chest and abdominal injuries

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CHEST AND ABDOMINAL INJURIES By ROHINI SHARMA

Slide 2: 

CHEST INJURIES

ANATOMY OF THORAX : 

ANATOMY OF THORAX Trachea Lungs Bronchi Mediastinum Heart Great Vessels. Bony Rib strctures Thoracic spine at back. Oesophagus Diaphragm

CHEST INJURIES : 

CHEST INJURIES ALSO CALLED AS THORACIC INJURIES RESULTING FROM BLUNT OR PENETRATING INJURIES TO THE CHEST .

MECHANISMS : 

MECHANISMS The injuries are classified as Open and Closed . The open are also called a s Penetrating injuries and the closed are called as the Blunt chest injuries . The primary injury is damage from the impact and secondary injury is associated with the force of the primary injury.

CAUSES : 

CAUSES BLUNT TRAUMA > Steering wheel injuries. > Motor vehicle accidents. > Seat belts, > Crush from equipments. >Assualt from blunt objects. > Explosions and compression injuries PENETRATING TRAUMA > Knife, Sticks , arrows , missiles , penetrating blows , penetrating gun shots causing break in the skin continuity.

Blunt trauma chest : 

Blunt trauma chest

Slide 8: 

splinter

OPEN CHEST WOUND : 

OPEN CHEST WOUND BULLETS KNIFE EXPLOSIONS SHRAPNEL BLADES STICKS BLAST DEBRIS

WHAT HAPPENS??? : 

WHAT HAPPENS??? Ventilation is the mechanical process of moving in and out of air from the lungs. Normal Ventilation depends on structural integrity and patency of conducting airways and integrity of respiratory muscles , chest wall , pleura and pulmonary parenchyma. The break in continuity of these causes variety of problems . The diffusion of gases across alveolar – capillary membrane also may be affected . The normal ratio of V/P is o.8 meaning that there is always slightly more flow past alveoli via pulmonary capillaries than there is ventilation into alveoli. Under trauma conditions this is aggravated and even great amount of blood flow wasted owing to the passage via under ventilated alveoli. This causes under oxygenation of the blood to the heart .Under extreme cases when alveoli have collapsed, there is shunting i.e low v/p , causing no exchange of gases resulting in hypoventilation tissue hypoxia, hypoxemia and acidosis to cellular death.

Pathophysiology of Chest Trauma : 

Pathophysiology of Chest Trauma hypovolemia ventilation- perfusion mismatch changes in intrathoracic pressure relationships Inadequate oxygen delivery to tissues TISSUE HYPOXIA

Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis : 

Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis Blunt or Penetration Trauma

TYPES OF INJURIES : 

TYPES OF INJURIES 1. Chest wall injuries : Rib fractures , Flail Chest , Sternal fractures , Thoracic spine injuries. 2. Pulmonary injuries to larynx , trachea , bronchi , Pneumothorax, Hemothorax, Pulmonary contusions. 3. Cardiac and Great Vessel Injuries. 4. Oesophageal and Diaphragmatic Injuries.

Chest Wall Injuries : 

Chest Wall Injuries Fractures including Rib and Sternum: > Single or Multiple Fractures occur. > Fracture of First Rib is Associated with Injuries to great vessels , head and neck and that of lower ribs is with injury to the underlying abdominal viscera. Ribs are frequently injured part of thoracic cage as not protected by muscles . If 8th/10th/11th/12th, be suspicious for liver or spleen or kidney injuries. If 1st/2nd/3rd, worry about injury to head, neck, spinal cord, lungs, and great vessels > Sternal fractures Associated with injury to Manubrium. >Occur due to blunt forces or crush injuries.

TYPES OF INJURIES. : 

TYPES OF INJURIES.

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RIB/STERNAL INJURY : 

RIB/STERNAL INJURY

Sign And Symptoms: : 

Sign And Symptoms: RIB FRACTURE IS CHARACTERIZED BY THE PAIN AGGRAVATED BY DEEP BREATHING, COUGHING ,MOVING ,AND LOCALIZED TENDERNESS. COMPLICATED FRACTURES SHOW SIGNS OF UNDERLYING INJURY AND INEFFECTIVE VETILATION , SECRETION AND SPLINTING. STERNAL FRACTURES SHOW DYSNEA , PAIN WITH MOVEMENT , HYOVENTILATION , CHEST WALL ECHYMOSIS , STERNAL DEFORMITY AND CREPITUS. DIAGNOSED BY RIB SERIES , CHEST X-RAY , EKG AND ABG’S.

MANAGEMENT : 

MANAGEMENT The basic goal is to decrease pain so that the patient can easily breathe to promote chest expansion. Intercostal Nerve blocks With LA are used . Oral or IV analgesia can also be used . Good pulmonary Toilet. Patient is asked to cough ,breathe deeply since the patient is usually unable to do so resulting in poor clearance of secretions.Reduces atelectasis and pneumonia. Severe injuries require Internal Fixation with plates and screws.

INTERCOSTALBLOCKS : 

INTERCOSTALBLOCKS

FLAIL CHEST : 

FLAIL CHEST It is a fracture in which two or more adjacent ribs break in two or more places due to blunt or crushing trauma. Due to the injury the continuity of the thorax is destroyed and the detached portion of chest wall moves opposite to the normal. During inspiraiton the negative pressure is created and detached portion shows movement in during inhalation and viceversa . The injured portion doesnot respond to the normal action of respiratory muscles.This is ParadoxicaL Chest Movement.

FLAIL CHEST : 

FLAIL CHEST

Slide 24: 

Flail Chest

SIGN AND SYMPTOMS : 

SIGN AND SYMPTOMS Paradoxical chest movement, Breathing accompanied with pain Rapid shallow respirations , dysnea , Tachypnea , Tachycardia , Pallor , Ecchymosis above the chest, Diaphoresis , confusion , Palpation reveals Crepitus of ribs as ends ride over each other. Diagnosed by ABG’s , CBC, Chest X rays , Paradoxical chest movement, Crepitus and Rib series.

MANAGEMENT : 

MANAGEMENT Done to: Establish airway Suspect spinal injuries Assist ventilation Stabilize chest wall

Management : 

Management First aid measures are to stabilize the segment by exerting firm but gentle pressure with help of the hand or bulky dressing taped to the chest wall to avoid paradoxical movement. Sand bags or positioning the client on the affected side may be used only temporarily or to treat a mild injury because the position may lead to hypoventilation. Position the patient upside down to immobilize flail chest to decrease the pain and discomfort .Most comfortable is semi recumbent position inclined to injured side. Ensure adequate oxygenation by humidified oxygen and maintaining airway.

Slide 28: 

Pain relief by intercostal nerve blocks Careful administration of the crystalloid IV fluids as may precipitate ARDS. If underlying lung injury start Ventilatory support with PEEP and bag and mask device. Non ventilatory support for patient conscious and without internal parenchymal injury. Intubation / tracheotomy indicated if Pa O 2 below 60 mm Hg or rate of respiration above 35 breaths / minute. Monitor carefully for change in respiratory rate and pattern , consciousness and vital signs. Coughing and deep breathing is important to prevent atelectasis and pneumonia . Suction as needed.

Treatment for flail chest : 

Treatment for flail chest

PULMONARY INJURIES : 

PULMONARY INJURIES They affect the inner pulmonary tissue and parenchyma along with the pleural spaces . They include Laryngeal , bronchial and tracheal injuries Pneumothorax and Hemothorax . Pulmonary contusion.

LARYNGEAL , BRONCHIAL AND TRACHEAL INJURY. : 

LARYNGEAL , BRONCHIAL AND TRACHEAL INJURY. They occur owing to the blunt and penetrating trauma to larynx , bronchi and trachea . Laryngeal injury is associated with hoarseness , Subcutaneous emphysema and crepitus. Tracheal and Bronchial trauma is associated with noisy breathing , emphysema , Dysnea , Pneumothorax , hemoptysis , Mediastinal crunch { Hamman’s Sign} , Intercostal retractions, Respiratory distress , Stridor.

Diagnostic X-rays –bronchial injury. : 

Diagnostic X-rays –bronchial injury.

Complications : 

Complications Emergency Repair or Resection Mediastinitis Empyema Atelectasis

Slide 34: 

Pneumonia Abscess Delayed Fibrosis

Management : 

Management Priority is to stabilize AIRWAY. For a patient with laryngeal injury , And having respiratory distress or complete obstruction intubation is indicated . Tracheostomy if intubation is hampered by airway obstruction. For tracheal injury Tracheostomy , for bronchial injury airway support till inflammation and edema resolve . Intubation and mechanical ventilation is done. Surgical repair is the definitive treatment.

PNEUMOTHORAX AND HEMOTHORAX : 

PNEUMOTHORAX AND HEMOTHORAX Pneumothorax is air in the pleural space resulting in parital or complete collapse of the lung space. Closed /Spontaneous pneumothorax is one in which chest wall is intact and air enters the pleural space from lung surface Open pneumothorax is Sucking Chest Wound in which air enters the pleural space through opening in the chest wall.

Slide 37: 

Tension Pneumothorax is a life – threatening condition occurring when accumulation of air in one pleural space forces thoracic contents to opposite side of chest . Hemothorax is free blood in pleural space resulting from bleeding in lung parenchyma , heart and major blood vessel injury .

PATHOPHYSIOLOGY : 

PATHOPHYSIOLOGY In open pneumothorax , there is loss of the intrapleural pressure .In this condition , Air enters through the hole in chest wall or surface of Lung as patient attempts to breathe , causing air to flow into pleural cavity . If hole is big enough sucking sound is actually heard as patient inhales and rushing sound as the client exhales out. In Closed type, rupture of the weak areas allows air to leak into pleural space . The affected lung collapses , losing its ability to expand and air enters the the pleural space from Lung surface.

OPEN PNEUMOTHORAX : 

OPEN PNEUMOTHORAX

Closed Pneumothorax : 

Closed Pneumothorax

Slide 41: 

In tension pneumothorax , the injury causes air into pleural space with the inspiration but it can’t escape during the expiration forming “ball- valve”.Air continues to accumulate increaing the intrapleural pressure , forcing the thoracic contents away from injury site called the mediastinal shift . The lung on the opposite side , heart and great vessels are compressed , cardiac output altered and compression of the vena cavas.

Slide 43: 

In hemothorax blood accumulates in the pleural space. Massive hemothorax involves the blood accumulation of more than 1500cc.

HEMOTHORAX : 

HEMOTHORAX

Sign and symptoms : 

Sign and symptoms Pain with breathing. If patient has sudden chest pain with shortness of breath – suspected closed type Decreased breath sounds , Dysnea , Tachypnea, Tachycardia , cyanosis. Respiratory movements on affected side absent or decreased.

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1.       I Open Pneumothorax: Sucking sound as patient inhales and of rushing air as he or she exhales. Respiratory movement on affected side may be absent or diminished, assymetrical movement with affected side lagging behind unaffected during inspiration. 3.       In Tension Pneumothorax: Increased respiratory rate, distress, distended neck veins, low BP, tachycardia, cyanosis, severe chest pain, feeling of impending doom, hypoxia, hypercapnia, acidosis, restlessness, agitation, intercostals retraction, nasal flaring and subcutaneous emphysema mediastinal shift. 4.       In Hemothorax: Respiratory and cardiac impairments, hypoodemic shock, dysnea, chest tightness, acchymosis over affected lung, hemoptysis, hypotension.  Diagnosis : Chest x-ray will confirm diagnosis showing accumulation of fluid in dependant area and amount of lung collapse. It also shows mediastinal shift. ABG’s, CBC and coagulation studies in hemothorax. Open end “U” manometer shows mediastinal shift.

Management : 

Management In Open Pneumothorax, utmost care has to be taken since it is emergency. The airway should be cleared; maintained and ventilatory support is given as needed with oxygen therapy. The open wound is sealed with a sterile occlusive dressing to prevent air from being sucked into chest through wound. Vaseline gauze, aluminum foil, plastic wrap or folded universal dressings are used. Taping the dressing on only three sides helps to allow air to leave and not return making one-way valve

IN OPEN PNEUMOTHORAX : 

IN OPEN PNEUMOTHORAX Expose the wound by removing, cutting, or tearing the clothing covering the wound Use scissors from aid bag, a knife . Do not remove clothing stuck to the wound Do not clean the wound or remove objects stuck in the wound

MANAGEMENT : 

MANAGEMENT

Management : 

Management Tape down three edges of airtight material vaseline gauze , aluminum foil, plastic wrap, folded universal dressing (top edge and two sides) to create a “flutter valve” effect that allows air to escape from but not enter the chest cavity Tell the casualty to resume normal breathing Dress and bandage the wound to protect the airtight material from damaging

MANAGEMENT : 

MANAGEMENT If the amount of air or fluid is minimal, pleural space can be aspirated with a large-bore needle (16-18 gauze). For Pneumothorax: it is inserted in 2nd or 3rd intercostal space in midclavicular line with 18 gauze needle. For Hemothorax: it is inserted in 5th or 6th intercostals space in midaxillary line with 16 gauze needle. A Heimlich valve can also be used to evacuate air from the pleural space.   The most common mode of treatment is to insert a chest tube for purposes of lung re-expansion and drainage of air, blood and clots from pleural space. This also decreases chances of tension pneumothorax .

Needle Chest Decompression : 

Needle Chest Decompression

Slide 53: 

Locate the insertion site: The second intercostal space just above the third rib at the mid-clavicular line (injury side).Done by needle at 90 degrees.

REMEMBER : 

REMEMBER A needle chest decompression is performed ONLY if the casualty has a penetrating wound to the chest and increased difficulty breathing. Emergency thoracentesis is performed too.

Inserting Chest Tube : 

Inserting Chest Tube

Drainage of the collected fluid : 

Drainage of the collected fluid

FOR THE MANAGEMENT OF HEMOTHORAX : 

FOR THE MANAGEMENT OF HEMOTHORAX EMERGENCY THORACOTOMY IS DONE TO CONTROL BLLEDING.

Pulmonary Contusion : 

Pulmonary Contusion Crushing and bruising of the lung parenchyma are referred to as contusions. It is a lethal chest injury. Sudden blow or blunt injury to the chest causing compression of thoracic cavity and lung followed by an equally sudden decompression. Concussive and compressive force is most important cause. Rapid deceleration of motor vehicles too.The force of impact against chest wall is transmitted into the lung, rupturing tissue, small airways and alveoli. The pressure wave abates, chest wall springs back, pulling the lung with it and causing additional injury.

Pathology of Pul. Contusion. : 

Pathology of Pul. Contusion. Disruption of alveolar architecture ( within minutes of initial injury) Hemorrhage into the alveolar and interstitial space ( within 1-2 hrs ) Mono and poly morphoneuclear cells infiltrate the affected area After 18-24 hours, lung architecture is distorted by accumulation of cellular debris, hemmorhage and inflammatory cells The inflammatory response also triggers the production of proteinaceous exudates Eventual return of lung function may take several weeks

Pulmonary Contusion : 

Pulmonary Contusion

Sign and symptoms : 

Sign and symptoms Signs and Symptoms: Dysnea, hemoptysis, cough, increasing hyperpnea, tachypnea, restlessness, breath sounds are decreased and roles may be present. Chest wall abrasion and ecchymosis is present.   Diagnostic Test: No specific test. Diagnosis is based on index of suspicion. ABG’s are helpful, CT scan is useful to quantify contusion. Auscultation or X-rays rarely detect abnormalities

AIM OF MANAGEMENT : 

AIM OF MANAGEMENT Supportive treatment with aim to reduce hypoxia and improve gas exchange .

Management : 

Management 1)     In mild cases, clients are treated with supplemental oxygen and closely monitored for obstruction. 2)     Broad spectrum antibiotic coverage to counteract formation of septicemia. 3)     Fluid is restricted because there is damage to pulmonary capillaries and administration of large amounts of fluid can cause fluid overload. 4)     In severe contusions, where hypoxia can’t be corrected or there is hypoventilation, chest may need to be intubated and placed on ventilator. 5)     Pulmonary care to mobilize and clear bloody secretions. Frequent suctioning for avoiding obstruction. Keep spare airway at bedside.

Cardiac and Great vessel injury : 

Cardiac and Great vessel injury Can be Cardiac contusion , Penetrating injuries and Cardiac Tamponade. There Can be laceration of great vessels including aorta and Superior and inferior venacava, pulmonary veins and arteries entering and leaving the heart. Hemorrhage and Shock are major characters.

Cardiac contusion : 

Cardiac contusion Bruise to the heart affecting myocardium mostly . Can be mild contusion or concussion injury caused owing to blunt trauma.

Cardiac Tamponade : 

Cardiac Tamponade Life threatening condition caused by accumulation of blood or other fluid in pericardium, the fibrous sac surrounding the heart due to penetrating or blunt anterior chest wall trauma . Can be associated to pericardial rupture and hemopericardium

PATHOPHYSIOLOGY : 

PATHOPHYSIOLOGY As blood or fluid collects in pericardium owing to injury, this prevents heart from filling during the diastolic phase, causing a decrease in amount of blood pumped to the body and decreased blood pressure. The addition of 50-100 ml (small amounts) of blood or air into the sac produces small rise in intrapericardial pressure. Continued bleeding increases this pressure sharply and produces symptoms of cardiogenic shock. Cardiac output falls, cardiac performance decreases, it compresses the heart until it can no longer function leading to cardiac arrest Signs and Symptoms: Soft and faint heart tones (muffled heart sounds), weak pulse, Beck’s triad – low B.P., a (decrease in difference between systolic and diastolic BP) ,increased venous pressure and muffled heart tones. Midthoracic pain, dyspnea, pulses paradoxus (higher than 15 mm Hg during inspiration), elevated CVP, narrow pulse pressure and falling cardiac output.

Chest X-rays in cardiac tamponade : 

Chest X-rays in cardiac tamponade

PERICARDIOCENTESIS : 

PERICARDIOCENTESIS

Large vessel Injuries : 

Large vessel Injuries Blunt or penetrating trauma are the causes. Chest pain, dysnea, hemoptysis, hemorrhagic shock, upper extremity hypertension, pulse deficit in any area especially lower extremities/lower arm (in aortic disruption), hoarseness owing to hematoma pressure around aortic arch.

Aortic Rupture : 

Aortic Rupture Viewed from behind

Oesophagal and Diaphragmatic Injuries : 

Oesophagal and Diaphragmatic Injuries Penetrating or blunt injuries result in tears. The left diaphragm is most affected since right one is protected by the liver. In ruptured oesophagus ,mediastinitis occurs as saliva and gastric contents get contaminated. In diaphragmatic injury, abdominal contents herniated into thorax. Loss of negative pressure in chest and inability of diaphragm to function normally compromise respiratory function.

Pathology of oesophagal injury. : 

Pathology of oesophagal injury.

X-ray shows: : 

X-ray shows: Traumatic diaphragmatic rupture.

COMPLICATIONS : 

COMPLICATIONS 1)     Emphysema: Results when air,pus or necrotic tissue accumulates between the visceral and parietal pleurae. All lacerations and penetrating wounds cause it. Fever, dysnea, plural pain, diminished to absent breath sounds, elevated WBC, thick, copious cloudy purulent chest tube drainage.  2)     Atelectasis: Complete collapse of lung. It occurs from external pressure on the lung tissue or from internal obstruction of a bronchus. Patient shows moist roles, diminished breath sounds, fever, tachycardia, dyspnea, cyanosis and abnormal ABG’s. 3) Traumatic Asphyxia: Severe compression injury to chest leading to asphyxia .

Traumatic asphyxia : 

Traumatic asphyxia

INITIAL ASSESSMENT AND MANAGEMENT : 

INITIAL ASSESSMENT AND MANAGEMENT PRIMARY SURVEY: Airway , Breathing , Circulation. RESUSCITATION OF VITAL FUNCTIONS. DETAILED SECONDARY SURVEY: Vital signs, head to toe examination. DEFINITIVE CARE.

Take Care Of Four Steps: : 

Take Care Of Four Steps: EVALUATION AND MANAGEMENT ON SITE(15 min ) INITIAL EVALUATION AND MANAEMENT AT THE EMERGENCY DEPARTMENT (30 min) COMPLETE EVALUATION (1 – 3 HOURS) RE-EVALUATION (24 HOURS)

WHAT TO DO??? : 

WHAT TO DO??? Hypoxia is most serious problem - early interventions aimed at reversing it. Immediate life-threatening injuries treated quickly and simply - usually with a tube or a needle. Secondary survey guided by high suspicion for specific injuries

PRIMARY SURVEY::: : 

PRIMARY SURVEY::: ASSESS ABC’S ASSESS THE MECHANISM OF INJURY DO A RAPID TRAUMA SURVEY /NOTE INDICATIVE SIGN AND SYMPTOMS.

A = Airway : 

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 : 

B = BREATHING Assess respiratory movements and quality of respirations - look, listen, feel. Shallow respirations are early indicator of distress - cyanosis is late. Respiratory rate showing rapid , shallow respirations, dysnea and tachypnea.

C = CIRCULATION. : 

C = CIRCULATION. Assess blood pressure and pulse pressure Skin - look and feel for color, temperature, capillary refill- Look for cyanosis. Assess pulses for quality, rate, regularity Look at neck veins - flat vs. distended-fluid deficit or decreased supply to body from heart due to compression. Assess the B.P.

Assess The MOI : 

Assess The MOI Mechanism of injury Penetrating trauma Gunshot or stab wounds Bullet trajectory is unpredictable Blunt trauma Visceral injuries occur from: Deceleration Compression Shearing forces Bursting

Assess Signs : 

Assess Signs Shock Cyanosis Hemoptysis Chest wall contusion Flail chest Open wounds – the wound , implaned object. Distended neck veins Tracheal deviation Subcutaneous emphysema.

Other Assessments. : 

Other Assessments. Diaphoresis-sweating , Pallor-pale , Cyanosis, Open wound ,Ecchymosis-bruising in skin. Position of trachea, Subcutaneous emphysema , Jugular venous distention ,Penetrating wounds in the neck. Contusions ,Tenderness , Asymmetry ,Open wounds or impaled objects ,Crepitation ,Paradoxical movement in chest. Assess lung sounds As increases , decreased , unilateral , bilateral , location . Note the presence of the implaned object.

ALSO BY : 

ALSO BY Palpation: One may note tracheal deviation, subcutaneous emphysema sternal and rib fractures. Fractures of 5th rib are associated with trauma since upper structures protect 1st rib. Ribs 5-9 sustain blunt injuries; lower ribs are not fractured commonly since they are mobile.   Percussion: Hyper resonance is present in emphysema and over inflated lung tissue. Tympany occurs in tension pneumothorax. Dullness indicates consolidation and non-resonance (the absence of sound transmission) is evident in fluid pressure

Assessing the Chest : 

Assessing the Chest Compare both sides of the chest at the same time when assessing for asymmetry

ASSESSING THE CHEST : 

ASSESSING THE CHEST FEEL CAREFULLY AND LISTEN CLOSELY FOR SUBCUTANEOUS EMPHYSEMA. FEE .

ASSESSMENT OF CHEST : 

ASSESSMENT OF CHEST Contusions Tenderness Asymmetry Open wounds or impaled objects Crepitation Paradoxical movement

AUSCULTATING : 

AUSCULTATING Listen between the rib spaces, paying particular attention to changes in tone from previous assessment.

EVALUATION : 

EVALUATION Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). Mediastmum (wide or normal) shifted or not. Lung parenchyma (Contusion). The heart (cardiac tamponade). Diaphragm. Pneumothorax, hemothorax. ECG CVP Arterial blood gases. Urine output. Lab. Investigations. Others.

TREATMENT POINTS : 

TREATMENT POINTS The treatment follows a certain protocol which includes. Adequate oxygenation. Fluid replacement. Surgical intervention. Treatment of septic complications. Adequate caloric and substrate supplementation. Prevention of stress bleeding. Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis.

Initial interventions : 

Initial interventions 1)     Ensure patent airway. 2)     Administer high flow oxygen with non-re-breather mask. 3)     Establish IV access with two large bore catheters. Begin fluid resuscitation as appropriate. 4)     Remove clothing to assess injury. 5)     Cover open chest wound with non-porous dressing taped on three sides. 6)     Stabilize impaled objects with bulky dressing but do not remove. 7)     Assess for significant injuries. 8)     Stabilize flail rib segment with hand followed by application of large pieces of tape horizontal across the flail segment. 9)     Place patient in semi-fowler’s position or position patient on injured side if breathing is easier after cervical spine injury is ruled out.

AIRWAY PATENCY : 

AIRWAY PATENCY Chin-lift - fingers under mandible, lift forward so chin is anterior

AIRWAY PATENCY : 

AIRWAY PATENCY Jaw thrust - grasp angles of mandible and bring the jaw forward

AIRWAY : 

AIRWAY Oropharyngeal airway inserted in mouth behind the tongue. DONOT PUSH THE TONGUE BACK.

DEFINITIVE : 

DEFINITIVE

IMPLANED OBJECT : 

IMPLANED OBJECT

Criteria for intubation in Patients with chest injury : 

Criteria for intubation in Patients with chest injury VENTILATORY RATE > 25/min HEART RATE > 100/min SYSTOLIC ARTERIAL PRESSURE < 100 mmHg RESPIRATORY FAILURE: PaO2 < 60 mmHg and/or PaCO2 > 45 mmHg and/or pH < 7,20 ASSOCIATED LESIONS: ABDOMINAL NEUROLOGICAL (Glasgow Score  7)

INDICATION FOR MECHANICAL VENTILATION : 

INDICATION FOR MECHANICAL VENTILATION Ventilatory failure secondary to trauma to chest wall , pleura or lung parenchyma.

Indication for Thoracotomy : 

Indication for Thoracotomy Its done for patient in hemodynamic instability. More than 1500 ml blood evacuated on initial chest tube insertion. Continued bleeding of more than 200 ml /hr for 3 consecutive hours. Bleeding of more than 150ml/hr for 3 consecutive hours in elderly patients.

INDICATIONS FOR THORACOTOMY : 

INDICATIONS FOR THORACOTOMY Post-traumatic cardiovascular collapse Pericardial tamponade Vascular injury to the thoracic outlet Traumatic thoracotomy Massive Air leak Proved tracheobronchial injury Post-traumatic cardiovascular collapse Pericardial tamponade Vascular injury to the thoracic outlet Traumatic thoracotomy Massive Air leak Proved tracheobronchial injury

NURSING DIAGNOSIS: : 

NURSING DIAGNOSIS: 1)     Ineffective breathing pattern related to unstable chest wall segment or lung collapse. 2)     Fluid volume deficit related to hemorrhage. 3)     Decreased cardiac output related to compression of heart and great vessels. 4)     Impaired gas exchange related to chest injury. 5)     Altered comfort related to pain associated with injury. 6)     Anxiety related to patient’s own condition.

ABDOMINAL INJURIES : 

ABDOMINAL INJURIES Abdominal trauma is suggested when an energy source is applied to person’s trunk anywhere from fourth rib to hips. The various injuries are: Gastric injury. Liver injury. Pancreatic/Duodenal injury. Splenic injury. Small bowel injury. Large bowel injury. Abdominal vascular injury.

Abdominal cavity : 

Abdominal cavity

MECHANISMS : 

MECHANISMS Blunt Trauma Compression- organs trapped and squeezed between vertebral column and impacting organ itself. crush Shearing- part of organ is able to move while other is fixed Deceleration - contents damaged due to change in velocity . As according to Newton’s law occupant’s body is in forward motion and organs continue to advance forward until structural impact ,tear or rupture occurs. Penetrating Trauma direct injury

INJURIES TO ABDOMEN : 

INJURIES TO ABDOMEN

IMPALEMENT INJURY : 

IMPALEMENT INJURY

TYPES OF INJURIES : 

TYPES OF INJURIES Blunt Trauma Aortic rupture Splenic rupture Liver rupture or laceration Diaphragmatic tear Pelvic fracture Intestinal tear Penetrating Trauma Laceration of blood vessels Splenic rupture Liver rupture or laceration Intestinal lacerations

CAUSES : 

CAUSES BLUNT TRAUMA Motor vehicle accidents Auto vs. pedestrian Falls Blast injuries PENETRATING TRAUMA Gunshot wounds Stab wounds Shrapnel wounds Impalements

Gastric Injuries : 

Gastric Injuries The injury interferes with peristalsis and digestion. If the stomach is penetrated, corrosive hydrochloric acid, enzymes and mucin may leak into the abdominal cavity and cause peritonitis. Injury to stomach interferes with action of enzymes. Commonly affected by penetrating trauma. Signs and Symptoms: Left upper quadrant pain and tenderness, signs of peritonitis secondary to release of gastric contents, hypotension, hematemesis. Diagnostic Tests: Labotory: Serum electrolytes, CBC (WBC may be elevated), ABG’s hemoglobin and hematocrit. Radiologic: Abdominal upright X-ray for free air. Nasogastric lavage. Goal of care is to stabilize the patient , NG decompression, IV therapy .

LIVER INJURIES : 

LIVER INJURIES It is highly vascular organ and right side is affected more and is associated with blood loss. Exsanguination also increases mortality rate of these patients.   Signs and Symptoms: Pain located in right upper quadrant or in right hypochondriac or epigastric region and may be referred to right shoulder, hypotension, bruising over right upper quadrant, hemodynamic instability, thready increased pulse, and diaphoresis.   Diagnostic Tests:  1)     Laboratory: WBC count, type and cross match, hematocrit, liver enzymes – Alkaline phosphatase, SGPT, SGOT, coagulation studies. 2)     Radiological Examination: Paracentesis or peritoneal lavage, flat plate of abdomen, possible hepatic vein damage on angiography, liver scan, decubitus films, ultrasound. Goal of Care is airway maintenance and treatment of shock.

PANCREATIC/DUODENAL INJURY : 

PANCREATIC/DUODENAL INJURY These injuries are associated with other abdominal injuries. These occur chiefly due to penetrating mechanisms or even in blunt trauma caused by steering wheel injuries. Since, pancreas is a retroperitoneal structure; symptoms of injury may not be evident for 24-72 hours after traumatic incident. Pancreatic injury alters the secretion of pancreatic juices containing enzymes and alteration in glucagons and insulin secretion. Duodenal injury occurs in association of pancreatic, bile duct or vena cava trauma. Injury to duodenum can produce intramural hematoma. Perforation causes contamination of retroperitoneal and peritoneal spaces with bile, pancreatic enzymes and gastric sections.  Signs and Symptoms 1)     Pain in epigastric area or back. 2)     Nausea, vomiting, restlessness. 3)     Abdominal guarding, tenderness. 4)     Absent bowel sounds. 5)     Pulse rate increases, BP decreases. 6)     Hypotension, shock, rebound pain.

SPLENIC INJURY : 

SPLENIC INJURY Pain in left upper quadrant referred to left shoulder (Kehr’s Sign), this may occur in neck related to phrenic nerve irritation (Saegasser’s Sign), BP than 90/60, pulse rate increased and thready, diaphoresis, decreased level of consciousness, dullness on percussion, especially if patient changes position (Balance’s Sign), ecchymosis and possible rib fractures. Diagnostic Tests 1)     Laboratory: CBC with differential (WBC elevated), hematocrit decreased. 2) Radiological and Other Tests: Chest X-ray shows diaphragm elevated with pneumothorax, Spleen scan, angiography, flat plate x-ray of abdomen, ultrasounds, peritoneal lavage/paracentesis positive for blood

SMALL BOWEL INJURY : 

SMALL BOWEL INJURY Pseudo-closed loop obstruction occurs when a segment of bowel partially filled with food and gas becomes trapped between an external force and affirm anatomic object creating a closed loop. Diagnostic Tests: WBC count, electrolytes, stool specimen positive for blood, ABG’s, X-ray chest, flat plate of abdomen, peritoneal lavage.   Signs and Symptoms: Pain, rebound tenderness, abdominal muscle guarding, hypotension, shock, nausea and vomiting, absent bowel sounds.

ABDOMINAL VASCULAR INJURY : 

ABDOMINAL VASCULAR INJURY Abdominal pain, back pain, hypoactive bowel sounds or tender abdominal mass, flank discoloration becomes evident later, rapid onset shock without obvious source of blood loss (shows vascular injury) large retroperitoneal hematoma indicates aortic injury, ecchymosis of midline of peritoneum, increased abdominal girth, hypotension/shock. Diagnostic procedures 1)     Laboratory: Complete blood count, type and cross-match, coagulation studies. 2)     Radiology and Other Diagnostic Procedures: Flat plate of abdomen, angiography, peritoneal lavage.

POINTS TO REMEMBER IN MANAGEMENT : 

POINTS TO REMEMBER IN MANAGEMENT As always, ABC’s Primary survey Secondary survey Access – IV . Fluid resuscitation Search for blood loss and stop it

INITIAL ASSESSMENT AND EVALUATION : 

INITIAL ASSESSMENT AND EVALUATION HISTORY Mechanism Blunt how fast restraint direction of forces time of injury witness accounts prehospital care Vitals Symptoms Associated Injuries Distracting injuries Penetrating type of weapon number of wounds time of wounds blood loss at scene witness accounts prehospital care

ASSESSING THE PATIENT : 

ASSESSING THE PATIENT Visually note wounds and abrasions Palpate abdomen for localized vs. diffuse tenderness Consider possible internal injuries Diffuse, severe tenderness is a sign of internal bleeding

DON’T FORGET : : 

DON’T FORGET : Turn the Patient when you can do so safely Visually inspect back Palpate ribs, spine, sacrum for tenderness and irregularities Dress the wound with an occlusive dressing Don’t count on a “down-side sweep” to discover injuries this size

ASSESS SIGN AND SYMPTOMS : 

ASSESS SIGN AND SYMPTOMS Signals of serious abdominal injury include— Severe pain. Bruising. External bleeding. Nausea. Vomiting (sometimes containing blood). Weakness. Thirst. Pain, tenderness or tight feeling in the abdomen. Organs protruding from the abdomen. Rigid abdominal muscles. Other signals of shock. Grey Turners Sign: Bluish discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancreas, kidney, or pelvic fracture. Cullen sign: Bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage. Kehr sign: L shoulder pain while supine; caused by diaphragmatic irritation (splenic injury, free air, intra-abd bleeding) Balance sign: Dull percussion in LUQ. Sign of splenic injury; blood accumulating in subcapsular or extracapsular spaces.

Slide 124: 

Inspection, auscultation, percussion, palpation Inspection: abrasions, contusions, lacerations, deformity Grey-Turner, Kehr, Balance, Cullen Auscultation: careful exam advised by ATLS. (Controversial utility in trauma setting.) Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding

DIAGNOSTIC TESTS : : 

DIAGNOSTIC TESTS : Plain films of the abdomen have virtually no utility in the evaluation Ultrasound Diagnostic Peritoneal Lavage CT scanning Operating room Laparotomy in extreme cases.

INDICATIONS FOR DPL : 

INDICATIONS FOR DPL Unidentified blood loss, hypotension. Indeterminate physical examination for alcohol, drugs , spinal cord injury. Pelvic or rib fractures. Patient need surgery with GA. Stab wound with peritoneal penetration to rule out visceral injury.

Management : 

Management Airway C-Spine if mechanism indicates High flow O2 Assist ventilations if needed Give nothing by mouth MAST may be helpful in slowing intraabdominal bleeding with shock

Abdominal Injuries: TACTICAL FIELD CARE : 

Abdominal Injuries: TACTICAL FIELD CARE Remember the ABCs Position casualty on back with flexed knees Expose the wound Stabilize any protruding objects Cover protruding abdominal organs with moist gauze or cloth Prepare to evacuate to surgical assets 9-line MEDEVAC

SURGICAL MANAGEMENT : 

SURGICAL MANAGEMENT Indications to go under the knife Blunt trauma with positive DPL or unstable patient with hemodynamic instability. Blunt trauma with recurrent hypotension despite resuscitation Peritoneal signs/Peritonitis /other hollow viscous injury. Penetrating wound with hypotension

INITIAL INTERVENTIONS : 

INITIAL INTERVENTIONS i)        Ensure patent airway. ii)      Administer oxygen via non-re-breather mask. iii)    Control external bleeding with direct pressure or sterile pressure dressing. iv)    Establish IV access with two large – bore catheters and infuse warm normal saline or lactated Ringer’s solution. v)      Obtain blood for type and cross-match and CBC. vi)    Remove clothing. vii)  Stabilize impaled objects with bulky dressing – do not remove. viii) Cover protruding organs/tissue with sterile, saline dressing. ix) Insert indwelling urinary catheter if there is no blood at the meatus, pelvic fracture or boggy prostrate. x) Obtain urine for urinalysis. xi)Insert NG tube if no evidence of facial trauma. xii)Anticipate diagnostic peritoneal lavage

NURSING DIAGNOSIS : 

NURSING DIAGNOSIS 1)      Ineffective airway clearance due to occlusion or airway obstruction. 2)      Inadequate cardiac output and cardiovascular instability due to hypovolemia alterations of cardiovascular structures. 3)      Impaired breathing patterns due to pain, activity intolerance, decreased energy or abdominall injury. 4)      Fluid electrolyte imbalance/deficit related to hemorrhage. 5)      Anxiety related to injury. 6) Altered comfort related to pain.

FOR IMPALED PATIENT : 

FOR IMPALED PATIENT DO NOT REMOVE OBJECT OR EXERT ANY FORCE UPON IT! Severe bleeding may occur causing shock Check pulses distal to impaled object Immobilize the object Apply bulky support bandages to hold in place

EVISRCERATION : 

EVISRCERATION

MANAGING EVISCERATION : 

MANAGING EVISCERATION Use sterile side of dressing to place protruding organs near the wound (NOT into wound) Cover organs and wound completely with sterile or clean moist dressing DO NOT APPLY PRESSURE TO WOUND or expose internal parts Tie dressing tails loosely around wound Prepare evacuation to surgical assets

Slide 135: 

1.      Abdominal Compartment Syndrome (ACS): A condition in which abdominal organ dysfunction occurs owing to increased intra abdominal pressure. It occurs in trauma patient as a result of abdominal distention secondary to resuscitation, oedema, ileus, bowel obstruction, bowel odema, post operative hemorrhage or abdominal packing.   Signs and Symptoms: Cardiovascular: Lack of perfusion of renal artery, decreased urine output. Pulmonary: Decreased tidal volumes, poor lung compliance, hypercarbia, increased intrathoracic pressure, oliguria.   2.      Acute Acalculous Cholecystitis (AAC): Acute inflammation of gall bladder in absence of gall stones.