Chest Trauma

Chest Trauma
Overview
 Anatomy Review
 Chest Trauma
 Chest Injuries
2
© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved
Anatomy Review
 Thoracic cavity and abdominal cavity:

two spaces in the trunk of the body
 They contain some of the body’s most
important organs
3
Chest Trauma
 Chest injuries result in a significant

number of deaths each year
 The chest contains organs vital to life
 Damage to vital organs threatens life
 Most common consequence is hypoxia
4
Chest Trauma
 Mechanism of injury (MOI):

Blunt chest trauma
– Most common cause of serious chest injuries
– Motor vehicle collisions (MVCs), falls, direct
blows, and crushing injuries
– Many injuries are not immediately apparent
in physical exam
5
Chest Trauma
 Mechanism of injury (MOI):

Blunt chest trauma
– Injuries linked to size of object applying force
and most important, to speed
– Speed kills
6
Chest Trauma
 MOI: Blunt chest trauma

– Evaluating MOI at a motor vehicle collision
• Significant damage to vehicle’s exterior?
• Damage to interior of vehicle?
• Broken or bent steering wheel means significant
force was applied to the driver’s chest
• The higher the forces, the higher the suspicion for
serious injury to patient
7
Chest Trauma
 MOI: Penetrating trauma

– Increasingly common in today’s society
– Immediate result can be severe bleeding
or impaired breathing
8
Chest Trauma
 MOI: Penetrating trauma

– Any chest wound can involve underlying
organ injury
• No matter how superficial it looks
– Injuries to the heart, lungs, and great
vessels can quickly lead to shock and
cardiac arrest
9
Chest Trauma
 Signs and symptoms

– Most common symptoms: pain and difficulty
breathing
– Signs are obvious injury to the chest wall
• Use DCAP-BTLS, looking at both the front and
back of the chest
• Deformities,contusions,abrasions,punctures-
burns,tenderness, lacerations, swelling
– Note any subcutaneous emphysema, or air
present under the skin
10
Chest Trauma
 Management
– Ensure patient has adequate
oxygenation and perfusion
– Provide high-flow oxygen, ventilating
when necessary
– Halt any obvious bleeding
11
Chest Trauma
 Management
– Support circulation when needed
– Rapidly transport patient to definitive care
12
Chest Trauma
 Transport
– Transport patient to a hospital with the
capability to diagnose and treat serious
traumatic injuries
– Arrange for ALS (advance life support)
intercept as guided
by local protocols
– Notify receiving hospital so staff
can prepare
13
Chest Injuries
 Open chest wounds

– A sharp object penetrates the skin on the
chest wall
– Laceration of vessels such as the vena cava
or aorta will likely cause bleeding between
the lung and the chest wall
• The accumulation of blood in the pleural space is
called a hemothorax
14
Chest Injuries

– If penetrating object has pierced pleura,
outside air can enter the thoracic cavity
– As the volume of air in the thoracic cavity
expands, the lung starts to collapse
– Air within the pleural space is called a
pneumothorax
15
Chest Injuries
 When air enters between

the lung and the chest wall,
pneumothorax is created
16
Chest Injuries

– As air passes in and out of an open wound,
it can create a sucking-type sound
– Sucking chest wound means possibility of
pneumothorax
– Signs of pneumothorax: difficulty breathing,
cyanosis, diminished breath sounds on the
affected side
17
Chest Injuries
 Open chest wounds: Management

– Cover open chest wounds with
occlusive dressing
– Gloved hand is an effective temporary
occlusive dressing
– Secure dressing on three sides
18
Chest Injuries
 Open chest wounds: Management

– High-flow oxygen
– Transport with unaffected side slightly elevated
– Arrange for ALS intercept
19
Open Chest Wound
 Watch this animation illustrating an open chest wound.
https://youtu.be/XPjhcCDeBk4
20
Stop and Review
 Name three signs of a simple pneumothorax.
 Difficulty breathing, cyanosis, diminished

breath sounds on the affected side
21
Chest Injuries
 Tension pneumothorax
– Buildup of pressure in pleural space resulting in
decrease in blood pressure
– Potentially life-threatening condition that must be
treated immediately
– Can occur in blunt or penetrating chest trauma
22
Chest Injuries
 Increasing pressure in the

lung pushes the heart and
the great vessels to the
opposite side of the chest.
23
Chest Injuries
 Tension pneumothorax: Signs

– Include all those of a pneumothorax
– Jugular venous distension (JVD)
– If ventilating becomes more difficult, significant
lung compression is indicated
24
Chest Injuries
 Tension pneumothorax: Signs

– Tracheal deviation is a late sign
– If patient is hypotensive, immediately lift
a corner of the occlusive dressing
• Transport this patient rapidly
• Consider ALS intercept
25
Chest Injuries
 Rib fractures
– Local swelling and tenderness may be
the only sign of a broken rib
– Can be very painful
– Patients often present with guarding
and shallow breathing
26
Chest Injuries
 Rib fractures: Management

– Move the patient carefully to prevent
the bone ends from puncturing a lung
– Administer oxygen
27
Chest Injuries
 Rib fractures: Management

– Allow patient to self-splint by assuming
the most comfortable position possible
– Encourage patient to limit movement
28
Chest Injuries
 Flail segment
– When three or more ribs are broken in two or
more places, a rib-cage segment may detach
from the rest
– Flail segment is free floating
29
Chest Injuries
 Flail segment
– Paradoxical movement: movement of flail segment
in opposite direction of the rest of the chest wall
– Paradoxical movement can significantly impair
breathing and cause injury to the underlying lung
30
31
Flail Chest Segment
 https://youtu.be/uJHfX1RFkF0Watch
32
Chest Injuries
 Flail segment: Management

– Quickly stabilize flail segment by placing gloved
hand over injured area
– After manual stabilization, place folded universal
dressing over segment and tape securely
33
Chest Injuries
 Flail segment: Management

– Consider assisting patient’s
breathing if tachypnea increases
– Transport on side with unaffected
lung on top
34
Chest Injuries
 Pulmonary contusion
– Bleeding into the lung itself is a
pulmonary contusion
– Bleeding and edema can impair
gas exchange, causing hypoxia
– Soft crackles may be heard over
injury site
– Chest pain, point tenderness, and
localized swelling over area of impact
35
Chest Injuries
 Pulmonary contusion: Management

– Support ventilation as needed
– Supply high-flow supplemental oxygen
– Transport to hospital
36
Chest Injuries
 Cardiac contusion
– Can impair heart’s ability to pump
– Bleeding into heart tissue can cause heart to
beat irregularly
– Irregular pulse should alert EMT to possibility
of a cardiac contusion
37
Chest Injuries
 Cardiac contusion: Management

– Ventilation support as needed
– Support of circulation if appropriate
– Prompt transport
– Request ALS backup
38
Chest Injuries
 Aortic injury
– In sudden decelerations such as high-speed head-
on MVCs, body organs are thrown forcefully
against the front of the body
– Most significant tear: aorta
– If tear is complete, patient will die in minutes
• Incomplete tears bleed severely
39
Chest Injuries
 Aortic injury: Management

– Treat patient for shock
– Transport rapidly to ED
– Notify hospital so staff can properly prepare
40
Chest Injuries
 Traumatic asphyxia
– Rapid ejection of blood and air out of chest
– Rapid compression of chest increases internal
pressure dramatically
• Blood is immediately forced out of the chest and into the
vessels in the neck, head, and face
41
Chest Injuries
 Traumatic asphyxia
– Neck veins immediately become distended
– Cyanosis is apparent in face
– Bleeding in the eyes’ sclera may occur
42
Chest Injuries
 Traumatic asphyxia: Management

– Treat patient for shock
– Transport rapidly to ED
– Notify hospital so staff can properly prepare
43
Stop and Review
 What is the management for traumatic

asphyxia?
 Prompt transport and high-flow oxygen
 Name two significant signs of pericardial
tamponade.
 JVD, narrowing pulse pressures
 What is a late sign of tension
pneumothorax?
 Tracheal deviation
44
Chapter 34
Care of Critically Ill Patients with
Respiratory Problems
Pulmonary Embolism
 Collection of particulate matter—solids,
liquids, air—that enters venous circulation
and lodges in pulmonary vessels
 Usually occurs when blood clot from a VTE in
leg or pelvic vein breaks off; travels through
vena cava into right side of heart
Pulmonary Embolus
Risk Factors
 Prolonged immobilization
 Central venous catheters
 Surgery
 Obesity
 Advancing age
 Conditions that increase blood clotting
 History of thromboembolism
Health Promotion & Illness
Prevention
 Smoking cessation
 Weight reduction
 Increased physical activity
 If traveling or sitting for long periods, get up
frequently and drink plenty of fluids
 Refrain from massaging/compressing leg
muscles
Clinical Manifestations
 Respiratory
– Dyspnea, tachypnea, tachycardia, pleuritic chest
pain, dry cough, hemoptysis
 Cardiac
– Distended neck veins, syncope, cyanosis,
systemic hypotension, abnormal heart sounds,
abnormal ECG
 Low grade fever, petechiae, flu-like
symptoms
Laboratory Assessment
 ABGs
 Pao2 – Fio2 ratio falls (O2 level in blood
compared to O2 that is breathed)
 Pulse oximetry
 Imaging assessment
Nonsurgical Management
 Oxygen therapy (nasal cannula, mask)
 Continuous patient monitoring
 Obtain adequate venous access
 Continuous monitoring of pulse oximetry
 Drug therapy
– Anticoagulants
– Fibrinolytics
Interventions
 Ensure appropriate antidotes are present on
the nursing unit!
 Assess for bleeding every 2 hr
 Examine all stool, urine, drainage, vomitus for
gross blood; test for occult blood
 Measure abdominal girth every 8 hr
 Monitor laboratory values
Surgical Management
 Embolectomy
 Inferior vena cava filtration
Acute Respiratory Failure
 ABG value of PaO2 <60 mm Hg, SaO2; <90%;
or PaCO2 >50 mm Hg with pH <7.30
 Ventilatory/oxygenation failure
 Patient is always hypoxemic
Ventilatory Failure
 Physical problem of lungs or chest wall
 Defect in respiratory control center in brain
 Poor function of respiratory muscles,
especially diaphragm
 Extrapulmonary causes
 Intrapulmonary causes
Oxygenation Failure
 Insufficient oxygenation of pulmonary blood
at alveolar level
 Ventilation normal, lung perfusion decreased
 Right to left shunting of blood
 V/Q mismatch (ventilation/perfusion)
 Low partial pressure of O2
 Abnormal hemoglobin
Combined
Ventilatory/Oxygenation

Failure
Often occurs in patients with abnormal lungs
(e.g., chronic bronchitis, emphysema, asthma
attack)
 Diseased bronchioles and alveoli cause
oxygenation failure; work of breathing
increases; respiratory muscles unable to
function effectively
Dyspnea Interventions
 Oxygen therapy
 Position of comfort
 Relaxation, diversion, guided imagery
 Energy-conserving measures
 Drugs
Acute Respiratory Distress
Syndrome (ARDS)
 Persisting hypoxia
 Decreased pulmonary compliance
 Dyspnea
 Noncardiac-associated bilateral pulmonary
edema
 Dense pulmonary infiltrates seen on x-ray
Causes of Lung Injury in ARDS
 Systemic inflammatory response is common
pathway
 Alveolar-capillary membrane injured
– Intrinsic causes—sepsis, shock
– Extrinsic causes—aspiration, inhalation injury
Diagnostic Assessment
 Lower Pao2 value on ABG
 Refractory hypoxemia
 “Whited-out” (ground glass) appearance to
chest x-ray
 No cardiac involvement on ECG
Interventions
 ET intubation, conventional mechanical
ventilation with PEEP or CPAP
 Drug and fluid therapy
 Nutrition therapy
Chest tube
 A drain placed in the pleural space to restore

intrapleural pressure and allow re-expansion
of lung
 Prevents air and fluid from returning to the
chest
 Drainage system consists of one or more
chest tubes or drains – collection container
placed below chest level, water seal to
prevent air from entering chest
64
Chest Tube
 Position patient to facilitate lung expansion
 Drainage system must be patent and intact to
function properly
 Looping the tube and securing to bedsheet
prevents direct pressure on the chest tube
and prevents tubing from lying on the floor
 Subcutaneous emphysema can occur under
the skin of the insertion site
 Encourage ambulation if possible to increase
lung ventilation and expansion
65
Endotracheal Tube
Verifying Tube Placement
 Chest x-ray
 Assess for breath sounds bilaterally,
symmetrical chest movement, air emerging
from ET tube
Stabilizing the Tube
Endotracheal Tubes: Nursing
Care
 Assess tube placement, minimal cuff leak,
breath sounds, chest wall movement
 Prevent movement of tube by patient
 Check pilot balloon
 Soft wrist restraints
 Mechanical sedation
Mechanical Ventilation
 Ventilator types:
– Negative-pressure
– Positive-pressure
• Pressure-cycled
• Time-cycled
• Volume-cycled
Modes of Ventilation
 Assist-control ventilation (AC)
 Synchronized intermittent mandatory
ventilation (SIMV)
 Bi-level positive airway pressure (BiPAP)
 Others
Ventilator Controls and
Settings
 Tidal volume (Vt)
 Rate—breaths/min
 Fraction of inspired oxygen (Fio2)
 PIP
 CPAP
 PEEP
 Flow and other settings
Nursing Management
 Always assess patient first, ventilator second
 Monitor patient response
 Manage ventilator system
 Prevent complications!
Complications
 Cardiac:
– Hypotension
– Fluid retention
– Valsalva maneuver
Complications (cont’d)
 GI
 Nutritional
 Infections—ventilator-associated pneumonia
(VAP)
 Muscle deconditioning
 Ventilator dependence
Complications (cont’d)
 Respiratory:
– Barotrauma
– Volutrauma
Weaning
 Process of going from ventilator dependence
to spontaneous breathing
Extubation
 Hyperoxygenate patient
 Thoroughly suction ET and oral cavity
 Rapidly deflate ET cuff
 Remove tube at peak inspiration
 Instruct patient to cough
 Monitor patient every 5 min; assess
ventilatory pattern for respiratory distress
Chest Trauma
 About 25% of traumatic deaths result from
chest injuries
– Pulmonary contusion
– Rib fracture
– Flail chest
– Pneumothorax
– Tension pneumothorax
– Hemothorax
– Tracheobronchial trauma
Pulmonary Contusion
 Potentially lethal injury
 May be asymptomatic at first, later develop
respiratory failure
 Bloody sputum, decreased breath sounds,
crackles, wheezes
 Treatment—maintenance of ventilation and
oxygenation
Rib Fracture
 Chest usually not splinted by tape or other
materials
 Main focus—decrease pain so adequate
ventilation is maintained
Flail Chest
 Paradoxical chest movement—“sucking
inward” of loose chest area during inspiration,
“puffing out” of same area during expiration
Tension Pneumothorax
Tension Pneumothorax
(cont’d)
 Assessment findings:
– Asymmetry of thorax
– Tracheal movement away from midline toward
unaffected side
– Respiratory distress
– Absence of breath sounds on one side
– Distended neck veins
– Cyanosis
– Hypertympanic sound to percussion
Hemothorax
Tracheobronchial Trauma
 Caused by blunt trauma, rapid deceleration
 Tracheal lacerations
 Upper airway obstruction
 Cricothyroidotomy, tracheotomy
A 65-year-old woman is brought to the ED by
her husband with new onset shortness of
breath. She had an abdominal hysterectomy 5
days ago. Her husband states that she stayed
in bed since she was discharged from her
surgery 48 hours ago, because she feels very
short of breath when she gets up.
What risk factors are present for DVT?
 Prolonged immobility; advancing age; recent
surgery.
88
(cont’d
)
During triage, the following vital signs and
assessments are noted:
Temp – 99.6° F BP – 80/44 mm Hg
P – 126 (sinus tachycardia) R – 28 and labored
O2 saturation – 84% (room air) Crackles bilaterally
Petechiae across chest and in axillae
Based on these findings, what do you suspect

might be happening with the patient?
 The patient may have a pulmonary embolism.
She could also have pneumonia based on
her recent surgery and immobility. Further
assessment should be performed to ascertain
the specifics of her symptoms.
90
(cont’d
)
When the ED physician is notified of the
patient’s manifestations, she is moved
immediately to a treatment room. The physician
writes the following orders:
– O2 at 2 L per nasal cannula
– Stat CBC, BMP, d-dimer, aPTT, INR
– Stat CT of the chest
– Start a saline lock
Which order takes priority at this time?
 Based on the patient’s pulse oximetry
reading, the priority order is the
administration of oxygen. Next, the saline lock
should be started. Once the vein is accessed,
blood can also be obtained for the CBC,
BMP, d-dimer, PTT, and INR. After the
laboratory specimens are sent, the radiology
department can be notified to perform the stat
CT of the chest.
92
(cont’d)
While in the treatment room, the patient says she needs to use the
bathroom. The nursing assistant is delegated this task.
What is the best approach for the nursing assistant to take?

A. Place the patient on a bedpan and stay with her until she is
finished.
B. Ambulate her into the hall bathroom on room air and stand
outside the door until she is done.
C. Ask the provider for an indwelling catheter because of her
shortness of breath when she ambulates.
D. Tell her to try to wait until the shortness of breath subsides.
 ANS: A
 The nursing assistant should place the patient on a
bedpan and stay with her. She is too short of breath
to ambulate to the bathroom and she should remain
on the oxygen at all times. The nursing assistant
should not ask the provider about an indwelling
catheter because this would only increase the
possibility of a UTI. The patient should never be told
to try to wait, because this could also increase the
risk for UTI.
94
(cont’d)
Two hours later, the patient is admitted to the medical
unit where she is started on a continuous IV heparin
weight-based protocol.
Which finding indicates that the heparin infusion is

therapeutic?
A. INR is less than 1
B. INR is between 2 and 3
C. aPTT is the same as the control
D. aPTT is 1.5 to 2.5 times the control
 ANS: D
 When a patient is started on continuous
heparin, the aPTT is drawn before therapy is
started and then every 4 hours until a
therapeutic range of 1.5 to 2.5 times the
control is reached. Thereafter, the aPTT is
checked daily.
96
(cont’d)
Three days later, the provider prepares to discharge the patient on
warfarin (Coumadin).
Which teaching points do you include about this therapy? (Select

all that apply.)
A. “Be sure to have follow-up INR laboratory tests done.”
B. “Report any bruising or bleeding to your provider.”
C. “Consume lots of foods that are rich in vitamin K, such as green
leafy vegetables.”
D. “Use a soft toothbrush to brush your teeth and an electric razor
to shave your legs.”
E. “A skin rash is expected while you are taking this drug.”
 ANS: A, B, D
 It will be important for the patient to have follow-up
INR laboratory tests done, reporting any bruising or
bleeding, and use a soft toothbrush and electric razor
while on warfarin therapy. Vitamin K is the antidote
for warfarin, so patients should not consume a great
deal of foods that are high in this vitamin. A skin rash
is a sign of an adverse drug reaction and should be
reported to the provider immediately.
98
Question 1
Which patient is at greatest risk of developing acute
respiratory distress syndrome (ARDS)?
A. 24-year-old male admitted with blunt chest trauma and

aspiration at the scene
B. 56-year-old male with a history of alcohol abuse and chronic
pancreatitis
C. 72-year-old male post heart valve surgery receiving 1 unit of
packed red blood cells
D. 82-year-old female on antibiotics for pneumonia
 Answer: A
 Rationale: All patient scenarios create a risk for ARDS.
However, the trauma patient with direct chest injury and known
aspiration is at greatest risk. ARDS risk factors include direct
lung injury (most commonly aspiration of gastric contents),
systemic illnesses, and injuries. The most common risk factor
for ARDS is sepsis. Other risk factors include bacteremia,
trauma with or without pulmonary contusion, multiple fractures,
burns, massive transfusion, near drowning, post-perfusion injury
after cardiopulmonary bypass surgery, pancreatitis, and fat
embolism.
100
Question 2
A patient is going home on warfarin (Coumadin) therapy
to manage an acute pulmonary embolism. Which
patient response indicates further discharge teaching is
needed?
A.“I should make a doctor’s appointment for weekly blood draws.”

B.“I should take the medication at the same time every day.”
C.“I should eat more green leafy vegetables like spinach.”
D.“I should limit my alcohol consumption.”
 Answer: C
 Rationale: Patients who experience a
venothromboembolism/pulmonary embolism are
frequently discharged on anticoagulant therapy (e.g.,
warfarin [Coumadin]). The patient should be
educated to understand the risks and monitoring of
this drug to include weekly monitoring for therapeutic
levels, consistency in dosing regimens, and foods to
avoid (e.g., leafy green vegetables, green tea,
alcohol, cranberry juice, etc.).
102
Question 3
A patient in acute respiratory failure is classified
as having ventilatory failure. A potential cause
of ventilatory failure is:
A. Opioid analgesic overdose

B. Pulmonary embolus
C. Hypovolemic shock
D. Pulmonary edema
 Answer: A
 Rationale: Acute ventilatory failure is the type of problem in
oxygen intake and carbon dioxide removal (ventilation) and
blood delivery (perfusion) that causes a ventilation-perfusion
(V/Q) mismatch in which perfusion is normal but ventilation is
inadequate. It occurs when chest pressure does not change
enough to permit air movement into and out of the lungs. As a
result, too little oxygen reaches the alveoli and carbon dioxide is
retained. Opioid analgesic overdose is a possible cause of
ventilatory failure. The others listed are related to oxygenation
failure.
104

Chest Trauma

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Chest Trauma

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Chest Trauma

 Thoracic cavity and abdominal cavity:

 Chest injuries result in a significant

 Mechanism of injury (MOI):

 Mechanism of injury (MOI):

 MOI: Blunt chest trauma

 MOI: Penetrating trauma

 MOI: Penetrating trauma

 Signs and symptoms

 Open chest wounds

 Open chest wounds

 When air enters between

 Open chest wounds

 Open chest wounds: Management

 Open chest wounds: Management

 Name three signs of a simple pneumothorax.

 Difficulty breathing, cyanosis, diminished

 Increasing pressure in the

 Tension pneumothorax: Signs

 Tension pneumothorax: Signs

 Rib fractures: Management

 Rib fractures: Management

 Flail segment: Management

 Flail segment: Management

 Pulmonary contusion: Management

 Cardiac contusion: Management

 Aortic injury: Management

 Traumatic asphyxia: Management

 What is the management for traumatic

 A drain placed in the pleural space to restore

What risk factors are present for DVT?

Based on these findings, what do you suspect

What is the best approach for the nursing assistant to take?

Which finding indicates that the heparin infusion is

Which teaching points do you include about this therapy? (Select

A. 24-year-old male admitted with blunt chest trauma and

A.“I should make a doctor’s appointment for weekly blood draws.”

A. Opioid analgesic overdose

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