81. Chest, Abdominal, and Eye Trauma




CHEST TRAUMA




I. Rib fracture


A. Definition


1. Fracture of one or more ribs


2. Possibly resulting in severe damage to underlying structures


a. Lungs (e.g., pneumothorax, pulmonary contusion)


b. Subclavian artery (SCA)


c. Subclavian vein (SCV)


B. Etiology/Incidence


1. Eighty-five percent of patients with blunt chest trauma experience rib fractures


2. Associated with motor vehicle crashes (MVCs), assaults, and falls


C. Subjective/Physical examination findings


1. Pain, worsening with breathing, coughing, movement, and on palpation


2. Shallow respirations


3. Splinting of region


4. Crepitus


5. Decreased breath sounds on the affected side



E. Management


1. Rule out underlying structural damage (e.g., lacerated SCA or SCV, pneumothorax, lacerated liver or spleen) by ordering arteriography, x-rays, CT scan


2. Pain medications


a. For minor injuries, outpatient management options such as aspirin, acetaminophen, and NSAIDs (e.g., Ibuprofen, 400-600 mg 4 times a day)


b. For acute injuries, consider ketorolac (Toredol) with opioid options such as morphine sulfate, 2 mg IV initially, then titrated as needed until pain is relieved (Note: Watch for respiratory depression.), or hydromorphone (Dilaudid), 0.1-0.5 mg given over at least 2 to 3 minutes, titrated every 6 to 10 minutes until analgesia is achieved (usual maximum, 2 mg per hour)


c. Intercostal nerve blocks (such as lidocaine 1%), patient-controlled analgesia, or epidural anesthesia options should be considered for severe pain management


3. Aggressive pulmonary toilet, such as Turn, Cough, Deep Breathe, chest physiotherapy should be used on nonaffected side, along with incentive spirometry; encourage resting on affected side if tolerable to promote expansion of the unaffected lung


4. Consider aerosol therapy with albuterol (Ventolin), 1-2 puffs every 4 to 6 hours to prevent atelectasis and pneumonia


5. Monitor oxygen saturation; consider giving O2 at 2 L per nasal cannula, with oxygen saturation (SaO2) maintained at above 92


II. Flail chest


A. Definition


1. Fracture of at least two adjacent ribs at two sites


2. Results in a “floating” segment or sternum


B. Etiology/Incidence


1. Most serious chest wall injury


2. High likelihood of underlying structural injury


3. Caused by blunt force/trauma



D. Laboratory/Diagnostic findings


1. ABGs: hypoxia, possible respiratory acidosis


2. Chest x-ray: reveals rib fractures


E. Management


1. Administer O2, correct possible respiratory acidosis, and consider ventilatory support with positive end-expiratory pressure (PEEP) and pressure support


2. Administer crystalloids, such as lactated Ringer’s solution


3. Consider supporting/stabilizing flail segment with sandbags, although controversy is expressed in the current literature regarding the effectiveness of this treatment; if ventilatory restriction is severe, provide operative stabilization


4. Pain medications


a. Morphine sulfate, 2 mg IV initially, then titrated as needed until pain is relieved (Note: Watch for respiratory depression.)


b. Hydromorphone (Dilaudid), 0.1-0.5 mg given over at least 2 to 3 minutes, titrated every 6 to 10 minutes until analgesia achieved (usual maximum, 2 mg per hour)


5. If lung contusion occurs, the patient may require long-term ventilation.


6. Ventilation with induced paralysis may also be provided

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Mar 3, 2017 | Posted by in NURSING | Comments Off on 81. Chest, Abdominal, and Eye Trauma

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