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TERM PAPER ON

CHEST TRAUMA

BY

NWANNA CHIDINMA

MAT NO.

SUBMITTED TO THE DEPARTMENT OF NURSING SCIENCE

FACULTY OF HEALTH SCIENCE IMO STATE
UNIVERSITY, OWERRI

IN PARTIAL FULFILLMENT OF ADVANCED CONCEPT OF

CRITICAL CARE NURSING NSC 723

LECTURER
DR. VINCENT CHINELO

FEBRUARY, 2022
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Introduction

Chest trauma has quickly risen to the second most common traumatic injury in

non-intentional trauma. Trauma to the chest comes with the highest mortality;

in some studies, up to 60%. World Health Organization (WHO) (2010) Quick

thinking and early interventions are key factors for evaluations, management,

and survival.

Chest trauma can be a result of penetrating or blunt trauma. Blunt trauma, on

the whole, is a more common cause of traumatic injuries and can be equally

life-threatening. It is important to know the mechanism as management may be

different. Lecky and Bouamra (2010) noted that most blunt trauma is managed

non-operatively, whereas penetrating chest trauma often requires operative

intervention.

All age ranges are at risk for chest trauma. After head and extremity trauma,

chest trauma is the third most common blunt injury and quickly rising to

second. Motor vehicle injuries are the most common of these. However, this is

declining with the advent of improved vehicle safety (McQueen, Hagberg,

McCunn 2014).

Early recognition of trauma to the chest is a priority. The first 3 steps of trauma

evaluation involve evaluation, recognition, and intervention of potential injuries

to “the box.” Following a routine method of evaluation reduces missed injuries.

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Injuries to the heart and lungs are primary and vital since they have the highest

mortality if missed. Injuries to other thoracic structures also need to be

considered; ribs, clavicle, trachea, bronchi, esophagus, and arteries including

the aorta and veins need to be evaluated in the secondary and tertiary survey

(Huber, Biberthaler and Delhey 2014)

Aim and Objectives

The aim of this seminar paper is to review the Chest trauma. The specific

objectives:-

1. To review the concept of chest trauma

2. To review the signs or symptoms chest Trauma

3. To review the diagnosis of Chest Trauma

4. To review the complications Chest Trauma

5. To review the management of Chest Trauma

Definition term
Chest trauma. A chest injury can occur as the result of accidental or deliberate
penetration of a foreign object into the chest.
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Concept of Chest Trauma

A chest injury or trauma is any injury to the ribs, heart, or lungs and can occur

as the result of accidental or deliberate penetration of a foreign object into the

chest. A chest injury can occur as the result of accidental or deliberate

penetration of a foreign object into the chest. Chest injuries are injuries to the

chest wall (the bones, skin, fat and muscles protecting your lungs, including

your ribs and sternum) or any of the organs inside the chest.

Chest injuries include:

 bruising or abrasions (cuts and grazes) to the chest area

 broken bones (for example, a rib fracture)

 damage to the lungs or heart

Chest injuries can be minor, such as bruising, or serious problems that need

urgent medical attention. One of the most common chest injuries is fractured

ribs. These are caused by a strong blunt force, such as a fall from a height or a

motor vehicle crash. In older people who have osteoporosis, only a slight force,

such as a minor fall, can fracture a rib.

A fractured rib is rarely serious. However, the force that caused the fracture can

occasionally cause other problems, such as a bruised or collapsed lung, so it’s

important to seek medical attention if you think you may have a fractured rib.
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Types of chest trauma

Chest trauma can be penetrating or blunt. If the injury pokes through the skin

(stabbing, gunshot wound, an arrow through the heart, etc.) we call it

penetrating chest trauma. If a sharp object tearing deep into skin and muscle

isn't the main cause of tissue damage, consider it blunt chest trauma. Some

blunt forces can still break the skin, getting kicked by a horse comes to mind,

but tearing the skin is not considered penetrating trauma (Battle, Hutchings, and

Evans (2014). The injuries are divided into four groups:

Rib fractures: Rib fractures are the most common injuries in trauma centers

and secondary care hospitals. They are commonly seen in adults, usually

secondary to blunt trauma that can be an insignificant injury or rather can lead

to serious complications due to injuries of the internal organs. Rib fractures are

clinically manifested bylocaltenderness, hematomas, inspiratory pain or while

coughing.

Sternal fractures: Fractures of the sternum occur with blunt trauma, with a

higher frequency in vehicular accidents. Recinos et al. (2015) studied the

demographic facts and the outcome of sternum fractures; of 37,087 patients,

125 cases (0.33%) had sternum fractures, more commonly in men. The most

common injury mechanism was collision between vehicles and patients that
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have been run over. They were associated with rib fractures and

hemothorax/hemopneumothorax.

Flail chest: The flail chest is an uncommon lesion that usually occurs with a

high speed vehicular accident. It is commonly characterized by three or more

rib fractures in two or more sites, with or without sternallesion (Battle and

Evans, 2015) where the injured segment of the thoracic wall show paradoxical

respiratory movement, mechanical respiratory dysfunction, and frequent

respiratory failure.

Pulmonary lesions: This type of lesions can be moderate to severe with

imminent death. The clinical skills during pre-hospital care and in the

emergency room are essential to determine if there is pulmonary damage as

describedin the following paragraphs.

Simple pneumothorax: It refers to a non-complex lesion that contains air

within the pleural cavity, non-progressive injury, usually secondary to rib

fractures or bronchial ruptures that produces a small pulmonary collapse.

Typically is a non-life-threatening damage and most patients are

hemodynamically stable, with reduced respiratory sounds, thoracic hyper

resonance to percussion, with or without hypoxia.

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Tension pneumothorax: In contrast with previous injury, these patients are in

extreme risk of death if a pleural catheter is not inserted immediately. It

pertains to a unidirectional valve effect that does not allow the interpleural air

outflow which has been accumulating to the point of becoming hypertensive,

creating severe collapsed lung, with dangerous contralateral deviation of the

mediastinal organs. There is a reduction in venous return.

Hemothorax: It refers to a blood accumulation in the pleural cavity, usually

secondary to rib fractures that damage venous vessel, pulmonary trauma and

rarely by arterial injury. The clinical diagnosis is similar to that of

pneumothorax, it differs in the mate sound at percussive maneuver instead of

hyper sonority, respiratory sounds are diminishing or abolish.

Pulmonary contusion: This is a serious, life-threatening injury. It can happen

in the absence of rib fracture sorflail chest, especially in young people whodo

not have fully ossified ribs. Respiratory failure may develop immediately. It

should be suspected in patients with blunt trauma who have SaO2 ˂90%,

PaO2˂65 torr with in the first hour after trauma.

Signs and symptoms

Symptoms include pain, which usually worsens with breathing if the chest wall

is injured, and sometimes shortness of breath.

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Common findings include chest tenderness, ecchymoses, and respiratory

distress; hypotension or shock may be present.

Neck vein distention can occur in tension pneumothorax or cardiac tamponade

if patients have sufficient intravascular volume.

Decreased breath sounds can result from pneumothorax or hemothorax;

percussion over the affected areas is dull with hemothorax and hyperresonant

with pneumothorax.

The trachea can deviate away from the side of a tension pneumothorax.

In flail chest, a segment of the chest wall moves paradoxically—that is, in the

opposite direction from the rest of the chest wall (outward during expiration

and inward during inspiration); the flail segment is often palpable.

Subcutaneous emphysema causes a crackling or crunch when palpated.

Findings may be localized to a small area or involve a large portion of the chest

wall and/or extend to the neck. Most often, pneumothorax is the cause; when

extensive, injury to the tracheobronchial tree or upper airway should be

considered. Air in the mediastinum may produce a characteristic crunching

sound synchronous with the heartbeat (Hamman sign or Hamman crunch).

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Hamman sign suggests pneumomediastinum and often tracheobronchial tree

injury or, rarely, esophageal injury (LoCicero and Mattox (2019).

Systemic effects of chest trauma

After the in the initial phase of thoracic trauma there are systemic

complications facilitating to rapid evolution like ARDS, ventilator-associated

pneumonia, pulmonary embolism and multiple organ failure. Blunt chest

trauma significantly increases the need for ventilatory support and ICU stay

time, when compared with non-chest trauma. It has been shown that unilateral

lung contusion has a mortality of 25%, when both lungs are contused this

mortality rate increased up to 38%, and reaches 50% if pneumothorax is

present. The severity of pulmonary contusion correlates with the incidence of

ARDS, especially when more than 20% has been injured. Pneumonia

secondary to chest trauma has an incidence of 5 to 40 %, and in some places is

the first cause of death. This can be facilitated by hypoventilation induced by

pain, atelectasis, and prolonged mechanical ventilation. Localimmune

mechanisms play an important role in infections, as has been demonstrated both

in animals and humans, who injured lungs experience acytokine-mediated

inflammatory response which is stronger than the systemic inflammatory

response. In experimental animals has been found that the injured lung
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parenchyma is an important source of proinflammatory mediators that

accumulate both in the bronchoalveolar fluid and lung tissue (Fröhlich Lefering

and Probst 2014).

While it is difficult to separate the general inflammatory response of

thoracictrauma from the local response of the lung damage, it is known that the

lung parenchyma has a very important role in the inflammatory response and

infectious complications. Lung trauma affects gas exchange; early damage of

the endothelial membrane increases the thickness of the capillary-alveolar wall

which negatively affects gas Exchange with increased intrapulmonary shunt

causing hypoxemia, which coupled with the low cardiac output and bleeding

anemia, are factors that favor persistence of shock and its consequences,

including death [43]. Experimentally, it has been seen that briefly postrauma

chest hiperoxia attenuates the local and systemic inflammatory response, which

promotes regeneration of injured tissues, especially associated bone fractures

(Byun, and Kim 2013).

Diagnostics

While chest radiography prevails, it does have limitations. Since chest

radiography is achieved in the supine position, small and medium-sized

pneumothoraces and hemothoraces may be missed (Marasco and Lee, 2014)

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The extended-Focused Assessment with Sonography in Trauma (eFAST) may

be done with the primary survey, especially in the unstable patient. This can

help quickly identify places with air and or blood and direct, definitive

management. Compared to supine chest radiography, bedside eFAST is more

sensitive to evaluate for pneumothorax.

The 4 views of the traditional Focused Assessment with Sonography in Trauma

(FAST) exam include the cardiac (subxiphoid) window, right upper quadrant

(RUQ, or Morrison’s pouch), left upper quadrant (LUQ), and suprapubic

(bladder) window. The presence of a black collection outside of an organ,

viscera, or pericardia suggests a +FAST exam (Recinos., Inaba, Dubose, and

Barmparas, Teixeira, 2009).

The EFAST includes pulmonary views to evaluate for pneumothorax and

hemothorax, in addition to the traditional four views. eFAST should be started

in the area where there is the highest suspicion for injury. If the thorax is of

concern, then this is where the eFAST should begin. This includes anterior

chest wall evaluation between ribs for pneumothorax and looking for the

continuation of the spinal stripe caudal to the diaphragm in the RUQ and LUQ

windows to evaluate for hemothorax. The spinal stripe can be present in cases
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of pleural effusion. Similar to a positive FAST exam, any presence of fluid in

the trauma patient is assumed to be blood.

Computed tomography (CT) is more sensitive and specific. However, this

requires the patient to be stable enough for transport.

Other adjuncts include endoscopy, bronchoscopy, and electrocardiography to

complete evaluation when warranted.

Treatment / Management

Once the ABCs (airway, breathing, circulation) have been addressed, injury-

specific interventions should be undertaken.

Immediate life-threatening injuries require prompt intervention, such as

emergent tube thoracostomy for large pneumothoraces, and initial management

of hemothorax. For cases of hemothorax, adequate drainage is imperative to

prevent retained hemothorax. Retained hemothorax can lead to empyema

requiring video-assisted thoracoscopic surgery (Oyetunji, and Jackson 2013).

The majority of thoracic trauma can be managed non-operatively. However,

operative management should not be delayed when appropriate. Operative

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exploration of thoracic injuries should be considered if tube thoracostomy

drainage exceeds 1000-1500mL immediately, about 200 mL per hour for 2 to 4

hours, or ongoing resuscitation (blood transfusion, persistent hypotension) with

no other discernable cause (Vana and Neubauer, 2014).

Admission

Minor injuries may simply require close monitoring and pain control. Care

should be taken in the young and the elderly. Patients with 3 or more rib

fractures, a flail segment, and any number of rib fractures with pulmonary

contusions, hemopneumothorax, hypoxia, or pre-existing pulmonary disease

should be monitored at an advanced level of care (Dehghan, and Mestral,

2014).

Pain Control

Pain control greatly affects mortality and morbidity in patients with chest

trauma. Pain leads to splints which worsen or prevent healing. In many cases,

can lead to pneumonia. Early analgesia should be considered to decrease

splinting.  In the acute setting, push doses of short-acting narcotics should be

used.
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Other pain control options include interpleural nerve blocks, transdermal

patches, intravenous patient control analgesia (PCA), and epidural analgesia.

Nonnarcotic transdermal patches are safe pain management options for many

patients. It should be considered for patients with persistent chest wall pain

despite lack of confirmed rib fractures, the patient's being discharged, or as an

adjunct while admitted (Pettiford, and Luketich 2017).

Antibiotics

Prophylactic antibiotics administration for tube thoracostomy for blunt thoracic

trauma did not reduce the incidence of empyema or pneumonia when placed

with sterile technique. It should be considered in cases of grossly contaminated

wounds, or in cases where the sterile technique was broken.

Operative Management of Rib Fractures

Open reduction and internal fixation (ORIF) has been shown to decrease

mortality in patients with flail chest, shorten the duration of mechanical

ventilation, reduce hospital length of stay, and reduce intensive care length of

stay.
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Nurse management

Nursing management of a patient with Acute Respiratory Failure using nursing

processes

The key role of the nurse is to identify the patents as high risk for Acute

Respiratory Failure in all patients

Nursing management using the nursing process e.g. nursing assessment,

nursing diagnosis, planning, implementation and evaluation

Nursing assessment for chest trauma

Nursing diagnosis-1: Ineffective breathing pattern 

Expected outcomes

The patient takes relaxed breathing at a normal rate and depth. There is the

absence of dyspnea and blood gas analysis shows normal parameters. 

The patient verbalizes his/her comfort without any sign of dyspnea. 

Nursing care plane for chest trauma

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Date Diagnosis Objectives plan Nursing intervention Rational on scientific principle Evaluation
Impaired gas Assess the rate, Reassure the patient and Change in rate and depth of respiration Take cardiac output
exchange related to rhythm, and depth of reduce the anxiety during is the early sign of respiratory measurements after a change in
Decreased lung respiration acute episodes of respiratory difficulty. positive pressure ventilation.
compliance, Low distress.
amount of
surfactant,
Increased breathing
rate, Any primary
medical problem
Check for the use of Check for the use of Provide proper position to the When lung compliance decreases, it Check vital signs and level of
accessory muscles. accessory muscles. client. A prone position is impacts the work of breathing and it consciousness in each half an
recommended. increases significantly. hour with changes in positive
pressure ventilation and inotrope
administration.
Assess the breath Assess the breath Schedule daily activities in An increase in pulmonary oedema Check peripheral pulses,
sound of the lungs. sound of the lungs. such a way that it will provide cause fluid to move into alveoli, as a capillary refill and skin
rest periods between result, a crackles sound is heard. temperature.
activities.
Check for any sign Check for any sign of Maintain oxygen saturation at Dyspnea causes an increase in anxiety Check the fluid balance by
of dyspnea. dyspnea. 90% or above. in the patient. Anxiety leads to increase maintaining an intake output
oxygen demand of the body and chart, and taking the daily
breathing pattern is altered. weight of the patient.
Assess for any sign Assess for any sign of Administer medications Bluish discolourisation of the tongue, Administer drugs as per
of cyanosis. cyanosis. according to the physician’s mucus membrane and skin indicates a physicians prescription and
prescriptions. (e.g., decrease in oxygen concentration in the observe for the response of the
antibiotics, bronchodilators, blood. drug.
steroids, and antianxiety
medications).
Check oxygen Check oxygen Do suction if required. Pulse oxymetry and ABG analysis help Administer fluid to maintain
concentration in concentration in pulse to interpret the current oxygen status in fluid status.
pulse oximeter and oximeter and do an the blood. In ARDS, oxygen saturation
do an arterial blood arterial blood gas decreases.
gas analysis. analysis.
Assess for any Check for the energy All the team members who An increase in pulmonary oedema and Check the ventilator setting.
cough]tcykf. level of the patient. are involved in the care of the fibrin build up stimulate cough reflex Ensure the alarms of the
patient must be informed and it leads to an increase in cough. ventilator are on.
about the patients respiratory
status.
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Conclusion

The trauma of the chest is a disease that has worsened due to the modernity

that means worldwide increases in violence and accidents. This is a serious

condition, which often multifaceted growing involves other anatomical

regions that merit simultaneous treatment. Ideal management should be

multidisciplinary and ideally start before their arrival at the hospital and

maintain it during transport, in the emergency room, the operating room and

then in ICU. Early diagnosis and early aggressive management are the key to

bring down morbidity and mortality. The anesthesiologist has a vital role in

the management of these patients throughout the perioperative period.

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References

World Health Organization (WHO) (2010) Injuries and violence: the facts.
Geneva, Switzerland: WHO.

Lecky FE, Bouamra O. (2010) Epidemiology of polytrauma. In: Pape HC et al.

(Eds.), Damage control management in the polytrauma patient. Springer Sc. LLC,
pp. 13-23.

McQueen KA, Hagberg C, McCunn M (2014) The Global trauma burden and
anesthesia needs in low and middle income countries. Am Soc Anesth 78(6): 16-
19.

Huber S, Biberthaler P and Delhey P, (2014) Predictors of poor outcomes after

significant chest trauma in multiply injured patients: a retrospective analysis from
the German Trauma Registry (Trauma Register GU®). Scand J Trauma Resusc
Emerg Med 22(1): 52.

Battle CE, Hutchings H, and Evans PA (2014) Risk factors that predict mortality in
patients with blunt chest wall trauma: a systematic review and meta-analysis.
Injury 43(1): 8-17.

Battle CE, and Evans PA (2015) Predictors of mortality in patients with flail chest:
a systematic review. Emerg Med J 204939.

LoCicero J, and Mattox K.L. (2019). Epidemiology of chest trauma. Surg Clin
North Amer 69(1): 15-19.

Fröhlich M, Lefering and Probst C. (2014). Epidemiology and risk factors of

multiple-organ failure after multiple trauma: an analysis of 31,154 patients from
the Trauma Register DGU. J Trauma Acute Care Surg 76(4): 921-927.

Byun JH, and Kim H.Y (2013). Factors affecting pneumonia occurring to patients
with multiple rib fractures. Korean J Thorac Cardiovasc Surg 46(2): 130-134.

Marasco and Lee G, M (2014). Quality of life after major trauma with multiple rib
fractures. Injury 46(1): 61-65.

Recinos G, Inaba K, Dubose J, Barmparas G, Teixeira PG, et al. (2009)

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Epidemiology of sternal fractures. Am Surg 75(5): 401-404.

Oyetunji TA, and Jackson H.T. (2013) Associated injuries in traumatic sternal
fractures: a review of the National Trauma Data Bank. Am Surg 79(7): 702-705.

Vana PG and Neubauer, D.C. (2014) Contemporary management of flail chest.

Am Surg 80(6): 527-535.

Dehghan N, and Mestral C, (2014) Flail chest injuries: a review of outcomes and
treatment practices from the National Trauma Data Bank. J Trauma Acute Care
Surg 76(2): 462-468.

Pettiford B.L, and Luketich J.D, (2017). The management of flail chest. Thorac
Surg Clin 17(1): 25-33.