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CHEST INJURIES
A chest injury is any form of physical injury to the chest including the heart and lungs.
Typically chest injuries are caused by blunt mechanisms such as motor vehicle collisions or
penetrating mechanisms such as stabbings.
Classification
on the basis of
mechanism of on the basis of
injury anatomical part
involvement
blunt Compres chest blood
penetrating sion pulmonar airway cardiac
trauma trauma wall injuries vessels
Injury- injuries y injuries injuries
injuries
ON THE BASIS OF MECHANISM OF INJURY
1. Blunt trauma is the Blunt force to chest when there is no injury to the skin but
trauma to chest occurs.
blunt steering wheel injury
crush injury
fall
sudden force to the chest due to hit of baseball, cricket ball
2. Penetrating trauma Projectile that enters chest causing small or large hole.
Gunshot or stab wound to chest
3. Compression Injury- Chest is caught between two objects and chest is compressed.
ON THE BASIS OF ANATOMICAL PART INVOLVEMENT
1. Injuries to the chest wall
o Chest wall contusions or hematomas.
o Rib fractures
o Flail chest
o Sternal fractures
o Fractures of the shoulder girdle
2. Pulmonary injury (injury to the lung) and injuries involving the pleural space
o Pulmonary contusion
o Pulmonary laceration
o Pneumothorax
o Hemothorax
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o
Hemopneumothorax
3. Injury to the airways
o Tracheobronchial tear
4. Cardiac injury
o Pericardial tamponade
o Myocardial contusion
o Traumatic arrest
5. Blood vessel injuries
o Traumatic aortic rupture, thoracic aorta injury, aortic dissection
Causes
Motor vehicle accidents
Fall
Assault with blunt object
Crush injury
Explosion
Penetrating injuries due to knife, gunshot, stick, arrow
Common chest injuries
A.) PNEUMOTHORAX is defined as air in the pleural space, so there is partial or
complete collapse of the lungs occurs mostly due to the blunt trauma to the chest.
Types
I. Closed pneumothorax
a. Opening in lung tissue that leaks air into chest cavity
b. Blunt trauma is main cause
c. May be spontaneous
d. Usually self correcting
Causes
Injury to the lungs from mechanical ventilation
Injury to the lungs from insertion of subclavian catheter
Injury to the lungs from broken ribs
Ruptured blebs or bullae in a patients with COPD
Perforation of the esophagus
Sign and symptoms
Chest Pain
Dyspnea
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Tachypnea
Decreased Breath Sounds on Affected Side
II. Open Pneumothorax
Opening in chest cavity that allows air to enter into the pleural cavity
Causes the lung to collapse due to increased pressure in pleural cavity
Can be life threatening and can deteriorate rapidly
Causes
Stab or gunshot wounds
Surgical thoracotomy
Sign and symptoms
Dyspnea
Sudden sharp pain
Subcutaneous Emphysema (Air collects in subcutaneous fat from pressure of air in
pleural cavity, Feels like rice crispies or bubble wrap, Can be seen from neck to
groin area)
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound
B. Tension Pneumothorax
Air builds in pleural space with nowhere for the air to escape due to the rapid
accumulation of the air in the air space.
Results in collapse of lung on affected side that results in pressure on mediastium,
the other lung, and great vessels
S/S of Tension Pneumothorax
Anxiety/Restlessness Severe Dyspnea
Violent Absent Breath sounds on affected side
Agitation Tachypnea
Air hunger Tachycardia
Narrowing Pulse Pressures Cyanosis
Hypotension Accessory Muscle Use
Tracheal Deviation JVD (jugular vein distension)
C. Hemothorax
Occurs when pleural space fills with blood
Usually occurs due to lacerated blood vessel in thorax
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As blood increases, it puts pressure on heart and other vessels in chest cavity
Each Lung can hold 1.5 liters of blood
Causes
Chest trauma
Lung malignancy
Complications of anticoagulant therapy
Pulmonary embolism
Tearing of pleural adhesions
S/S of Hemothorax
Anxiety/Restlessness
Tachypnea
Signs of Shock
Frothy, Bloody Sputum
Diminished Breath Sounds on Affected Side
Tachycardia
Flat Neck Veins
Dullness to percussion
D. Chylothorax
It is defined as the lymphatic fluid in the pleural space due to a leak in the thoracic duct.
Causes
Trauma
Surgical procedures
Malignancy
Sign and symptoms
Mild to moderate tachycardia
Dyspnea
Shallow or rapid respirations
E. Flail chest
It results from multiple rib fractures causing unstable chest wall.
The flail segment usually involves the anterior or lateral rib fractures
The affected area move paradoxically
S/S of Flail Chest
Shortness of Breath
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Paradoxical Movement
Bruising/Swelling
Crepitus( Grinding of bone ends on palpation)
F. Pericardial Tamponade
Blood and fluids leak into the pericardial sac which surrounds the heart.
As the pericardial sac fills, it causes the sac to expand until it cannot expand anymore
Once the pericardial sac can’t expand anymore, the fluid starts putting pressure on
the heart
Now the heart can’t fully expand and can’t pump effectively.
With poor pumping the blood pressure starts to drop.
The heart rate starts to increase to compensate but is unable
The patient’s level of conscious drops, and eventually the patient goes in cardiac
arrest
Sign and symptoms
• Classic “Beck’s triad”
– elevated venous pressure - neck veins
– decreased arterial pressure - BP
– muffled heart sounds
• May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP
during inspiration
Distended Neck Veins
Increased Heart Rate
Respiratory Rate increases
Poor skin color
Narrowing Pulse Pressures
Hypotension
Death
G. Traumatic Aortic Rupture
The chances of survival are very slim and are based on the degree of the tear.
If there is just a small tear then the patient may survive.
If the aorta is completely transected then the patient will die instantaneously
Sign and symptoms
Burning or Tearing Sensation in chest or shoulder blades
Rapidly dropping Blood Pressure
Pulse Rapidly Increasing
Decreased or loss of pulse or b/p on left side compared to right side
Rapid Loss of Consciousness
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Diaphragmatic Rupture
A tear in the Diaphragm that allows the abdominal organs enter the chest cavity
More common on Left side due to liver helps protect the right side of diaphragm
Associated with multiple injury patients
Sign and symptoms
Abdominal Pain
Shortness of Air
Decreased Breath Sounds on side of rupture
Bowel Sounds heard in chest cavity
Diagnostic evaluation
CT Scan
MRI
Chest X- ray
ABG analysis
Initial management
Goal
Maintain the patent airway.
Maintain the respiratory pattern.
Decrease the level of pain so that patient can breathe normally.
Promote good chest expansion.
Management
A = Airway
• Assess for airway patency and air exchange - listen at nose & mouth
• Assess for intercostal and supraclavicular muscle retractions
• Assess oropharynx for foreign body obstruction
B = Breathing
• Assess respiratory movements and quality of respirations – look, listen, feel
• Shallow respirations are early indicator of distress – cyanosis is late
C = Circulation
• Assess pulses for quality, rate, regularity
• Assess blood pressure and pulse pressure
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• Skin - look and feel for color, temperature, capillary refill
• Look at neck veins - flat vs. distended
• Cardiac monitor
Collaborative care
Administer high flow oxygen to the patient.
Begin fluid resuscitation as appropriate.
Most blunt injuries are managed with relatively simple interventions like tracheal
intubation and mechanical ventilation and chest tube insertion.
Penetrating injuries often require surgery, and complex investigations are usually not
needed to come to a diagnosis.
Patients with penetrating trauma may deteriorate rapidly, but may also recover much
faster than patients with blunt injury.
Stabilize the flail rib segments with hand followed by application of large piece of
tape horizontal across the flail segment.
Place the patient in a semi fowler’s position.
Monitor vital signs, level of consciousness, oxygen saturation, urinary output and
respiratory status of the patient.
Administer opioids to the patient with caution because these cause respiratory
depression.
Needle Decompression
Locate 2-3 Intercostal space midclavicular line
Cleanse area using aseptic technique
Insert catheter ( 14g or larger) at least 3” in length over the top of the 3rd rib( nerve,
artery, vein lie along bottom of rib)
Remove Stylette and listen for rush of air
Place Flutter valve over catheter
Reassess for Improvement
Pericardiocentesis
Using aseptic technique, Insert at least 3” needle at the angle of the Xiphoid
Cartilage at the 7th rib
Advance needle at 45 degree towards the clavicle while aspirating syringe till blood
return is seen
Continue to Aspirate till syringe is full then discard blood and attempt again till signs
of no more blood
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Closely monitor patient due to small about of blood aspirated can cause a rapid
change in blood pressure
Chest tube drainage
• Large-bore (32 to 36 F) tube to drain blood
• If moderate sized (500 to 1500 ml) and stops bleeding, closed drainage usually
sufficient
• If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN
THORACOTOMY indicated
Thoracotomy
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