Blunt Thoracic Trauma

Hey everyone. So today we’re going to get into blunt thoracic trauma. This is all about what we cannot see.

This is very true, thoracic injuries run the gamut from simple to absolute insanity.  Now I know in the trauma survey lesson we talked about how we can care for our patient without a history. That’s true. But the fact is, that a good history will help to guide us not only in our diagnosis, but our treatment as well.

We are going to talk about a number of injuries that result from blunt thoracic trauma. Some of them I am mentioning in this unit but we will go more in depth in later units. Things like a diaphragmatic rupture can actually be in 4 different units, both thoracic and abdominal, but we will get into that. In fact, some of these are even found in our med-surg units, so if you have a chance, check them out.  So….let’s not waste any more time guys and dive right in.

When it comes to trauma, our assessments are pretty much always the same. We do our ABC’s. We look listen and feel. We trend our vital signs and we send our patients to radiology (or we bring radiology to us in some cases). If we get a good history, maybe we look a little more at that area. If i know our guy was hit in the chest, i might not focus on his feet first. I won’t forget his feet, but they just won’t be first on my list.

We all know what a contusion is, right. Well we can actually get them on our lungs. Just like the black and blue on our skin, we get bruises on the lung. This is usually due to a rapid deceleration, like from a motor vehicle collision, or some other sort of blunt impact to the chest.

This is usually on the less serious side of things we might see, but depending on the severity, we might have to intubate these patients. If a simple contusion is their only concerning injury, we might just put them on a non-rebreather and keep their O2 between 94 and 98%.

So just like a bruise to the lung, you can also get a contusion to the heart due to a direct cardiac impact. This is also known as a blunt cardiac injury. The treatment for this type of injury is usually just monitoring. This is done with Serial EKG’s and maybe chest X-rays.

Rib fractures and flail chest. So when it comes to rib fractures, our treatment really depends on the severity and location of the fracture. a single hairline fracture at fib 9 or 10 will require a much different course of treatment than compound fractures of ribs 1,2 and 3. And if you are wondering why, just picture the anatomy that lies under each rib. Up top, heart, lungs, great vessels, trachea, esophagus. Down low….well, really low, not too much. I mean the base of the lungs, and the diaphragm. Understand?

When we get a series of rib fractures, usually multiple rib fractures in 2 or more places, we call this a flail segment, or flail chest. This is basically a floating section of ribs. Obviously not something we want, especially if we are near the lungs. Flail chest is where we could also see that paradoxical chest movement. Remember, the two sides of the chest going in opposite directions. Trust me, first time you see this you will never forget what it looks like.

So when it comes to treatment, the severity is key. Simple rib fractures can get some analgesics, some basic monitoring, some o2 and usually a same day discharge. Multiple fractures, and flail segments can require surgical interventions, and a procedure called rib plating, which is exactly what it sounds like. Trust me, google rib plating. actually wait….google rib plating and your going to get menu pictures from bar-b-que joint. May google surgical rib fracture repair. yea, that might work better.

Tracheobronchial injuries are just that, injuries or tears to the trachea or bronchus. Obviously tears in these areas are going to cause issues with both airway and breathing so securing an airway becomes our number one priority.

These type of injuries are where we might commonly see a phenomenon called subcutaneous emphysema. This is when air that is leaking from somewhere gets trapped in the tissues under the skin. It looks and feels like popcorn, or like really small bubble wrap. It is a very bad sign and you usually find it as you are packing up your guy for the OR. In actuality i say that because if your patient has an injury bad enough to cause subq emphysema, is bet my paycheck he is going to need surgery.

If you look here you can see how the trachea sits in the middle of neck. If we have a tear here you can see how the air will escape into the neck and cause some swelling. When the air gets between the tissue under the skin, we get that popcorn feeling.

Pneumothorax and hemothorax. Both of these involve something that should not be in the chest, being in the chest. Pneumo means air in the pleural space. Hemo means…..yes blood in the pleural space. Neither of these are good and both can cause partial or complete lung collapse. Just think of the air pressure building up or the blood that can accumulate. In blunt trauma, there may not be any exit of the air or blood so it’s just going to start crushing things. You can see in the picture above, how the lung on our right is significantly smaller than the left. It is being compressed by air.

Treatment here is based on severity. Simple pnuemo and hemo can be watched. Patient is probably going to be admitted for serial blood work and radiology but my not require any interventions. The docs in those cases hoping the issues will heal themselves. More severe cases need several things. In a severe pneumo, a first line treatment could be a needle decompression. This is the insertion of a 14g needle between the 2 and 3 rib, midclavicular line in an effort to let air escape the pleural cavity. While the ENA endorses ER nurses to perform this skill, it is facility specific, so check with your educators or management to see if you can do it.

For both pneumo and hemo, a definitive line of treatment is the chest tube. This is a closed suction and drainage system that allows the release of air and fluids while maintaining proper pressure in the chest cavity. While we can not insert the tube, it is our responsibility to assist with setting it up and monitoring it once in place. 

A thoracotomy is when we literally cut the patients chest open to get to the stuff in the chest cavity. We will talk about thoracotomies more when we talk about penetrating traumas.

So a pericardial tamponade is cause by some sort of bleeding from the heart itself. However, the pericardial sac has not been punctured, so the blood that is coming from the heart has nowhere to go. Because of this, the pericardium fills with blood and starts to compress the heart. Delay treatment here and our patient will go into obstructive shock. A failure of the heart to pump correctly secondary to compression.

To treat this, we need to remove the blood from the pericardium. We do that with a procedure called pericardiocentesis. We stick a large needle through the chest and right into the pericardium and withdraw the blood. This in and of itself will correct the tamponade, but we will have to worry about the leaking heart. Our trauma docs may perform a procedure called a pericardial window which is just what it sounds like. Cutting a hole in the chest to visualise the heart, locate the problem and fix it.

An aortic disruption is any tear or separation in the aorta. Now if you think about how much blood the aorta carries and where it goes, you know how severe an injury this is. These patients can bleed out very fast with a true separation or dissection and require massive transfusions and surgery.

One sign of a true dissection is significant differences in pulses in the upper and lower extremities. Oh yea, and if the guys legs are turning blue, probably a good sign that he isn’t getting any blood down there.

Yup…this is exactly what it sound like. The force of whatever trauma they underwent cause the heart basically to open up. Their heart has ruptured. If somehow they manage to live long enough to survive transport to the trauma center, these guys need immediate surgical care. This is the case on ER or Grey’s Anatomy when you hear the doc say he has his finger in the guys heart. Not common, but it does happen.

We will talk more about this in our abdominal units, but for now know that it is something to think about when dealing with thoracic trauma as the contents of the abdominal cavity can come through the diaphragm into the thoracic cavity.

These patients are headed to the OR

Alright guys, blunt trauma requires us to use our clinical judgement as we cant see many of the injuries. A lot of the procedures we talked about are all evidenced based as is much of current trauma care. And as always in chest trauma, we always have to keep that O2 sat in mind.

So, never forget the basics guys…Airway, breathing and circulation

Just because you cant see blood, does not mean your guy isn’t bleeding. You have to look for other signs.

In a true trauma we want to try to get as much info as possible about what happened to our patient.

With any trauma to the chest, we always have to keep concurrent injuries in mind. If the ribs are fractured, are the lungs involved, or the great vessels. Always think if one injury can lead to another.

And in the trauma bay, use your tools. FAST, CT’s X-rays, whatever you may have in order to help diagnose.

So thanks again for joining us on our trauma journey, and as always

Happy nursing!