SILLIMAN UNIVERSITY

COLLEGE OF NURSING

Dumaguete City

LESSON PLAN on CHEST TRAUMA

Placement: NCM 103, 1st Semester, LEVEL III

Time Allotment: 1 hour and 30 minutes

Topic Description: This topic deals on the appropriate care that should be given to patients with chest trauma. It also includes discussion on the thorax, the

different types of chest trauma, the complications that may occur and the priority interventions and management that should be done.

General Objective: At the end of one hour and thirty minutes varied teaching-learning strategies, the students shall gain knowledge, demonstrate beginning skills,

and manifest positive attitude and values towards the care of patients with chest trauma.

OBJECTIVES CONTENT

At the end of our one hour and thirty

minute discussion, the students shall

be able to:

1. define the following terms of

at least 76% level of mastery

I. Introduction

According to the Centers for Disease Control and Prevention’s National Center for Injury Prevention and

Control (NCIPC), more than 29.7 million nonfatal injuries – and more than 157, 00 fatal injuries – were

reported in 2001. Motor vehicle crashes (MVCs), falls, overexertion, and being cut, stabbed, or struck are

among the leading causes of nonfatal injuries, and MVCs, gunshots, and MVCs, gunshots, and falls are among

the leading causes of fatal injuries.When we talk about morbidity and mortality, trauma is the leading cause of

death, hospitalization, and disability in Americans aged 1 year to the middle of the fifth decade of life. As such,

it constitutes a major health care problem.

By far, the most important cause of significant blunt chest trauma is motor vehicle accidents (MVAs).

MVAs account for 70-80% of such injuries. And for this morning, we are going to talk about chest trauma and

the complications it may bring.

II. Definition of Terms

1. Thoracic kyphosis - excessive convex curvature of the thoracic spine

2. Emphysema- chronic pulmonary condition in which the air sacs or alveoli are dilated and distended

2. review the anatomy of the thorax,

including its landmarks, shapes and

sizes accurately.

3.Thoracentesis - a procedure to remove fluid from the space between the lining of the outside of the lungs

(pleura) and the wall of the chest

4.Thoracotomy - an incision into the pleural space of the chest to gain access to the thoracic organs, most

commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine

5. Heimlich valve - a one-way valve used with a chest tube to drain fluid, clots, and air from the chest.

III. Review of the Thorax

The body has two lungs, each enclosed in a separate airtight area within the chest. If an object punctures the

chest wall and allows air to enter one of these areas, the lung within that area will begin to collapse.

The thorax is bordered superiorly by the thoracic inlet, just cephalad to the clavicles. The major arterial

blood supply to and venous drainage from the head and neck pass through the thoracic inlet.

The chest wall is composed of layers of muscle, bony ribs, costal cartilages, sternum, clavicles, and

scapulae. The inner lining of the chest wall is the parietal pleura. The visceral pleura invests the lungs. Between

the visceral and parietal pleurae is a potential space, which, under normal conditions, contains a small amount of

fluid that serves mainly as a lubricant.

1. Chest Landmarks

Before beginning the assessment, the nurse must be familiar with a series of imaginary lines on the chest

wall and be able to locate the position of each rib and some spinous processes. These help the nurse to identify

the position of underlying organs and to record abnormal assessment findings.

The midsternal line is a vertical line running through the center of the sternum.

The midclavicular line (right and left) are vertical lines from the midpoints of the clavicles.

The anterior axillary lines (right and left) are vertical lines from the anterior axillary folds.

The posterior axillary line is a vertical line from the posterior axillary fold.

The midaxillary line is a vertical line from the apex of the axilla.

The vertebral line is a vertical line along the spinous processes.

The scapular lines (right and left) are vertical lines from the inferior angles of the scapulae.

Locating the position of each rib and certain spinous processes is essential for identifying underlying lobes

3. satisfactorily identify the different

types of chest trauma, including its

assessment findings, appropriate

nursing interventions, and medical

management.

of the lung. Each lung is first divided into the upper and lower lobes by an oblique fissure that runs from the

level of the spinous process of the third thoracic vertebra (T3) to the level of the 6th

rib at the midclavicular line.

The right lung is further divided by a minor fissure into the right upper lobe and right middle lobe. The starting

point for locating the ribs anteriorly is the angle of Louis, the junction between the body of the sternum and the

manubrium.

The counting of ribs is more difficult on the posterior than on the anterior thorax. For identifying

underlying lung lobes, the pertinent landmark is T-3. The starting point for locating T-3 is the spinous process

of the seventh cervical vertebra (C-7).

2. Shape and Size

In adults, the thorax is oval. Its anteroposterior diameter is half its transverse diameter. The overall shape

of the thorax is elliptical; its diameter is smaller at the top then at the base. In older adults, kyphosis and

osteoporosis alter the size of the chest activity as the ribs move downward and forward.

There are several deformities of the chest:

Pigeon chest (pectus carinatum) - a permanent deformity, may be caused by rickets. Is characterized

by a narrow transverse diameter, an increased anteroposterior diameter and a protruding sternum.

Funnel chest (pectus excavatum) - a congenital defect, the opposite of pigeon chest in that the

sternum is depressed, narrowing the anteroposterior diameter. Because the sternum points posteriorly in

clients with a funnel chest, abnormal pressure on the heart may result in altered function.

Barrel chest- the ratio of the anteroposterior to transverse diameter is 1 to 1, is seen in clients with

thoracic kyphosis and emphysema.

IV. Chest Trauma

This frequently produces life-threatening disruptions and injury to the thoracic cage and its contents can

restrict the heart’s ability to pump blood or the lungs’ ability to exchange air and oxygenate blood.

Major dangers associated with chest injuries are internal bleeding and punctured organs.

Chest injuries can range from relatively minor bumps and scrapes to severe crushing or penetrating trauma.

1. Blunt Trauma

- This type of trauma is more common.

- It is often difficult to identify the extent of the damage because the symptoms may be generalized

and vague.

- This occurs when the body is struck by a blunt object, such as steering wheel. The external injury

may appear minor but the impact may cause severe, life-threatening internal injuries such as ruptured

spleen.

- Patients may not seek medical attention which may complicate the problem.

1.1 Pathophysiology

Injuries to the chest are often life-threatening and result in one or more of the following

pathologic mechanisms:

Hypoxemia from disruption of the airway; injury to the lung parenchyma, rib cage, and

respiratory musculature; massive hemorrhage; collapsed lung; and pneumothorax

Hypovolemia from massive fluid loss from the great vessels, cardiac rupture or hemothorax

Cardiac failure from cardiac tamponade, cardiac contusion, or increased intrathoracic

pressure.

These mechanisms frequently result in impaired ventilation and perfusion leading to ARF,

hypovolemic shock, and death.

1.2. Assessment and Diagnostic Findings

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.

1.3. Nursing Interventions

1.3.1. Initial Interventions

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.

1.3.2. 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.

1.4. Medical Management

Operative 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 Findings

Assessment 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 Interventions

2.2.1. 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.

4. determine the possible

complications, its clinical

manifestations and management that

may occur following chest trauma

comprehensively.

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 Intervention

Any 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. Complications

Thoracic 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. Pneumothorax

A pneumothorax (noo-mo-THOR-acks) is a collapsed lung.

This occurs when air leaks into the space between your lungs and chest wall. This air pushes on the

outside of your lung and makes it collapse. In most cases, only a portion of the lung collapses.

Can be caused by a blunt or penetrating chest injury, certain medical procedures involving your

lungs, or damage from underlying lung disease. Or it may occur for no obvious reason. Symptoms

usually include sudden chest pain and shortness of breath.

A small, uncomplicated pneumothorax may quickly heal on its own. When the pneumothorax is

larger, doctors usually insert a flexible tube or needle between your ribs to remove the excess air.

5.1 Open Pneumothorax

A life threatening injury where penetrating trauma opens the pleural space, causing a

pneumothorax and a ‘sucking’ chest wound.

Management: Immediate management is life saving and consists of:

• Supplemental (100%) oxygen

• Applying a flap-valve dressing

• Inserting a chest drain and applying a totally occlusive dressing to the open wound.

5.2 Tension Pneumothorax

Tension pneumothorax is a consequence of a flap-valve, one way mechanism in the pleural

membrane where the pleural space is in communication with the outside atmosphere or a

conducting airway. Air flows in one way only and creates positive pressure (tension) in the

pleural space. It is rapidly life-threatening.

Manifestations:

Cyanosis, air hunger, violent agitation, tracheal deviation away from affected side,

subcutaneous emphysema, neck vein distension, hyperresonance to percussion

Immediate Management = Needle decompression: No further investigations are required.

Immediate action is essential. Needle decompression by insertion of a 14 gauge, 5cm long

needle in the second intercostal space in the mid-clavicular line should be performed.

Be sure to use a long enough needle. Cadaveric studies indicate that at this site, the pleural

cavity can be deeper than perceived, and you are unlikely to cause significant harm through

this procedure.

Once needle decompression has been performed, the pleural space is decompressed. This

buys time for definitive management, which is insertion of a formal chest drain.

In Summary:

1. Confirm the affected side clinically,

2. Inform the patient,

3. Antiseptic swab the skin at the 2nd intercostal space in the mid-clavicular line,

4. Insert a 14 Gauge cannula (usually orange or brown capped) +/- syringe,

5. Listen for ‘hiss’ (or ‘bubbling’ if the syringe barrel is filled with water and the

plunger removed),

6. Protect with gauze swab, tape, and *leave in situ*,

7. Set up chest drain.

6. Haemothorax

Haemothorax is a collection of blood in the pleural space and may be caused by blunt or

penetrating trauma. Most haemothoraces are the result of rib fractures, lung parenchymal and

minor venous injuries, and as such are self-limiting. Less commonly there is an arterial injury,

which is more likely to require surgical repair.

Is frequently found in association with open pneumothorax and is then called a

hemopneumothorax.

Causes include chest trauma, lung malignancy, complication of anti-cagulant therapy,

pulmonary embolus and tearing of pleaural adhesions.

Clinical Manifestations:

If pneumothorax is small, mild tachycardia and dyspea may be the only manifestations. If it is

large, respiratory distress may be present, including shallow, rapid respirations, dyspnea and air

hunger. Chest pain and a cough with or without hemoptosis may be present. On auscultation, there

are no breath sounds over the affected area, and hyperresonance may be present.

Management and Treatment:

Treatment depends on the severity of the pneumothorax and the nature of the underlying

disease. If the patoent is stable and the amount of air and fluid accumulated in the intrapleural

space is minimal, no treatment may be needed as the the pneumothorax resolves spontaneously.

As a life-saving measure, needle venting (using a large bore needle) of the pleural space may be

used.

A Heimlich valve may also be used to evacuate air from the pleural space.

COLLEGE OF NURSING

SILLIMAN UNIVERSITY

Dumaguete City

VISION:

A leading Christian institution committed to total human development for the well-being of society and environment.

MISSION:

In this regard, the University

Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and

relationship can be nurtured and promoted.

Provide opportunities for growth and excellence in every dimension of the university life in order to strengthen character, competence and faith.

Instill in all members of the university community an enlightened social consciousness and a deep sense of justice and compassion.

Promote unity among peoples and contribute to national development.

Bibliography

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Kozier, B., et. al. (2008). Kozier & Erb’s fundamentals of nursing: concepts, process, nursing and practice. (8th

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Trauma.Org. (2010). Haemothorax. Retrieved from: http://www.trauma.org/index.php/main/article/397/