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Untitled Prezi

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Keylenz Carantes

on 25 June 2013

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Blunt Chest Trauma
 Results from sudden compression or positive pressure inflicted to the chest wall.
 Motor vehicle crashes, falls, and bicycle crashes are the most common causes of this.
 More common but the extent of damage because of the symptoms may be generalized and vague

Chest Trauma
Penetrating Trauma
 Occurs when a foreign object penetrates the chest wall.
 The most common causes of penetrating chest trauma include gunshot wounds and stabbings.

PATHOPHY
Injuries to the chest are often life threatening and result in one or more of the following pathologic mechanisms:

1. Hypoxemia from disruption of the airway; injury to the lung parenchyma, rib cage, and respiratory musculature; massive hemorrhage; collapsed lung; and pneumothorax
2. Hypovolemia from massive fluid loss from the great vessls, cardiac rupture, or hemothorax
3. Cardiac failure from cardiac tamponade, cardiac contusion, or increased intrathoracic pressure

Rib
Fractures
Fractures
&
Manifestation
• Rib fractures are the most common type of chest trauma, occurring in more than 60% of patients admitted with blunt chest injury
• Fractures of the first three ribs are rare but can result in a high mortality rate because they are associated with laceration of the subclavian artery or vein.
• The fifth through ninth ribs are the most common sites of fractures.
• Fractures of the lower ribs are as- sociated with injury to the spleen and liver, which may be lacer- ated by fragmented sections of the rib.
• Most rib fractures heal in 3-6 weaks.

MANIFESTATIONS
• Severe pain
• Point tenderness
• Muscle spasm over the area of the fracture which is aggravated by coughing, deep
breathing and movement
• Area around the fracture may be bruised
• Diminished ventilation due to reluctance to move or breathe deeply
• Collapse of unerated aveoli (atelectasis)
• Pneumonitis
• Hypoxemia

Some
Assessment
Diagnosis
Management
MEDICAL
• Goal: control pain and detect and treat the injury
• Sedation to relieve pain and to allow deep breathing and coughing
• Intercostal nerve block and ice over the fracture site
• Chest binder to decrease pain upon movement
• Usually the pain subsides after 5-7 days and discomfort can be controlled with epidural analgesia or nonopiod analgesia
• Close monitoring for signs and symptoms of associated injuries

ASSESSMENT AND DX FINDINGS
• Xray rib films of the specific area
• ECG
• Continuous pulse oximetry
• ABG analysis

FLAIL
Chest

• Frequently a complication of blunt chest trauma from a steering wheel injury.

• It usually occurs when three or more adjacent ribs (multiple contiguous ribs) are fractured at two or more sites, resulting in free-floating rib segments. As a result, the chest wall loses stability and there is subsequent respiratory impairment and usually severe respiratory distress.


Results in  impaired ventilation and perfusion leading to ARF, hypovolemic shock, and death
PATHOPHYSIOLOGY

 During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pen- delluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs.
 On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient’s ability to exhale.

 The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
Retained airway secretions and atelectasis frequently accompany flail chest.

 The patient has hypoxemia, and if gas exchange is greatly compromised, respiratory acidosis develops as a result of CO2 retention. Hypotension, inadequate tissue perfusion, and metabolic acidosis often follow as the paradoxical motion of the mediastinum decreases cardiac output.

Managements
Medical
NURSING
• Supportive
• Ventilator support
• Clearing secretions from the lungs
• Controlling pain key to successful treatment
• Carefully monitored by chest x-rays, ABG analysis, pulse oximetry and bedside pulmonary function monitoring.

Based
ON
The degree
OF
Respiratory
Distress
1. Small segment of the chest
• Clear the airway through positioning, coughing, deep breathing, and suctioning to aid in the expansion of the lung
• Relieve pain by intercostal nerve blocks, high thoracic epidural clocks, or IV opioids

2. Mild to moderate flail chest injuries
• Underlying pulmonary contusion is treated by: monitoring fluid intake and appropriate fluid replacement
• Relieve chest pain
• Pulmonary physiotherapy focusing on lung volume expansion
• Secretion management techniques are performed
• Close monitoring for further respiratory compromise

3. Severe flail
• ET
• Mechanical ventilation
• Allows pneumatic stabilization of underlying pulmonary contusion, stabilize thoracic cage to allow fractures to heal and improves alveolar ventilation.
• RARE surgery for high risk patients with underlying lung disease or who is difficult to ventilate

Pneumothorax
• Occurs when the parietal or visceral pleura is breached and the pleural space is exposed to positive atmospheric pressure
• Normally the pressure in the pleural space is negative or sub atmospheric compared to atmospheric pressure; this negative pressure is required to maintain lung inflation. When either pleura is breached, air enters the pleural space, and the lung or a portion of it collapses.
1. SIMPLE/SPONTANEOUS
• Occurs when air enters the pleural space through a breach of either the parietal or visceral pleura.
• A spontaneous pneumothorax may occur in an apparently healthy person in the absence of trauma due to rupture of an air-filled bleb, or blister, on the surface of the lung, allowing air from the airways to enter the pleural cavity.
• It may be associated with diffuse interstitial lung disease and severe emphysema.

2. TRAUMATIC/OPEN PNEUMOTHORAX
• Occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall.
• It can occur with blunt trauma (eg, rib fractures) or penetrating chest trauma, abdominal trauma (eg, stab wounds or gunshot wounds to the abdomen)
• Traumatic pneumothorax resulting from major injury to the chest is often accompanied by hemothorax (collection of blood in the pleural space resulting from torn intercostal vessels, lacerations of the great vessels, and lacerations of the lungs).

TYPES
MEDICAL
Management
MANAGEMENT:
1. The severity of open pneumothorax depends on the amount and rate of thoracic bleeding and the amount of air in the pleural space.
2. The pleural cavity can be decompressed by needle aspiration (thoracentesis) or chest tube drainage of the blood or air.
3. Thoracotomy when more than 1,500 mL of blood is aspirated initially by thoracentesis or when there is suggested cardiovascular injury secondary to chest or penetrating trauma

3. TENSION PNEUMOTHORAX
• Occurs when air is drawn into the pleural space from a lacerated lung or through a small hole in the chest wall.
• It may be a complication of other types of pneumothorax.

MANAGEMENT:

1. Immediately given high concentration of supplemental oxygen to treat hypoxemia
2. Pulse oximetry
3. In an emergency situation, a tension pneumothorax can be decompressed or quickly converted to a simple pneumothorax by inserting a large-bore needle (14-gauge) at the second intercostal space, midclavicular line on the affected side. This relieves the pressure and vents the positive pressure to the external environment.
4. A chest tube is then inserted and connected to suction to remove the remaining air and fluid, re-establish the negative pressure, and re-expand the lung.
5. If a prolonged air leak continues despite chest tube drainage to underwater seal, surgery may be necessary to close the leak.

Management
&
Manifes
tation
1. Immediately given high concentration of supplemental oxygen to treat hypoxemia
2. Pulse oximetry
3. In an emergency situation, a tension pneumothorax can be decompressed or quickly converted to a simple pneumothorax by inserting a large-bore needle (14-gauge) at the second intercostal space, midclavicular line on the affected side. This relieves the pressure and vents the positive pressure to the external environment.
4. A chest tube is then inserted and connected to suction to remove the remaining air and fluid, re-establish the negative pressure, and re-expand the lung.
5. If a prolonged air leak continues despite chest tube drainage to underwater seal, surgery may be necessary to close the leak.


• Depends on it’s size and cause
• Pain is usually sudden and may be pleuritic
• If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs.


• SIMPLE:
1. Pain is usually sudden and may be pleuritic
2. Minimal respiratory distress
3. Slight chest discomfort
4. Tachypnea


• SEVERE
1. Anxious
2. Dyspnea and air hunger
3. Increased use of the accessory muscles
4. May develop central cyanosis from severe hypoxemia.

• Severe chest pain may occur, accompanied by tachypnea, decreased movement of the affected side of the thorax, a tympanic sound on percussion of the chest wall, and decreased or absent breathe sounds and tactile fremitus on the affected side.
• The clinical picture is one of air hunger, agitation, increasing hypoxemia, central cyanosis, hypotension, tachycardia, and profuse diaphoresis.

Types
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