CARDIAC TRAUMA AND THORACIC INJURIES  penetrating wounds to the mediastinum Inspection

- The primary mechanisms of injury responsible for of the airway, thorax, neck veins, and breathing
chest trauma as either blunt trauma or penetrating difficulty.
trauma  Assessing the rate and depth of breathing for
- Rib and sternal fractures can lacerate lung tissue. abnormalities, such as stridor, cyanosis, nasal
In a high-velocity impact, shearing forces can flaring, use of accessory muscles, drooling, and
overt trauma to the face, mouth, or neck
result in laceration or tearing of the aorta.
- Compression of the chest may result in contusion,
crush injury, and organ rupture ATLS algorithms
- The external injury may appear minor, but A Airway with c-spine Is the patient speaking
internally organs may have been severely protection in full sentences?
damaged. B Breathing and Is the breathing
Ventilation labored? Are
BLUNT CHEST TRAUMA symmetrical, breath
sounds present
- Blunt chest trauma results from bilaterally?
sudden compression or positive C Circulation with Are pulses present and
pressure inflicted to the chest wall. hemorrhage control symmetric? How does
- Motor vehicle crashes (trauma due to the patient’s slin
steering wheel, seat belt), falls, and appear? (cold, clammy,
bicycle crashes (trauma due to warm well-perfused)
handlebars) are the most common D Disability What is the GCS scale?
causes of blunt chest trauma Are they moving all
extremities?
Pathophysiology E Exposure/Environmental Completely expose the
Control patient. Is rectal tone
a. Hypoxemia from disruption of the airway; injury to present? Is there any
the lung parenchyma, rib cage, and respiratory gross blood per
musculature; massive hemorrhage; collapsed lung; rectum?
and pneumothorax
b. Hypovolemia from massive fluid loss from the
great vessels, cardiac rupture, or hemothorax Assessment of Breathing
c. Cardiac failure from cardiac tamponade, cardiac R Respiratory Rate
contusion, or increased intrathoracic pressure I Inspection
Assessment P Palpation
Time is critical in treating chest trauma. Therefore, it is P Percussion
essential to assess the patient immediately to A Auscultation
determine the following: S Saturations
 When the injury occurred
 Mechanism of injury Inspection of the airway, thorax, neck veins, and
 Level of responsiveness breathing difficulty.
 Specific injuries  Assessing the rate and depth of breathing for
 Estimated blood loss abnormalities, such as stridor, cyanosis, nasal
 Recent drug or alcohol use flaring, use of accessory muscles, drooling, and
 Prehospital treatment overt trauma to the face, mouth, or neck
Initial Assessment includes: The chest should be assessed for:
 Airway obstruction  symmetric movement,
 Tension pneumothorax  symmetry of breath sounds,
 Open pneumothorax  open chest wounds,
 Massive hemothorax  entrance or exit wounds,
 Flail chest  impaled objects, tracheal shift,
 Cardiac tamponade  distended neck veins,
Secondary Assessment would Include:  subcutaneous emphysema,
 simple pneumothorax  paradoxical chest wall motion.
 hemothorax
The chest wall should be assessed for:
 pulmonary contusion
 Bruising
 traumatic aortic rupture
 Petechiae
 tracheobronchial disruption
 Lacerations
 esophageal perforation
 Burns
 traumatic diaphragmatic injury
The vital signs and skin color are assessed for signs of
shock. The thorax is palpated for tenderness and
crepitus; the position of the trachea is also assessed.
The Thorax is palpated for tenderness and crepitus;
the position of the trachea is also assessed
Diagnostic Test movement
- The area around the
The initial diagnostic workup includes: fracture may be
 Chest x-ray bruied
 CT scan
 Complete blood count
Assessment & Diagnostic Findings
 Clotting studies
Assessment Diagnostic Test
 Type and crossmatch
 Electrolytes  Closely evaluated for 1. Chest x-ray
 Oxygen saturation underlying cardia 2. Rib films of a specific
 Arterial blood gas analysis injuries area
 ECG  A crackling, grating 3. ECG
sound in the thorax 4. Continuous pulse
Medical Management (Subcutaneous oximetry
crepitus) 5. Arterial blood gas
1. The goals of treatment are to evaluate the patient’s May be detected with exchange
condition and to initiate aggressive resuscitation. auscultation
2. An airway is immediately established with oxygen
support and, in some cases, intubation and
ventilatory support. Medical Management
3. Re-establishing fluid volume and negative
intrapleural pressure and draining intrapleural fluid 1. Medical management of the patient with a sternal
and blood are essential. fracture is directed toward controlling pain,
4. Strategies to restore and maintain avoiding excessive activity, and treating any
cardiopulmonary function: associated injuries.
- include ensuring an adequate airway and 2. Surgical fixation is rarely necessary unless
fragments are grossly displaced and pose a
ventilation
potential for further injury
- stabilizing and re-establishing chest wall
3. In most cases, a broken sternum will heal on its
integrity
own. It can take 3 months or longer for the pain to
- occluding any opening into the chest (open
go away
pneumothorax),
4. Sedation is used to relieve pain and to allow deep
- draining or removing any air or fluid from the breathing and coughing.
thorax to relieve pneumothorax, hemothorax, 5. Care must be taken to avoid over sedation and
or cardiac tamponade. suppression of the respiratory drive.
STERNAL FRACTURE 6. Alternative strategies to relieve pain include an
intercostal nerve block and ice over the fracture
- Sternal fractures are most common in motor 7. Usually, the pain abates in 5 to 7 days, and
vehicle crashes with a direct blow to the sternum discomfort can be controlled with epidural
via the steering wheel and are most common in analgesia, patient-controlled analgesia, or non-
women, patients over age 50, and those using opioid analgesia. Most rib fractures heal in 3 to 6
shoulder restraints. weeks.

RIB FRACTURE FLAIL CHEST

- Rib fractures are the most common type of chest - Flail chest is frequently a complication of blunt
trauma. chest trauma from a steering wheel injury.
- Fractures of the first three ribs are rare but can - It usually occurs when three or more adjacent ribs
result in a high mortality rate because they are (multiple contiguous ribs) are fractured at two or
associated with laceration of the subclavian artery more sites, resulting in free-floating rib segments.
or vein. - It may also result as a combination fracture of ribs
- The fifth through ninth ribs are the most common and costal cartilages or sternum
sites of fractures. - As a result, the chest wall loses stability and there
- Fractures of the lower ribs are associated with is subsequent respiratory impairment and usually
injury to the spleen and liver, which may be severe respiratory distress
lacerated by fragmented sections of the rib
Pathophysiology
Clinical Manifestation
a. During inspiration, as the chest expands, the
Sternal Fracture Rib Fracture
detached part of the rib segment (flail segment)
- Anterior chest pain - Severe pain
moves in a paradoxical manner (pendelluft
- Overlying - Point tenderness movement) in that it is pulled inward during
tenderness - Muscle spasm over inspiration, reducing the amount of air that can be
- Ecchymosis the area of the drawn into the lungs.
- Crepitus fracture, which is b. On expiration, because the intrathoracic pressure
- Swelling aggravated by exceeds atmospheric pressure, the flail segment
- Potential of a chest coughing, deep bulges outward, impairing the patient’s ability to
wall deformity breathing, and exhale.
c. The mediastinum then shifts back to the affected Pathophysiology
side
d. This paradoxical action results in increased dead a. The primary pathologic defect is an abnormal
space, a reduction in alveolar ventilation, and accumulation of fluid in the interstitial and
decreased compliance. intra- alveolar spaces.
e. This paradoxical action results in increased dead b. It is thought that injury to the lung parenchyma
space, a reduction in alveolar ventilation, and and its capillary network results in a leakage of
decreased compliance. serum protein and plasma. The leaking serum
f. Hypotension, inadequate tissue perfusion, and protein exerts an osmotic pressure that
metabolic acidosis often follow as the paradoxical enhances loss of fluid from the capillaries.
motion of the mediastinum decreases cardiac c. Blood, edema, and cellular debris (from
output. cellular response to injury) enter the lung and
accumulate in the bronchioles and alveolar
Medical Management surface, where they interfere with gas
exchange.
Treatment of flail chest is usually supportive. d. An increase in pulmonary vascular resistance
Management includes: and pulmonary artery pressure occurs.
1. Providing ventilatory support e. The patient has hypoxemia and carbon dioxide
2. Clearing secretions from the lungs retention.
3. Controlling pain Clinical Manifestation
If only a small segment of the chest is involved, the Pulmonary Contusion may be mild, moderate, or
objectives are to clear the airway through: severe. The clinical manifestation may vary from:
Mild/Moderate Severe
1. Positioning - Tachypnea - More severe
2. Coughing - Tachycardia tachypnea
3. Deep breathing - Pleuritic chest pain - Tachycardia
4. Suctioning - Hypoxemia - Crackles
5. Relieve pain - Blood-hinge - Frank bleeding
secretions - Severe hypoxemia
Medical Management - The patient with - Respiratory acidosis
MILD/MODERATE SEVERE
moderate pulmonary - The signs and
1. Monitoring 1. Endotracheal contusion has a large symptoms of ARDS,
fluid intake intubation and amount of mucus,
2. Appropriate mechanical serum and frank
fluid ventilation are blood in the
replacement tracheobronchial tree.
required.
- Changes in sensorium, including increased
3. Relieving chest pain
agitation to combative irrational behavior, may be
4. Pulmonary signs of hypoxemia
physiotherapy is
performed
Assessment and diagnostic findings
Surgery may be required to stabilize the flail segment a. The efficiency of gas exchange is determined by
more quickly. pulse oximetry and arterial blood gas
This may be used in the patient who is difficult to measurements.
ventilate or the high-risk patient with underlying lung b. Pulse oximetry is also used to measure oxygen
disease who may be difficult to wean from mechanical saturation continuously.
ventilation. c. The chest x-ray may show pulmonary infiltration.
1. Rib Fracture Fixation d. The initial chest x-ray may show no changes; in
2. Regardless of the type of treatment, the patient is fact, changes may not appear for 1 or 2 days after
3. carefully monitored by serial chest x-rays, arterial the injury
blood gas analysis, pulse oximetry, and bedside Medical Management
pulmonary function monitoring. Mild Pulmonary Contusion
4. Pain management is key to successful treatment 1. Maintaining the airway
PULMONARY CONTUSION 2. Providing adequate oxygenation - supplemental
oxygen is usually given by mask or cannula for 24
- It is defined as damage to the lung tissues to 36 hours
resulting in hemorrhage and localized edema. 3. Controlling pain - managed by intercostal nerve
- It is associated with chest trauma when there is blocks or by opioids via patient-controlled
rapid compression and decompression to the analgesia
chest wall (i.e., blunt trauma). 4. Intravenous fluids and oral intake
- It may not be evident initially on examination but
will develop in the posttraumatic period.
5. Volume expansion techniques, postural drainage, Diagnostic Test:
physiotherapy including coughing, and
endotracheal suctioning  Chest X-Ray
6. Antimicrobial therapy  Chemistry Profile
 Arterial Blood Gas Analysis
Moderate Pulmonary Contusion  Pulse Oximetry
7. Maintaining the airway  ECG
8. Providing adequate oxygenation - supplemental  CBC
oxygen is usually given by mask or cannula for 24  Blood Typing
to 36 hours  Cross-Matching
9. Controlling pain - managed by intercostal nerve  Ct Scan of The Chest
blocks or by opioids via patient-controlled  Flat Plate X-Ray of The Abdomen
analgesia
10. Intravenous fluids and oral intake Medical Management:
11. Volume expansion techniques, postural drainage,
physiotherapy including coughing, and Objective of immediate management is to restore and
endotracheal suctioning maintain cardiopulmonary function.
12. Antimicrobial therapy 1. Adequate airway and ventilation
13. Medical Management: Severe Pulmonary 2. Examine for shock and intrathoracic and intra-
Contusion abdominal injuries.
14. Maintaining the airway 3. Undressed the patient completely
15. Providing adequate oxygenation - supplemental 4. IV therapy with colloids, crystalloids, and blood
oxygen is usually given by mask or cannula for 24 5. Insert indwelling catheter
to 36 hours 6. Insert NGT
16. Controlling pain - managed by intercostal nerve 7. Insert chest tube
blocks or by opioids via patient-controlled 8. If the patient has a penetrating wound of the heart
analgesia and great vessels, the esophagus, or the
17. Intravenous fluids and oral intake tracheobronchial tree, surgical intervention is
18. Volume expansion techniques, postural drainage, required
physiotherapy including coughing, and
endotracheal suctioning PNEUMOTHORAX
19. Antimicrobial therapy
- Occurs when the parietal or visceral pleura is
breached, and the pleural space is exposed to
PENETRATING CHEST TRAUMA positive atmospheric pressure.
- Normally the pressure in the pleural space is
Gunshot and stab wounds are the most common types negative or sub atmospheric compared to
of penetrating chest trauma atmospheric pressure; this negative pressure is
required to maintain lung inflation.
Foreign object impales or passes through thr body - When either pleura is breached, air enters the
tissues, creating an open wound.
pleural space, and the lung or a portion of it
Stab Wounds Gunshot Wounds collapses
- Knives and - May be classified as Types of Pneumothorax
switchblades cause of low, medium, or
Simple Pneumothorax Traumatic Pneumothorax
most stab wounds. high velocity.
- The appearance of - A bullet can cause - A simple, or - Occurs when air
the external wound damage at the site of spontaneous, escapes from a
may be very penetration and along pneumothorax occurs laceration in the lung
deceptive, because its pathway.
when air enters the itself and enters the
pneumothorax, - It also may ricochet
pleural space through pleural space or enters
hemothorax, lung off bony structures
contusion, and a breach of either the the pleural space
and damage the
cardiac tamponade, chest organs and parietal or visceral through a wound in the
along with severe and great vessels. pleura. chest wall.
continuing - If the diaphragm is - Most commonly this - Blunt trauma,
hemorrhage, can involved in either a occurs as air enters penetrating chest
occur from any small gunshot wound or a the pleural space trauma or even
wound, even one stab wound, injury to through the rupture of abdominal trauma
caused by a small- the chest cavity must a bleb or a - Traumatic
diameter instrument be considered bronchopleural fistula. pneumothorax may
such as an ice pick - It may be associated occur with invasive
with diffuse interstitial thoracic procedures
lung disease and (i.e., thoracentesis)
severe emphysema - Hemothorax -
collection of blood in
the pleural space
 resulting from torn TENSION PNEUMOTHORAX
intercostal vessels,
- Occurs when air is
lacerations of the great
drawn into the pleural
vessels, and
space from a lacerated
lacerations of the lungs lung or through a small
Hemothorax Chylothorax hole in the chest wall
- Causes the lung to
- is an accumulation of blood in the pleural space collapse and the heart
from injury to the chest wall, diaphragm, lung, - Increased intrathoracic
blood vessels, or mediastinum pressure decreases venous return to the heart,
- When it occurs with pneumothorax, it is called a causing decreased cardiac output and impairment
hemopneumothorax. of peripheral circulation
- The patient with a traumatic hemothorax needs
Clinical Manifestation
immediate insertion of a chest tube for evacuation
of the blood is the presence of lymphatic fluid in  air hunger
the pleural space.  agitation
- thoracic duct is disrupted either traumatically or  increasing hypoxemia
from cancer, allowing lymphatic fluid to fill the  central cyanosis
pleural space.  Hypotension
 Tachycardia
 profuse diaphoresis

Clinical Manifestations Medical Management

If the pneumothorax is large and the lung collapses 1. High concentration of supplemental oxygen
totally: 2. In emergency situation, inserting a large-bore
needle (14-gauge) at the second intercostal space,
 Acute respiratory distress midclavicular line on the affected side.
 Anxious 3. A chest tube is then inserted and connected to
 Dyspnea suction to remove the remaining air and fluid, re-
 Air hunger establish the negative pressure, and re-expand the
 Increased use of the accessory muscles lung.
 May develop central cyanosis from severe
hypoxemia CARDIAC TAMPONADE
 Severe chest pain may occur, accompanied by
tachypnea - Cardiac tamponade is a rapid, unchecked increase
 decreased movement of the affected side of the in pressure in the pericardial sac.
thorax - The increased pressure compresses the heart,
 a tympanic sound on percussion of the chest wall impairs diastolic filling, and reduces cardiac output.
 decreased or absent breath sounds and tactile - The increase in pressure usually results from
fremitus on the affected side. blood or fluid accumulation in the pericardial sac.
- Even a small amount of fluid (50 to 100 mL) can
The signs and symptoms associated with cause a serious tamponade if it accumulates
pneumothorax depend on its size and cause. rapidly
For small simple or uncomplicated pneumothorax:
 Minimal respiratory distress
 Slight chest discomfort
 Tachypnea
Medical Management
The goal of treatment is to
evacuate the air or blood
from the pleural space:
1. A small chest tube (28 Causes
French) is inserted
near the second a. Viral or post irradiation pericarditis
intercostal space b. Acute MI
2. If with hemothorax, a c. Chronic renal failure requiring dialysis
large-diameter chest tube (32 French or greater) is d. Connective tissue disorders
inserted, usually in the fourth or fifth intercostal e. Effusion
space at the midaxillary line. f. Hemorrhage due to nontraumatic causes
3. Autotransfusion g. Hemorrhage due to trauma (most common)
4. Chest tube connected to water-seal drainage h. Idiopathic causes (such as Dressler syndrome)
5. Antibiotics
i. Drug reaction from procainamide, hydralazine, 2. Infuse IV solutions and inotropic drugs, such as
minoxidil (rogaine), isoniazid, penicillin, or dopamine, as ordered to maintain the patient’s
daunorubicin (daunoxome). blood pressure.
3. Administer oxygen therapy as needed and assess
Pathophysiology oxygen saturation levels. Monitor the patient’s
a. In cardiac tamponade, accumulation of fluid in the respiratory status for signs of respiratory distress,
pericardial sac causes compression of the heart such as severe tachypnea and changes in the
chambers. patient’s LOC. Anticipate the need for ET
b. The compression obstructs blood flow into the intubation and mechanical ventilation if the
ventricles and reduces the amount of blood that patient’s respiratory status deteriorates.
can be pumped out of the heart with each 4. Prepare the patient for pericardiocentesis or
contraction. thoracotomy.
5. If the patient has trauma-induced tamponade,
Assessment assess for other signs of trauma and institute
appropriate care, including the use of colloids,
Three (3) classic features known as the Beck triad: crystalloids, and blood component therapy
6. Assess renal function status closely, monitoring
 elevated CVP with jugular vein
urine output every hour and notifying the
 distention muffled heart sounds
practitioner if output is less than 0.5 mg/kg/hour.
 pulsus paradoxus other signs include:
7. Monitor capillary refill time, LOC, peripheral
 Restlessness
pulses, and skin temperature for evidence of
 Anxiety
diminished tissue perfusion.
 cold, clammy skin
- cyanosis 8. Anticipate transfer of the patient to a CCU when
- diaphoresis appropriate.
- orthopnea
- decreased arterial pressure
- decreased systolic blood pressure
- narrow pulse pressure
- tachycardia
- weak
- thready pulse
Diagnostic Test
 Chest X-ray shows a slightly widened mediastinum
and an enlarged cardiac silhouette.
 ECG may show a low-amplitude QRS complex
and electrical alternans or an alternating beat-to
beat change in amplitude of the P wave, QRS
complex, and T wave. Generalized ST segment
elevation is noted in all leads.
 Echocardiography may reveal pericardial effusion
with signs of right ventricular and atrial
compression.
 CT scan or MRI may be used to identify pericardial
effusions or pericardial thickening caused by
constrictive pericarditis
Medical/Surgical Treatment
The goal of treatment is to relieve intrapericardial
pressure and cardiac compression by removing
accumulated blood or fluid, which can be done in three
different ways:
1. Pericardiocentesis (needle aspiration of the
pericardial cavity)
2. Insertion of a drain into the pericardial sac to drain
3. the effusion
4. Surgical creation of an opening called a
pericardial window
Nursing Responsibility
1. Watch closely for signs of increasing tamponade,
increasing dyspnea, and arrhythmias; report them
immediately.