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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 tree Classification Blunt injuries Penetrating injuries Etiology Motor vehicle accidents Fall from height Violence Iatrogenic Mechanisms involved Acceleration force Deceleration force Transmission of blunt force to structures Direct trauma Compression internal force to Chest trauma Chest wall injuries Pneumothorax Sternal fractures Hemothorax Flail chest Mediastinal injuries Pulmonary and cardiac injuries pleural injuries Traumatic asphyxia Tracheo bronchial injuries Great vessel injuries Diaphragmatic injuries Oesophageal injuries From history (King Tut 1341 BC – 1323 BC) Pulmonary injuries Pneumothorax Collection 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 manifestations Distended neck veins Hypotension/hypoperfusion Absent breath sounds on affected side Tracheal deviation to contra lateral side 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 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 Pneumothorax Clinical manifestations •Air entry and breath sounds diminished in the affected side •Impaired chest wall motion Pathophysiology Negative intrapleural pressure during inspiration Air leak into the pleural cavity Increased intra thoracic pressure Reduced vital capacity and venous return 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 Pneumothorax Open pneumothorax 3-side dressing Asherman chest seal Massive hemothorax Accumulation of at least 1500 ml or two thirds of the available hemithorax in an adult Hemothorax Life threatening by three mechanisms Acute hypovolemia causing decreased preload Collapsed lung promoting hypoxia Hemothorax compressing venacava impairing preload Hemothorax Clinical manifestations Abnormal vital signs Dullness to percussion Diminished breath sounds Diagnosis Plain chest radiography completely opacified hemithorax Ultrasonography-fluid between chest wall and lung 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 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 Flail chest Clinical manifestations Paradoxical 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 Management-Flail chest Analgesics Ventilator support stabilization 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 Management- Repair of diaphragm Cardiac injuries 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 Cardiac tamponade Pathophysiology Elevated intra cardiac pressure Decreased right and left ventricular filling Decreased cardiac output Management-Pericardiocentesis Great vessel injuries The main vessels Aorta Brachio cephalic branches Pulmonary arteries and veins Venae cavae Thoracic duct 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 Aortic rupture 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 Nursing diagnoses Acute pain Fluid volume deficit Decreased cardiac output Inability to sustain spontaneous ventilation Ineffective breathing pattern Impaired gas exchange Impaired tissue perfusion Other investigations CT Bronchoscopy Oesophagoscopy Oesophagography Angiography Airway management Indications for mechanical ventilation o Altered mental status o Excessive secretions o Associated face and neck injuries o Impending respiratory failure o Cardiopulmonary collapse o Significant co morbidities o Advanced age o ABG abnormalities 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