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Trauma Services

Chest Trauma

OBJECTIVE:

1. Describe the assessment and interventions of a trauma patient with chest trauma.

2. Describe the pathophysiology, assessment and treatment of common chest trauma injuries.

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I. Introduction

II. Thoracic Assessment

A. Airway

1. Airway assessment

a. Vocalization – Confirms A,B,C,D

b. Tongue – Most common obstruction in the unconscious adult

c. Loose teeth or foreign objects

d. Bleeding

e. Vomitus or other secretion

f. Traumatic airway disruptions

2. Airway interventions - Maintain spinal immobilization

a. Positioning of patient

b. Jaw thrust

c. Chin lift

d. Suction air, as appropriate

e. Oral or nasopharyngeal airway

f. Alternative airways

1) Combitube

2) King Airway

g. Endotracheal intubation

1) Oral

2) Nasal

h. Cricothyroidotomy – Emergency, temporary surgical airway

i. Reassess any interventions

B. Breathing

1. Breathing assessment

a. Spontaneous breathing

b. Chest rise and fall

c. Skin color

d. Respiratory rate AND depth

e. Pulse oximetery – SpO2

f. End tidal carbon dioxide – EtCO2

g. Chest wall integrity

h. Use of abdominal and/or accessory muscles?

i. Breath sounds

1) Listen anterior and lateral

2) Compare both sides

j. Bowel sounds in chest?

k. Jugular vein distension – Increased pressure around heart

l. Position of trachea

2. Breathing interventions

a. Oxygen is the trauma patient’s best friend!

b. Open chest wound dressing

1) Occlusive material

2) Taped down on three sides

3) Open side down

c. Assist with ventilation - Bag-valve-mask (BVM)

d. Intubate

1) Oral – Most patients

2) Nasal

a) Requires spontaneously breathing patient

b) High incidence of sinus infection

3) Intubation assessment

a) Primary assessment

(1) Negative epigastric sounds

(2) Bilateral, equal breath sounds

(3) Misting in tube with exhalation

b) Secondary assessment

(1) EtCO2

(2) Esophageal detector device (EDD)

e. Needle thoracostomy

f. Chest tubes

g. Reassess interventions

C. Circulation

1. Circulation assessment

a. Palpate carotid pulse

b. Inspect skin for:

1) Color

2) Temperature

3) Diaphoresis

4) Capillary refill

c. Compare upper and lower extremities for:

1) Pulse strength

2) Blood pressure

d. Inspect for signs of active external bleeding

2. Circulation intervention

a. Control serious bleeding

1) Direct pressure

2) Pressure dressing

3) Tourniquet – Sooner rather than later

b. Insert two large (14 – 16 ga), short IV catheters

c. Obtain blood for type and cross match, if in the hospital

d. Intraosseous (IO) devices, if unable to get IV

1) FAST 1 – Sternum

2) Bone Injection Gun (BIG) – Humerus, tibia

3) EZ-IO – Humerus, proximal and distal tibia

e. Use blood tubing, if available

f. Infuse warmed IV fluid (NS or LR) at a fast rate to maintain systolic blood

pressure > 90 mm/Hg

g. Blood products after 2 liters of crystalloid fluid

h. Reassess interventions

D. Radiology

1. Chest X-ray

2. FAST – Focus Abdominal Sonogram for Trauma

3. Computerized Tomography (CT)

III. Specific Chest Trauma

A. Simple vs. complex

1. Simple will cause discomfort but seldom serious

2. Complex can cause death

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B. Flail Chest

1. Pathophysiology

a. Usually caused by blunt trauma

b. Three or more consecutive ribs fractured in two or more places

c. May incorporate sternal fractures

d. “Flail” segment moves opposite to rest of chest

e. Interferes with respiratory mechanics

f. Likely to also have pulmonary contusions

2. Assessment

a. Observe for paradoxical chest wall motion

b. Respiratory distress

c. Palpation/auscultation of subcutaneous emphysema

d. Rib fractures identified by x-ray or CT

3. Interventions:

a. May require endotracheal intubation

b. Positive pressure ventilation

c. Careful IV volume replacement

d. Aggressive pain control

1) Narcotics – PCA

2) NSAIDS – Tordol

3) Epidural

e. Consider underlying injuries, especially lung injuries & pneumothroax

C. Pulmonary contusions

1. Pathophysiology

a. Usually caused by blunt trauma

b. Contusions cause gradual fluid accumulation in injured lung tissue

c. Decreased ability to ventilate lungs

2. Assessment:

a. Increasingly ineffective cough

b. Tachypnea

c. Increasing dyspnea

3. Interventions:

a. Support oxygen and ventilation

b. Limit IV fluids

c. May require long term ventilator support

D. Pneumothorax

1. Pathophysiology

a. May be caused by:

1) Blunt trauma

2) Penetrating trauma

3) Sudden increase of intra-thoracic pressure causes “popping” of fragile lung bleb

b. Air enters pleural space (between chest wall and lung)

c. Breaks seal of lung to chest wall, allowing lung to collapse

d. If open, air moves freely in and out of pleural space

e. If closed, air enters pleural space but cannot leave

2. Assessment:

a. Dyspnea

b. Chest pain

c. Decreased breath sounds over the affected area

d. Subcutaneous emphysema

e. Bubbling at wound site

f. Chest x-ray shows collapsed lung on affected side

3. Interventions:

a. Support oxygenation and ventilation

b. Seal wound with three-sided occlusive dressing

1) Preferred material - flexible plastic

2) Taped down on three sides

3) Open side in the “down” position

c. Chest tube placement

1) High anterior

2) High lateral

3) May need more than one

E. Tension Pneumothorax

1. Pathophysiology

a. May be caused by:

1) Blunt trauma

2) Penetrating trauma

3) Excessive intra-thoracic pressure “popping” bled

b. Air enters pleural space (between chest wall and lung)

c. Breaks seal of lung to chest wall, allowing

d. Air enters pleural space but cannot leave

e. Pressure builds on affected side, causing compression of heart and opposite lung

2. Assessment:

a. Severe shortness of breath

b. Increasing difficulty in ventilation

c. Subcutaneous emphysema

d. Distended jugular veins (due to compression of heart)

e. Decreased blood pressure

f. Deviated trachea (late sign)

g. Chest x-ray shows:

1) Collapsed lung on affected side

2) Mediastinum shifted away from affected side

3. Interventions:

a. Support oxygenation and ventilation

b. Needle thoracostomy

1) Placed 2nd intercostal space, mid-clavicular line (MCL)

2) Hit rib? – Advance OVER rib into intercostal space

3) Converts tension pneumothroax into open pneumothroax

4) Requires chest tube insertion

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F. Hemothorax

1. Pathophysiology

a. Lung blood vessels or costal arteries injured by:

1) Penetrating trauma

2) Fractured ribs

b. Blood pulled by gravity to dependent portion of chest

c. Inhibits full expansion of lungs

d. Blood loss may be SIGNIFICANT

2. Assessment:

a. Rapid, shallow respirations

b. Signs of hypovolemic shock

c. Decreased breath sounds over area of suspected injury

3. Interventions:

a. Support oxygenation & ventilation

b. IV access and fluid administration

c. Large bore chest tube placement

1) Low lateral

2) Low posterior

3) Possibility of causing more blood loss by removing tamponade affect

G. Blunt cardiac trauma

1. Pathophysiology

a. Usually caused by blunt trauma directly over heart or sternum

b. Bruising of heart muscle disrupts:

1) Ability of heart muscle to contract

2) Conduction of electrical impulse

2. Assessment

a. High degree of clinical suspicion based on mechanism of injury

b. Bruising over sternum

c. Chest pain

d. Right ventricle more commonly injured

e. Arrhythmias common

f. Cardiac enzymes do not relate well to extent of injury

2. Interventions

a. Serial or continuous ECG monitoring

b. Supportive therapy to maintain cardiac output and blood pressure

1) Dysrrhythmia treatment

2) Vasoactive drips

H. Cardiac Tamponade

1. Pathophysiology

a. May be caused by penetrating or blunt trauma, causing damage to:

1) Coronary arteries

2) Coronary sinuses

3) Aortic root

b. Injury allows accumulation of blood in pericardium

c. As blood accumulates, it compresses the heart and prevents adequate filling

2. Assessment

a. Distended jugular veins

b. Cyanosis

c. Paradoxical pulse – Pulse strength varies with respiration

1) Pulse strength increases with expiration

2) Pulse strength decreases with inspiration

d. Muffled heart sounds

3. Interventions:

a. Support oxygenation & ventilation

b. Initiate IV and administer volume

c. Pericardiocentesis

I. Ruptured Aorta

1. Pathophysiology

a. Usually cause by acceleration/deceleration injury (“It’s not the 200 foot fall that kills you. It’s the sudden stop at the bottom”)

b. As body stops, fluid filled heart and aorta continue to move

c. Movement causes stretching of connecting ligament in back of chest

d. Stretch of ligament causes tearing of aorta

1) If aorta is completely torn = instant death

2) If aorta is partially torn = may survive

2. Assessment

a. Anterior chest wall bruise

b. Decreased lower extremity pulse strength & blood pressure, when compared to the upper extremity

c. Tracheal deviation to the right

d. Chest x-ray – Widened mediastinum

3. Interventions:

a. High degree of suspicion based on mechanism of injury

b. IV access for massive fluid resuscitation (?)

c. Surgical intervention ASAP

J. Tracheobronchial disruption

1. Pathophysiology

a. Usually cause by acceleration/de-acceleration injury

b. May be caused by penetrating trauma

c. Tear occurs between the stiff rings of the trachea or main stem bronchi

d. Allows air to escape into pleural space

e. May create intermittent airway obstruction = “ball-valve effect”

2. Assessment:

a. Airway obstruction, may be intermittent

b. Hemoptysis – Coughing up blood

c. Subcutaneous emphysema

d. Possible tension pneumothorax

e. Bronchoscopy or radiology

3. Interventions:

a. Maintain an open airway, using manual ventilations as needed

b. Oxygen

c. Chest tube (?)

d. Surgery or bronchoscopy repair

K. Traumatic asphyxia

1. Pathophysiology

a. Compression of the chest by external forces

1) Entrenchment

2) Avalanche

b. Pressure pushes blood into exposed shoulder/head

c. May cause damage to lung or chest structures

2. Assessment

a. Discolored upper torso

b. Protruding bloodshot eyes

c. Cyanotic lips and tongue

d. Underlying lung or chest injury (?)

3. Interventions

a. Support ventilation and oxygenation

c. Intubation if needed

d. Treat any underlying lung or chest injury

L. Ruptured diaphragm

1. Pathophysiology

a. Usually caused by sudden, sharp pressure to abdomen

1) Vehicle rear seat belt injury

2) Falling into sharp edge

b. Sudden increase in abdominal pressure

c. Stomach pushes up and “pops” left diaphragm

d. Rupture allows abdominal contents into chest

e. May damage pancreas

1. Assessments

a. Dyspnea

b. Abdominal pain

c. Pain radiating to the left shoulder (Kehr’s sign)

d. Bowel sounds in the chest

e. Decreased breath sounds on the injured side.

3. Interventions

a. Support ventilation and oxygenation

b. Insert a gastric tube to decompress the stomach

c. Transport to definitive surgical care ASAP

IV. Summary

Compiled and edited by Michael W. Day, RN, MSN, CCRN, Trauma Nurse Coordinator, Sacred Heart Medical

Center and Children’s Hospital, Spokane, WA 99220; 509-474-7111; michael.day@

References:

American College of Surgeons, Committee on Trauma. (2012). Advanced Trauma Life

Support (ATLS) for Doctors, 9th ed. Chicago, IL: Author

American College of Surgeons, Committee on Trauma. (2011). Prehospital Trauma Life

Support (PHTLS), Military 7th ed. Chicago, IL: Author

Emergency Nurses Association. (2007.) Trauma Nurse Core Curriculum, 6th ed. (Revised).

Park Ridge, IL: Author.

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