Australasian Emergency Nursing Journal (2011) 14, 257263

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

CASE STUDY

Assessment, monitoring and emergency nursing care in blunt chest injury: A case study
Belinda Munroe, RN, MN a,d,, Kate Curtis, RN, PhD a,b,c,d,e
a

St. George Hospital, Trauma Service, Australia Sydney Nursing School, University of Sydney, Australia c The George Institute for Global Health, Australia d Emergency Department, The Wollongong Hospital, Australia e St. George Clinical School, Faculty of Medicine, University of NSW, Australia
b

Received 20 December 2010; received in revised form 11 March 2011; accepted 22 May 2011

KEYWORDS
Blunt chest trauma; Lung injury; Nursing assessment; Rib fractures; Emergency care

Summary The case study highlights several complications that commonly develop in trauma patients who sustain blunt chest injuries with underlying lung injury and discusses essential nursing assessment and care. Rib fractures are one of the most common injuries sustained from blunt chest trauma and frequently co-exist with underlying lung injury. Rib fractures alone are associated with high morbidity and mortality. The addition of underlying lung injury such as lung contusions increases the incidence of adverse outcomes. Emergency nursing care must involve thorough assessment and timely intervention with a particular focus on maximising respiratory function and reducing pain. This can be achieved by appropriate oxygen therapy, early chest physiotherapy and adequate analgesic strategies. 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

A 58-year-old female, unrestrained front seat passenger was hit at high speed by another vehicle on the front passenger side at 0930 h. There was major deformity to the vehicle. No airbags were deployed. She was trapped by connement for 20 min and extricated by Advanced Life Support Paramedics who applied a cervical hard collar. At the scene her heart rate (HR) was 134 bpm, blood pressure (BP) 140/76 mmHg,

Corresponding author at: Trauma Service, St. George Hospital, Gray St., Kogarah, NSW 2217, Australia. Tel.: +61 2 91133499; fax: +61 2 91133974. E-mail address: belinda.munroe@sesiahs.health.nsw.gov.au (B. Munroe).

Glasgow Coma Score (GCS) 15 and oxygen saturations (SaO2 ) were 100% on high ow oxygen via a non-rebreather (NRB) mask. A 22 gauge intravenous (IV) cannula was inserted in the patients right hand. 10 mg IV metoclopramide and 10 mg IV morphine were administered prior to being transferred to the regional trauma centre. The patient arrived at 1000 h. On arrival to the Emergency Department (ED) the patient was given a Triage Category 2, a trauma call was activated and the patient was transferred directly to the resuscitation room. A primary and secondary survey was conducted. Airway was patent and spinal immobilisation was maintained. The patients respiratory rate was 40 and SaO2 89% on room air, increasing to 100% on oxygen via NRB mask. Air entry was decreased in the right lung base and crackles were heard

1574-6267/$ see front matter 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2011.05.005

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B. Munroe, K. Curtis

Figure 1 Initial CXR demonstrating right sided rib fractures and lung contusion.

Figure 2 Initial chest CT demonstrating right sided haemothorax and lung contusion.

across the right lung elds. The HR was 138 bpm and BP 137/72 mmHg. She had a GCS of 15 and pupils were equal and reactive. Temperature was measured 36.2 C and warm blankets were applied. The patient was exposed and a log roll was performed. Bruising and tenderness was present across the right anterior chest wall. A laceration to the chin, pain to the right jaw and deformity to the right knee was also identied. No signicant medical history was reported. A second 18 gauge IV cannula was inserted in the left cubital fossa and baseline bloods were collected (Venous Blood Gas; Full Blood Count; Urea, Creatinine and Electrolytes; Liver Function Tests; Troponin I; and Group, Screen and Hold). An electrocardiograph (ECG) reported the patient was in sinus tachycardia. Continuous cardiac monitoring and pulse oximetry were commenced. Further increments of IV morphine were administered to reduce pain levels. One litre of Hartmanns solution was administered over 1 h to treat the tachycardia, potentially caused by hypovolaemia. A Focused Assessment with Sonography for Trauma (FAST) was attended by an accredited ED staff specialist. FAST is a bedside ultrasound used to identify the presence of blood in the peritoneal cavity as a result of trauma. No intra thoracic, abdominal or pericardial uid was seen. A mobile X-ray of the chest (CXR) (Fig. 1) and right knee were attended. Multiple right rib fractures and a right tibia plateau fracture were reported. Given the high index of suspicion for multiple injuries, the patient was transferred for a computed tomography (CT) pan scan which includes the head, neck, chest, abdomen and pelvis. The scan reported a fractured right mandible, right rib fractures 35, a right upper lobe lung contusion and small right haemothorax (Fig. 2). While still in ED 90 min after presentation, the patients HR remained elevated at 130 bpm. The systolic BP dropped to 75 mmHg and GCS to 9. To maintain airway patency the patient was intubated with an endotracheal tube using rapid sequence intubation. An orogastric tube was inserted and Synchronised Intermittent Mandatory Ventilation (SIMV) with pressure support (PS) was commenced. A repeat haema-

globin was found to be 70 d/L and the patients BP was stabilised with 4 units of packed red blood cells infused via a uid warmer. A repeat FAST was not attended as there was no accredited staff available at this time. Once the patients BP stabilised a chest CT was repeated 3 h after presentation to identify the cause of the patients deterioration and reported worsening lung contusions (Fig. 3). The facial laceration was sutured and a back slab was applied to the right leg. The mandible fracture was managed non-operatively and the patient was admitted to the Intensive Care Unit (ICU) for ongoing management and Pressure Controlled Ventilation (PCV). Her progress CXR demonstrated signicant progression of lung contusion (Fig. 4). On day 2 the patient developed thick purulent sputum, fevers and increased oxygen demands. A repeat CXR identied bilateral lower lobe pneumonia. Positive end-expiratory pressure (PEEP) and PS were increased, chest physiotherapy was conducted twice daily and IV antibiotics were administered. Respiratory function gradually improved and on day

Figure 3 Repeat chest CT at 3 h post injury demonstrating worsening lung contusions.

Assessment, monitoring and emergency nursing care in blunt chest injury: A case study

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the age of 65 years.3,4,9,1115 This is likely associated with increased comorbidities and loss of physical reserve seen in the elderly.7 The presence of injury to the thoracic cage often coexists with underlying lung tissue. Lung injury such lung contusions and haemathoraces are seen in 50% of patients with rib fractions.3,5 Patients with multiple rib fractures or a ail segment have been shown to have a higher incidence of underlying lung injury.3,16 The combination of chest wall and lung injury signicantly reduces pulmonary function, resulting in a higher incidence of patients requiring mechanical ventilation and length of stay in ICU17 as demonstrated in the case study. Further, blunt chest injury affects 70% of long term lung capacity which has detrimental results specically on pulmonary quality of life.18 The cause of this is unclear, however, it is thought this is may be due to a mechanical cause such as muscle weakness and rib cage deformity or as a result of obstruction and increased residual lung volumes.18
Figure 4 CXR at 9 h post injury demonstrating progression of right sided lung contusion.

Pathophysiology of lung injury

Injury results from MVC due to acceleration, deceleration and crush forces. There are three points of contact involved in MVCs: rstly the impact of the vehicle with another object; secondly the body impact with internal structures of the car; and thirdly the shifting of internal organs until they collide with other internal structures.19 A rib fracture occurs when the thoracic cage is unable to absorb force applied to the chest. Underling lung injury occurs in rib fractures because of the pliability of the bone. The ribs bend prior to fracturing which damages the lung tissue located underneath the ribs impacted.20 While less common, lung injury can occur in the absence of rib fractures, particularly in patients 25 years old or younger as their bones are more exible and less susceptible to fracture.21 The purpose of the breathing is to supply oxygen to cells and remove carbon dioxide.22 This is achieved through ventilation, the movement of air in and out of the lungs and respiration, the exchange of oxygen and carbon dioxide across the alveolar and peripheral capillary membrane.22 The combinations of injuries displayed in the case study impair ventilation and oxygen exchange by reducing vital capacity, weakening the patients ability to clear secretions and decreasing surface area available for oxygenation. This was clearly demonstrated by the patients signs of respiratory compromise and subsequent pneumonia. The presence of rib fractures recruit accessory muscles as injury increases workload and causes fatigue of respiratory muscles used in passive breathing.23 The ability of the lung to ventilate is impaired and lower airways collapse decreasing surface area available for respiration. The small haemothorax may have impaired lung function as the accumulation of blood in the pleural cavity compresses alveoli and prevents the lung from fully expanding.24 Contusion or bruising to the lung produces inammation of the lower airways resulting in the collection of water and blood in the alveoli.24 This causes obstruction resulting in increased airway pressures and subsequently respiratory effort. Less oxygenated air moves in and out of the lungs reducing the surface area available for respiration to occur. Alveolar consolidation and collapse result, explaining the patients impaired oxygenation.

8 the patient was extubated and transferred to the ward where she received ongoing chest physiotherapy, frequent review by the pain team and regular oral analgesia. Day 13 she underwent an open reduction and internal xation of her right tibia plateau which was initially delayed due to the development of pneumonia. The patient was discharged home on day 18 with outpatient rehabilitation and followup with the orthopaedic surgeon.

Discussion
The case study highlights several complications that commonly develop in trauma patients who sustain blunt chest injuries with underlying lung injury. These include hypoxia, hypovolaemic shock, decreased level of consciousness and pneumonia. As a result the patient required active uid resuscitation, intubation and a prolonged hospital admission.

Epidemiology of blunt chest trauma

Blunt chest injury as a result of motor vehicle collisions (MVC) in Australia is extremely prevalent. 90% of all major trauma is caused by a blunt mechanism with the chest being the second leading body region affected.1 MVC account for 34% of all major blunt trauma1 and for nearly 70% of blunt chest injuries.2 Blunt chest injuries are associated with high morbidity and mortality rates due to the prevalence of complications. Adverse outcomes such as respiratory failure and pneumonia frequently occur in the acute phase.38 This is as a result of pain and inability to effectively clear secretions which causes atelectasis.9,10 The risk for complications is greater in patients with more than 3 rib fractures.3,9 This is due to higher pain levels and an associated increase in work of breathing. Aggressive pain relief and physiotherapy has shown to improve outcomes in these patients.7 The risk of pneumonia and respiratory failure increases with age from as young as 45 years old11,12 and particularly over

260 Lung contusions may also result in hypovolaemic shock as seen in the case study manifested by hypotension, persistent tachycardia and drop in the haemoglobin. This is due to blood pooling into the lung tissue as a result of the injury.23 The development of respiratory failure may have also contributed to this which causes uid to shift from alveoli capillaries into the lung,25 decreasing circulating blood volume. The blood pressure drops as a result of the decrease pressure in the intravascular space and heart rate increases as a compensatory mechanism. The combination of hypotension and hypoxia reduces cerebral perfusion22 and is responsible for the suppressed level of consciousness in the case study.

B. Munroe, K. Curtis All trauma patients who sustain blunt chest injury should have an ECG and continuous cardiac monitoring. This is essential to identify variation in HR and cardiac rhythm which could be a response to hypovolaemia, hypoxia, pain or blunt cardiac injury.29 Cardiovascular changes were identied in the case study indicating hypovolaemia manifested by tachycardia and subsequent fall in BP, requiring active uid resuscitation to replace circulating blood volume lost from lung injury. All major trauma patients should have a CXR as part of their initial assessment.30 However, as seen in this case not all injuries are identied in the initial CXR. It has been demonstrated that more than 50% of rib fractures are not seen on CXR,3 15% of pneumothoraces seen on CT are not seen on CXR31 and greater than 23% of occult lung contusions are not seen on an initial CXR.8 While imaging is at the discretion of the medical staff in major trauma, nurses should consider if diagnosis of injury on the CXR is consistent with the clinical picture of the patient. If not, a chest CT may be useful to guide management. It is also important to remember that the initial CXR or chest CT is likely not to show the extent of lung contusions as seen in this case study as these develop slowly over several hours,8 thus close monitoring is essential. Opacities seen on chest CT representing lung contusions will gradually increase over time as the bruising to lung tissue develops. Worsening lung contusions is manifested by signs of respiratory compromise such as a decrease in oxygen saturations and increased work of breathing in addition to cardiovascular changes such as hypotension and tachycardia. These signs were evident in the case study. Respiratory support, early and adequate pain management and aggressive physiotherapy decreases infection, ventilator days, length of stay and mortality in patients with blunt chest injury.32 The initiation of these practices in the ED will ensure optimal patient recovery. Respiratory function should be supported with oxygen therapy to treat hypoxia and reduce work of breathing. The amount and type of oxygen therapy utilised needs be selected according to the respiratory status and injury severity of the patient. Nurses should initiate oxygen therapy when the patient arrives to the ED as supplemental oxygen has been shown to reduce lung related complications.33 An increasingly popular form of respiratory support is the administration of humidied oxygen via high ow nasal cannula (HFNC). HFNC oxygen reduces work of breathing through decreasing oxygen demands, improving expectoration of secretions and recruiting alveoli by supplying a small amount of positive end expiratory pressure.34 The commencement of HFNC oxygen in the ED will ensure optimal oxygen support early and may also be utilised as a prophylactic treatment to prevent sputum retention, although further research is needed into this therapy. Non-invasive ventilation should be considered in patients in respiratory distress as it has also been proven to decrease patients hospital stay through delaying the need for mechanical ventilation.35 As exhibited in this case some lung injury causes hypoventilation and hypoxia requiring mechanical ventilation. While lifesaving, mechanical ventilation may cause further injury as a result of over inating the lungs.36 The goal of mechanical ventilation is therefore to maintain adequate oxygenation without causing further lung injury. In lung

Implications for nursing care

Timely nursing assessment and pro-active emergency nursing care is needed to recognise clinical signs of thoracic injury, deterioration and the need for rapid intervention. Like all trauma patients, assessment must follow the systematic primary and secondary survey to ensure the most life threatening injuries are managed rst and that all systems are examined, optimising the best possible outcome for trauma victims.26,27 In this case the initial primary and secondary survey revealed problems with breathing as exhibited by elevated RR, crackles and decreased air entry, but no obvious pneumothorax or haemothorax was identied requiring urgent intervention. These signs are however indicative of injury which should be closely monitored by the ED nurse. In blunt chest trauma respiratory function, cardiovascular status and pain are the highest priorities in order to prevent hypoxia and associated complications and will therefore be the focus of discussion. When caring for patients who have sustained a blunt chest injury the nurse should conduct a comprehensive respiratory assessment including the measurement of RR and pulse oximetry, auscultation, percussion and visual examination of the chest. The chest should be inspected for visible signs of injury, unequal rise and fall of the chest and increase work of breathing. Unequal movement of the chest wall may indicate the presence of a ail segment, or tension pneumothorax and/or haemothorax that may be preventing adequate lung expansion. It is vital to identify the presence of a major pneumothorax and/or haemothorax as an urgent chest tube may be required to improve lung ination. The nurse should palpate for abnormalities such as deformity or pain. Subcutaneous emphysema indicates leakage of air into the subcutaneous tissue which often occurs when a pneumothorax is present. It is important to listen for breath sounds such as crackles as noted in the case study may indicate injury. Air entry should also be assessed through auscultation to identify if the patient is effectively expanding their lungs or if the presence of pain or air and/or blood in the pleural space is restricting lung expansion. The insertion of a chest drain is indicated in the presence of large pneumothorax and/or haemothorax to decompress the pleura and improve lung ination.28 In the case study the treating clinicians did not elect to insert a chest drain due to the small size of the haemathorax only seen on CT and absence of pneumothorax.

Assessment, monitoring and emergency nursing care in blunt chest injury: A case study contusions ventilation can be difcult due to the pooling of blood in the affected lung, lowering lung compliance and causing asymmetrical ventilation.37 Recommended strategies include the use of PEEP to keep alveoli open to aid respiration; inspiratory/expiratory (I/E) ratio reversal to increase the time respiration has to occur; and the use of PCV opposed to Volume Controlled Ventilation to increase mean airway pressures in order to recruit more alveoli without delivering high tidal volumes that over inate the lungs and cause further injury.3739 Other more advanced methods such as High Frequency Oscillatory Ventilation, Nitric oxide, Extracorporeal Membrane Oxygenation and Prone Positioning have been shown to have some benet in lung injury25 however are beyond the scope of clinical practice within the ED. In the case study SIMV with PS was used as this was the most optimal setting available on the ED ventilator. This delivers a set number of volume breathes but it allows the patient to take spontaneous breathes which are pressure controlled.36 A PEEP and I/E ratio can also be set. While a PEEP was set and pressure controlled spontaneous breaths were allowed, as the patient was sedated and paralysed as they often are during the initial phases in the ED setting the use of set volume controlled breaths increased the patients risk for secondary lung injury. This risk was reduced by setting a peak inspiratory pressure and changing the patient to PCV when the patient was transferred to ICU. In patients with suspected pneumothorax it is recommended that a chest drain be inserted if being placed on positive pressure ventilation.40 This is due to the risk of tension pneumothorax developing as a result of the positive pressure which can be life threatening. There was no evidence of a pneumothorax on CT, a chest drain was therefore not inserted. Pain experienced as a result of chest injury inhibits adequate lung expansion and suppresses the individuals ability to cough and expectorate secretions.10,41 This causes further alveolar collapse and can result in infection and hypoxia. Accurate pain assessment is vital to prompt administration of adequate analgesia to improve lung expansion and pulmonary toilet.42,43 The nurse should conduct regular pain assessments and the severity of pain should dictate the route, type and amount of analgesia administered. There has been extensive research conducted into the pain management of blunt chest trauma which recommend a number of effective approaches. IV morphine is commonly used in the ED as it has been shown to effectively reduce pain and is easily titrated to meet patients needs.23,44 The use of patient controlled analgesia,45 paravertebral46 and intercoastal blocks47 are also successful in providing sufcient pain relief. Thoracic epidurals have been found to be particularly benecial in patients with four or more rib fractures.42,43,48,49 Oral analgesics including opiods, paracetamol and non-steroidal anti-inammatory drugs are also valuable in addition to parental routes or for less severe pain.43 While many of these methods are routinely initiated on the ward, to ensure optimal pain control such methods should be commenced early while the patient is still in the ED, with early referral to a pain team if available. Established pain teams have been shown to select the best analgesic regime, improve pain relief and reduce inci-

261

dence side effects from medications.43 The pain team should be notied of patients from the ED as they will assist with the early commencement of the appropriate analgesia. Early and aggressive chest physiotherapy is vital to improve expectoration of secretions and reduce ventilation days.50 Patients should be seated out of bed and mobilised early (other injuries permitting) to aid work of breathing.51 The use of incentive spirometry has also been shown to promote lung expansion and sputum expectoration reducing the incidence of pneumonia, hospital length of stay and mortality rates.32,33 Patients with blunt chest injuries should be referred to physiotherapist from the ED and commenced on incentive spirometry early.The complex and multidisciplinary nature of trauma patients require a coordinated approach to care. This can be commenced by the ED nurse and continues by models of care such as Trauma Case Management, which effectively reduce complications in trauma patients.52

Conclusion
ED nurses should have a high index of suspicion for lung contusion in patients with blunt chest injury, as it leads to signicant adverse outcomes if not managed effectively. Clinical assessment must be accurate and repeated regularly to determine the needs of the patient and recognise deterioration. The identication of abnormalities should be communicated to the treating medical team immediately to ensure timely intervention. Early initiation of appropriate oxygen therapy, effective analgesia and physiotherapy are vital to restore normal respiratory function, prevent complications and optimise patient recovery.

Provenance and conict of interest

None declared. Author Kate Curtis is an Associate Editor with the Australasian Emergency Nursing Journal but had no role in the peer review or editorial decision-making regarding this paper. This paper was not commissioned.

Funding
None.

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