University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2018
Views:

176

Pages:

35
Author:

KillSteel

Chest Lectures Anatomy The respiratory system consists of the : Nose , Nasal passage , Nasopharynx , larynx ,Trachea ,Bronchi & lungs . The chest wall is covered by Pectoralis muscle anteriorly while posteriorly both (Latissmus dorsi and serratus muscle) are encountered . There are (12) pairs of ribs , Seven of which are termed (True Ribs) as the cartilages articulate with the sternum. The lower five ribs are termed (False Ribs) which are not connected directly to the sternum. The eleventh and the twelfth ribs are termed (Floating Ribs ) Because they are not attached anteriorly . The sternum is divided into the Manubrium .Body and xiphoid . The clavicle articulates with the sternum and Ist.costal cartilage . Muscles associated with the intercostals space are , The external intercostals ,internal intercostals and transversus thoracic muscles .There are (11) intercostal spaces containing a vein ,an artery and a nerve which course along the lower edge of each rib . Pleura is a fibro elastic membrane lines by squamous epithelial cells . It consists of two portions:1-Parietal pleura which lines the thoracic cavity and it is divided into four parts a- Costal pleura which lies against the ribs &intercostal muscles b-Diaphragmatic pleura which covers the upper surface of the diaphragm. C-Mediastinal pleura which lies against the mediastinum . D-Cervical pleura which covers the dome of the thoracic space 2-Visceral pleura which intimately invests the lung . Costo –phrenic angle is the angle between the costal &diaphragmatic pleura. Cardio –phrenic angle is the angle between the heart &diaphragmatic pleura Inferior pulmonary ligament is the anterior & posterior reflection of the pleura between the root of the lung & the diaphragmatic surface The function of the pleura is to maintain the environment of the pleural space in which the lung is function. The bronchial arteries originate from the aorta or the intercostals arteries . Pulmonary veins drain into the left atrium .No bronchial veins. The Lymph nodes found along the lobar branches are termed(hilar LN).There are also Tracheal and tracheo-bronchial LN. Phrenic nerve located anteriorly while the vagus nerve located posteriorly in the thoracic cavity . The Trachea is a fibro muscular tube (10-12 cm) in length and (13-22 mm) in width. Supported laterally and ventrally by (16-22) U-shaped hyaline cartilages . The trachea originates at the level of the cricoid cartilage down to its bifurcation at the level of the sternal angle where it divided into right and left main bronchi .The spur at the bifurcation is termed the (Carina) . The right main bronchus is (12-16 mm) in diameter ,the left is ( 10-16 mm) in diameter .The right main bronchus deviates less from the axis of trachea than the left ,this explains why foreign body is more common in the right main bronchus .The main bronchi are divided into the segmental bronchi which end into the terminal bronchiole which divided into the respiratory bronchiole which terminate into the alveoli . Clinical manifestations of respiratory dieases 1-Cough 2-Dyspnea or breathlessness , it is an unpleasant subjective awareness of the sensation of breathing . 3-Chest pain in diseases with pleural or chest wall involvement . 4-Haemoptysis . Investigations :- 1-Chest X-Ray 2-CT chest 3-MRI mediastinum 4-US chest to detect any effusion . 5-Pleural aspiration . 6-Bronchoscopy flexible or rigid . Pulmonary Function Tests 1-Tidal Volume (TV) Is the amount of air inspired or expired per single breath . 2-Functional residual Capacity (FRC) The amount of gas contained in the lung at the end of quiet expiration . 3-Inspiratory reserve volume;Is reached when the patient makes a maximum inspiration and increased the lung volume ,compared with that contained at the peak tidal volume. 4-Vital capacity :The volume expired from maximal inspiration to maximal expiration. 5-residual volume :Is the amount of air remaining in the lung after maximal expiration. 8—FEV1 Is the volume of air expired in one second . Chest Trauma Chest trauma • Cardiothoracic surgeons are usually called to see trauma patients after initial evaluation and management has been carried out, but it is important to be aware of the general principles of trauma management. • Initial approach consists of a focused primary survey aimed at detecting and treating immediately life-threatening conditions, followed by a more detailed secondary survey. • Chest trauma can be divided into blunt and penetrating: the majority of blunt chest trauma does not require operative intervention. • Chest trauma is the third most common cause of trauma-related mortality behind head and spinal cord respectively PRIMARY SURVEY • This is aimed at identifying immediately life threatening injuries and it consists of: A: Airway maintenance and cervical spine care. B: Breathing and ventilation. C: Circulation and control of hemorrhage. D: Disability and neurological state. E: Exposure. Immediately life threatening injuries • • • • • Tension pneumothorax. Massive hemothorax. Open pneumothorax. Cardiac tamponade. Flail chest. Airway and maintenance of cervical spine • Establish an airway: using basic life support maneuvers, simple Venturi mask, suction, nasopharyngeal tubes, oropharyngeal airways, endotracheal intubation, or rarely emergency cricothyroidotomy • The cervical spine is immobilized, and all patient movements performed with in-line traction, if the nature of the injury includes a signiﬁcant impact or fall, until it is possible to exclude instability with a complete AP and lateral C-spine radiograph or CT. Breathing and ventilation • Check ventilation by looking at chest expansion, ascultating for breath sounds, and monitoring O2 saturations and blood gases where appropriate. • Causes of inadequate ventilation, all of which need immediate treatment are: – – – – – – Upper airway obstruction. Malplacement ET tube if used. Pneumothorax. Hemothorax. Massive lung contusion. Flail segment. Circulation and control of hemorrhage • Signs of hypovolemic shock include confusion, pallor, tachycardia, tachypnea, oliguria. If peripheral access is difﬁcult place a large lumen catheter into the femoral vein, or perform saphenous vein cut-down. Fluid resus-citation is aimed at expanding the intravascular space and may initially be titrated against pulse, BP, and later against urine output and central venous pressure. Causes of circulatory collapse include: Cardiac arrest. Hypovolemia: obvious bleeding site, or occult, e.g., fracture of femur or pelvis, intra-abdominal bleed, hemothorax. Cardiac tamponade. Cardiac contusion. Aortic transesction. Disability and neurological state • Crucial in the evaluation of head and spinal injury, this is of less importance to the cardiothoracic surgeon Exposure • Examine the patient front and back, swiftly but carefully for any evidence of penetrating or blunt trauma. • Penetrating wounds below the fourth intercostal space may well have crossed the diaphragm, raising the specter of abdominal injury SECONDARY SURVEY • This is a more detailed and complete clinical examination aimed at elucidating some form of basic history, and identifying and managing the following potentially life-threatening injuries: – Rib fractures and ﬂail chest. – Pulmonary contusion. – Simple pneumothorax. – Blunt aortic injury. – Blunt myocardial injury. Investigations • First-line investigations performed once the primary survey and management is established include: – CXR (C-spine and pelvis as indicated). – TTE if pericardial effusion suspected. – CT if there is any suspicion about injury to major thoracic structures, and the patient is hemodynamically stable. – Aortography if aortic injury is suspected. Chest trauma causes: 1-Blunt Trauma 2-Pentrating & perforating injuries 3-Blast injuries Classification 1-Chest wall injury wall Superficial chest wall injury affecting the skin and muscles of the chest without affecting the ribs or the underlying pleura as proved by normal chest x-ray . Management is to arrest any bleeding and wound debridement with primary closure if possible . 2-Ribs & Sternal injuries May lead to Single rib fracture the important thing is to relief pain by analgesic , chest wall strapping or intercostal nerve block . or Multiple ribs fractures , flail chest in that case four or more ribs are fractured anteriorly and posteriorly which lead to paradoxical respiratory movement with the resultant hypoxia and severe dyspnea that nictitates emergency intubation and assisted ventilation and if the patient needs prolonged intubation for more than one week then tracheostomy is indicated . End tracheal tube Flail chest Costo chondral disruption Chest wall haematoma 3-Pleurl injuries Can lead to A-Pneumothorax which can be partial or complete closed or open sucking or tension pnemothorax . B-Haemothorax may be mild or severe and may be with pneumothorax Pneumothorax Collapsed lung Fractures Traumatic haemothorax 4-Pulmonary injuries Trauma can lead to pulmonary contusion with interstitial edema which may lead to consolidation of the lung tissues and can be manage by antibiotics administration and clearing of secretion 5-Tracheo-bronchial injuries It may lead to crushing or complete tracheal separation which needs immediate air way management and repair of the trachea. Bronchial injuries can be so severe that it lead to complete separation of the bronchus which lead to pneumothorax with severe air leak, haemoptysis &haemothorax .Bronchoscopy will establish the diagnosis and surgery is mandatory to reanastomosed the bronchus . 6-Great vessels injuries Injuries to the thoracic aorta and its branches can occur mainly with deceleration injury . Most patients with ruptured aorta die immediately but in 10% of patients the per aortic tissues and pleura are able to maintain the intravascular pressure producing false aneurysms ,which can be diagnose by CT angiography and needs immediate surgery . Traumatic aortic disruption is a timesensitive injury requiring rapid and accurate diagnosis to prevent death. Widen mediasinum Descending aortic injury Endo vascular stent control 7-Diaphragmatic injuries Trauma can lead to rupture of the diaphragm ,most commonly the left side affected ,leading to herniation of the viscera. Stomach is the most frequent organ to herniated followed by the transverse colon , spleen leading to collapse of the lung and mediastinal shift which can be seen on chest X-ray .Barium study is of great help in the diagnosis .Treatment surgery through abdominal , thoracic ,combined approach or by laparoscopy . 8-Esophageal injuries Thoracic esophagus rarely injured but mostly the cervical esophagus due to penetrating injury to the cervical region .Pain and dysphagia ,sometime fever .Diagnosis can be established by contrast study which will visualized the site of perforation. Treatment may be conservative by intravenous fluid , heavy antibiotics & NPO for 5-7 days which may be enough to seal the perforation , otherwise surgery is indicated to close the perforation . 9-Cardic injuries May vary from superficial laceration to transmural damage which lead to atrial or ventricular septal defect or coronary artery injury .The patient may present with dyspnea ,hypotension & tachycardia .Diagnosis can be accomplished by Echocardiography . Management includes resuscitation & immediate thoracotomy or sternotomy to treat the injury . "The surgeon who should attempt to suture a wound of the heart would lose the respect of his surgical colleagues" - Theodore Bilroth, 1882 Thoracotomy in chest trauma 90% of chest injuries can be treated by chest tube (tube thoracostomy or intercostal drain (ICD) ). Thoracotomy may be …immediate (resuscitative thoracotomy ) ……emergency .. … elective Emergency Department Thoracotomy Resuscitative thoracotomy Penetrating thoracic injury - Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital) - Unresponsive hypotension (BP < 70mmHg) Blunt thoracic injury - Unresponsive hypotension (BP < 70mmHg) - Rapid exsanguinations from chest tube (>1500ml) Immediate(urgent) thoracotomy 1-Massive haemoptysis 2-Massive haemothorax / initial dain1500 ml. or more than 200 ml /hr. for few hrs. 3-Ruptured bronchus with massive air leak 4-when great vessels injury is suspected 5- In combined lung & diaphragmatic injury 6-Some cases with esophageal injury . 7-In cardiac injury 8-In some cases of flail chest . Elective thoracotomy 1-Clotted haemothorax 2-Trapped lung syndrome 3-Big foreign body Complications of chest injuries 1-ARDS: Syndrome of acute RF with the formation of a non –cardiogenic pulmonary edema leading to reduced lung compliance and hypoxaemia which is refractory to oxygen therapy characterized by bilateral diffuse pulmonary infiltrate on chest X-ray (white lung) . A less severe case (ALI=acute lung injury ) which consists of a non specific pathological changes in the lung in response to a specific insult . 2-Atelectasis 3-Infection 4-Pulmonary embolism 5-Air embolism 6-Traecheal complications 7-Cardiac arrhythmias