Chest Trauma

Chest Trauma
• Chest injuries are potentially life-threatening because of immediate
disturbances of cardiorespiratory physiology and hemorrhage and
later developments of infection, damaged lung and thoracic cage.
• Traumatic chest injuries include rib fracture, hemothorax, flail chest,
pulmonary contusion, pneumothorax and cardiac tamponade.
• Patients with chest trauma may have injuries to multiple organ
systems.
• The patient should be examined for intra-abdominal injuries, which
must be treated aggressively.
Chest Trauma
Rib Fracture
• Results from direct blunt chest trauma and causes a potential for
intrathoracic injury, such as pneumothorax or pulmonary contusion.
• Pain with movement and chest splinting result in impaired ventilation
and inadequate clearance of secretions.
• Most common chest injury.
Flail Chest
• Occurs from blunt chest trauma associated with accidents, which may
result in hemothorax and rib and sternum fractures.
• The loose segment of the chest wall becomes paradoxical to the
expansion and contraction of the rest of the chest wall.
Pulmonary Contusion
• Characterized by interstitial hemorrhage associated with intraalveolar
hemorrhage, resulting in decreased pulmonary compliance.
• The major complication is acute respiratory distress syndrome.
Pneumothorax
• Accumulation of atmospheric air in the pleural space, which results in a rise in
intrathoracic pressure and reduced vital capacity.
• The loss of negative intrapleural pressure results in collapse of the lung.
• A spontaneous pneumothorax occurs with the rupture of a pulmonary bleb.
• An open pneumothorax (simple and traumatic) occurs when an opening through
the chest wall allows the entrance of positive atmospheric air pressure into the
pleural space.
• A tension pneumothorax occurs from a blunt chest injury or from mechanical
ventilation with PEEP when a buildup of positive pressure occurs in the pleural
space.
• Diagnosis of pneumothorax is made by chest x-ray.
Pneumothorax
Hemothorax
• Blood in pleural space as a result of penetrating or blunt chest
trauma.
• Accompanies a high percentage of chest injuries.
Cardiac Tamponade
• A pericardial effusion occurs when the space between the parietal
and visceral layers of the pericardium fills with fluid.
• Pericardial effusion places the client at risk for cardiac tamponade, an
accumulation of fluid in the pericardial cavity.
• Tamponade restricts ventricular filling, and cardiac output drops.
Assessment Findings
Rib fracture:
• Pain at the injury site that increases with inspiration.
• Tenderness at the site.
• Shallow respirations.
• Client splints chest.
• Fractures noted on chest x-ray.
Assessment Findings
Flail Chest:
• Paradoxical respirations (inward movement of a segment of the thorax
during inspiration with outward movement during expiration).
• Severe pain in the chest.
• Dyspnea and Cyanosis.
• Tachycardia.
• Hypotension.
• Tachypnea, shallow respirations.
• Diminished breath sounds.
Assessment Findings
Pulmonary Contusion:
• Dyspnea.
• Hypoxemia.
• Increased bronchial secretions.
• Hemoptysis.
• Restlessness.
• Decreased breath sounds.
• Crackles and wheezes.
Assessment Findings
Pneumothorax:
• Absent breath sounds on affected side.
• Cyanosis, Hypotension.
• Decreased chest expansion unilaterally.
• Dyspnea, Tachypnea, Tachycardia.
• Sharp chest pain.
• Subcutaneous emphysema as evidenced by crepitus on palpation.
• Sucking sound with open chest wound.
• Tracheal deviation to the unaffected side with tension pneumothorax.
Assessment Findings
Hemothorax:
• Asymptomatic.
• Dyspnea.
• Apprehensive.
• Shock.
• Hidden blood loss.
Assessment Findings
Cardiac Tamponade:
• Pulsus paradoxus (audible blood pressure fluctuation with
respiration).
• Increased Central venous pressure (CVP).
• Jugular venous distention with clear lungs.
• Distant, muffled heart sounds.
• Decreased cardiac output.
• Narrowing pulse pressure.
Nursing Process
Nursing Diagnosis:
• Ineffective Breathing Pattern.
• Impaired Gas Exchange.
• Anxiety.
Nursing Planning and Goals:
• Achieving effective breathing pattern.
• Resolving impaired gas exchange.
• Understand the treatment regimen.
Nursing Evaluation: Expected Outcome.
• Breath sounds equal bilaterally; less dyspneic.
• ABG levels improved.
• Patient and significant others understand the treatment regimen.
Nursing Interventions and
Treatment:
Rib Fracture:
• Note that the ribs usually reunite spontaneously.
• Place the client in a Fowler’s position.
• Administer pain medication as prescribed to maintain adequate
ventilator status.
• Monitor for increased respiratory distress.
• Instruct the client to self-splint with the hands and arms.
Nursing Interventions and
Treatment:
Flail Chest:
• Maintain the client in a Fowler’s position.
• Administer humidified oxygen as prescribed.
• Monitor for increased respiratory distress.
• Encourage coughing and deep breathing.
• Administer pain medication as prescribed.
• Maintain bed rest and limit activity to reduce oxygen demands.
• Prepare for intubation with mechanical ventilation, with positive
endexpiratory pressure (PEEP) for severe flail chest associated with
respiratory failure and shock.
Nursing Interventions and
Treatment:
Pulmonary Contusion:
• Maintain a patent airway and adequate ventilation.
• Place the client in a Fowler’s position.
• Administer oxygen as prescribed.
• Monitor for increased respiratory distress.
• Maintain bed rest and limit activity to reduce oxygen demands.
• Prepare for mechanical ventilation with PEEP if required.
Nursing Interventions and
Treatment:
Pneumothorax:
• Apply a nonporous dressing over an open chest wound.
• Administer oxygen as prescribed.
• Place the client in a Fowler’s position.
• Prepare for chest tube placement, which will remain in place until the lung has
expanded fully.
• Monitor the chest tube drainage system.
• Monitor for subcutaneous emphysema.
• Caring for a client with chest tubes.
• Clients with a respiratory disorder should be positioned with the head of the bed
elevated.
Nursing Interventions and
Treatment:
Hemothorax:
• Assist with thoracentesis to aspirate blood from pleural space, if being
done before a chest tube insertion.
• Assist with chest tube insertion and set-up drainage system for
complete and continuous removal of blood and air.
• Auscultate lungs and monitor for relief of dyspnea.
• Monitor amount of blood loss in drainage.
• Replace volume with I.V. fluids or blood products.
Nursing Interventions and
Treatment:
Cardiac Tamponade:
• The client needs to be placed in a critical care unit for hemodynamic monitoring.
• Administer fluids intravenously as prescribed to manage decreased cardiac output.
• Prepare the client for chest x-ray or echocardiography.
• Prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed.
• Monitor for recurrence of tamponade following pericardiocentesis.
• If the client experiences recurrent tamponade or recurrent effusions or develops
adhesions from chronic pericarditis, a portion (pericardial window) or all of the
pericardium (pericardiectomy) may be removed to allow adequate ventricular filling
and contraction.