Asuhan Keperawatan Klien dengan Trauma dada Tuti Herawati, SKp, MNIntroduction • Struktur Organ: Jantung, pembuluh darah besar, esofagus, trakeobronkial dan paru -paru • 25% of kematian akibat KLL disebabkan karena trauma dada • Trauma abdomen um umnya disertai dengan trauma dada • Penyebab: trauma tumpul dan trauma tajam • Fokus pencegahan Sistem yang memperbaiki keselamatan penumpang seperti airbags, safet y belt Anatomi & Fisiologi Thorax • Tulang dinding thorax – 12 pasang tulang-tulang iga yang berbentuk C • Ribs 1-7: Join at sternum with cartilage end-points • Ribs 8-10: Join sternum with combined cartilage at 7 th rib • Ribs 11-12: No anterior attachment – Sternum • Manubrium – Joins to clavicle and 1st rib – Jugular Notch • Body – Sternal angle (Angle of Louis) » Junction of the manubrium with the sternal body » A ttachment of 2nd rib • Xiphoid process – Distal portion of sternum . . pisau. Shotguns. Trauma. Type I: >7 meters: injuri jaringan lunak Type II: 3-7 meters : penetrasi ke fasc ia dan organ internal Type III: <3 meters: kerusakan jaringan yang hebat. tergantung jarak dengan senjata dan kaliber.PENYEBAB TRAUMA DADA • Trauma Tajam Panah. handguns.org . Penyebab Trauma dada Trauma Tumpul . Injuri yang menyertai trauma pada dada • Closed pneumothorax • Open pneumothorax (including sucking chest wound) • Tension pn eumothorax • Pneumomediastinum • Hemothorax • Hemopneumothorax • Laceration of vascular structures • Tracheobronchial tree lacerations • Esophageal lacerations • Penetrating cardiac injuries • Pericardial tamponade • Spinal cord injuries • Diaphragm trauma • Int ra-abdominal penetration with associated organ injury . . Dinding dada • Contusion – Umumnya disebabkan trauma tumpul – Signs & Symptoms • • • • • • • • Erythema Ecchymosis DYSPNEA Nyeri saat bernafas Suara nafas yang menurun Limi breath sounds HYPOVENTILAsi (nyeri saat bernafas) Crepitus Gerakan dinding dada paradox . dapat menuebabkan injuri paru – Iga 4-9 tempat yang paling umum terjadi farktur – Iga 9-12 jarang terjadi fraktur • Transmisikan energy trauma ke organ internal • Bila fraktur.Dinding dada • Fraktur Iga – >50% trauma dada disebabkan oleh trauma tumpul – Compressional forces flex and fra cture ribs at weakest points – Iga 1-3 diperlukan kekauatan yang besar bila terjad i fraktur. curigai adanya injuri hepar dan limpa – Hypoventilasi umum terjadi karena nyeri . . e.Dinding dada • Sternal Fracture & Dislocation – Associated with severe blunt anterior trauma – Typical MOI • Direct Blow (i. Steering wheel) – Incidence: 5-8% – Mortality: 25-45% • • • • Myocardial contusion Pericardial tamponade Cardiac rupture Pulmonary contusion – Dislocation uncommon but same MOI as fracture • Tracheal depression if posterior . Dinding dada • Flail Chest – Segment of the chest that becomes free to move with the pressure changes of resp iration – Three or more adjacent rib fracture in two or more places – Serious chest wall injury with underlying pulmonary injury • Reduces volume of respiration • Adds to increased mortality – Paradoxical flail segment movement – Positive pressure ventilation can restore tid al volume . . Paradoxical chest wall movement . or to the side (about 2 in [5 cm]) above the stern oxiphoid junction (lower junction of the sternum.The point of insertion in the chest most commonly occurs on the side (lateral th orax). at a line drawn from the armpit (anterior axillary line) to the side (lat eral) of the nipple in males. . or chest bone) in females. Injury Paru-Paru • Simple Pneumothorax – Closed Pneumothorax • Progresses into Tension Pneumothorax – Occurs when lung tissue is disrupted and air leaks into the pleural space – Progressive Pathology • • • • Air accumulates in pleural space Lung collapses Alveoli collapse (atelectasis) R educed oxygen and carbon dioxide exchange – Increased ventilation but no alveolar perfusion – Reduced respiratory efficiency r esults in HYPOXIA • Ventilation/Perfusion Mismatch . Injury Paru-Paru • Open Pneumothorax – Free passage of air between atmosphere and pleural space – Air replaces lung tissu e – Mediastinum shifts to uninjured side – Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger – Signs & Symptoms • • • • • Penetrating chest trauma Sucking chest wound Frothy blood at wound site Severe D yspnea Hypovolemia . . – Excessive pressure reduces effectiv eness of respiration – Air is unable to escape from inside the pleural space – Progr ession of Simple or Open Pneumothorax .Injuri Paru-paru • Tension Pneumothorax – Buildup of air under pressure in the thorax. . . Pulmonary Injuries Tension Pneumothorax Signs & Symptoms • Dyspnea – Tachypnea at first • Progressive ventilation/perfusion mismatch – Atelectasi s on uninjured side • Hypoxemia • Hyperinflation of injured side of chest • Hyperreson ance of injured side of chest • Diminished then absent breath sounds on injured si de • Cyanosis • Diaphoresis • JVD • Hypotension • Hypovolemia • Tracheal Shifting – LATE SIGN . . 5 00 mL of blood • Mortality rate of 75% • Each side of thorax may hold up to 3.000 mL – Blood loss in thorax causes a decrease in tidal volume • Ventilation/Perfusion Mismatch & Shock – Typically accompanies pneumothorax • Hemopneumothorax .Injuri Paru-Paru • Hemothorax – Accumulation of blood in the pleural space – Serious hemorrhage may accumulate 1. . . Hemothorax sign & symptoms • Blunt or penetrating chest trauma • Shock – Dyspnea – Tachycardia – Tachypnea – Diaphoresis – Hypotension • Dull to percussion over injured side . 1 ½ L of blood loss in alveolar tissue • Progressive deterioration of ventilatory status – Hemoptysis typically present .Pulmonary Injury • Pulmonary Contusion – – – – Soft tissue contusion of the lung 30-75% of patients with significant blunt ches t trauma Frequently associated with rib fracture Typical MOI • Deceleration – Chest impact on steering wheel • Bullet Cavitation – High velocity ammunition – Microhemorrhage may account for 1. Cardiovascular injury • Myocardial Contusion – Occurs in 76% of patients with severe blunt chest trauma – Right Atrium and Ventri cle is commonly injured – Injury may reduce strength of cardiac contractions • Reduced cardiac output – Electrical Disturbances due to irritability of damaged myocardial cells – Progress ive Problems • Hematoma • Hemopericard • Myocardial necrosis • Dysrhythmias • CHF & or Cardiogenic shoc k . Myocardial contusion sign & symptom • • • • Bruising of chest wall Tachycardia and/or irregular rhythm Retrosternal pain sim ilar to MI Associated injuries – Rib/Sternal fractures • Chest pain unrelieved by oxygen – May be relieved with rest – THIS IS TRAUMA-RELATED PAIN • Similar signs and symptoms of medical chest pain . very high mortality – Results from tear in the coronary artery or penetration of myocardium • Blood seeps into pericardium and is unable to escape • 200-300 ml of blood can res trict effectiveness of cardiac contractions – Removing as little as 20 ml can provide relief .Cardiovascular injury • Pericardial Tamponade – Restriction to cardiac filling caused by blood or other fluid within the pericar dium – Occurs in <2% of all serious chest trauma • However. QRS. thready pulse • Shock • Kussmaul’s sign – Decrease or absence of JVD during inspiration Pulsus Paradoxus – Dro p in SBP >10 during inspiration – Due to increase in CO2 during inspiration Electr ical Alterans – P.Pericardial Tamponade Signs & Symptoms • Dyspnea • Possible cyanosis • Beck’s Triad – JVD – Distant heart tones – Hypotension or narrowing pulse pressure • • • • Weak. & T amplitude changes in every other cardiac cycle PEA . Cardiovascular injury • Traumatic Aneurysm or Aortic Rupture – Aorta most commonly injured in severe blunt or penetrating trauma • 85-95% mortality – Typically patients will survive the initial injury insult • 30% mortality in 6 hrs • 50% mortality in 24 hrs • 70% mortality in 1 week – Injury may be confined to areas of aorta attachment – Signs & Symptoms • Rapid and deterioration of vitals • Pulse deficit between right and left upper or lower extremities . Expansion of chest – Palpate – Auscultate – Percuss – Blunt T rauma Assessment – Penetrating Trauma Assessment • Ongoing Assessment .Assessment of the Thoracic Trauma Patient • Scene Size-up • Initial Assessment • Rapid Trauma Assessment – Observe • JVD. SQ Emphysema. 000 mL • BVM at a rate of 12-16 – May be beneficial for chest contusion and rib fractures – Promotes oxygen perfusio n of alveoli and prevents atelectasis • Anticipate Myocardial Compromise • Shock Management – Fluid Bolus: 20 mL/kg – AUSCULTATE! AUSCULATE! AUSCULATE! .General Management of the Chest Injury Patient • Ensure ABC’s – High flow O2 via NRB – Intubate if indicated – Consider overdrive ventilation • If tidal volume less than 6. Management of the Chest Injury Patient • Rib Fractures – Consider analgesics for pain and to improve chest excursion • Morphine Sulfate – CONTRAINDICATION • Nitrous Oxide – May migrate into pleural or mediastinal space and worsen condition . Management of the Chest Injury Patient • Sternoclavicular Dislocation – Supportive O2 therapy – Evaluate for concomitant inju ry • Flail Chest – Place patient on side of injury • ONLY if spinal injury is NOT suspected – Expose injury site – Dress with bulky bandage against flail segment • Stabilizes fracture site – High flow O2 • Consider PPV or ET if decreasing respiratory status – DO NOT USE SANDBAGS TO STABILIZE FX . Trauma.org . Management of the Chest Injury Patient • Open Pneumothorax – High flow O2 – Cover site with sterile occlusive dressing taped on three sides – Pro gressive airway management if indicated . Management of the Chest Injury Patient • Tension Pneumothorax – Confirmation • Auscultaton & Percussion – Pleural Decompression • 2nd intercostal space in mid-clavicular line – TOP OF RIB • Consider multiple decompression sites if patient remains symptomatic • Large over the needle catheter: 14ga . Management of the Chest Injury Patient • Hemothorax – High flow O2 – 2 large bore IV’s • Maintain SBP of 90-100 • EVALUATE BREATH SOUNDS for fluid overload • Myocardial Contusion – Monitor ECG • Alert for dysrhythmias – IV if antidysrhythmics are needed . Management of the Chest Injury Patient • Pericardial Tamponade – High flow O2 – IV therapy – Consider pericardiocentesis. rapidly deteriorating patie nt • Aortic Aneurysm – AVOID jarring or rough handling – Initiate IV therapy enroute • Mild hypotension may be protective • Rapid fluid bolus if aneurysm ruptures – Keep patient calm . 3.Diagnosa keperawatan 1. Inefektif bersihan jalan napas berhubu ngan dengan peningkatan sekresi sekret dan penurunan batuk sekunder akibat nyeri dan keletihan. 5. 2. Risiko terhadap infeksi berhubungan dengan tempat masuknya organisme sekunder terhadap trauma. Perubahan kenyamanan : Nyeri akut berhubungan dengan trauma jaringan dan refl ek spasme otot sekunder. 6 . 4. Kerusakan integritas kulit berhubungan dengan trauma mekanik terpasang bullow drainage. Hambatan mobilitas fisik berhubungan deng an ketidakcukupan kekuatan dan ketahanan untuk ambulasi dengan alat eksternal. Ketidakefektifan pola pernapasan berhubungan dengan ekpansi paru yang tidak m aksimal karena akumulasi udara/cairan. . Tujuan : Pola pernapasan efektive. Observasi fungsi pernapasan. dispnea atau perubahan tanda-tanda vital. o A daptive mengatasi faktor-faktor penyebab. Balik ke sisi yang sakit. Jelaskan pada klien b ahwa tindakan tersebut dilakukan untuk menjamin keamanan . Kriteria hasil : o Memperlihatkan frekuensi p ernapasan yang efektive. biasanya dnegan peninggian kepala tempat tidur.Ketidakefektifan pola pernapasan berhubungan dengan ekspansi paru yang tidak mak simal karena trauma. Intervensi : Berikan posisi yang nyama n. catat freku ensi pernapasan. Dor ong klien untuk duduk sebanyak mungkin. o Mengalami perbaikan pertukaran gas-gas pada paru. Pertahankan perilaku tenang. Kolaborasi dengan tim kesehatan lain Pemberian analgetika. cek setiap 1 – 2 jam Periksa pengontrol penghisap untuk jumlah hisapan yang benar. Posisikan sistem drain age slang untuk fungsi optimal.Intervensi … • • • • • • • • • Jelaskan pada klien tentang etiologi/faktor pencetus adanya sesak atau kolaps pa ru-paru. . pertahankan pada batas ya ng ditentukan. Catat karakter/jumlah drainage selang dada. atau menggantung di bawah saluran masuknya ke tempat drainage. Periksa batas cairan pada botol penghisap. yakinkan slang tidak terlipat. Alirkan akumulasi drainase bila pe rlu. Konsul photo toraks. bantu pasien untuk kontrol diri dnegan men ggunakan pernapasan lebih lambat dan dalam. Observasi gelembung udara botol penampung. Perhatikan alat chest drainase berfu ngsi baik. • Tidak ada lagi penumpu kan sekret di sal. meningkatkan masukan cairan 1000 sampai 1500 cc/hari bila tidak ko ntraindikasi. pemberian analgesik . Dorong atau berikan perawatan mulut yang baik setelah batuk. pernapasan. • Ajarkan latihan pernapasan dan batuk efektif • • • • Auskultasi paru sebelum dan sesudah klien batuk. Intervensi : • Jelaskan klien tentang kegunaan batuk yang efektif dan mengapa terdapat penumpukan sekret di saluran p ernapasan.Inefektif bersihan jalan napas berhubungan dengan peningkatan sekresi sekret dan penurunan batuk sekunder akibat nyeri dan keletihan. Lakukan penghisapan lendir jika diperlukan • Kolaborasi dengan tim kesehatan lain : Pemberian expectoran. • Klien nyaman. Ajarkan mempertahankan hidrasi yang adekuat. . Tujuan : Jalan napas lanca r/normal Kriteria hasil : • Menunjukkan batuk yang efektif.