Page 660 - ACCCN's Critical Care Nursing

Trauma Management 637

TABLE 23.6 Clinical manifestations of chest trauma

System Manifestation Clinical signs and symptoms
Respiratory Any sign of respiratory compromise, noting Abnormal respiratory rate (<12 or >20 breaths/min)
l Airways that serial observations are an important Abnormal chest wall movement, including asymmetrical
l Lungs indicator of imminent decompensation chest wall expansion
l Diaphragm Reduced breath sounds
Obstructed airway
Hypoxia (<94%)
Hypercarbia
Apnoea
Dyspnoea
Orthopnoea
Crepitus/surgical emphysema
Cardiovascular Circulatory insufficiency resulting in decreased Abnormal heart rate (<60 or >100 beats/min)
l Heart tissue perfusion Dysrhythmia
l Great vessels In severe cases, Pulseless Electrical Activity (see Ch. 8)
Pulsus alternans
Decreased cardiac output
Lowered blood pressure (systolic <100 mm Hg)
Reduced peripheral perfusion
Confusion and reduced consciousness level
Gastrointestinal Perforation and contamination of mediastinum Crepitus
l Oesophageal rupture Haemopneumothorax
Pain
Cough
Stridor
Bleeding
Sepsis (late)
Systemic May occur in response to injury of a vessel that Varied depending on location, but may include:
l Air embolism traverses an air space; manifestations will l Focal neurological sign
vary depending on location and associated l Cardiac deterioration
injuries

Independent practice: positioning
Early mobilisation of the patient with chest trauma is
vital to prevent the complications of prolonged bedrest
and immobility. Patients should be nursed side-to-side
and in a variety of positions, including sitting upright.
The extent to which the patient can be mobilised is
dependent on other injuries. Patients should be mobil-
ised to sit out of bed as soon as they are conscious and
their injuries permit.
Care must be taken to accommodate the increased work
of breathing that is associated with injuries to the lungs.
Appropriate use of supplemental oxygen will assist the
patient’s exercise tolerance. Further, if the patient is
mechanically ventilated, additional mechanical support
(i.e. transient increase in pressure support) may be
applied to assist the patient’s exercise tolerance. Being
unable to catch their breath is a terrifying experience that
is likely to result in increased levels of anxiety for patients,
FIGURE 23.5 Right tension pneumothorax (Courtesy The Alfred, and should be avoided wherever possible.
Melbourne).

Independent practice: pain relief
Practice tip
The principles of managing pain in chest trauma patients
Unexplained hypotension in a patient with chest trauma may are similar to those for other patients, although the
indicate a tension pneumothorax; an urgent chest X-ray is potential severity of pain, particularly as a result of frac-
required for diagnosis. tured ribs, should not be underestimated. Effective pain
management in the chest trauma patient is a major