Medical and Nursing Management of Chest Trauma

I. Definition

Injury to the chest wall or lungs can interfere with inspiration, gas exchange or expiration. Types of injuries include:

• Blunt chest trauma results from sudden compression or positive pressure inflicted to the chest wall.
• Penetrating trauma occurs when a foreign object penetrates the chest wall.
• Hemothorax (blood in the pleural space)
• Tension pneumothorax (air in the pleural space)
• Open pneumothorax (a sucking chest wound)

II. Risk Factors

• Hemothorax results from penetrating or blunt chest injury.
• Tension pneumothorax can result from disease or injury, most commonly from laceration of the lung parenchyma, tracheonbronchial tree or esophagus.
• Open pneumothorax most commonly results from penetrating chest injury.

III. Pathophysiology

• Hemothorax. The blood in the pleural cavity compresses the lungs and can produce blood loss, resulting in shock.
• Tension pneumothorax is considered a medical emergency. Pressure in the pleural space compromises ventilation and can lead to lung collapse, decreased ventilation in the other lung, and decreased venous return to the heart, known as a mediastinal shift.
• Open pneumothorax, an acutely life-threatening condition, involves an opening in the chest wall large enough to allow air passage into and out of the chest cavity with each attempted respiration; the rush of air produces a characteristic “sucking” sound. Tidal volume diminishes, and ventilation is compromised.

IV. Assessment/Clinical Manifestations/Signs and Symptoms

• Dyspnea
• Tachypnea, tachycardia
• Pain on breathing on affected side
• Rapid development of cyanosis
• Asymmetric chest movement
• Absent breath sounds on affected area
• Hypotension progressing to shock (hemothorax)
• The electrocardiogram may reveal cardiac arrhythmias
• Chest x-rays will reveal the size and type of injury

V. Medical Management

The goals of treatment are to evaluate the patient’s condition and to initiate aggressive resuscitation. An airway is immediately established with oxygen support and in some cases intubation and ventilatory support.

Reestablishing fluid volume and negative intrapleural pressure and drainage intrapleural fluid and blood are essential

Strategies to restore and maintain cardiopulmonary function include:
• Ensuring adequate airway and ventilation
• Stabilizing and reestablishing chest wall integrity
• Occluding any opening into the chest
• Draining or removing any air of fluid

VI. Nursing Diagnosis

• Impaired gas exchange
• Acute pain

VI. Nursing Management

Provide emergency care
• Establish and maintain a patent airway by suctioning and endotracheal intubation as appropriate.
• Control hemorrhage. Treat damage to chest and other injured structures.
• Stabilize the chest wall if necessary.
• As ordered, assist with insertion of a chest tube, and maintain a closed drainage system.

• Promote measures to maintain adequate chest tube drainage. Assess the chest tube insertion site for crepitus and bleeding. Assess tubing for kinks, clots, or dependent loops. Assess the drainage chamber for color, consistency, and amount of drainage. Assess water-seal chamber for fluctuation “tidaling” with inspiration and expiration. Assess suction chamber for gentle bubbling.
• Promote coping. Providing emotional support to reduce anxiety and fear.

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