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

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 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

Pathophysiology

Negative 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 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

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 hemorrhage

Insert at least two large bore IV catheters

Central/femoral/subclavian/IJV access

Control hemorrhage and then replace

Consider auto transfusion