Unit 2: Chest Trauma Flashcards
2 Types of Chest Trauma
- blunt-force
- prenetrating trauma
Blunt Chest Trauma
the result of a blunt object hitting the chest or the chest striking a blunt surface such as the steering wheel
- can be further characterized as acceleration or deceleration injuries
- more diffuse than penetrating trauma
- may cause injuries that may not be obvious at the time of initial assessment
Deceleration Injuries
the movement of the body is suddenly stopped but the internal organs remain in motion and collide with the chest wall
-body has been moving and comes to an abrupt stop
Accelerated Injuries
- occurs when the body is abruptly set in motion (rear-end collisions) or when the body is hit by a rapidly moving object
- sudden increase in speed
Penetrating Trauma
the result of sharp objects (knives, bullets) entering the chest and causing damage to internal structures or organs
- other causes: objects that enter a motor vehicle during a collision (intrusion) or shrapnel from explosions
- the depth, angle, and location of the penetration can differentiate whether the penetrating trauma is a superficial wound or is potentially life-threatening
Common Injuries occurring as a result of Chest Trauma
- fractured ribs
- pneumothorax
- hemothorax
Common Injuries: Fractured ribs
most common injury associated w/ chest trauma
- the integrity of the entire thorax and chest wall movement are compromised
- patient cannot take deep, effective breaths, largely b/c of pain, effectively limiting the ability to maintain normal tidal volumes w/ each breath
- there may be collateral penetrating damage to the organs and vessels located near the site of injury (ex: liver)
A Flail Chest
three or more adjacent ribs that have been fractured in two or more places as a result of blunt or crush chest trauma, resulting in a “free” segment of the ribs
- “paradoxical” chest-wall movement is a hallmark sign
- with each inhalation the damaged area moves inward; on exhalation, this section of the chest wall moves outward
- chest wall movement is compromised largely b/c of pain; may result in respiratory insufficiency
Pneumothorax
the collection of air in the pleural space
- there is a reduction in the negative thoracic pressure because of the presence of air in the pleural space; makes inspiration more difficult, and the lung cannot adequately expand
- results in a reduction of gas exchange at the alveolar level, resulting in hypoxemia
Hemothorax
presence of blood in the pleural space
-occurs if there has been a laceration of the pulmonary vessel with blunt or penetrating trauma
-as blood fills the pleural space, the negative pressure is lost, limiting the lungs ability to expand
-the loss of blood from the vascular space mat result in hemodynamic compromise
>Drainage greater than 1500 mL = massive; may become hemodynamically unstable
Clinical Manifestations
- decreased oxygenation and ventilation
- gas exchange is compromised; decreased oxygenation
- initially, hyperventilation occurs in an effort to increase oxygen availability to the tissues, but eventually as the patient tires, CO2 will begin to rise
- Initial ABGs may = respiratory alkalosis d/t hyperventilation but respiratory acidosis will develop rapidly as CO2 is not exchanged
- early sign of hypoxemia is agitation and anxiety, then qa decreased LOC
- shortness of breath
- subcutaneous emphysema (air in the tissues under the skin) may occur with blunt trauma and pneumothorax
- pain; compromising chest wall expansion, thus oxygenation and ventilation
- exhibit splinting, assuming a protective posture around the site of injury; further compromises lung expansion on the side of injury and pneumonia may result
To Diagnose: Imaging Studies
- Chest x-ray
- Ultrasonography
- Chest CT
Chest X-Ray
to evaluate the skeletal features of the chest and to evaluate the integrity of the lungs
- x-ray is viewed to look for fractures, lung expansion, or mediastinal damage
- pneumothorax or hemothorax is visible on x-ray
Ultrasonography
focused assessment w/ sonography in trauma (FAST), is a valuable tool for a quick assessment in an emergency situation
-used to r/o cardiac tamponade (blood in the pericardium resulting in compression of the heart); life-threatening
Chest CT
performed upon a patient’s arrival to the ED in the case of high-impact thoracic trauma
-High-impact trauma: involves rapid deceleration and may result in chest wall deformities, multiple rib fractures, pneumothorax, or hemothorax
Laboratory Studies
- ABGs
- Serum lactate
- Hemoglobin/Hematocrit
- CBC and complete metabolic profile, coagulation studies, and a type and crossmatch in the event that the patient needs a blood transfusion
Laboratory Values: ABGs
arterial blood gases used to determine whether hypoxemia and abnormalities in the acid-base balance exist
-initially may indicate respiratory alkalosis d/t hyperventilation, but will quickly develop respiratory acidosis b/c of ineffective gas exchange and tiring
Laboratory Values: ABGs
arterial blood gases used to determine whether hypoxemia and abnormalities in the acid-base balance exist
-initially may indicate respiratory alkalosis d/t hyperventilation, but will quickly develop respiratory acidosis b/c of ineffective gas exchange and tiring
Laboratory Values: Serum Lactate Level
drawn to determine the adequacy of oxygen delivery to the tissues
-if the respiratory system is compromised, resulting in insufficient oxygen for cellular metabolism, anaerobic metabolism results
>this causes the production of lactic acids; rise in lactate levels within hours
Laboratory Values: Hemoglobin and Hematocrit
may be reduced if there is bleeding
-bleeding may be internal and not readily observable
Routine Labs Drawn in Any Trauma
- Electrolyte panels
- CBC
- Coagulation studies
- Patient specific tests
Treatment for Chest Trauma
ABCs!!
Airway, Breathing, Circulation
Treatment: Airway
evaluate the airway
- airway patent?
- show any signs of respiratory compromise or obstruction?
- partial or complete obstruction is a medical emergency
- intubation may be necessary to provide an adequate airway
Treatment: Breathing
- Does the patient demonstrate the ability to breathe w/o any compromise in gas exchange?
- Is there chest wall damage or other signs of respiratory compromise as indicated by abnormal ABGs, increased work of breathing, or signs of hypoxemia or hypercapnia?
- intubation and assisted ventilation may be necessary
- if not severe and able to protect the airway, use of supplemental oxygen
- if pneumothorax or hemothorax is present, chest tube insertion may be required to facilitate breathing and adequate oxygenation
Treatment: Circulation
- Is circulation sufficient?
- Does patient have adequate pulses and skin color?
- Is the blood pressure WNL? if not, IV fluid resuscitation to maintain hemodynamic stability
- if injury resulted in blood loss (hemothorax), blood transfusions may be indicated
Safety Alert: If the chest tube becomes disconnected from the drainage system
immediately submerge the end of the chest tube in sterile water to preserve the water seal; this prevents air from entering through the disconnected chest tube and reaccumulating in the pleural space
- as quickly as possible, reconnect to a new chest tube system
- be aware of hospital policy
Safety Alert: If the chest tube becomes dislodged from the chest
- apply a Vaseline gauze dressing and notify provider immediately
- prepare for insertion of new chest tube
Indications for Chest Tube Placement
indicated if a pneumo- or hemothorax occurs as a result of chest trauma
- In cases of a pneumothorax: b/c air rises, chest tube is placed high (2 ICS, midclavicular line)
- For hemothorax, d/t effects of gravity, the chest tube is placed lower, in order to drain blood and fluid from the pleural space
Chest Tube
placement allows for the expulsion of air and/or fluid while allowing the lung to re-expand
-chest tube connected to chest-drainage system
Chest Tube Drainage System Components
> Collection chamber: allows for accumulation of blood and fluid
Water seal: acts like a one-way valve, allowing for the removal of the air/blood over time w/o the introduction of air back into the pleural space
Suction: applied to assist in re-expansion of the lung; D/C as the lung re-expands
Medications Used for Chest Trauma
primarily analgesic
- patient in extreme pain may not breathe deeply enough to avoid atelectasis
- Initially, IV narcotic analgesia (morphine)
- Regional block or epidural analgesia may be administered to reduce pain w/o the narcotic side effects; allows pt to breathe more effectively
- in cases of penetrating trauma, prohpylatic broad-spectrum antibiotics to prevent infection
Complications: Tension Pneumothorax
may occur if air or blood collects in the pleural space and is not removed
- positive pressure in the pleural cavity increases, and affected lung collapses
- as the positive pressure increases, it may cause a mediastinal shift toward the unaffected side; can result in compression of the heart, vena cava, aorta, and contralateral (unaffected) lung
- Tracheal deviation toward the unaffected side is a hallmark sign of tension pneumothorax
- in emergent cases, a needle decompression performed to remove the air from the pleural space, may be required; chest tube immediately after
Complications: Cardiac Tamponade
caused by excessive air, fluid, or blood collecting in the pericardial sac
- the heart cannot adequately fill or contract b/c of the compression of the ventricles
- manifest as hypotension, muffled heart sounds, and distended neck veins (Beck’s Triad)
- cardiac tamponade d/t fluid accumulation in the pericardial sac is treated w/ pericardiocentesis, the insertion of a large bore needed into the pericardial space to drain fluid
Surgical Management: Thoracotomy
surgical excision to the chest wall
- for patients w/ an unstable chest wall
- for cases of severe flail chest for stabilization
- indicated if the chest trauma has resulted in damaged organs or major vessels
Connection Check 27.6:
You are caring for a client who sustained a chest injury following a motor vehicle collision, requiring a chest tube, and is receiving morphine via patient-controlled analgesia (PCA) for pain. Which of the following would alarm you and initiate a call to the primary care provider?
A. Somnolence
B. Restlessness and anxiety
C. Itching at the IV site
D. Minimal amounts of bloody chest tube drainage
B. Restlessness and Anxiety
Nursing Management: Assessment and Analysis for Chest Trauma
Clinical manifestations of chest trauma are caused by damage to the chest wall and/or lungs causing problems with ventilation and oxygenation
>Tachypnea/hyperventilation
>Tachycardia
>Shortness of breath
>Decreased oxygenation
>Decreased LOC
>Decreased or absent lung sounds
>Asymmetrical chest excursion (in the case of a flail chest)
>Subcutaneous emphysema (air under a layer of the skin)
Nursing Diagnoses
- Impaired gas exchange r/t hypoventilation and pain
- Acute pain r/t structural damage secondary to fractured ribs; presence of chest tube
- Decreased cardiac output r/t hemorrhage and decreased circulating volume (hemothorax)
Nursing Interventions: Assessments for Chest Trauma
- Respiratory effort
- Vital signs and pulse oximetry (SpO2)
- Pain
- LOC
- ABGs
- Chest Tube
- Subcutaneous emphysema
Assessments: Respiratory effort
increased work of breathing such as SOB, accessory muscle use, or nasal flaring may indicate a need for further evaluation and treatment of chest trauma or pneumothorax and/or a need for an advanced airway
Assessment: Vital Signs and Pulse Oximetry (SpO2)
- tachypnea and tachycardia may occur in response to decreased oxygen levels, increased oxygen demands, and/or pain
- hypotension can indicate tension pneumothorax or cardiac tamponade d/t compression of the heart, vena cava, and aorta
- hypotension can indicate excessive blood loss w/ hemothorax
- decreased SpO2 (< 95%) may be present if there is ineffective respiration d/t pain or injury
- continuous readings help evaluate response to treatment
Assessments: Pain
severe pain d/t fractures may limit the patients ability to breathe deeply, which may result in decreased gas exchange
Assessment: Level of Consciousness
agitation, anxiety, and eventually a decreased LOC may result from hypoxemia
Assessment: ABGs
- initial note a respiratory alkalosis d/t tachypnea and hyperventilation
- a decreased PaO2 (normal: 80-95) may be present b/c of the impaired ventilatory effort and decreased surface area available for gas exchange in a collapsed lung
Assessment: Chest Tube
> Amount of color and drainage:
- red, free-flowing drainage in excess of 70 mL per hour indicates hemorrhage
- cloudiness may = infection
> Water-seal chamber:
- initially, there is bubbling on expiration, indicating air removal from the pleural space
- Later, after the air has escaped from the pleural space, the water level fluctuates with respiratory effort (Tidaling)
- When the pleural wall disruption is healed, the water fluctuation may no longer be present; evaluated for chest tube removal
- continuous bubbling in the water-seal chamber = air leak
Assessments: Subcutaneous Emphysema
- produces a crackling feeling under the skin
- not painful but may become uncomfortable if excessive
- indicative of air from a chest injury escaping into the subcutaneous space, indicating potential chest trauma
- subcutaneous emphysema of the head and neck could be life-threatening b/c the airway could be compromised
Nursing Actions for Chest Trauma
- Apply oxygen as ordered
- Anticipate and prepare for intubation
- Elevate HOB
- Encourage deep breathing and coughing q 1 to 2 hours
- Encourage ambulation ASAP
- Chest tube management
- Administer pain medications; encourage use of patient-controlled analgesia before ambulation and pulmonary toileting
Chest Tube Management
> Maintain a closed system. Tape all connections, and secure the chest tube to the chest wall
-to prevent inadvertent tube removal or disruption of the systems integrity
> Keep collection device below the level of the chest; keep tubing free from kinks or loops
- pleural fluid drains into the collection apparatus by gravity flow as well as low-level suction
- kinks or loops can interfere w/ drainage
> NEVER CLAMP THE CHEST TUBE
-may result in increased air or fluid collection in the pleural space, worsening the pneumo- or hemothorax, and may result in a tension pneumothorax
> When chest tube is removed, immediately apply a sterile occlusive petroleum jelly dressing
-occlusive dressing prevents air from re-entering the pleural space through the chest wound
Nursing Teachings for a Patient with Chest Trauma
- Use of pain medications
- Importance of coughing and deep breathing, ambulation, splinting w/ pillow while coughing
- Motor vehicle safety; use seat belts, avoid distracted driving
Evaluating Care Outcomes
a well-managed patient following chest trauma has unlabored respiratory effort, and ABGs within normal ranges
- lung sounds are clear in all fields
- pain is under control
- if had a chest tube, skin integrity is intact
Example of Deceleration
a motor vehicle traveling at 50 mph that hits a brick wall; causing the vehicle to come to a sudden stop
-all passengers inside the vehicle come to a sudden stop, typically against a hard surface in the car
Example of Acceleration
pedestrian standing on the side of the road who is hit by a moving vehicle, causing the pedestrian to be thrown 20 feet
-deceleration forces are applied when the pedestrian hits the ground
Compression injuries
organs or tissues compressed between two immovable surfaces such as bones or a steering wheel
Shearing Injuries
occurs when skin or tissue slides in opposite but parallel directions
Most Common Forms of Blunt Trauma
- Motor vehicle crashes
- Motorcycle crashes
- Pedestrians struck
- Bicycle injuries
- Sports (football) injuries
- Falls
- Assaults
