Page 659 - ACCCN's Critical Care Nursing

636 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Chest trauma includes: side of the heart is most commonly injured, probably
as a result of the anterior placement of this side of the
l rib fractures: a very common form of chest trauma, heart in the thorax.
often a source of severe pain and often associated with l aortic injuries: generally, injuries to the brachioce-
other injuries such as haemothorax, pneumothorax phalic, left subclavian or right subclavian branches of
and pulmonary contusion. 57 the aorta and associated with high mortality at the
l flail chest: fractures to two or more ribs, in two or scene. 57
more places, resulting in a freely-moving section of l tracheobronchial injuries: tend to occur as a result of
the rib cage. Usually such fractures occur in the ante- direct blunt trauma and in close proximity to the
rior or lateral sections of the rib cage, where there is carina, but are relatively rare. 60
less muscle protection. The significant impact of this
injury is paradoxical movement of the flail segment Clinical Manifestations
during spontaneous ventilation, so that when a patient
inspires, the flail segment moves inwards with the Injuries to the thoracic cavity can manifest according to
negative intrapleural pressure instead of expanding the structures and systems involved (see Table 23.6).
with the rib cage. Compromised respiratory function When multiple organs and systems are involved, the com-
is caused by the increased work of breathing that this bined injuries pose an increased threat to life.
ineffective flail segment creates, as well as the con-
tused lung that normally occurs underneath the flail Nursing Practice
segment. 57 Given the underlying structures of heart, lungs and great
l diaphragmatic injuries: generally consist of diaphrag- vessels, chest trauma can cause rapid deterioration in the
matic rupture when there has been a significant rise in patient. Ongoing and thorough assessment, particularly
intra-abdominal pressure, usually with compression in relation to the signs and symptoms outlined in Table
injuries. When the rupture is sufficiently large, protru- 23.6, is essential. Other essential aspects of care include
sion of the abdominal contents into the thoracic patient positioning and management of pain relief.
space, resulting in respiratory compromise, is likely. 58
l pulmonary contusion: consists of bruising to the lung Independent practice: assessment
tissue, usually as a result of mechanical force. This Initial assessment in the emergency department should
bruising is followed by diffuse haemorrhage and inter- be conducted on an ongoing basis, with formal docu-
stitial and alveolar oedema, resulting in impaired gas mentation of these findings occurring every few minutes
exchange. 57,59 until stabilisation. The frequency of ongoing assessment
l pneumothorax: the accumulation of air in the pleural will then be based on the patient’s condition, but is likely
space. A pneumothorax may be closed (no contact to be needed every 15 minutes initially, reducing to
with the external atmosphere) or open (a communi- hourly with transfer to the critical care unit. Signs of chest
57
cating channel with the atmosphere). Closed pneu- trauma that represent life-threatening emergencies
mothoraces are generally caused by blunt chest trauma include the following.
and result from a fractured rib puncturing the lung
parenchyma. Open pneumothoraces generally occur l Cardiac tamponade: as blood collects in the pericar-
in the setting of penetrating trauma, where air is able dium, the venous return to the heart is impeded,
to move from the external atmosphere to the pleural resulting in reduced cardiac output. Signs of cardiac
space during inspiration. If not all of the inspired air tamponade include:
is able to escape during expiration, due to a tissue flap l elevated heart rate
or similar obstruction covering the opening, the l reducing pulse pressure, with falling systolic BP
volume of the pneumothorax will gradually expand and rising diastolic BP
and cause collapse of the adjacent lung, with resultant l increased preload (CVP and/or PCWP)
hypoxaemia. Where air is not able to escape at all from l distended neck veins
the pleural space, this is referred to as a tension pneu- l signs of reduced cardiac output, including lower
mothorax, and rapidly becomes a life-threatening level of consciousness, poor peripheral perfusion
event due to the increasing pressure on the lungs, and reduced urine output.
heart and trachea. l Tension pneumothorax: the lung or lungs collapse as
l haemothorax: the accumulation of blood in the the pleural space fills with air that cannot escape (see
pleural space. Blood may collect from the chest wall, Figure 23.5). As the volume of air grows with each
57
the lung parenchyma or major thoracic vessels. breath, the thoracic cavity contents are compressed or
Breath sounds are usually reduced on the side of the pushed against the opposite side of the chest. Signs of
haemothorax. Small haemothoraces (<200 mL blood) tension pneumothorax include:
may not be apparent on clinical or radiological inves- l elevated heart rate
tigation, although respiratory compromise is likely to l increased respiratory rate
be present. l decreased air entry, particularly over the affected
l cardiac trauma: encompasses a number of different lung
injuries, ranging from relatively mild bruising of the l tracheal deviation
heart muscle to rupture of the heart wall, septum or l distended neck veins
57
valves or damage to the coronary arteries. The right l surgical emphysema.