical manifestations Abnormal vital signs Dullness to percussion Diminished breath soundsDiagnosisPlain chest radiography completely
opacified hemithoraxUltrasonography-fluid between chest wall
and lung
ManagementChest tube insertionCare of chest tubePosition-last hole 2.5-5 cm inside chest wallSuction chamber with 20-30 cm of waterNever clamp the tubesBottle at 1-2 ft lower than patient’s chestLeft in place for 24 hrs after leak has stopped
Flail chestFree floating lung segment that is no
longer connected to the rest of the thorax
CauseSegmental rib fractures in two or
more locations of the same rib of three or more adjacent ribs
Flail chestClinical manifestationsParadoxical inward movement of the involved portion of the chest wall during inspiration and outward movement during expiration
Pathophysiology-flail chest
Decreased ventilatory efficiency
Increased work of breathing
Hypoxemia
Sudden respiratory arrest
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Management-Flail chest
AnalgesicsVentilator support
stabilization
Diaphragmatic injuryOften unnoticed if not very big defectCauses referred shoulder painRespiratory distress (herniation of abdominal
contents into the thorax)DiagnosisDecreased breath soundsAuscultation of bowel sounds in the chestTension viscero thoraxBowel obstruction and strangulation
Management- Repair of diaphragm
Cardiac injuries
Cardiac tamponadeAccumulation of blood in the pericardial
cavity under pressureCommon causes are gunshot wounds and
stabsClinical features Tachycardia Narrow pulse pressure Elevated CVP Hypotension
Becks triad
Cardiac tamponade Pathophysiology
Elevated intra cardiac pressure
Decreased right and left ventricular filling
Decreased cardiac output
Management-Pericardiocentesis
Great vessel injuriesThe main vessels AortaBrachio cephalic
branchesPulmonary arteries
and veinsVenae cavaeThoracic duct
Aortic injuryCommonly injured part is proximal descending aortaClinical manifestationsHypo tensionhypertension in upper extremity& hypotension in
lower extremitiesIntra capsular murmurs or bruitsDiagnosisChest radiographTEECHOAortography
Aortic rupture
ManagementPharmacologic control of heart rate and blood
pressure(around 60/mt and 100-120 mmHg systolic)
Hemodynamic monitoring (pul.catheter)SedativesAnalgesicsVasodilators (sodium nitroprusside)β –blockers (esmolol)Auto transfusionSurgical repair
Nursing diagnosesAcute painFluid volume deficitDecreased cardiac outputInability to sustain spontaneous ventilation Ineffective breathing patternImpaired gas exchangeImpaired tissue perfusion
Other investigationsCTBronchoscopyOesophagoscopyOesophagographyAngiography
Airway management- Airway management- IndicationsIndications for mechanical ventilation for mechanical ventilationo Altered mental statusAltered mental statuso Excessive secretionsExcessive secretionso Associated face and neck injuriesAssociated face and neck injurieso Impending respiratory failureImpending respiratory failureo Cardiopulmonary collapseCardiopulmonary collapseo Significant co morbiditiesSignificant co morbiditieso Advanced ageAdvanced ageo ABG abnormalitiesABG abnormalities
Fluid resuscitationGoal: to stabilize the intravascular volume sufficiently
to provide time to manage hemorrhageInsert at least two large bore IV catheters
Central/femoral/subclavian/IJV accessControl hemorrhage and then replaceConsider auto transfusion