3. Chest cavity Soft tissues Lungs Heart Great vessels diaphragm oesophagus

4. Bony areas Ribs Sternum Clavicle Tracheo broncheal tree

5. Classification Blunt injuries Penetrating injuries

6. Etiology Motor vehicle accidents Fall from height Violence Iatrogenic

7. Mechanisms involved Acceleration force Deceleration force Transmission of blunt internal force to force to structures Direct trauma Compression

8. Chest trauma Chest wall injuries Sternal fractures Flail chest Pulmonary and pleural injuries Traumatic asphyxia Tracheo bronchial injuries Pneumothorax Hemothorax Mediastinal injuries cardiac injuries Great vessel injuries Diaphragmatic injuries Oesophageal injuries

9. Pulmonary injuries Pneumothorax Collection of air in the space between the parietal and visceral pleura

10. Tension pneumothorax An expanding collection of intra pleural air without communication with external environment  Clinical manifestations Distended neck veins Hypotension/hypoperfusion Absent breath sounds on affected side Tracheal deviation to contra lateral side

11. Management Immediate needle aspiration 14 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

13. 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

14. Pneumothorax  Clinical manifestations Air entry and breath sounds diminished in the affected side Impaired chest wall motion

15. Pathophysiology Negative intrapleural pressure during inspiration Air leak into the pleural cavity Increased intra thoracic pressure Reduced vital capacity and venous return

16. Pneumothorax  Diagnosis Chest radiography(double pleural markings) Ultrasound  Management Cover the wound with a three sided dressing Air can escape during expiration but do not enter during inspiration(one way valve) Chest tube insertion

17. Pneumothorax

18. Open pneumothorax 3-side dressing Asherman chest seal

19. Massive hemothorax Accumulation of at least 1500 ml or two thirds of the available hemithorax in an adult

20. Hemothorax  Life threatening by three mechanisms Acute hypovolemia causing decreased preload Collapsed lung promoting hypoxia Hemothorax compressing venacava impairing preload

21. Hemothorax  Clinical manifestations Abnormal vital signs Dullness to percussion Diminished breath sounds  Diagnosis Plain chest radiography completely opacified hemithorax Ultrasonography-fluid between chest wall and lung

22. Management  Chest tube insertion Care of chest tube Position-last hole 2.5-5 cm inside chest wall Suction chamber with 20-30 cm of water Never clamp the tubes Bottle at 1-2 ft lower than patient’s chest Left in place for 24 hrs after leak has stopped

25. Flail chest Free floating lung segment that is no longer connected to the rest of the thorax  Cause Segmental rib fractures in two or more locations of the same rib of three or more adjacent ribs

26. Flail chest  Clinical manifestations Paradoxical inward movement of the involved portion of the chest wall during inspiration and outward movement during expiration

27. Pathophysiology-flail chest Decreased ventilatory efficiency Increased work of breathing Hypoxemia Sudden respiratory arrest

28. Management-Flail chest Analgesics Ventilator support stabilization

29. Diaphragmatic injury Often unnoticed if not very big defect Causes referred shoulder pain Respiratory distress (herniation of abdominal contents into the thorax) Diagnosis Decreased breath sounds Auscultation of bowel sounds in the chest Tension viscero thorax Bowel obstruction and strangulation

30. Management- Repair of diaphragm

31. Cardiac injuries

32. Cardiac tamponade Accumulation of blood in the pericardial cavity under pressure Common causes are gunshot wounds and stabs  Clinical features  Tachycardia  Narrow pulse pressure  Elevated CVP  Hypotension Becks triad

33. Cardiac tamponade  Pathophysiology Elevated intra cardiac pressure Decreased right and left ventricular filling Decreased cardiac output

34. Management-Pericardiocentesis

35. Great vessel injuries  The main vessels Aorta Brachio cephalic branches Pulmonary arteries and veins Venae cavae Thoracic duct

36. Aortic injury Commonly injured part is proximal descending aorta  Clinical manifestations Hypo tension hypertension in upper extremity& hypotension in lower extremities Intra capsular murmurs or bruits  Diagnosis Chest radiograph TEECHO Aortography

37. Aortic rupture

38. Management Pharmacologic control of heart rate and blood pressure(around 60/mt and 100-120 mmHg systolic) Hemodynamic monitoring (pul.catheter) Sedatives Analgesics Vasodilators (sodium nitroprusside) β –blockers (esmolol) Auto transfusion Surgical repair

39. Nursing diagnoses Acute pain Fluid volume deficit Decreased cardiac output Inability to sustain spontaneous ventilation Ineffective breathing pattern Impaired gas exchange Impaired tissue perfusion

42. Other investigations CT Bronchoscopy Oesophagoscopy Oesophagography Angiography

43. Airway management- Indications for mechanical ventilation Indications for mechanical ventilation o Altered mental status o Excessive secretions o Associated face and neck injuries o Impending respiratory failure o Cardiopulmonary collapse o Significant co morbidities o Advanced age o ABG abnormalities

44. Fluid resuscitation Goal: 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