Chest Trauma

Question 1

Causes of Chest Trauma

Answer 1

1. Planned Trauma or Intentional Trauma (Chest Surgery)

• Thoracotomy: Surgical opening into the thoracic cavity
• Pneumonectomy: removes the entire lungs
• Lobectomy: removes the entire lobe
• Wedge Resection: removes a small portion of a lobe
• Segmental Resection: removes a larger portion of a lobe

2. Unplanned Trauma

Penetrating Trauma**

• When a foreign body impales or passes through the body tissues
• Serious injury is possible to heart, lungs and thoracic structures.> Gunshot, stabbing wounds, Arrow, other missiles

Nonpenetrating or Blunt Trauma

• The body is struck by a blunt object (steering wheel)
• External injury may appear minor, but the impact my cause severe, life threatening internal injuries.

        \> Falls or blows to the chest (slamming into the steering wheel), deceleration injuries, pedestrian accident, crush injury, explosion

Question 2

Assessment

Answer 2

• Initial Assessment: ABC’s

        \> Airway patency
        \> Adequate breathing
        \> Circulatory sufficiency

**Any chest trauma is considered life threatening.
**

A Quick History
- What happened?
- What was the mechanism of injury?
- How long ago did it happen?
- Where is the pain?
- Is there anything that makes the pain better or worse?
- What does the pain feel like?
- How severe is the pain on a scale of 1 - 10?

- Is there any medical history?
> Meds??: Coumadin

• Physical Examination
• Chest X-ray
• Lab Data

Question 3

Chest Trauma Complication: Pneumothorax

Closed and Open

Answer 3

• Presence of air in the pleural space
• Result to a complete / partial collapse of a lung d/t accumulation of air in the pleural space
• Dyspnea, decrease movement of affective chest wall, decrease/no breath sounds on affective side

  \> Partial – Complete
  \> Closed – Open 

_Closed or Spontaneous Pneumothorax _

• Most common
• Air enters into the pleural space from a puncture or tear in an internal respiratory structure.
• Accumulation of air in the pleural space w/o apparent antecedent event

        \> Puncture into the pleural space
        \> Not evident; you don’t see it when you look directly at the patient

• Has no associated external wound
• Cause by the rupture of small blebs.
• Spontaneous pneumothorax

Open Pneumothorax

• Air enters the pleural space directly through a hole in the chest wall or diaphragm. ( opening in the chest call
• The air moves in and out with each breath, can hear a sucking or slurping sound which is clearly 
audible on the affected side.

        \> Only a tiny bit of air escapes after exhaling
        \> Can lead to lung collapse d/t accumulation of air getting trap in the plural space
        \> Stab wounds, gunshot and surgical thoracotomy.
          \> should be stabilize until a physician is present

Question 4

Chest Trauma Complication: Mediastinal Flutter

Answer 4

• As the air (inspiration) enters the pleural space from an open wound, all the mediastinal structures and the collapsed lung are pushed to towards the unaffected side.
• On expiration these structures move back into the affected side.

Question 5

Chest Trauma Complication: Tension Pneumothorax

Answer 5

A medical emergency!

1. The result of a open pneumothorax
2. Result of an untreated chest trauma

• Air enters the pleural space with each breath, becomes trapped there and is not expelled (one-way valve effect) due to an internal injury.
• High intra-pleural pressures with resultant tension on the heart and great vessels.

        \> Interfering with the function of the organs and blood flow

• Air continues to enter. Positive pressure builds and the lung collapses. The mediastinal contents shift to the unaffected side.
• Air enters and contents move to the unaffected side
• The functional lung can be twisted which can cause torsion or kinking of great vessels.

        \> Blood return to the heart is reduced,
        \> Cardiac output is reduced
        \> Blood pressure is lowered.
        \> Can result in shock and death. 


Question 6

Assessment findings of all pleural injuries

Answer 6

• Tachycardia
• Dyspnea, respiratory distress
• Sudden sharp pain with chest movements, breathing or coughing 
(suspect broken ribs)
• May have hemoptysis (coughing up blood)
• Diminished or absent breath sounds on the affected side
• Decrease 02 sat
• Frothy Secretion
• Restlessness
• Anxiety

___________________________________________

• Distended neck veins
• Asymmetrical chest wall movement
• Muffled heart sounds
• Subcutaneous emphysema

** > Crepitates**

• Laryngeal & tracheal deviation toward the unaffected side
• Rapid, thready pulse

___________________________________________

• Tightness or pressure in the chest

        \> A lot of pressure

• Progressive cyanosis

        \> Lips, nail beds, mucous membranes

• Severe hypotension
• Shock
• ABG’s show hypoxia & resp. alkalosis
• Progresses to respiratory acidosis (ICU)

To validate what is going on…

• Chest x-ray shows tracheal shift away from the affected side and retraction of the lung back from the parietal pleura.
  > CXR will help you determine: Bleeding? Fracture ribs? Air?

Question 7

Emergency Care

Answer 7

• Airway maintenance
  -Oxygen
  > 2L/min NP
• Closed chest drainage will drain off air and blood and helps the lung expand by establishing negative pressure.
• Needle decompression
• Thoracotomy – to repair injured tissues and vessels etc.