Chest Trauma

I. IntroductionII. Definition of Terms

III. Review of the Thorax1. Chest Landmarks2. Chest Shape and Size

IV. Chest Trauma1. Blunt Trauma

1.1. Pathophysiology1.2. Assessment and Diagnostic Findings1.3. Nursing Interventions

1.3.1. Initial Interventions1.3.2. Ongoing Monitoring

1.4. Medical ManagementOperative intervention is rarely necessary in blunt thoracic injuries.

According to a report, only 8% of cases with blunt thoracic injuries required an operation. Therapeutic measures such as thoracentesis, chest tube insertion, bronchoscopic aspiration, or thoracotomy may commonly be indicated.

Clients with chest injuries may experience significant hypovolemia because massive blood loss and exsanguination is potentially high because of injury of the great blood vessels. Fluid replacement is with blood products, if indicated, or with crystalloid IV solutions such as lactated Ringer’s solution and normal saline. The volume of blood replacement is determined through assessment of clinical findings, hemodynamic measurements, and laboratory results such as hemoglobin and hematocrit.

Pain associated with chest injuries may cause the client to breathe rapidly and shallowly, which leads to atelectasis and pooling of tracheobronchial secretions. Analgesics minimize pain and permit periods of rest and relaxation. They also allow the client to cough and take deeper breaths. Narcotics are most effective if given IV. Intercostal nerve blocks or epidural analgesia may be used in clients with underlying health problems. Splinting the chest may also be helpful.2. Penetrating Trauma

Penetrating trauma occurs when a foreign body impales or passes through the body tissues.  The penetrating object may remain in the tissues, come back out the way it entered, or pass through the tissues and exit from another area. This kind of trauma can be serious because it can damage internal organs and presents a risk of shock and infection. The severity of the injury varies widely depending on the body parts involved, the characteristics of the penetrating object, and the amount of energy transmitted to the tissues.

The mechanism of injury in penetrating trauma may be categorized as low, medium, or high velocity. Low-velocity injuries include impalement, such as knife and

stab wounds, which disrupts only the structures penetrated. Medium-velocity injuries include bullet wounds from most types of handguns and air-powered pellet guns and are characterized by much less primary tissue destruction than wounds caused by high-velocity forces. High-velocity injuries include bullet wounds caused by rifles and wounds resulting from military weapons.

2.1. Assessment FindingsAssessment can be difficult because much of the damage is often internal and not

visible so the patient must be thoroughly examined. Initial assessment is directed toward identifying and treating life-threatening

conditions. Any client with chest trauma should be considered to have a serious injury until it is proved otherwise. Airway patency, adequacy of breathing, and circulatory sufficiency are always of primary concern. Respiratory assessment findings may include dyspnea or respiratory distress, cough with or without hemoptysis, cyanosis of mouth, face, nail beds, mucous membranes, tracheal deviation, audible air escaping from chest wound, decreased breath sounds on side of injury, decreased oxygen saturation, and frothy secretions. Cardiovascular assessment findings may include rapid, thread pulse, decreased blood pressure, narrowed pulse pressure, asymmetric blood pressure values in arms, distended neck veins, muffled heart sounds, chest pain, crunching sound synchronous with heart sounds, and arrhythmias. Surface findings may include bruising, abrasions, open chest wound, asymmetric chest movement and subcutaneous emphysema.

Laboratory examinations are rarely required in the acute treatment of patients with penetrating chest injuries. Hemoglobin or hematocrit values and arterial blood gas determinations offer the most useful information for treating these patients; however, tests may be temporarily delayed until patients are stabilized. Blood chemistry results, serum electrolyte values, and WBC and platelet counts add little information for initial treatment but can establish a baseline by which to follow the course of the patient through his or her therapy. Underlying medical conditions, such as diabetes and chronic renal insufficiency, either known or discovered via the laboratory examinations, should be noted and treated when appropriate.

With improvements in modern imaging, a number of different diagnostic modalities are available to aid in precisely defining the extent of trauma. Chest radiography remains the basis for initiating other investigations. CT scanning is considered a primary diagnostic tool because of its ability to image various intrathoracic structures and to differentiate substances of different densities such as solid and air-containing fluid collections.

2.2 Nursing Interventions2.2.1. Initial Intervention

Ensure patent airway. Administer high-flow oxygen, with non-rebreather mask.

Establish IV access with two large-bore catheters. Begin fluid resuscitation as appropriate.

Remove clothing to assess injury. Cover sucking chest wound with non-porous dressing taped on three sides. Stabilize impaled objects with bulky dressings. Do not remove. Assess for other significant injuries and treat appropriately. Stabilize flail rib segment with hand followed by application of large

pieces of tape horizontal across the flail segment. Place patient in a semi-Fowler position or position patient on the injured

side if breathing is easier after cervical spine injury has been ruled out.2.2.2. Ongoing Monitoring

Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status and urinary output.

Anticipate intubation for respiratory distress. Release dressing if tension pneumothorax develops after sucking chest

wound is covered.2.3. Medical InterventionAny organ within the chest is potentially susceptible to penetrating trauma, and

each should be considered when evaluating a patient with thoracic injury. The primary treatment of chest wall injuries is a combination of pain control, aggressive pulmonary and physical therapy, selective use of intubation and ventilation, and close observation for respiratory decompensation. After the status of the peripheral pulses is assessed, a large-bore intravenous line is inserted. An indwelling catheter is inserted to monitor urinary output. A nasogastric tube is inserted to prevent aspiration, minimize leakage of the abdominal contents, and decompress the gastrointestinal tract. A chest tube is inserted into the pleura space in most patients with penetrating wounds of the chest to achieve rapid and continuing re-expansion of the lungs. The insertion of the chest tube frequently results in a complete evacuation of the blood and air. It also allows early recognition of continuing intrathoracic bleeding, which would make surgical exploration necessary.

Shock is treated simultaneously with colloid solutions, crystalloids, or blood, as indicated by the patient’s condition.

Surgical intervention is required if the patient has a penetrating wound of the heart and great vessels, the esophagus, or the tracheobronchial tree.

V. ComplicationsThoracic injuries range from simple rib fractures to life-threatening tears of the

aorta, vena cava and other major vessels.1. Fractured Ribs

Rib fractures are the most common type of chest injury, particularly in the elderly. They are usually associated with a blunt injury, such as fall, a blow to the chest, or the impact of chest against a steering wheel. Ribs 5 through 10 are most commonly fractured

because they are least protected by chest muscles. If the fractured rib is splintered or displaced, it may damage the pleura and the lungs.Clinical manifestations of fractured rib include localized pain and tenderness, especially on inspiration, at the site of injury, shallow respirations, tendency of the client to hold the chest protectively or breathe shallowly in order to minimize chest movements, bruising or surface markings at the site of injury and protruding bone splinters if the fracture is compound. Fractured ribs also predisposes atelectasis and pneumonia.

The main goal in treatment is to decrease pain so that the patient can breathe adequately to promote good chest expansion. Intercostal nerve blocks with local anesthesia may be used to provide pain relief. Opioid drug therapy must be individualized and used with caution because these drugs can depress respirations.2. Fractured Sternum

Sternal fractures usually result from blunt deceleration injuries.They are usually accompanied by other major injuries such as flail chest, pulmonary and myocardial contusions, ruptured aorta, trachea, and haemothorax. Clinical manifestations include sharp, stabbing pain, swelling and discoloration over the fracture site, and crepitus. The main priority is to control associated injuries. Clients with a nondisplaced fracture may need analgesics or intercostal nerve blocks for pain relief. Severe sternal fractures may require surgical fixation.3. Flail Chest

Flail chest results from multiple rib fractures, causing instability of the chest wall. The chest wall cannot provide the bony structure necessary to maintain bellows action and ventilation. The affected area will move paradoxically to the intact portion of the chest during respiration. During inspiration the affected portion is sucked in, and during expiration it bulges out. This chest movement prevents adequate ventilation of the lung in the injured area.

A flail chest is usually apparent on visual examination of the unconscious patient. The patient manifests rapid, shallow respirations and tachycardia.

Initial therapy consists of adequate ventilation and humidified oxygen. The definitive therapy is to re-expand the lungs and ensure adequate oxygenation. A short period of intubation and ventilation may be necessary until the diagnosis of the lung injury is complete.4. Cardiac Tamponade

Cardiac tamponade is the compression of the heart as a result of fluid within the pericardial sac and is usually cause by blunt or penetrating trauma to the chest. Penetrating trauma to the pericardium and heart occurs. The small hole in the pericardium rapidly seals with clot, but bleeding from the heart continues and fills the pericardial space. The fibro-elastic pericardial sac cannot dilate and the cardiac chambers are compressed, especially the atria, which are prevented from filling, leading to obstructive shock. Cardiac output falls and the patient progresses to cardiac arrest without intervention.

Clinical manifestations include muffled, distant heart sounds, hypotension, neck vein distention and increased central venous pressure.

Urgent intervention can be life-saving. Resuscitation should be continued, with 100% oxygen and administration of intravenous fluid or blood products if available. This increases cardiac filling pressure and can temporarily improve the situation. The aim is to maintain cerebral perfusion but not to chase a normal systolic pressure as this will increase the rate and volume of bleeding into the pericardial sac. Pericardiocentesis with appropriate surgical repair should also be done.

5. Pneumothorax5.1. Open Pneumothorax and Mediastinal Flutter5.2. Tension Pneumothorax and Mediastinal Shift

6. Haemothorax