CHAPTER 38 Thoracic Trauma

John Fazio, RN, MS, FAEN

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Thoracic Injuries

Rib and Sternal Fractures

Flail Chest

Pneumothorax

Tension Pneumothorax

Hemothorax

Pulmonary Contusion

Ruptured Diaphragm

Tracheobronchial Injury

Blunt Cardiac Injury

Pericardial Tamponade

Aortic Injuries

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)

2. Focused assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)

b) Pain (see Chapter 9)

c) Level of consciousness

d) Dyspnea

e) Vital signs or signs of life observed prior to hospital arrival

f) Cardiopulmonary resuscitation performed

g) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous surgery

c) Smoking history

d) Substance and/or alcohol use/abuse

e) Last normal menstrual period: female patients of childbearing age

f) Current medications

(1) Prescription

(2) Over-the-counter/herbal

g) Allergies

h) Immunization status

3) Psychological/social/environmental factors

a) Extremes of age

b) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Posture, position of comfort

c) Vital signs

d) Odors

e) Level of distress/discomfort

2) Inspection

a) Respiratory rate, rhythm, depth, and effort

b) Pulse rate, cardiac rhythm, and R-wave amplitude

c) Skin and mucosa: color

d) Work of breathing: nasal flaring, accessory muscle use, retractions

e) Neck veins: flat or distended

f) Wounds to chest: open or closed

g) Chest wall movement with respirations: symmetric or asymmetric

h) Paradoxical chest motion

3) Auscultation

a) Breath sounds: present, absent

b) Heart sounds: present, muffled

c) Bowel sounds: present, diminished, absent

4) Palpation

a) Skin: temperature and moisture

b) Tracheal position: midline or deviated

c) Areas of tenderness, deformity, or bony crepitus

d) Subcutaneous emphysema

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serial hematocrits

3) Coagulation profile

4) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

5) Arterial blood gas (ABG)

6) Type and screen, crossmatch

7) Serum and urine toxicology screens

8) Urinalysis; pregnancy test in female patients of childbearing age

b. Imaging studies

1) Cervical spine radiograph

2) Chest radiograph

3) Chest computed tomography (CT) scan

4) Focused Assessment Sonography for Trauma (FAST)

5) Aortography

6) Transesophageal echocardiography (TEE)

7) Multiple-gated acquisition (MUGA) scan

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Bronchoscopy or laryngoscopy

3) Diagnostic peritoneal lavage (DPL)

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Ineffective airway clearance

2. Ineffective breathing pattern

3. Impaired gas exchange

4. Decreased cardiac output

5. Deficient fluid volume

6. Acute pain

7. Anxiety/fear

8. Risk for infection

9. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood products/medications

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) Ribs are more compliant

2) Mediastinum thinner, more mobile

3) Infants are obligate nose breathers; children depend on their diaphragm for adequate chest expansion; may exhibit grunting or head bobbing with increased work of breathing (nasal flaring, accessory muscle use, retractions)

4) Airways are small and easily obstructed by edema or mucus

5) Children’s metabolic rate and oxygen consumption are much higher than those of adults

b. “Pearls”

1) Increased thoracic compliance may result in internal injury without external evidence of trauma (visual or chest radiograph findings)

2) Airway resistance in infants is 15 times greater than in adults

3) Accessory muscles of inspiration tire quickly, owing to less reserve muscle glycogen

4) Obstructive shock and multiple varieties of dysrhythmias are unusual in pediatric patients

2. Geriatric

a. Aging related

1) Decreased vital capacity, forced expiratory volume, maximum midexpiratory flow

2) Increased residual volume and functional residual capacity

3) Decreased static muscle strength and elastic lung recoil

4) Decreased diffusion capacity and arterial oxygenation

5) Increased ventilation-perfusion inequality, alveolar-arterial oxygen gradient

b. “Pearls”

1) Pulmonary defense mechanisms are reduced, making older adults more susceptible to infections

2) Diminished ventilatory response to hypoxic and hypercapnic challenge

3) Elderly persons report dyspnea as breathlessness

4) Causes of dyspnea in elderly patients may include the following:

a) Functional impairment of pulmonary or cardiopulmonary system

b) Impaired ventilation secondary to supine positioning

5) ECG may be necessary because dyspnea may be associated with an acute myocardial infarction

6) Aspiration mortality rate of 40% to 70%; also significant cause of pulmonary morbidity

7) Concurrent use of medications may mask classic clinical signs following trauma

II. SPECIFIC THORACIC EMERGENCIES

A. Rib and Sternal Fractures

Rib fractures are common thoracic injuries, usually resulting from blunt force or crush injuries during motor vehicle crashes. Rib fractures are not by themselves life-threatening, but they are especially significant because they may be associated with underlying lung injury. Fractures of the sternum, first, and second ribs rarely occur; however, because they are associated with significant force, they are commonly associated with injury to the lungs, aortic arch, or vertebral column. First rib fractures have a 40% mortality rate because of the frequently associated laceration of the subclavian artery or vein. Left lower rib fractures are associated with splenic injury in 20% of patients. Right lower rib fractures are associated with hepatic injury in 10% of patients. Sternal fractures are associated with an increased incidence of blunt cardiac injury. Children’s ribs and sternum are very flexible, making rib fractures less common in children than in adults, but children with rib fractures still can present with significant underlying lung injury. The treatment for all age groups with rib fractures is very similar.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Pain (see Chapter 9): localized pain, aggravated by chest wall movement, palpation, or inspiration

b) Onset may be associated with severe coughing

c) Dyspnea

d) Mechanism of injury (see Chapter 30)

2) Past medical history

a) Current or preexisting diseases/illness

(1) Pulmonary disease

(2) Osteodegenerative processes

b) Medications

c) Allergies

d) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Position intended to splint injured area

(2) Facial expression of pain on movement

(3) Moderate distress/discomfort

b) Inspection

(1) Chest wall contusion or ecchymosis

(2) Hypoventilation

c) Auscultation

(1) Breath sounds: diminished

d) Palpation

(1) Localized point tenderness

(2) Bony crepitus or deformity

(3) Subcutaneous emphysema if underlying pneumothorax or tracheal injury

2) Diagnostic procedures

a) ABGs

b) Chest radiograph

c) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Ineffective breathing pattern

b. Acute pain

c. Activity intolerance

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluids/medications as needed

d. Prepare for/assist with medical interventions

1) Place in high Fowler’s position, or position of comfort, to facilitate ventilation

2) Institute cardiac and pulse oximetry monitoring

3) Incentive spirometry to help prevent atelectasis during recovery

4) Assist with collection and maintenance of physical and forensic evidence as indicated (see Chapter 43)

5) Assist with possible hospitalization if any of the following:

a) Fractures of more than three adjacent ribs

b) Fracture of first or second rib

c) Suspected underlying visceral injury, sternal fracture, or hypoxia

e. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Anesthetics for intercostal nerve block

4) Tetanus immunization if open wounds.

f. Educate patient and significant others

1) Importance of analgesia

2) Appropriate splinting techniques

3) Hydration and breathing exercises, including incentive spirometry

4) Sandbags, strapping, or rib belts are not currently used

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Breath sounds and pulse oximetry

c. Cardiac rate and rhythm

d. Pain relief

B. Flail Chest

Flail chest occurs when two or more adjacent ribs are fractured in two or more locations or when the sternum is detached. The result is a free-floating segment that is drawn inward with inspiration and outward with expiration, thus causing paradoxical motion during respiration. The flail segment may not be clinically evident for several hours after injury because of muscle spasms and splinting of the injured area. Flail chest injuries are painful and cause impaired ventilation. Inefficient ventilation is caused by the loss of the bellows effect (less negative intrapleural pressure to expand the lung) and associated pulmonary contusion, dead space, and atelectasis. The patient has increased respiratory effort, decreased tidal volume, impaired cough, and hypoxia. Associated injuries may include underlying hemothorax, pneumothorax, pulmonary contusion, and blunt cardiac injury.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Pain (see Chapter 9): localized chest pain

b) Dyspnea

c) Mechanism of injury (see Chapter 30)

2) Past medical history

a) Current or preexisting diseases/illness

(1) Osteodegenerative processes

(2) Pulmonary disease

(3) Cardiovascular disease

b) Recent thoracic surgery

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: restlessness or confusion

(2) Position intended to splint injured area

(3) Hypotension, tachycardia, tachypnea

(4) Severe distress/discomfort

b) Inspection

(1) Chest wall contusion or ecchymosis

(2) Paradoxical chest motion

(3) Hyperventilation

(4) Work of breathing: nasal flaring, accessory muscle use, retractions

c) Auscultation

(1) Breath sounds: diminished or absent on injured side

(2) Heart sounds: distinct

d) Palpation

(1) Localized point tenderness

(2) Bony crepitus or deformity

(3) Subcutaneous emphysema if underlying pneumothorax or tracheal injury

2) Diagnostic procedures

a) ABGs

b) CBC with differential

c) Type and crossmatch

d) Urinalysis; pregnancy test in female patients of childbearing age

e) Chest radiograph

f) Cervical spine radiograph

g) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired gas exchange

b. Ineffective breathing pattern

c. Acute pain

d. Anxiety/fear

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen

1) Rapid-sequence intubation (RSI) and ventilatory support in patients with respiratory compromise

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluids/blood products/medications

1) Infuse warmed normal saline solution

d. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Stabilize injured chest wall: place patient on injured side in semi-Fowler’s position, or position of comfort, to facilitate ventilation

3) Institute cardiac and pulse oximetry monitoring

4) Maintain normothermic body temperature

5) Insert gastric tube and attach to suction

6) Insert indwelling urinary catheter

7) Assist with collection and maintenance of physical and forensic evidence if indicated (see Chapter 43)

8) Assist with hospital admission or transfer to an institution providing a higher level of care

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Non-narcotic analgesics

3) Narcotics

4) Tetanus immunization if wound opens

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Hemodynamic status

c. Breath sounds and pulse oximetry

d. Cardiac rate and rhythm

e. Intake and output

f. Pain relief

C. Pneumothorax

Pneumothorax results when air enters the pleural space. It causes a loss of negative intrapleural pressure and subsequent partial or total collapse of the lung on the affected side. Pneumothorax may occur following either blunt or penetrating thoracic injury, if a laceration occurs from either a fractured rib or penetrating object, or when increased intrathoracic pressure produces a ruptured bleb. In addition, mechanical ventilation or iatrogenic procedures in the trauma patient may cause pneumothorax. Pneumothorax may be simple or closed (no external opening) or open (wound through the chest wall present).

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Patient may be asymptomatic, especially if pneumothorax is small

b) Pain (see Chapter 9): localized chest pain

c) Dyspnea

d) Mechanism of injury (see Chapter 30)

2) Past medical history

a) Current or preexisting diseases/illness

(1) Pulmonary disease

b) Medications

c) Allergies

d) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Position intended to facilitate respiration

(2) Tachypnea

(3) Moderate to severe distress/discomfort

b) Inspection

(1) Chest wall contusion, ecchymosis, or open wound

c) Auscultation

(1) Breath sounds: decreased or absent on injured side

(2) Sucking sound from chest if open pneumothorax

d) Palpation/percussion

(1) Localized point tenderness to injured chest wall

(2) Bony crepitus or deformity

(3) Subcutaneous emphysema

(4) Hyperresonance on injured side

2) Diagnostic procedures

a) ABGs

b) CBC with differential

c) Chest radiograph

d) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired gas exchange

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