Chapter : Chest Trauma

5 Contact Hours

Author: Jassin M. Jouri Jr., MD

Learning objectives

ŠŠ Describe the common etiology of chest trauma. ŠŠ Describe diagnosis strategies for blunt chest injuries. ŠŠ Explain the pathophysiology of chest trauma. ŠŠ Identify common treatments for blunt chest injuries. ŠŠ List common injuries to the chest wall. ŠŠ Explain common treatment strategies for penetrating chest injuries. ŠŠ Identify common types of pulmonary and pleural space injuries. ŠŠ Describe recovery procedures for chest injuries. ŠŠ Recognize the impact of chest trauma on the tracheobronchial ŠŠ Identify the most common cause of penetrating chest injuries. region. ŠŠ Explain pain management strategies for chest injuries. ŠŠ Define common types of cardiac injury. ŠŠ Describe the purpose of intubation and ventilation in patients with ŠŠ Identify the two categories of chest injury. cardiac injury. ŠŠ Recognize the visual signs of a blunt chest injury.

Introduction

Chest trauma is ranked 3rd highest cause of morbidity and mortality positive pressure imposed on the chest wall. [13] These are typically in the USA after head and extremity trauma. [2] An accident or caused by accidents and fall injury. Blunt injury can affect all the areas premeditated penetration of a foreign object into the chest is the usual of the chest wall, thoracic cage and its contents. These components cause of chest trauma or injury. This type of injury may further result may range from the bony structures like ribs, clavicles, scapulae, and in bruises, fracture of ribs or severe injury to the chest wall such as sternum and viscera like lungs and pleurae, trachea-bronchial tree, lung or heart contusions. Furthermore, major chest trauma may occur esophagus, heart, great vascular structures, and the diaphragm. [2] alone or in combination with multiple other injuries. [1] Here we While on the other hand, when a foreign object breaks through the have discussed the approach to chest trauma in detail to get complete chest wall, Penetrating trauma occurs. It usually enters the tissue of understanding in terms of etiopathology, various types of injuries and the body, creating an open wound. Stabbing, gunshot wound, arrow their effective management. through the heart and such, are the major cause of penetrating trauma, Chest traumas are classified into two types: blunt or penetrating [5] [13] which will be further discussed. trauma. Blunt chest trauma occurs due to sudden compression or

I.ETIOLOGY

A. Motor vehicle accidents

By far, the most vital cause of major blunt chest trauma is motor over a short distance, or what we called deceleration, are the cause vehicle accidents (MVAs). [2] Due to the increasing occurrence of motor vehicle accidents. Severity of the injury depends on energy of traffic and vehicular accidents, blunt chest injuries are the most transferred during deceleration as a result of the crash. Motor vehicle common problems in civil practice. Motor vehicular accidents report accidents accounts for half of the death, usually with unintentional for 70-80% of such injuries. According to statistics from Peitzman’s causes, and the risk of having major injury incidence can increase from The Trauma Manual, motor vehicle accidents are the leading cause 300% to 500% if the victim is ejected from the vehicle. [1] of injury death, accounting for 44, 800 deaths in 2003 or 15.4 deaths One of the determinants of injury caused by motor vehicle accidents is in 100,000 populations. Over 3.5 million sustained nonfatal injuries by magnitude of force, or the strength or measurement of the amount secondary to motor vehicle crashes in 2003. Despite these, the death of an applied force, equals to mass times acceleration (force=mass x rate per vehicle miles traveled (VMT) has gradually declined over a acceleration). [1] Although the body tries to stand still after it hits an period of century from 18 deaths per 100 million per VMT in 1925 to object, the internal organs continue to move until they hit something, approximately 5 per 100 million VMT in 1960 to as low as 1.56 per such as the lungs hit the ribs, or the heart strikes the sternum, or the 100 million VMT in 2003. In the 2005 National Trauma Data Bank aorta presses against the spine. All of these adverse events following (NTDB), motor vehicle crashes accounted for 43.1% of cases and 47% accidents lead to contusion, bleeding, and rupture within the thoracic of mortalities. Motor vehicle crash-related deaths occurred in 4.9% of cage. We can also determine the extent of injury by the location of NTDB cases. [1] the victim from the vehicle. It depends where the victim was seated, Incidence of different vehicular collisions, or accidents that happened in the front seat or the back, or he or she was the passenger in the with pedestrians are reported almost every day. These kinds of mishaps vehicle, or the driver itself. Furthermore, vehicle restraint devices frequently cause a person’s injury, mild to severe cases, and even are also identified for the extent of damages to the victim, may it worse, death. Injuries that are produced by a rapid decrease in velocity be used or not, or the kind of restraint that are worn or applied. Of

Nursing.EliteCME.com Page 1 course, it is obvious that injuries to the unrestrained are at greatest twice the mortality of frontal impacts, causing the occupant to project risk. On the other hand, the use of Lap belts may reduce injury by to the next compartment. Meanwhile, rear-end impact collisions do 50%, that should be worn correctly (designed to fit across the pelvis). not usually cause severe injury, but a usual extension-flexion injury is Meanwhile, optimal protection can be provided when three-port common. [1] constraints plus airbags are used, especially applicable in front-end Motorcycle vehicles are at more risk in accidents, with the fact that collisions. Still with the use of the three-point restraint, secondary the driver usually absorbs the impact and the associated kinetic collision of the occupant with the vehicle is reduced. Ejection is also energy, though the majority of deaths are because of cranial injuries, prevented and mortality is substantially decreased, though with the use and extremity fractures are much more common. In the meantime, of these restraints, injury to the extremities are not prevented. On the pedestrian-automobile incidents are accountable for two percent of other hand, the use of shoulder belts that are worn but without the lap the injuries, but they still account for the 13% of the traffic-related component may associate with multiple vascular injuries that include deaths. Six percent holds the prevalence of trauma to the torso internal damage or thrombosis of major arteries. [1] (including chest, abdomen and pelvis), though musculoskeletal and As stated earlier, there is greater damage and injury to a victim that is intra-abdominal injuries are more common. Children, elderly, and unrestrained. The majority of injuries in frontal crashes are the result intoxicated victims are more common in this kind of impact. [1] of impact in the steering wheel, windshield, dashboard or floorboards. With its frequent association with motor vehicle accidents, chest At least 46% causes the injury and trauma to the major thoracic area. trauma typically occurs in connection with injuries to other major On the other hand, thoracic and abdominal injuries are more prevalent systems like the head and abdomen. It is said that at least 86% of in a lateral crash. [1] Because of the limited space between the driver victims with thoracic injuries has involvement of one or more other and the colliding vehicle, it results to the direct impact between the bodily system. This is good enough to have an idea regarding the high vehicle and the occupant. Lateral impact collisions are associated with level of force involved in chest trauma.

B. Falls

There are a variety of definitions about falls, one of which differs from mostly occurs in children. These measurements are still not enough its origin. According to the World Health Organization, Fall is defined to highlight the impact of disabilities related to afall for elderly as an event which results in a person coming to rest inadvertently on people having fewer life years to lose. In addition to this, the elderly the ground or floor or other lower level, [3] while to Tinetti, Speechley, individuals who suffer a fall related disability are at a high risk for and Ginter, a fall in the non-hospitalized geriatric population is defined subsequent long-term care and hospitalization care. It is proven as “an event which results in a person coming to rest unintentionally globally that falls are one major public health problem. [3] on the ground or lower level, not as a result of a major intrinsic event Falls are classified into a variety of means. One of which is the use of (such as a stroke) or overwhelming hazard.”[3] Another definition by International Classification of Diseases published by the World Health Agostini, Baker, and Bogardus, which was adapted for the inpatient, Organization. [41] The code is widely used for the analysis of the acute, and long-term care areas to define it as “unintentionally coming general health situation of a particular population group. This includes to rest on the ground, floor, or other lower level, but not as a result the classification of disease and other health problems, depending of syncope or overwhelming external force.” Other meanings are on the incidence and nature that appear on the health record or death extensive and include falls related to intrinsic events such as syncope certificate of a victim. This helps in the monitoring of incidence, or stroke. Just like Nevitt’s definition of a fall is “falling all the way mortality and morbidity of a particular health problem. [41] Accidents, down to the floor or ground, or falling and hitting an object like a including fall-related injuries are also included in the International chair or stair.” Meanwhile, the American Nurses Association, National Classification of Diseases, 10th Revision, Clinical Modification Database of Nursing Quality Indicators (ANA–NDNQI) provides an (ICD-10-CM), since these incidences are also considered as a health all-inclusive definition of fall, stated as “An unplanned descent to the problem. Fall-related injury classifications fall on the categorization floor (or extension of the floor, e.g., trash can or other equipment) made in chapter 20 (W00-W19) [52]. In this classification, you can with or without injury.” These definitions may be resulted from an identify falls depending on their causes. Examples of codes include assortment of reasons, such as physiological or environmental reasons. fall from the same level from slipping, tripping, and stumbling (W01), [6] Other falls on the same level due to collision with, or pushing by, Fall-related injuries may be fatal, but most cases are non-fatal. Falls another person (W03), fall involving objects such as fall involving can be precipitated by two types of factors- intrinsic or extrinsic. The wheelchair (W05), fall involving bed (W06), fall involving chair preventing strategies can be planned after distinguishing these two (W07), and fall involving other furniture (W08). Fall from out of factors. As the name suggests the intrinsic factors have always some or through building and structure (W13), Diving or jumping into physiologic origin, and extrinsic factors have its precipitation from water causing injury other than drowning or submersion (W16), and some environmental conditions or other hazards. [6] unspecified falls (W19), was also included. [52] According to statistics from the World Health Organization, fall Generally, ICD-10-CM diagnoses for the related injured body part incidences are the second ranked cause of unintentional injury deaths, and characterizes fall-related injuries in the community, home care, after road traffic injuries, with an estimated 424,000 cases of fatal and long-term care areas. In contrast, incident reports in the acute care falls occurring every year. More than 80% of fall-related deaths occur setting use the following ANA–NDNQI fall-related injuries categories in low- and middle-income countries, the main regions involved are which are enumerated as: [6] Western Pacific and South East Asia, accounting for more than two 1. None indicates that the patient did not sustain an injury secondary thirds of these deaths. Death rates are noted highest among the elderly to the fall. individuals those who are more than 60 years of age, all over the 2. Minor indicates those injuries requiring a simple intervention. world. Though falls are said to be not fatal, there are approximately 3. Moderate indicates injuries requiring sutures or splints. 37.3 million falls. These numbers are severe enough to require 4. Major injuries are those that require surgery, casting, further medical attention and intervention each year. The largest morbidity examination (e.g., for a neurological injury). occurs in young adults aged between 15-29 years to elderly people 5. Death refers to those deaths that result from injuries sustained aged 65 years or older. Such falls are responsible for over 17 million from the fall. disability-adjusted life years (DALYs) lost, and approximately 40%

Page 2 Nursing.EliteCME.com On the other hand, according to Morse, inpatient falls are being and in these, fall incidence occurs. Another is the intrinsic quality of classified into three main categories. First is Accidental falls, which their surroundings environmental conditions with increasing levels occur due to extrinsic facto like certain environmental conditions of independence which encourage children to have challenging or situations. Anticipated physiologic falls is the second one which behaviors commonly termed as ‘risk taking behavior’. Other occur due to intrinsic physiologic factors, such as confusion; and the commonly cited risk factors are the inadequate parental supervision; third category is called unanticipated physiologic falls which occur interacting with poverty, single parenting, and certain kinds of due to sudden intrinsic events, such as new event of syncopal attack hazardous environments. Falls in children tend to be from balconies, or a major intrinsic event like stroke. By using this classification, windows, and trees and most frequently tend to occur in homes, Morse asserts that approximately 78 percent of the falls are related to followed by schoolyards and playgrounds. [4] anticipated physiologic events. This would help in early identification Gender is also a risk factor for fall incidence, and irrespective of and safety measures that can be rendered to prevent the fall. Careful age, sex or region of the people, both genders are almost at equal examination of each case of a fall along with research to identify risk of falls. Males are noted to be more likely to die from a fall in precursors to sudden intrinsic events, such as screening for early signs some countries, possibly defined greater burdens seen among them of syncopal events, will definitely be useful in early identification of may include higher levels of risk-taking behaviors and lifestyle, also anticipated physiologic falls, which will help to prevent more falls. [6] including hazards within occupations. While females, on the other All people who experience a fall are at high risk of injury. But still, hand, suffer more non-fatal falls. Elderly women and younger children varieties of factors affect the type and severity of injury. Amongst the are especially more prone to falls and increased severity of injury. most important, age is one of the major risk factors related to falls Worldwide, males consistently sustain higher mortality rates and with older people gaining the spot on having the highest risk of death DALYs lost. [3] or life-threatening injuries arise from a fall and with increasing risk Other risk factors for fall incidence include occupations at high as the age advances. Falls in the elderly tend to occur with activities altitude or other risky working circumstances, alcohol or substance of daily living. In the United States of America, 20–30% of elderly abuse; socio-economic factors like poverty, overcrowding, single people are found to suffer from moderate to severe injuries like parenting, early pregnancy and young motherhood; underlying medical bruises, hip fractures, or head traumas following falls. [3] This may conditions like neurological, cardiac or other disabling illnesses; be due to physical, sensory, and cognitive alteration and limitation medicinal side effects; obesity; physical inactivity and loss of balance, related with the process of ageing, including poor muscle tone, vision particularly among elderly individuals; poor mobility, cognitive and problems, medication use, and sedentary lifestyle. Other contributing visual impairment, especially among those residing or working in an factors are noted as relatively poor adaptation for aging population institution, such as a nursing home or chronic care facility; and unsafe to environmental circumstances such as poor lighting and absence environments, particularly for those with disturbed gait and impaired of handrails. Meanwhile, children also belong to a high risk group. vision.[3] This includes reasons such as their evolving developmental stages,

C. Acts of violence

In this case, acts of violence such as wounds due to gunshot and stab Bullets are made up of a casing carrying an explosive powder charge, injuries are more commonly causes of penetrating trauma. According which, on striking, throws the end projectile element out at minimal to Peitzman, firearm-related injury was the second leading cause in speeds of up to 1,500 meter/second which of course, is depending injury-related mortality for all ages that results in 28, 827 deaths in on the type of ammunition and type of gun. The most crucial factors 2003. Fifty-one percent of which is identified by suicide while forty- involving significant injury or deaths are their placement and projectile one percent were homicide-related. Gunshot wounds were identified in path. The most vulnerable areas of injury are the head and torso, with 65,834 patients in the same year as nonfatal consequences. Most of the incapacitation due to CNS impairment or massive organ damage and fatal shootings involved young males between the ages of 15 and 34. hemorrhage. The depth of tissue and organ damage will be dependent Handguns were involved in 80% of the cases of homicide. [1] on the terminal ballistics, which is influenced by the type of bullet, its There are three categories to identify mechanism of injury: low, velocity and mass as well as the physical characteristics of the tissue medium, or high velocity. Low-velocity injuries consist of impalement being penetrated. [8] (e.g., knife wounds), which affects only the structures which have In able to further understand the mechanisms of gunshot injuries, been penetrated. On the other hand, bullet wounds from most types firearms which are the cause of injury should be identified by its of handguns and air-powered pellet guns are medium-velocity nature and projectiles (particularly bullets), or with what is called injuries. These are characterized by a low amount of primary tissue Ballistics – the science of propulsion, flight, and impact of projectiles. destruction than wounds caused due to high-velocity forces. High- [7] It is divided into three major subcategories, namely internal, velocity injuries include mainly bullet wounds caused by rifles and external, and terminal. Internal ballistics deals with propulsion or the military weapons. Though when talking about shotgun injuries that are characteristic of projectile, typically within the barrel of a gun. Factors considered in medium-velocity projectiles, are many times integrated affecting the projectile during its way to the target, including wind within management discussions to classify it as high-velocity resistance and gravity were examined in identifying external ballistics. projectile injuries. This inclusion is rational because of the kinetic On the other hand, terminal ballistics calculates the projectile as it force transmitted to the adjacent tissue and subsequent cavitations, strikes its target. [1] as described by the equation KE = ½ MV2, in which KE stands for Still, major factors of identifying the extent of injury due to gunshot kinetic energy in the form of joules, M is mass in grams, and V is are the type of firearm used, the type of projectile, the type of tissue velocity in feet per second. [5] that was injured, and the distance or range between the weapon and A gunshot injury usually happens in the occurrence of someone who is the victim. Though wounding potential is a part of the equation, the shot by a bullet or other kinds of projectile from a weapon. A variety amount of tissue damage can still be a direct proportion to the amount of incidence and situations occur that result in gunshot injury. This of energy exchanged between the penetrating object and the body. may result from criminal and terrorist attacks, along with shots fired Projectile crushes the tissue and may end up killing that tissue. The by law enforcement agents, suicidal attempts as well as unintended bullet may also cause temporary cavitations by expansion of the tissue firearm accidents by civilian and even amongst the armed forces. [10] particles away from the bullet and stretching tissue with displacement.

Nursing.EliteCME.com Page 3 Though this cavity is temporary, but we have to consider that it was stabbing. Stabbings are a relatively common cause of homicide in the once present to fully understand the degree and intensity of the injury. USA, with a total of 1,694 reports of deaths in the statistics last 2011. On the other hand, stab wounds are caused by a penetration of a sharp [9] Organ failure, or blood loss are the typical cause of death related object, usually a knife or a sharp weapon. A person with a stab wound to stabbing. They are the mechanism of approximately 2% of suicides. has a deep puncture wound that damages the tissue beneath the skin. [14] In order to imply proper planning management to stab wounds, As said earlier, stab wounds are classified as low-velocity penetrating the identification of length and size of the knife blade, as well as the wounds that damages tissue by the offending weapon passing through. trajectory it followed, may be of importance as it can be a predictor of The severity is dependent on the location of the wound, the manner what structures were damaged. Irrespective of the above, the victim of stabbing, the depth of penetration, and the type of weapon used for most of the time experiences pain and bleeding, with some very rare cases where they are unaware something has penetrated their bodies.

D. Blast injuries

Blast injuries are a complex type of physical trauma that result from in the absence of any evident physical injury. In the typical normal explosions, with direct or indirect contact to it, that has the capacity reflex, blood pressure falls when systemic vascular resistance does not to cause multisystem, life-threatening injuries in one or more victims rise adequately. But then, in this response, there is a decrease in heart at the same time. These results to increase mortality rates, but it still rate, stroke volume, and cardiac index. This effect may happen within varies widely between incidences. [11] just seconds, and if this response is not fatal, recovery typically occurs On the breakdown of 29 large terrorist bombing events that happened within 15 minutes to 3 hours. However, even nonlethal primary blast between 1966 and 2002, it showed 8,364 casualties, including 903 injury can impair pulmonary functions for hours to days. [11] immediate deaths and 7,461 immediately surviving injury. On the Following primary blast injury is the secondary blast injury, another other hand, immediate death and injury rates were higher for bombings category that is caused by flying objects that strikes a victim, causing that involved structural collapse (25%) compared to confined spaces penetration. Unfortunately, this is the mechanism which is responsible (8%) and open air detonations (4%). [12] for the most of the casualties occurring due to explosions. One Because of their extreme high velocities, penetrations from explosion common cause of death in the relation to secondary blast injury is the fragments or from fragmentation weapons can be scrupulously penetrating thoracic trauma, which includes lacerations of the heart destructive. Weapons such as mines and grenades that are designed and great vessels. For example, one incidence is the glass facade of specifically for antipersonnel effects can generate fragments with the Alfred P. Murrah Federal Building in Oklahoma City, where glass initial velocities of 4500 feet per second. This is by far a greater shattered into thousands of heavy chunks were propelled throughout velocity than most rifle bullets. With the tremendous force imparted the populated areas of the building with devastating injuries. While in to tissue from fragments with such a high velocity causes widespread another incident happened during the 1998 terrorist bombing of the US disruption and thermal tissue damage. Improvised explosive devices Embassy in Nairobi, flying glass wounded people up to a distance of (IEDs) are the most common weaponry of the 21st century. These two kilometers away from the site of infrastructure. The use of military devices are homemade bombs and they are known to create a fatal explosive casings such as hand grenades is specifically designed to triad of penetrating, blast, and burn wounds, causing 40% of the fragment and to get maximum damage from flying debris (shrapnel). casualties to suffer penetrating chest trauma. [5] While another technique of the Civilian terrorist bombers is the placement of small metal objects like screws around their weapons to To help us to identify the extent of damage that a blast injury may increase the severity of secondary blast injuries. [11] cause, it is therefore divided into the following four categories. [11] More than one of these categories can be a possible cause of injury to Meanwhile, the incidence of a much more high-energy explosion a victim: categorizes a tertiary blast injury. This usually happens when people fly through the air, or results from individuals being thrown away A primary blast injury is typically caused due to the direct effect of due to the blast wind and strike to surrounding objects. In this case, blast producing overpressure on the tissues. Because air is easily a victim that is identified to have tertiary blast injury is noted to be compressible, unlike water, a primary blast injury most of the times definitely very close to the explosion source, effects produced due affects air-filled structures like the lung, ear, and gastrointestinal to the bulk flow of gas away from the point of explosion, unless the tract. Production of incidence of primary blast injury is evident with explosion is of tremendously high power or focused in some way, such enclosed-space explosions; including those occurring in buses, and as through the door, window or a hatch. It can affect any part of the in-water explosions, turn out to be more primary blast injury. As body of the victim, usually causing abrasions and contusions when he explosive gases may continue to spread out from their source of origin, or she tumbles to the ground, fracture and traumatic amputation and a longer negative under pressure (relative vacuum) follows the peak much worse, brain injuries. [11] positive overpressure. Both the positive overpressure and the negative under pressure are capable of causing significant primary blast injury. Last of the categories of the mechanism of blast injury is the [11] miscellaneous blast-related injury, or sometimes termed as Quaternary. This encompasses all other injuries caused by explosions, including Blast injury provides a significant effect on different organ systems chemical or thermal burns, injury from falling debris, crush injuries of a victim, and pulmonary barotrauma is the most commonly fatal from collapsed structure or buildings and displaced heavy objects, in primary blast injury. This affects most of the respiratory and toxic, dust or gas inhalations, or exposure to radiation. The unprotected pulmonary part of the body, including pulmonary contusion (a bruise human body has capacity to tolerate a blast up to a peak overpressure or injury to the lung parenchyma that can cause lung edema); systemic of 30 psi, but buildings and other structures collapse with stress of only air embolism, which most commonly obstructs the blood flow to the a few pounds psi. This means that persons can survive from the effects brain or spinal cord by occluding blood vessels, and free radical– of the blast but can be killed or injured by collapsing buildings or other associated injuries like thrombosis. Such injury may last from hours quaternary injuries. One example of this incidence is the collision of up to days with impaired pulmonary performance. Meanwhile, another two jet airplanes into the World Trade Center of USA, which only part of the body that produces injury caused by blast incidence is the produced a relatively low-order pressure wave, but unfortunately, the thoracic area. Thoracic primary blast injury can produce a unique consequential fire and collapse of building killed more number of cardiovascular response which is severe enough to cause death even victims. [11]

Page 4 Nursing.EliteCME.com Explosions can produce a unique pattern of injury seldom seen outside Besides identifying the mechanism of blast injury, several factors combat. It has got the capacity to cause multisystem, life-threatening are also considered to recognize the pattern and the extent of injuries serious injuries in one or more victims simultaneously. Explosions produced by an explosion. One inclusion is the composition and can create different injury patterns from blunt and penetrating amount of the explosive material used for the blasts, such as the trauma mechanisms to several organ systems. Not only to that, it presence of shrapnel or loose material that can be propelled, biological also gives rise to unique injury patterns to specific organs such as or radiological contamination, or the class of explosives used (namely the lungs and the central nervous system. There is an importance in high-ordered and low-ordered explosives). The presence of intervening understanding the extent of injury a victim had possessed, and these protective barriers at the surrounding environment is also taken into crucial differences is critical in managing these situations. In these consideration. The identification of distance between the victim and types of events, it can present a health care provider with management the blast is also a factor. Identification of the delivery method of the challenges on present complex triage and diagnostics of the different explosive, especially if a bomb is involved is also crucial, and also cases. the recognition of any other environmental hazards. Technically, no two events are identified to be identical, and the range and extent of injuries produced varies widely.

II. PATHOPHYSIOLOGY

A. Restricted flow of air

As stated earlier, different accidents such as motor vehicle crash is a very crucial factor and awareness of serious injuries related with and falls may lead to blunt chest trauma. Mechanisms of blunt chest blunt and penetrating chest trauma, will simply help to easily identify trauma include acceleration, stated as either hitting the chest caused the correct management for the patient. [13] by moving objects, or a victim was being tossed into an object; Meanwhile, with rib fractures present due to a particular incident can deceleration, meaning sudden decrease in rate of speed or velocity, compromise ventilation by a variety of mechanisms. Whenever there such as a motor vehicle crash; stretching forces to areas of the chest is injury to the ribs, the patient experiences tremendous pain which causing tears, ruptures, or dissections; and, direct blow to the chest, increases while breathing. Therefore, patient avoids taking deep just like on a crush injury that results in compression. Chest injuries breaths, in an attempt to decrease the pain. In this case the pain felt are often life-threatening and result in one or more of the following from rib fractures can cause respiratory splinting and high chances of pathological changes that may result in disruption of airways, massive infection once the lung underlying the injury does not expand, which fluid and blood loss and cardiac failure [13] further results in atelectasis and pneumonia. Multiple contiguous rib There is a variety of mechanisms that impair the flow of air due to fractures such as flail chest gets in the way of normal costo-vertebral blunt chest injuries. It may be due to chest wall injuries, resulting and diaphragmatic muscle excursion and can potentially result in in rib fracture that associates pain, causing the victim to experience ventilatory insufficiency. The sharp edges of the rib separated due difficulty of breathing. In much worse cases, it may penetrate the to fractures can also play a major role in causing penetrating lung lungs. There are also identified direct lung injuries that may present injuries, lead to more complicating conditions like hemothorax or a the same mechanism. Impairment of oxygenation may also be caused pneumothorax. Ribs get fractured usually at the area of impact or at by shunting and dead space ventilation. On the other hand, a space- the weakest area like the posterior angle of the ribs. Ribs from four to occupying lesion also compromises ventilation due to compression of nine (4-9) are the most vulnerable for the injury. [14] a healthy lung parenchyma. [13] A blunt trauma that was caused by accidents may cause bruises to the Respiratory system holds the role of breathing and gas exchange of lungs due to a hard impact and was termed as pulmonary contusion. one’s body. Normally, it is enclosed in a chest wall, which its crucial Once a direct traumatic insult to the lungs occur, it produces an innate role is to protect underlying sensitive structures by surrounding inflammatory response that includes the recruitment and activation of internal organs, such as the heart and lungs, and consists of hard blood leukocytes, the activation of lung tissue macrophages, and the osseous structures like ribs, clavicles, sternum, and scapulae. At its production of multiple mediators such as cytokines and chemo-kines. simplest, it’s composed of three main components: a membrane in This inflammatory response, in conjunction with direct lung contusion- which gas exchange takes place, a bellow mechanism of gaseous induced tissue injury, damages the barrier integrity of the alveolo- exchange to and from the membrane, and a control mechanism that capillary membrane and increases epithelial cell apoptosis/necrosis. drives the process while monitoring and doing adjustments. The Plasma proteins and other substances in permeability edema enter the respiratory system is composed of the upper and lower respiratory alveoli and inhibit lung surfactant, exacerbating respiratory deficits. tracts. Together, the two tracts are responsible for ventilation This blunt lung injury develops over the course of 24 hours, leading to (movement of air in and out of the airways). It works in conjunction impaired gaseous exchange, elevated pulmonary vascular resistance with the cardiovascular system; which is then responsible for and decline in lung compliance. [15] perfusion (Farquhar & Fantasia, 2005). [13] Normal respiration can be It is also essential that there is an equal amount of air and blood maintained with the help of intact chest wall. In normal breathing, as that enters the respiratory portion of the lungs. That is why the gas we inhale the air the ribs and lungs expand. The ribs move outwards exchange properties of the lung should also depend on matching while the diaphragm moves downwards. ventilation and perfusion. Two factors may affect the matching of A chest injured patient is in a particularly risky situation, for he or she ventilation and perfusion: dead air space and shunt. Dead air space may be involved in not only one but three evolving injuries. Firstly refers to the volume of air that is moved in during each breath but there could be an injury to the tissues themselves. Secondly the oxygen does not actively participate in gaseous exchange. Two types of dead supply may be compromised because there is the effect of hampered air space are present, namely, anatomic dead space which remains in ventilation and the needs for the increased metabolic demands after the conducting airways (nose, upper airway-trachea) that normally do trauma cannot be met. Lastly, the effort on ventilation becomes further not participate in gaseous exchange; and alveolar dead space results uncoupled, that the patient can enter into a negative cycle because of from alveoli that are ventilated but do not participate in the process the hypoxia and acidosis that is exacerbating all other injuries. Time of perfusion. On the other hand, shunt refers to blood which moves

Nursing.EliteCME.com Page 5 from the right to the left side of the circulatory system without being atelectasis and airway obstruction that was caused by a chest trauma, oxygenated. There are mainly two types of shunts. In an anatomic there would be a perfusion without ventilation, resulting in a low shunt, blood moves from the venous side to the arterial side of the ventilation–perfusion ratio. The blood oxygen level shows the mixing circulatory system bypassing the lungs. In physiologic shunting, of blood from alveolar dead space and physiologic shunting areas as the blood passes through the unventilated parts of the lung leaving soon as it travels through the pulmonary veins. [13][16] the blood non-oxygenated. In this case, when there is a presence of

B. Restricted flow of blood

The crucial role of the circulatory system is the distribution of blood- be able to understand easily, hemodynamic changes in tamponade can carrying nutrients and oxygen all over an individual’s body, and occur in three phases [19]: First phase starts once an infliction of any maintaining homeostasis in order for the other systems to function sharp object happens that penetrates the heart, and a hole was made, well. The circulatory system consists of a hollow organ essential to in which the pericardium rapidly seals with accumulation of clot. But pump blood called the heart; a system which distributes oxygenated still, there is a continuous bleeding from the heart and it will fill the blood to the tissues called the arterial system; a system responsible pericardial space. Due to the fibro-elastic nature of the pericardial for collecting deoxygenated blood from the tissues and return it to the sac, it fails to dilate much, and on the other hand, compression of the heart called the venous system; and little structures where exchange cardiac chambers happens. In short, the accumulation of pericardial of gases, nutrients, and wastes takes place called the capillaries. This fluid increases the ventricular stiffness and requires a higher filling system is segregated into two parts: the low pressure pulmonary pressure, and during this period, the left and right ventricular filling circulation, which takes place in the lungs that links circulation and pressure remains higher than the intra-pericardial pressure. [20] In gas exchange, and the high-pressure systemic circulation where blood the second phase, with further accumulation of the fluid, there is an has the mechanism for providing oxygen and nutrients to the tissues. increased pressure on the heart and reduction of size of the ventricle, To make the distribution of oxygen and nutrients to the other parts of which in turn reduces the end-diastolic filling volume and leads to a body possible, the blood continuously flows down a pressure gradient drop in cardiac output. Following this, the third phase occurs with a from the high pressure arterial circulation to the low-pressure venous further decrease in cardiac output, which is due to the equilibration of circulation. The circulation is a closed system, making the right and pericardial and left ventricular filling pressures. [19] left heart have equal output over time for effective functioning and to On the other hand, the systemic venous return also gets altered maintain homeostasis on the circulation. [13] during tamponade. Due to the increased intrapericardial pressure, However, any injury that may affect the chest and produces trauma compression of the heart occurs throughout the cardiac cycle. This can result in different cardiovascular anomaly. As stated earlier, impairs systemic venous return and disintegration of the right atrium derangements on a respiratory part can occur in traumas inflicted by and right ventricle occurs. At the expense of left ventricular filling and accidents or any other incidence, and also to the cardiovascular and collapse of the right side of the heart, blood accumulates in the venous circulatory part, for they are adjacent to each other, not only to their circulation on the part of the vast pulmonary vascular bed, which location, but also when it comes to mechanism. This may include further leads to decreased cardiac output and venous return. [13] cardiac failure from the conditions like cardiac tamponade, cardiac In this case, a tamponade can occur with an accumulation of only less contusion, or increased intra-thoracic pressure. Such pathology often than 100ml of blood that can diminishes cardiac output, leading the results in impaired ventilation and perfusion leading to acute renal victim to undergo a much worse case: cardiac arrest. [19] failure, hypovolemic shock, and death. [13][16] With a sudden blood loss that usually happens in penetrating A direct blunt trauma to the anterior chest, caused by rapid traumas, it is not impossible for a shock to happen. Shock manifests deceleration of injury, such as bumping against a steering wheel clinically as hemodynamic disturbances and organ dysfunction due to during a motor vehicle accident, can result in cardiac contusion. [13] inadequate tissue perfusion. It also results from insufficient delivery of Once direct force is inflicted, it causes bruises to the heart, usually to required metabolic substrates, principally oxygen, to sustain aerobic the myocardium. It affects the viscoelastic chest wall which causes metabolism and maintain body’s homeostasis. The most common direct pressure on the myocardium and indirectly affects secondary cause of shock in the setting of trauma is the loss of circulating blood to elevated intra-thoracic pressure with shearing stresses. Myocardial volume from hemorrhage. Other potential factors include inadequate injury occurring due to blunt trauma may range from myocardial oxygenation, mechanical obstruction, such as in cardiac tamponade contusion without any cellular damage to severe contusion with severe or tension pneumothorax, neurologic dysfunction in high-spinal cord tissue damage. [18] The characterization of severe contusion is the injury, and cardiac dysfunction. [13] presence of irregular and patchy pattern of myocyte necrosis along with epicardial haemorrhage which extends in a unique pyramidal Hypovolemic shock, the most common shock that can happen on a fashion intramurally or even transmurally. Because of its position victim with chest trauma, is characterized by decreased intravascular behind the sternum, the right ventricle is most commonly injured. volume, caused by external fluid losses, in the case of trauma, as in While in the absence of direct injury because of reduced preload, traumatic blood loss, but other factors include internal fluid shifts, as there can be a presence of descend in the output of the left ventricle. in severe dehydration, severe edema, or ascites. Intravascular volume A contribution to biventricular failure is the reduced left ventricle can be reduced both by fluid loss and by fluid shifting between the compliance from intraventricular septum shift. As a result of this the intravascular and interstitial compartments. [13][20] cardiac output may drop by 40% and can persist for several weeks. In a hypovolemic shock, there is an occurrence in a decrease in Once a force disrupts the vasculature in the heart, it may lead to intravascular volume, that results in decreased venous blood returns to collection of blood and inflammatory mediators in the myocardium. the heart and subsequent decrease ventricular filling. This follows in The highest risk to the patient suffering myocardial contusion is decrease stroke volume, or the amount of blood ejected from the heart, cardiac dysrhythmia. [17] [18] and a decrease in cardiac output. Blood pressure will also drop and this An inflicted trauma to the chest may also result in an accumulation will cause diminished tissue perfusion. [13] of fluid in the pericardium, a membrane that surrounds the heart, which is termed as cardiac tamponade. Although tamponade happens rarely, it is often present due to stab wounds inflicted to the chest. To

Page 6 Nursing.EliteCME.com C. Sepsis

Once a sharp object causes penetration and injury to the chest due to into the circulation. One mediator is the prostaglandin, chemically accident or any other incident, it would create an open wound that is related fatty acids that in this case, is responsible to regulate body susceptible for the entrance of organism, and may result in infection. temperature and platelet aggregation, and control inflammation It is crucial to know the mechanism of sepsis in order to identify the and vascular permeability. Cytokines are also a mediator released. proper management and treatment to a patient, before the situation gets They are accountable for cell communication in immune responses aggravated and other complications may happen. and stimulate the movement of cells towards sites of inflammation, Any infection that is found in the bloodstream is termed as sepsis. infection and trauma. In this case, they are released by WBCs in Sepsis is termed to be a systemic response to infection, which is reaction to endotoxins. Proinflammatory mediators also include the presence of microorganisms, such as bacteria, that trigger an the release of tumor necrosis factor and interlukins. All of these inflammatory response. In addition, it is said to be manifested by two are released into the circulation, and they are the ones responsible or more of the Systemic inflammatory response syndrome (SIRS) for vasodilatation, increased capillary permeability, and increased criteria as a significance of a presumed infection. On the other hand, coagulation. Normally, the body can control these processes that will Systemic inflammatory response syndrome (SIRS) is said to be result into healing. Otherwise, in a patient with sepsis, the endotoxins an inflammatory state that affects the whole body, mostly, but not stimulate the excess release of the immunomodulators causing an necessarily an immune system response to infection. There are criteria exaggerated response. [25] established for SIRS modified by heart rate, temperature, respiratory To make the body’s infection control possible, transportation of rate and the number of leukocytes. SIRS can be diagnosed when white blood cells, such as macrophages is necessary. Thus, to two or more of these criteria are present. [22] In the meanwhile, make this transportation possible, one’s body is initiating a way these criteria are modified by a number of times, and not a specific to increase the blood flow in the affected area, and this process is identification of sepsis. [21] The physiologic presentation of SIRS is called vasodilatation. However, in this case, that vasodilatation does similar to sepsis, except there is no identifiable source of infection not release a proportionate blood volume increase and it may cause (Dellinger, et al., 2008; King, 2007). But therefore, causes of SIRS are decrease in blood pressure. Edema can also occur when fluid leaks categorized as infectious or noninfectious. As stated before, sepsis is out to the bloodstream and to the surrounding tissues with increased considered when SIRS is due to an infection; while on the other hand, capillary permeability that can also result in further decrease in blood trauma, burns, pancreatitis, ischemia, and hemorrhage are classified as pressure. Meanwhile, a normal body process, fibrinolysis, which noninfectious. [23] keeps naturally occurring blood clots from growing and causing Sepsis is noted to be a chief cause of mortality and morbidity in problems, is impaired which causes a decrease in clot breakdown. The the trauma patient. Collectively with the extent of injury and the uncontrolled formation of fibrin clots will lead to microthrombi that anatomical setting, sepsis following traumatic injury is related to results in hypoperfusion of tissues, followed by tissue necrosis, and the type of injury inflicted. The highest risk of sepsis is identified to much worse, organ failure. [25] be caused by burns. Statistics show that in the US, there are around If not given immediate attention, a sepsis may progress to a septic 750,000 or more new cases of sepsis noted each year. Annually, the shock. Tissues may become less perfused, while compensation incidence of it is increasing. The infection has a tendency to spread continually fails. Organ dysfunction may gradually be present. As the quickly and is not easy to identify in the early stage. The mortality rate circulatory system also begins to fail, blood pressure may not respond associated with severe sepsis is very high —approximately 28% to to fluid resuscitation and vasoactive agent therapy. This may comprise 50%. These percentages increase if more number of organs are being other organ and organ system failure, such as in renal, pulmonary and affected by the underlying infection, with mortality rates increasing up hepatic. With the progression of sepsis to septic shock, the skin turns to 75% to 85% when multi organ failure occurs with involvement of out to be cool, pale and mottled, temperature may range from normal four or more vital organs. [24] to below normal. As blood pressure decreases, heart and respiratory rate becomes rapid. There would also be a cease in urine production and dysfunction of multiple organs that may result in death. [25] Sepsis undergoes a complex process, where one’s system identifies an organism’s entrance in able to create a response for infection. During One must keep in mind that sepsis does not only occur in the presence a trauma, there is a chance of an organism invading a system that of burns and wounds. Once other organs are also penetrated and have may result in infection. The body cannot easily contain a localized presented damage, such as at the alimentary tract and esophageal infection at its source. Therefore, this may be the start of an infecting perforations, a leakage of their contents may take place and occurrence organism to leak into the bloodstream that results into sepsis. Once of sepsis must also be considered. [13][25] an invading organism enters the bloodstream, for example, bacteria, a Early detection of the signs of sepsis is the key to prevent the spread of toxic substance bound to the bacterial cell wall will be released when infection. Early recognition of these signs may prompt a patient to start it ruptures or disintegrates. This is called an endotoxin. It is usually appropriate treatment sooner, decreasing the chance of progression to associated by gram-negative bacteria. In response to the release of septic shock and especially to the associated development of organ endotoxin, proinflammatory mediators were released by the system system failure that may lead to a death.

D. Space-occupying lesions

Space-occupying lesions happen when a trauma was inflicted and lung to collapse, hemmorhagic states, and hypovolemia that resulted causes injury to the chest. The ribcage is crucial to protect the organs it from fluid and blood loss, cardiac rupture or hemothorax. [13] surrounds, and the organs are usually hollow and on a closed system. The respiratory system, including the lungs, maintains the role Once injury was imposed to the chest, any organ at that part can be of oxygenation and ventilation. A usual incident of motor vehicle affected. When we talk about the chest part, it usually includes the accident or fall incident that may result in chest trauma may cause heart and the lungs, which cordially work with each other to maintain compression of the lungs parenchyma that may interfere with good circulation to the whole body. Injuries to the chest are often oxygenation and ventilation. Some of these are pneumothorax, life-threatening and may result in various pathological states, such as hemothorax, and hemopneumothorax. A common concerned situation hypoxemia from disruption of airway, lung injuries that may cause the

Nursing.EliteCME.com Page 7 is tension pneumothorax. As pressure continues to build, air leaks from changes, variation on the weight of an individual and amount of the pulmonary parenchyma into the pleural space. This can disarrange bleeding and blood loss would determine if a victim can still undergo mediastinal contents toward the opposite hemothorax. Mediastinal changes or compensation. If a significant amount of loss was met, it shift takes place that decrease blood return to the heart, because of the may cause early symptoms of shock. Meanwhile, a collection of blood distortion of the superior vena cava, compromises the circulation, and within the pericardial space would determine the respiratory response. may also result in shock. [13] Oxygenation and ventilation anomaly may result, and an individual Once a healthy lung parenchyma was compressed due to a chest may show dyspnea and tachypnea. Factors including the severity of trauma, impairment to ventilation occurs. Normally, the pleural cavity injury, organ damage and underlying pulmonary and cardiac reserve is free of air and contains only a thin layer of fluid and once air enters will determine the volume of blood required for the production of the pleural cavity, it causes partial or complete collapse of the affected symptoms. [13][26] lung called pneumothorax. A classification of this, called tension On a hemothorax, blood that enters the pleural space was depicted by pneumothorax usually happens when air is drawn into the pleural the motion of the lungs, diaphragm and other intrathoracic structure. space through a lacerated lung or from a small opening or wound of Defibrination or the removal of a protein structure from the blood the chest wall. With each inspiration, the air that enters the chest cavity called fibrin occurs and incomplete clotting takes place. Lysis of is trapped and fails to get expelled during the process of expiration existing clots by pleural enzyme follows, that will result in increase through the airways or through the opening of the chest wall. This of the protein concentration of the pleural fluid, therefore also follows the one-way valve or ball valve mechanism where air can enter increasing osmotic pressure of the pleural cavity. This produces an into the pleural space without any scope to escape. Positive pressure osmotic gradient between the pleural space and the adjacent tissues that causes tension is increased within the affected pleural space with which facilitates transudation of fluid into the pleural space. This can each breath. This results in a collapsed lung, and mediastinal shift progress into pleural effusion. While on the other hand, if hemothorax happens, where the heart with its great vessels and the trachea get were unresolved, late physiologic sequel such as empyema, which shifted toward the unaffected side of the chest. With the presence of results in contamination of bacteria, and developed deposition of fibrin increased intra-thoracic pressure, both respiration and circulatory on the parietal and visceral surfaces, called fibrothorax occurs. [26] function are compromised, which, on the other hand, reduces venous Once infliction of trauma to the chest occurs, it will result in damage return to the heart, leads to decrease in cardiac output and causes to the lungs and its adjacent organs, including the pleural space and impaired peripheral circulation. In severe cases, pulse-less electrical intrathoracic cavity where blood and air may accumulate, and may activity happens, where the pulse may be undetectable. [16] compromise the mechanism of these organs. An accumulation of air On the other hand, hemothorax is another consequence of blunt or and blood to the cavities may occur separately, or either of the two, penetrating chest trauma. It is simply defined as the presence of blood but it can also happen simultaneously, depending on the severity of within the pleural space. Once the tissue on the chest wall, pleura or injury imposed or the part that was affected. A combination of the the intrathoracic structure is disrupted, it may cause the accumulation accumulation of both air and blood in the pleural cavity is simply of bleeding in the pleural space. A response is determined by termed as hemopneumothorax. Spontaneous hemopneumothorax the volume and rapidity of blood loss, which is manifested as a can be life-threatening, and is a cause of patients presenting with hemodynamic or respiratory response. For instance, on hemodynamic unexplained signs of significant hypovolemia. [70]

III. INJURIES TO CHEST WALL

A. Contusions or hematomas

Chest traumas are one of the most dangerous cases that can be (a localized collection of the blood, or blood clot outside the blood handled. As a health practitioner, it is important for us to identify vessels) to the heart and lungs. immediately the extent of injuries that chest traumas present to be In a direct blunt trauma that was caused by bumping into a steering prepared for the early diagnosis, management and treatment of the wheel during a motor vehicle accident, that direct force inflicted to victim. In this way, we can prevent further complications that were the chest wall may cause bruises to the heart, or termed as cardiac brought by the trauma, and otherwise can start rehabilitation for the contusion. It usually affects the myocardium, or the muscle of the patient. Thus, this may reduce deaths, mortality and morbidity caused heart. It should not be confused with myocardial infarction. Infarction, by chest injury. on the other hand, is caused by a lack of blood flow to the heart that The chest wall plays a significant role in protecting the internal organs results in severe damage and even death of the surrounding tissues. in the chest, specifically the heart, which contributes to the circulation A bruise to the heart can be caused by a powerful force, which will of blood, and the lungs, which, on the other hand, significantly play bring direct pressure on the myocardium by the affected chest wall. the role in oxygenation and ventilation. Serious injuries inflicted by There would also be indirect effects, such as shearing force due to any incident, may it be an accident, or intentionally to the chest wall intrathoracic pressure. When it comes to the cellular level, necrosis may cause serious problems to the underlying organs that it surrounds. of myocardial muscle fibers and permeation of red blood cells occur Therefore it may interfere with the normal functioning of these said in the myocardial tissue. Hemorrhage on the epicardial surface of organs, bringing alterations to the mechanism and maintenance of the heart may appear, may it be extensive, necrotic cells or even homeostasis of an individual’s body. presence of polymorphonuclear leukocytes extending intramurally Chest wall injuries are more commonly caused by a blunt trauma, or transmurally happens as a result of cellular damage. Creatinine usually by a vehicular accident. The harder the impact of the victim phosphokinase (CPK), an enzyme found in the heart, was then released to the object, the more serious damage it can inflict to the affected to the circulation as a result of the myocardial cellular damage. As the organ. Since chest wall injuries refer to the damages brought on the healing process occurs, there would be a subsequent scar formation as chest part, the heart is the most prevalent part of the trauma. Though the hemorrhage was absorbed gradually. Pertaining to the injury, there a trauma to the chest does not always involve a tear to the skin, an are certain areas where myocardial contusions are more susceptible, impact can cause contusions (or in other term, bruises), or hematomas and because of its location behind the sternum, the right ventricle is the most vulnerable. With its position, any impact can be transmitted

Page 8 Nursing.EliteCME.com immediately causing injury. Plus, there is also an increase in the Other complications include the presence of cardiac tamponade, susceptibility to injury with the mitral and aortic valves due to the where muffled heart sound was determined, presence of jugular vein high pressures that are brought by the left side of the heart. On the distention was also noted, evidence of elevated venous pressure, and other hand, there would also be a presence of compromised blood signs of shock. Meanwhile, murmurs and thrills can be an onset to a supply due to the injuries met by the valves. These are followed by valve or cord rupture. Another serious complication that can be present possible thrombosis, vasoconstriction and lacerations that impede with myocardial contusion that can be initiated by increase of heart the circulation. [27] While on the other hand, in the absence of rate is cardiac arrhythmia, which usually occurs within 24 to 48 hours. direct injury, there can be a presence of descend in the output of Other symptoms associated with myocardial contusion that is due the left ventricle because of the reduced preload. A contribution to to the impending circulation includes shortness of breath, weakness, biventricular failure is the reduced left ventricle compliance from lightheadedness, nausea and vomiting. [27] [59] intraventricular septum shift. The resultant drop in cardiac output may To diagnose myocardial contusion properly, several tests and be up to 40% and can persist for several weeks. Once a force disrupts imaging studies are done that will help the further management and the vasculature in the heart, it may lead to accumulation of blood and rehabilitation of a patient with this disorder. One is cardiac enzyme inflammatory mediators in the myocardium. [27] tests that determine the presence of creatinine phosphokinase. As A patient with myocardial contusion can experience various stated earlier, CPK was released to the circulation as a result of the symptoms that may lead to severe complications when not given myocardial cellular damage. In myocardial contusion, there is said proper attention. Pain is the most crucial complaint of the patient to be evidence of elevation in CPK within 24 hours of injury. An with myocardial contusion. [27] They usually locate the pain just abnormal electrocardiogram is also a determinant, such as ST-T wave above the ribs, and was unrelieved by analgesics imitating the abnormalities due to the contusion, and other ECG anomalies due to symptoms of angina or myocardial infarction. There can be evident, different complications that may be present. An echocardiography may but sometimes absence of signs and symptoms of external trauma and also be used to provide direct visualization of right and left ventricles fracture, including pneumothorax, hemothorax, fractures of the ribs for the determination of contusions. While on the other hand, nuclear and sternum or flail chest, or even great vessel injuries. Most cases studies, such as radionucleotide imaging determine the reduced areas are associated with thoracic trauma, but at times, the symptoms are of perfusion that may indicate the extent of myocardial injury. [26] incomprehensible because of the sustained injuries during the incident.

B. Flail Chest

There is a complex system that provides a rigid protection to the of osteoporosis) then even on a much lower force, it can easily result underlying organs of the chest, namely the heart, liver and the lungs. It in rib fracture. On inspiration, the chest expands to accumulate air in is termed as the chest wall. Aside from providing protection to the said the lungs, while the fragmented part of the rib segment moved on a vital organs, it also provides stability and flexibility of the movement paradoxical manner, which is pulled inward during inspiration, thus of the arms and shoulder, which contributes to the respiration process. decreasing the amount of air drawn into the lungs. On the other hand, This framework consists of 12 sets of ribs on front, and another 12 when the flail segment was pushed outward on expiration that happens thoracic vertebrae that are articulated and connected around. There when intrathoracic pressure exceeds atmospheric pressure; it causes are another three sets of flat polygonal bones that make up the central impairment on the ability of the patient to exhale. The limitation in anterior chest, namely the sternum, the manubrium and the xiphoid mechanical motion affects the actual size of the alteration in thoracic process. [13] volume and lung tidal volume generated by the body. This shifts A serious accident can cause severe damage to a person’s body, the mediastinum to the affected side, resulting in increased dead including the chest part. The chest wall, which protect the internal space, alveolar ventilation reduction and this affects compliance of organs it surrounds are very susceptible to serious injury that may need breathing to decrease. The patient may also experience hypoxemia immediate attention. Fracture to the ribs is the most common incident due to retained airway secretion and atelectasis. Respiratory acidosis that happened in a trauma incident, one of which is motor vehicle also develops as a result of carbon dioxide retention, especially when accidents. Improper use of restraints or driving without it can cause there is a compromised gas exchange. As the paradoxical motion these incidents, and it is very crucial that a victim who is suspected to continuously occurs, it also decreases cardiac output that leads to have a rib fracture seek immediate medical attention. decreased blood pressure, inadequate tissue perfusion and metabolic acidosis. [13] It requires a great potential force in order to inflict a serious trauma.A blunt chest trauma may cause injury to the chest wall, especially to the The crucial part that has to be given attention is not only to the fracture ribs that may cause fracture. Two or three fractured ribs are considered of ribs per se, but also to the underlying complications and damages it to be called as flail chest. Flail chest is said to be a common can bring to the internal organs the chest wall surrounds, particularly complication of a blunt chest trauma, usually an injury from a steering the heart and lungs. Any damage to it can affect either the circulation wheel that causes at least three adjacent ribs at two or more sites to or mechanism of respiration of the patient. For instance, a result of break. This results in free floating rib fragments. Aside from ribs, the underlying severity of pulmonary contusion that can be caused costal cartilages or sternum may be involved in the combination of the by a flail chest is an insufficiency in respiration and a mismatch in fracture. This causes instability of the chest, followed by impairment ventilation perfusion. The deformity should be identified to help a of respiration and severe respiratory distress. [13] There are a variety health practitioner to determine the physiologic compromise caused of fractures like anterior flail segments, posterior flail segments and due to the severe pain occurring due to the rib fracture, the changes in flail including the sternum with ribs on either sides of the rib cage tidal volume, and the injury present to the cardiac and pulmonary part. fractured. [13] [28] A patient with presence of flail chest can experience difficulty in Management of flail chest is very crucial to relieve the underlying respiration while in spontaneous breathing. Mechanically, a shearing damages it can further bring to other organs. It includes the provision force that is inflicted to the chest can break the ribs and form multiple of support in ventilation, lung secretion clearance and implementing fragments and even anterior and posterior rib fractures. The extent pain control. The management still depends on the severity of the of damage depends on the force made. Other factors include the dysfunction in respiration. Usually, to aid proper lung function, essence of weakened structural components, (for instance, a presence positioning, coughing, deep breathing exercises and suctioning can

Nursing.EliteCME.com Page 9 be a simple management for the clearance of airway if only a small rare cases, usually to the high-risk patient with underlying lung disease segment of chest is injured. Intercostal pain can be relieved by nerve who may be difficult to wean from mechanical ventilation. [13][28] block or intravenous opioid analgesics. For the pulmonary contusion, Chest x-rays are the usual diagnostic tool used to determine the monitoring of intake and replacement of fluids is essential. In the fracture. Other tools used for diagnostic are arterial blood gas analysis focus of lung expansion, pulmonary physiotherapy and secretion and monitoring, pulse oximetry, and monitoring of pulmonary management techniques are performed. While on the other hand, function. Otherwise, pain management, with the use of patient- endotracheal intubation and mechanical ventilation are performed with controlled analgesia, intercostal nerve blocks, epidural analgesics and severe flail chest to provide stabilization internally and correct gas administration of intrapleural analgesics can be the aid for a successful exchange abnormalities. Surgery, on the other hand, was performed in treatment of flail chest. [13]

C. Fractures

Any break in the continuity of a bone that is usually caused by a On the other hand, any break in the bone that lies in the middle front trauma, may it be complete or incomplete disruption, is termed to be part of the chest, called the sternum, is termed as sternal fracture. The a fracture. Direct blows, crushing force, sudden twisting motions and sternum consists of three main parts, from inferior to superior, namely extreme muscle contractions are the usual source of the presence of the manubrium, the gladiolus, and the xiphoid process. Like rib fracture. Adjacent organs or structures are affected when there is a fractures, it is commonly caused by a severe infliction of force to the broken bone. Aside from instability and deformity that a fracture may chest caused by motor vehicle accident, especially in the absence of cause, hemorrhage from the muscle, joints and even organs affected, restraints, or even in the presence of seatbelts but no airbags present. dislocations, ruptured tendons, damage to the nerves and blood vessels Though stress or spontaneous fractures are rare, in an instance, the may take place. Body organs can also be severely affected by the victims of these have been noted to be golfers, weight lifters, and other fragments of fracture once force was implied. [13] usual participants in non-contact sports. Sternal fractures can also In able to easily determine and simply understand the severity and occur during cardiopulmonary resuscitation. That is why it is crucial variety of fracture, it is categorized into five typical types. Complete for the provider to imply the right technique of reviving patients fracture involves a rupture on the entire section of the bone causing suffering from an illness that may result in cardiac arrest. [13][28] its displacement, or removal from its original positioning. On the Clinical manifestations presented by a patient with sternal fractures other hand, a break on the cross section of the bone is considered as include anterior chest pain, tenderness, ecchymosis or a small incomplete or what they call greenstick fracture. Meanwhile, when hemorrhagic spot in the skin or a mucous membrane, larger than bone fragments are severally produced through a powerful force, it is a petechiae, forming a non-elevated, rounded, or irregular blue or then called comminuted. A closed fracture also differs from an open purplish patch, a crackling or crunching sound heard when the ends fracture, with the closed one having an absence of break in the skin, of a fractured piece of bone rub against each other called crepitus, while the latter has an evidence of skin rupture. [13] possible swelling, and deformity of the chest. Similar clinical Fractures are also classified according to the location of the body part manifestations are found in patients with rib fracture, such as point where the trauma was inflicted. Motor vehicle accidents, falls, or any tenderness, severe pain, and spasm of the muscle surrounding the other incidents that causes blunt trauma can also cause fractures in fracture that was aggravated by deep breathing, coughing or any multiple body parts. Otherwise, when a chest trauma occurs with this gradual movement. In addition, contusion or bruises in the area of incident, the chest wall, specifically the ribs and sternum are the ones the fracture may be present. The patient may show chest splinting by mostly affected. Rib and sternal fractures will be discussed separately. avoiding deep breaths, coughing, deep sighs, and sudden movements to avoid aggravation of the pain. [13][28] The most common injury that is sustained from a blunt chest trauma is rib fracture. It occurs when a force was applied to the chest wall, Close evaluation for any underlying cardiac injuries must be done. causing a break in a rib. On the other hand, two or more rib fractures Detection of crackling and grating sound on the thorax that can be can be considered as flail chest. Approximately 10% of patients caused by a crepitus in the subcutaneous are can be done through who suffer from blunt trauma have the presence of one or more auscultation. Chest x-ray and electrocardiogram are used for diagnostic rib fractures. [14] Rib fractures are dangerous, that it can be the workup for the determinant of immediate management and treatment underlying cause of an injury to the visceral organs adjacent to them, for the patient. Other diagnostics include pulse oximetry, and analysis specifically the heart, lungs or abdomen. Elderly persons and children of arterial blood gas. [13] are susceptible to this kind of fracture due to falls, while in adults, it is Management of rib and sternal fracture includes the relieving of commonly inflicted through a motor vehicle accident. In adolescence, pain, proper positioning to avoid excess activity, and treatment of it can be sustained secondary to accidents in recreational and sports the associated injuries. Implementing pain control and relief to the activity. Ribs commonly fracture at the point of impact or at the patient, such as use of sedation, intercoastal nerve blocks and cold posterior angle (structurally their weakest area). Ribs four through nine compression to the fracture site is the usual goal of treatment. This (4-9) are the most commonly injured. [14] allows the patient to avoid deep breathing, coughing, and excessive In rib fracture, instances such as compromised ventilation may occur. movements. Still, caution of oversedation and suppression of An injury to the ribs may cause immense pain to the patient that respiration must be kept in mind. The use of a chest binder contributes exaggerates when breathing, thus, preventing him or her to take deep to the support of stability and also decreases pain to the chest wall. breaths to reduce it. This pain can cause respiratory splinting that With proper management, the pain and discomfort can be relieved also prevents the underlying injured lung to expand and cause high within five to seven days with the use of epidural analgesics, non- chances of having infection that may further lead to atelactasis and opioid, or patient-cotrolled analgesics; and most rib fractures can heal pneumonia. Flail chest interferes with the excurtion of costovertebral within three to six weeks. Still, signs and symptoms of the associated and diaphragmatic muscles, thus, causing insufficiency on ventilation. injury should be kept closely monitored. [13] The sharp edges of ribs can also penetrate the organs underneath the rib cage, leading to formation of pneumothorax and hemothorax. [28]

Page 10 Nursing.EliteCME.com IV. PULMONARY INJURY/ PLEURAL SPACE INJURY

A. Pulmonary contusion

Motor vehicle accidents and falls are said to be the cause of an include hypoxemia, increased carbon dioxide, and increased effort underlying injury to the chest wall that can lead to serious trauma in breathing with variation to duration and severity. Manifestations and damage to the underlying organs that it protects. A blunt chest of mild pulmonary contusions include increase in respiratory rate injury may cause fractures to the ribs that further causes injury to the that severely progresses with blood-tinged secretions to frank heart and lungs. A serious trauma to the organs such as to the lungs bleeding; decreased breath sounds and presence of crackles upon may impede mechanism on respiration, oxygenation and proper lung auscultation, chest pain and tachycardia, hypoxemia that can be severe ventilation. and lead to cyanosis and can also result to changes in sensorium Once a force was inflicted, it initially causes injury to the chest wall, (combative irrational behavior and agitation), and respiratory acidosis. leading to fracture and serious injury to the heart and/or lungs, such Meanwhile, aside from the manifestations given to recognize mild as bruising. Once a lung was bruised, as mentioned earlier, abnormal lung contusion, abundant production of mucus, blood and serum on the respiration may occur. The presence of a bruise in the lungs is called tracheobronchial tree on a patient with moderate pulmonary contusion pulmonary contusion. [13] can also result in constant cough but unable to clear the secretions. Patients with severe pulmonary contusions, on the other hand, manifest A bruised lung that is caused by a serious trauma, associated in signs and symptoms of acute, respiratory distress syndrome that compression and decompression to the chest wall can be classified includes productive cough associated with frothy bloody secretions, as mild or severe depending on the force inflicted. . Pulmonary central cyanosis, alterations in sensorium such as combativeness and contusions can also be present on any location of the lungs, or on one agitation. [13] or both of them. It is a common thoracic injury and it also correlates with flail chest and rib fracture. Thirty to seventy percent of the Meanwhile, in order to determine the severity of pulmonary contusion, patients that are associated with blunt chest trauma happen to have including the management and treatment modalities that can be sustained pulmonary contusions. That is why it is also considered given to patients with this kind of lung injury, thorough assessment as a life-threatening injury to the lungs, though mortality is more and specific diagnostic tools are used. Pulse oximetry is utilized often attributed to the other underlying complications and injury. The to determine gas exchange and measurement of arterial blood gas. condition can get worse within twenty four to seventy two hours, while Oxygen saturation is commonly measured in pulse oximetry. Chest it would take six to eight weeks to heal with proper management and x-rays are also used to determine the extent of injury, though no implementation of treatment. [13] changes are significant on initial chest x-ray. An extent of one to two days may show the significant modification, as pulmonary infiltrates With pulmonary contusions, damages to the lung tissues may cause may appear. [13] localized edema and hemorrhage. Development of lung infiltrates and dysfunction on respiration may also happen, and can be followed by Maintenance of patent airway, provision of adequate oxygenation, respiratory failure. Pulmonary contusions may not be immediately and pain control are the treatment modalities used for patients evident on initial examinations; however it can further develop at a with pulmonary contusion. To mobilize secretions, intravenous post traumatic period. [13] therapy of fluids and oral intake is given, as long as only mild lung contusion is present, but with closely monitoring to prevent the A pulmonary contusion involves a process in inflammatory response occurrence of hypervolemia. For the mobilization of secretions, that is initiated by the trauma from a direct force. Inflammatory postural drainage physiotherapy such as coughing and deep breathing, response includes the activation and recruitment of blood leukocytes, endotracheal suctioning, and volume expansion techniques are done. lung tissue macrophages and multiple mediator production. There Pain management includes intake of patient controlled analgesics, would also be an occurrence in increase in alveolocapillary membrane. nerve blocks, or opioids. Antibiotic therapy is also induced for any An entrance of plasma proteins in the bronchioles and alveoli results underlying infection due to secretions. Oxygenation is promoted to the evidence of pulmonary edema which inhibits lung surfactant through the use of supplemental oxygen delivered via nasal cannula or and interferes with gas exchange. Thus loss of lung compliance and mask. Meanwhile, intubation and mechanical ventilation are used for mismatch in ventilation and perfusion takes place. [15] support in patients who suffers from moderate pulmonary contusion. Contusions of the lungs can be varied to mild, moderate, or severe, To avoid respiratory failure, more aggressive treatments of intubation, depending on the injury it has met. Clinical manifestations of patients ventilation and fluid resuscitation are implied for patients with severe with pulmonary contusion may depend on its severity. This may pulmonary contusion. [13]

B. Lacerations

As stated earlier, chest trauma is a serious injury caused by an that may result in organ system failure, up to death of a patient accident, such as in motor vehicle accident or falls, or intentionally, suffering from it. such as in stab wounds and acts of violence. A force inflicted to the In a blunt trauma, a victim may not present any tear or opening of the chest may cause blunt chest trauma, while a shear force that can cause skin, thus there may be an underlying injury internally. The severity a sharp object to tear the skin and enter the body is considered a depends on the impact the force has made. On the other hand, a penetrating trauma. Whatever classification of trauma inflicted to the break or opening in the skin was evident on a person suffering from chest can cause further damage to the underlying organs. The heart penetrating trauma. A cut, break, or tear of the skin that is caused by and lungs are the most susceptible organ of injury to the chest, because trauma is termed as laceration. Laceration does not only affect the of its location. Any injury to the chest can cause fractures of ribs, external part of the body, such as skin, but also affects the underlying contusions, lacerations, internal hemorrhage, that can impede blood structures of the body, such as muscle, tendons, nerves, capillaries and circulation, insufficient gas exchange, improper ventilation, instability blood vessels, and penetration of internal organs. As we focused on of body structure and other aggravating condition and complications the chest part, susceptible parts include the heart and lungs. Once a

Nursing.EliteCME.com Page 11 penetration was made to injure the lungs, it can cause a tear to the lung includes chest x-ray or chest radiographs, computed tomography tissues. It is defined to be a pulmonary laceration. [33] scanning, and thoracoscopy. In the initial chest x-rays, pulmonary Evidently, pulmonary lacerations are usually caused by penetration, lacerations are not yet clearly evident due to the hemorrhage and but a blunt trauma can also inflict laceration to the lung tissues due contusions that may mask the tissue tear. It can be present after two to to fracture of ribs. In involves damage to the architecture of the lung four days, when the lung contusion starts to disappear. On the other that can cause formation of cavities that both air and blood can fill. hand, computed tomography scanning is better and a more accurate Once a laceration was made by a trauma, it can cause leakage of air or tool to detect the severity of laceration, especially at the time when blood from the lungs to the pleural space, resulting in pneumothorax, these lacerations do not seem to be evident on chest x-rays. Pulmonary hemothorax, or hemopneumothorax. The difference in the formation of lacerations in CT scan are evident in a contused part of lung, usually hemothorax due to pulmonary contusion is that it is due to pulmonary shown as round-shaped due to appearance of air or blood-filled cavity laceration; those due to lacerations are larger in size and long lasting. and elasticity of the lungs. [32] Same on radiographs, hematoma However, hemorrhage in the lungs are not that evident due to the low appears as round smooth masses that are initially hidden with lung pressure and small blood vessels involved, but pneumothorax is more contusions, but appears as the contusions starts to heal. [33] susceptible to form. [30] Hematomas form when the laceration starts Treatment modalities for pulmonary contusions are the same as to close by itself, causing blood to be trapped . A round cyst filled with treatment for pneumothorax and hemothorax: ventilation management, air called pneumatoceles, or blood, called pulmonary hematomas, oxygen supplementation, and fluid drainage from the chest cavity with can also be formed with this closure and that usually shrinks over the insertion of a thoracostomy tube. Surgical managements are also a period of months. Edema and bleeding can cause the laceration to implied in some cases. To close the lacerated parts, stapling, suturing become severely thick. The cause of death in a patient with pulmonary or wedging is done by a surgeon. The failure of lung re-expansion laceration was uncontrollable pleural hemorrhage or disseminated may require undergoing a thoracotomy, or otherwise. Lobectomy and intravascular coagulation with hemorrhage. [31] pneumonectomy are also done occasionally. [13] Complications associated with pulmonary laceration, though not With proper management and treatment, full recovery from a commonly evident, may include air embolism (entrance of air in the pulmonary laceration can be met. Insertion of chest tubes contribute to bloodstream) that can cause death; pulmonary abscess and infection; fast healing that does not progress to major long term complications. and a possible leak of air in the pleural space, despite the insertion of a However, it would take months for an injured lung to heal, leaving a chest tube, called bronchopleural fistula. [34] scarred area to the lacerated part. Healing process may depend on the Diagnostic tests that can help a health practitioner to identify treatment size of laceration and the treatment modalities used for the injured and management of patients suffering from pulmonary contusion lung. [33]

C. Pneumothorax

Blunt or penetrating chest injury can cause further damage, not only trauma with association of hemothorax, or even hemopneumothorax to the vital organs that is surrounded by the chest wall, but also to can also be a result of traumatic pneumothorax. Other factors that the underlying pleural space. In an instance, when the chest wall is cause traumatic pneumothorax include rib fractures due to blunt penetrated by a pointed object, it can damage the pleura, causing chest injury, stab or gunshot wounds from penetrating trauma, or entrance of the air in the cavity. This occurrence of air in the pleural diaphragmatic tears. Invasive procedures, such as barotraumas from cavity is called a Pneumothorax. [13] mechanical ventilation, thoracic procedures like thoracentesis and Once penetration occurs, it creates an opening between the such, can also contribute to the unintentional penetration of pleura. environment and the pleural space that causes both intrathoracic and Chest surgery is also considered a traumatic pneumothorax. Air is less environment pressures to attempt to compensate with each other. A likely to accumulate and enter the pleural space with the procedure. penetration in the pleural space can cause a break in the fluid bond, Once a chest wall injury is large enough to allow air to enter liberally resulting in limited pleural and lung expansion. The severity of the to the thoracic cavity with each attempted respiration, a form of case, however, depends on the type and location of the wound and traumatic pneumothorax called open pneumothorax can occur. Sucking how would the wound heal itself spontaneously. Hyperresonance, chest wounds are sucking-like sounds that are produced because of a hollow tympanic sound, should be evident on a patient with the rush of air that enters through the chest wound. Lung collapse and pneumothorax upon percussion. A decrease in breath sound is also mediastinal shift or mediastinal flutter may happen next, causing an determined by auscultation. [35] In addition, a partial or complete lung impediment to the mechanism of circulation. A life-saving measure to collapse may also take place in a patient with pneumothorax. a traumatic pneumothorax includes impeding the flow of air from the chest opening. [13] [39] Variation in pneumothorax depends on the occurrence of injury to the pleural space. Therefore, it is characterized into different types: [13] Tension pneumothorax, on the other hand, describes a life- threatening condition, where air is trapped into the chest cavity. With A simple or spontaneous pneumothorax takes place when a breach a lacerated lung, air is withdrawn in the pleural space through each within the parietal or visceral pleura happens, leading the air to enter inspiration and cannot be expelled on expiration, the volume of the into the pleural space, often caused by a rupture of either a present air builds, which results in lung compression because of the increased bronchopleural fistula, or an air-filled blister or bleb of the unknown pressure in the pleural space. Because of the increased intrathoracic cause on the surface of the lungs. Primary spontaneous pneumothorax pressure, respiratory mechanism is compromised with presence of occurs in a healthy-wise person, though smoking is a risk factor for tachypnea, lung sounds on affected side are diminished, tympany and the occurrence of this; while on the other hand, secondary spontaneous hyperresonance are noted on percussion. Trachea and great vessels pneumothorax happens in patients with underlying lung disease, with shift to the unaffected side, called mediastinal shift, restricting the severe emphysema as its common cause. [13] heart’s ability to expand and impedes venous return. Other circulatory A common causation of a penetrating trauma is called the traumatic anomalies include hypotension and subsequent hypoperfusion due pneumothorax. From the term itself, it can result from a trauma in to decreased stroke volume, cyanosis, tachycardia, and markedly the chest where the air escapes from the lung laceration, or from the decreased pulse during inspiration called paradoxical pulse. Tension wound where the air enters to the pleural space. Occurrence of major pneumothorax commonly develops in patients with spontaneous

Page 12 Nursing.EliteCME.com pneumothorax but most often seen with traumatic pneumothorax, that To treat the underlying hypoxemia that is manifested in pneumothorax, may also be consequenced from mechanical ventilation. [19] supplementation of high concentration of oxygen should be given. Pleuritic sudden pain is one of the manifestations associated with Monitoring of oxygen saturation through pulse oximetry is also pneumothorax. On a simple uncomplicated pneumothorax, slight chest essential. Needle compression of pneumothorax in an emergency discomfort, minimal distress on respiration and increased respiratory situation helps to relieve the pressure, thus, expels the positive rate are possibly present. Acute respiratory distress happens when pressure to the external environment. To remove the air and fluid from the pneumothorax is large enough to result in total lung collapse. the pleural space, thus, re-expanding the lungs and re-establishing the Difficulty in breathing, air hunger, increased use of accessory muscle pressure, a chest tube is inserted and should be connected to suction. and anxiousness may be present in a patient suffering from it. Severe Surgery is performed to close prolonged air leaks despite of the aid of hypoxemia may result in cyanosis. Assessment of the tracheal chest tube drainage to the underwater seal. [13] alignment, chest expansion, and presence of breath sounds may further determine the type of pneumothorax a patient possesses. [13]

D. Hemothorax

An injury caused by a penetrating or blunt trauma can cause further Because hemothorax can be a result of both blunt chest wall injury damage to the underlying organs on the chest wall, including the and penetrating chest trauma, fractures of the rib may be associated pleural spaces beneath. Any damages can cause a leakage of air from in the origin of a hemothorax. The more severe chest fractures that the lungs or the outer environment, or blood from the damaged vessels are present, the more it can produce a large accumulation of blood in that can lead into circulatory and pulmonary anomaly. As stated earlier, the pleural cavity, leading to substantial impairment of respiration. when there is damage to the pleural space that allows the air to enter This may include simple or complex rib fractures and flail chest. through it, may lead to lung compression and other complications, Chest radiographies can show the presence of these fractures on and this is defined as a pneumothorax. On the other hand, when blood the initial evaluation; however, it cannot immediately present the accumulates on the pleural space that is caused by the damaged great underlying hemothorax until hours or days of the injury. That is why vessels, it is then defined as hemothorax. delayed hemothorax are considered after a blunt chest injury, which Hemothorax depends on the location of the origin of blood: is believed to be aggravated because of the respiratory movements extrapleural includes the leakage of blood from the great vessels such as coughing that displaces the fracture, causing disruption to the that is located in the mediastinum. Most commonly, the usual cause intercoastal and pleural spaces. On the other hand, lacerations of the of profuse bleeding is the internal arteries of the mammary and the blood vessels due to penetrating trauma can cause bleeding and blood extrapleural intercostals. On the other hand, intrapleural includes the loss, leading to impairment of circulation. [26][35] bleeding damages of the aorta and the main branch of pulmonary Clinical manifestations of hemothorax are due to the substantial arteries. This may result in a more aggravating case called massive systemic blood loss and respiratory distress. This may include pneumothorax, in which a patient shows signs of respiratory distress, evidence of signs of hypovolemic shock; decrease in blood pressure, or even shock. [35] pale, cold and clammy skin due to impediment of circulation, and The physiologic response of a patient with hemothorax also depends an increase in heart rate. Rapid, shallow breathing are also evident, on two major locations: hemodynamically and respiratory. The accompanied by restlessness. Dull sound upon percussion is also noted amount of blood loss and the rapidity of bleeding are determined on in affected area. [26] a hemodynamic response. The blood loss depends on the patient’s Supplementary oxygen is essential to a patient with hemothorax. Just weight and volume that is loss during an injury. The heavier the patient like in a pneumothorax, it aids the oxygenation and ventilation of is, the more blood loss required to produce a shock, which shows poor the respiratory aspect. Otherwise, as the hemorrhage and blood clot perfusion and may lead to exsanguinating hemorrhage. Meanwhile, was already detected through diagnostics such as chest x-rays and respiratory response depends on the accumulation of blood in the CT scans, a surgical management called tube thoracostomy should pleural space, compressing the lungs and impairs the respiratory be performed. This is said to be the primary mode of treatment for movement. The volume of blood loss also varies to the severity of the patients with hemothorax, wherein a tube was inserted in the pleural damage in the affected organ and underlying pulmonary and cardiac space. Through the tube drains the accumulated blood in the pleural reserve. The more accumulation of blood is present, the more dyspneic space, aiding treatment for the compromised respiratory mechanism. a patient will be, and may show manifestations of tachypnea. [26] [13][26] Hemothorax is initiated when blood that enters the pleural space was Complications due to hemothorax include retained clot, or undrained depicted by the motion of the lungs, diaphragm and other intrathoracic blood even with the aid of tube insertion to the pleural space. This is structure. Defibrination or the removal of a protein structure from often diagnosed through CT scan, which shows an accumulation of the blood called fibrin occurs and incomplete clotting takes place. 500ml of blood, or about one third percent on chest radiographies. Lysis of existing clots by pleural enzyme follows, that will result in A thoracoscopy is needed to be performed when the condition increase of the protein concentration of the pleural fluid, therefore also still persists. Meanwhile, presence of a superimposed infection increasing osmotic pressure of the pleural cavity. This produces an from the retained clot may cause empyema, which also requires osmotic gradient between the pleural space and the adjacent tissues surgical intervention for drainage. On the other hand, retained which favors the process of transudation of fluid into the pleural hemothorax can also result to a late, though uncommon complication space. This can progress into pleural effusion. While on the other called fibrothorax. Required treatment includes thoracotomy and hand, if hemothorax were unresolved, late physiologic sequel such as decortications, where fiber tissues are surgically removed. [26] empyema, which result in contamination of bacteria, and developed deposition of fibrin on the parietal and visceral surfaces, called fibrothorax occur. [26]

Nursing.EliteCME.com Page 13 E. Hemopheumothorax

Lungs are one of the vital organs that are encased by the chest wall, combined as one. Pain, difficulty in breathing, signs and symptoms of responsible for oxygenation and ventilation. Meanwhile, there is a impending blood circulation such as hypotension, decreased peripheral presence of elastic property that allows the chest wall and lungs to pulse and skin that is cold to touch are also evident, as they are also expand and aid movement, causing opposing force that produces signs of pneumothorax and hemothorax. As the lung collapses, it loses pressure to the alveolar and a thin dual-layered membrane that local tamponade capability. Hemorrhage can be evident as small- surrounds the lungs called the pleura. The pleura significantly protect caliber vessels can cause the bleeding in the cavities of the chest. the lungs and other vital organs from collapsing with the chest wall. Pleural effusion is also evident as the most important indicator of a It consists of a layer that is adjacent to the lungs, while another one spontaneous hemopneumothorax. A massive fluid level is shown on layer lies on the chest wall’s inner aspect. These two layers are then a chest radiograph on a patient with this case. In cases of penetrating separated by serous fluids, and the spaces between these layers are trauma, an injury called pulmonary parenchymal injury is common termed as cavities. The pleural cavities are then separated by the in patients suffering from a combination of pneumothorax and mediastinum. hemothorax. Bleeding in this case is usually self-limited. [39] Any injury caused by blunt or penetration may cause air or blood Since hemopneumothorax is a life-threatening condition, proper entrance to the pleural space, altering the respiratory and circulatory assessment and interventions are essentially done by a health pattern. Entrance of air or blood into the pleural cavity causes practitioner. This includes management and treatment that aids compression of the lungs that may lead to respiratory distress and to improve oxygenation and ventilation, as well as to correct the increased needs for oxygenation and ventilation; otherwise, it can impediment of circulation to avoid further complications that may also cause blood loss and hemorrhage that may result in impending lead to death. Usual treatment modalities for hemopneumothorax are circulatory process or shock. A term called pneumothorax is defined almost similar with hemothorax and pneumothorax. Sometimes, it aids as air enters the pleural cavity, while on the other hand, when blood to treat independently. Oxygen supplementation and improvement of accumulates inside the pleural space; it is then termed as hemothorax. ventilation are the goals that should be met to improve mechanism [13] of respiration. On the other hand, intravenous fluid support is also In some instances, both blood and air can enter the pleural space, essential for the improvement of blood circulation to the body. causing both to compromise circulation and respiration. This is termed Because of massive blood loss that a hemopneumothorax can have, to be a hemopneumothorax. In this case, both air and blood can rush blood transfusions are also an option. [37] into the pleural space in order to compensate with the atmospheric A tube thoracostomy is indicated for patients with hemopneumothorax. pressure. Disruption of pleural fluid happens, and the two membranes This drains the air and blood through a tube that is inserted in the tend to not to adhere with each other. This also shows abnormality intercoastal space, with the incision made between the ribs. In this in lung expansion, resulting in impeded respiration. In this case, the way, a negative pressure can be established in able to restore normal affected lung shrinks, making the lung collapse. [13] respiratory functioning. An alternative treatment called video-assisted Spontaneous hemopneumothorax can be a rare disorder; otherwise it thoracoscopic surgery (VATS) can also be done which directly can be a result of both pneumothorax and hemothorax that is due to a removes the clot and chest tubes are precisely placed. Thoracotomy, penetrating or blunt trauma. This is also considered a life-threatening on the other hand, is the procedure in which surgical exploration condition of a primary and secondary pneumothorax and also as a is intended for the presence of persistent bleeding or massive result of a excessive blood loss into the pleural cavity resulting in hemothorax. Other indications for thoracotomy include impaired hypovolemic shock. [36] Whitaker was the first to report a patient with expansion of the lungs, persistent air leak, hypovolemic shock and Spontaneous hemopneumothorax in 1876, and was successfully treated periodic pneumothorax. Within the exploration, control of the bleeding by thoracocentesis; while in 1948, Elrod and Murphy [37] first did a source is promoted and the hemothorax can be evacuated. [40] A decortication (surgical removal of fiber tissues) in a patient suffering combination of video-assisted thoracoscopic surgery and thoracotomy from SHP 6 weeks after the onset of symptoms. [38] can provide much more advantage, as it removes the blood clot easier and controls the bleeding source rapidly. [38] Clinical manifestations in hemopneumothorax are also similar to the manifestations seen with pneumothorax and hemothorax, which of Other surgical managements are also done to manage such injury; such course, occursmore severely than the latter two because it is definitely as sealing of the open wound through suturing, stapling or stitching, to avoid further entrance of blood and air into the affected part. [38]

V. Injury to airways

Any serious blunt or penetrating injury can cause further damage to the ventilation are involved, such as the pleura, the mediastinum, the lobes organs though they are enclosed by the chest wall. This injury results and the bronchi and bronchioles. [41] The upper respiratory tract, as in the impediment of respiration and circulation, depending on the the upper airway is most responsible for the passage of air through the organ that is inflicted by the trauma. These traumas can also result in lungs. It filters and warms the air inspired, so that the lungs can carry obstruction of airway that may lead to the impairment of gas exchange out gas exchange. The lower respiratory tract, on the other hand, is and ventilation, or destruction of blood vessels that may result in responsible for the exchange of gas, wherein oxygen was conveyed hindering perfusion. to the tissues by the bloodstream and expells waste gas, or the carbon Clear airways may provide a good circulation and exchange of dioxide through expiration. oxygen and carbon dioxide. This aids the proper respiration along Any part of the respiratory tract is susceptible for injury inflicted to with the distribution of oxygen throughout one’s system via blood the chest wall. It may cause obstruction to the airway and impairment circulation. Respiratory system plays this role. It is then divided into of gas exchange. For instance, damage to the trachea may cause the two parts: the upper respiratory tract and the lower respiratory tract. obstruction of air passage to the larynx and bronchi. The trachea is a Upper respiratory tract includes the nose and sinuses, pharynx or structure with smooth muscle and C-shaped rings of cartilage, which throat, larynx or the voice box, adenoids or pharyngeal tonsils, and the may be incomplete on the posterior surface that aids its stability by trachea or the windpipe. The lower respiratory tract, on the other hand, providing firmness in its wall. On the other hand, an injury to the includes the lungs, where essential structure for gas exchange and lower respiratory tract part, such as in the bronchi and bronchioles may

Page 14 Nursing.EliteCME.com impair the gas exchange. Bronchi are the passageway of air into the may result in a lesion from the trauma related to injured vertebrae lungs that will divide into smaller structure called bronchioles. These that may penetrate it. Lesions could be made transversely, spiral, or bronchioles are then lead to the alveoli, where oxygen and carbon longitudinal that can be present along the membranous part or to the dioxide exchange takes place. [41] ring of trachea, to the main ronchi, or even both. These injuries are The trachea and bronchi is involved in an airway structure, where also classified as incomplete (in which the layer of tissue adjacent to air and gas passes from the outer environment through the inside of the bronchus remains intact and keeps the airway intact and prevents the lungs, called the tracheobronchial tree. Any blunt or penetrating the air leaking into the neighboring parts of the airways), and complete injury that will cause damage to the tracheobronchial tree is defined (a severe tear in the tissue that cannot remain intact) [44] The most as tracheobronchial tear. Though it is commonly due to trauma, a common bronchial injury is on the right main bronchus rather than tracheobronchial tear may also be due to aspiration of liquids or the left because of the underlying structure or tissues in the chest objects or inhalation of dangerous fumes or smoke. [42] wall, such as the aorta may protect the latter [43] On the other hand, the most common tracheal injury is seen near the ridge of the trachea Blunt chest trauma due to any of the underlying etiological causes can called carina, or in the trachea membrane. [45] produce an significant amount of injury to the tracheobronchial tree. Tracheobronchial injury occurs mostly due to a blunt chest trauma Though tracheobronchial injuries are not as common as lung due to motorcycle accidents and falls that causes injury to the chest contusions or other chest injuries they can prove to be more serious wall. Aside from blunt trauma, gunshot wounds are the most common as far as the saving the life of the victim is concerned. Injuries to the penetrating injury that may result in tracheobronchial tear. [45] It airways are often so severe that most of the victims may not survive to reach the medical help. [46]

Tracheobronchial tear

Tracheobronchial tear is an uncommon occurrence with highly serious Complications of a tracheobronchial tear include subcutaneous complication following blunt chest trauma. The main reason for the emphysema that is located in the abdomen, neck, head and poor prognostic consideration is due to its hidden nature of the injury. chest. Subcutaneous emphysema is defined as air trapped in the In many cases the initial evaluation of the patient in the emergency subcutaneous tissue and can be caused by the damage in the airway, room may not reveal the signs of underlying tracheobronchial tear. letting the air transport into the subcutaneous tissue. [43] Another Emergency care health care providers are often diverted to other more complication is the pneumothorax. In this time, the air can be trapped severely looking external injuries significant enough to over look in the chest cavity outside the lungs. Atelectasis, or incomplete bronchial injuries. Highly experienced critical care or emergency care expansion of the lung, also occurs with obstructed bronchioles. Late specialists can only diagnose such injuries with keen observation and complications involve bronchiectasis and pneumonia, so as sepsis ruling out other causes of presenting symptoms. Most of the cases resulted from increased risk of infection due to delayed diagnosis, are diagnosed on day 2 of hospitalization as a case of non- resolving and worse, multi-organ dysfunction syndrome.[43] That is why it is pneumothorax even after ICD drainage tube placement. [46][47] important for patients with tracheobronchial injury to prompt an early Tracheobronchial tear means an injury to the bronchus and/or trachea diagnosis and recognition, because most people with tracheobronchial or to the mucosal layers of it leading to treat or complete transection tear die within minutes of inflicted damage due to complications. of any of it. It is often a life threatening type of injury with no specific Treatment regimen for patients with tracheobronchial tear is essential. presenting set of symptoms. Incidence rate of tracheobronchial injury This is mostly to ensure a patent airway and maintain good circulation are around 1-3 % of all the blunt chest injuries. Around 75% of injuries and exchange of gases to the lungs. One method to maintain a patent affect the area 2 cm around the carina. It is seen that right bronchus is airway to patients with tracheobronchial tear is through intubation on more prone to such injuries than the left one. [46] the uninjured bronchus. This secures ventilation to the unaffected part Clinical presentation: of the lungs. [49] Other alternative methods include laryngoscopy, or Clinical manifestations of tracheobronchial tear also depend on the tracheostomy to patients with an injured trachea, though it is used in location and the severity of damage inflicted. Signs and symptoms of moderation due to the impending infection and possible narrowing tracheobronchial injury can have a similarity to those that are present of larynx and trachea. Supplementation of oxygen is crucial to these with pneumothorax. [48] Common manifestations include difficulty patients, thus it can be supported through the use of mechanical in breathing and presence of respiratory distress. Hemoptysis, or ventilation. [49] Other treatment regimen include the management for coughing up blood can also be present due to the tear. Rapid breathing, the underlying complications such as removal of secretions, treatment diminished breath sounds, and an abnormal high-pitched breath sound of infections, and other surgical treatment such as lobectomy and called stridor is also noted due to the obstructed airway. On the other pneumonectomy associated to damaged lung tissue [50] and suturing hand, profuse bleeding is present when there is damage inflicted to of the tear if necessary [49], to support pulmonary compliance. the blood vessels that result in rupture and usually present only with isolated tracheobronchial injury cases. [43]

VI. CARDIAC INJURY

A. Cardiac tamponade

Cardiac tamponade (also known as Pericardial tamponade) is a serious It is classified into clinical presentations which are clinical syndrome brought by the filling of blood, clots, pus, gas or 1. Acute cardiac tamponade; fluids within the space between the heart muscle (myocardium) and 2. Subacute cardiac tamponade; external covering space of the heart (pericardium) placing extreme 3. Regional cardiac tamponade: and pressure in the heart. This filling of the heart is impeded by an external 4. Low pressure cardiac tamponade. [54] force. In which, the normal outer layer of the heart can stretch to fill The risks of mortality of this condition vary on the early detection, enough cardiac volume. But, when its reserve volume is exceeded, the underlying cause of the disease and treatment implemented. When this outer layer of the heart stiffens. [13] [53]

Nursing.EliteCME.com Page 15 case is not immediately attended and not treated, the condition may 4. Pale, blue or gray skin; progress rapidly and is generally fatal. [53] 5. Fainting or light headedness; One major cause of cardiac tamponade is due to the use of chest 6. Tachypnea or rapid breathing; tubes after a cardiac surgical procedure. These tubes are often used 7. Palpitations; to drain fluids. On the other hand, they may become clogged with 8. Enlargement or swelling of abdomen or other body areas. [51][55] clotted bloods and will probably make fluids to fill in the heart spaces. [56] The other causes of cardiac tamponade are most of the following The pericardial space can only accumulate from 20 to 50 ml of fluid conditions: [55] which is necessary to decrease friction for the beating heart. A high ●● High levels of radiation to the chest fluid level in the pericardial sac increases the pressure within its ●● Pericarditis – inflammation of the pericardium space and compresses the heart which increases both left and right ●● Gun shots or stab wounds ventricular end-diastolic pressures. It also decreases venous return ●● Blunt trauma to the chest from an accident (car or industrial) and ventricles will be unable to distend and fill adequately. Cardiac ●● A ruptured aortic aneurysm tamponade happens in a simple process when pericardial fluid fills ●● Punctures during placement of central lines slowly, with unnoticeable signs and symptoms, until it fills the sac ●● Accidental perforation after angiography, insertion of pacemaker, in a large amount. But, a fast developing effusion can expand the or cardiac catheterization external layer (pericardium) to its maximum size and, due to increased ●● Systemic Lupus Erythematosus – an inflammatory disease where pericardial pressure, reduce venous return to the heart and decrease the immune system mistakenly attacks the healthy tissues CO. ●● Heart attack The following are tests used to diagnose cardiac tamponade: [53][54] ●● Heart trauma [55][56] ●● Kidney failure ●● Chest x-rays present a slightly widened and enlargement of the ●● Leukemia cardiac space The signs and symptoms of cardiac tamponade may start with the ●● Echocardiography records pericardial effusion with signs of right patient reporting chest tightness, shortness of breath, or dizziness. You atrial and ventricular compression (confirmatory test) may observe that the patient is becoming progressively anxious and ●● Pulmonary artery pressure monitoring shows increased right atrial restless. Pulsus parodoxus or blood pressure that reveals a decrease of pressure or CVP and right ventricular diastolic pressure. 10 mmHg or more in the systolic blood pressure during inspiration can ●● Electrocardiography (ECG) rules out other cardiac diseases. be an assessment. More often, the systolic blood pressure decreases ●● CT and CMR while the diastolic pressure remains stable; but, the pulse pressure ●● Cardiac catheterization narrows (cardinal sign). When chest pain occurs, the patient will In most situations, the nurse must notify the physician immediately experience stabbing and sharp pain radiating to the neck, shoulder, and prepare to assist with diagnostic pericardiocentesis (puncture of back or abdomen and worsened during coughing and deep breathing. the pericardial sac to aspirate the fluid in the pericardium) if the test Usually, the patient has increased heart rate or tachycardia and the confirms the tamponade and pericardiotomy (to permit drainage of ECG test may reveal that the QRS complexes may alternate in height the pericardial fluid into the lymphatic system) if recurrent pericardial (electrical alterans) or ECG voltage may be lower than the normal effusions happen. [55] voltage. Other signs and symptoms are: 1. distended neck veins but blood pressure may be low; Treatment of the disorder depends on the cause of the tamponade. 2. Peripheral pulses are absent or weak; The patient will be given oxygen, fluids and medications to control 3. Discomfort, sometimes relieved by leaning forward or sitting the blood pressure. [56] Once the condition of the patient has been upright; controlled and stabilized, the physician will perform other additional tests to identify the underlying cause of the tamponade. [55]

B. Myocardial contusion

Blunt cardiac injury or blunt myocardial injury refers to the injury Signs and symptoms include (1) light-headedness; (2) shortness of sustained due to the trauma in the heart which can happen with a breath; (3) nausea and vomiting; (4) excessive fatigue; (5) pain in the serious body injury. The most common form is “myocardial contusion” breastbone (sternum) and: (6) feeling of racing of the heart due to that refers to bruising of the heart muscle. [58] increased heart rate. [57][58][59] There is a great difference between myocardial contusion and During physical examination, the physician may observe the myocardial infarction and they should not be confused . Myocardial following: [59] infarction is damage in the heart where there is a lack of blood ●● Rapid or shallow breathing circulation to the muscle. [58] ●● Abnormal chest movement Since the heart is well secured within the bony thorax (ribs and ●● Decreased blood pressure sternum), it requires an extreme force to cause a myocardial injury. ●● Crunching sensation when touching the skin This can be done by vehicular accidents, performing cardiopulmonary ●● Bruise or scrapes on the chest wall resuscitation (CPR), falls from a height higher than 20 feet, and person ●● Tenderness upon touching being hit by a vehicle. The right part of the heart is the usual affected ●● Fast and Irregular heartbeat area and an easy target of injury since it is the closest part to the Any of the signs and symptoms noted above must be evaluated anterior chest wall. [57][58][59] properly and immediately to prevent or decrease any possible risks and Myocardial contusion can be classified as mild to severe that varies complications if possible. [58] on the extent of injury. A medical professional should immediately Examinations and laboratory tests are also required after physical evaluate the injury to prevent complications specifically if the examination to completely identify the extent of injury to the arteries, condition has not been attended or left untreated. Severe cardiac lungs, ribs and heart. [58] contusion may cause sign and symptoms of a heart attack. [57][58][59] ●● Echocardiogram – to show the blood flow through the heart

Page 16 Nursing.EliteCME.com ●● Electrocardiogram (ECG or EKG) – monitors electrical function the patient experiences difficulty or shortness of breathing. [57][58] of the heart [59] Pacemaker may be temporarily given and some times, will be ●● X-ray of the chest permanent later. Placement of IV lines or catheter placement through ●● Computed tomography scan (CT scan) of the heart a vein, pain relievers such as acetaminophen and ibuprofen (ask your ●● Complete blood count (CBC) – helps the diagnosis by identifying doctor especially if you are pregnant or taking any pain medications), the extent of the damage; some enzymes may be available in the medications for heart rate abnormalities and low blood pressure are blood when there is damage in the heart muscles and tissues. also given upon admission. Other treatment therapies are used for heart These tests may show fast heart rhythm originating at the sinus node of injury such as blood drainage around the heart, chest tube placement the heart (sinus tachycardia), wall motion abnormalities or inability of and surgery to repair blood vessels in the chest. [57] Mild contusion the heart ventricle to contract. Injury in the ribs, lung or blood vessel can be treated and recover immediately while more serious injuries to and presence of fluid or blood in the cavity surrounding the heart the heart muscle may cause high risk for heart failure or heart rhythm (pericardium) is also visible in the intervened exams. [59] disturbance. [59] In all cases of contusion regardless of the extent of damage, the patient Accidents are not predictable and not all can be prevented. But in experiencing myocardial contusion is watched round-the-clock or some ways, certain steps must always be considered to decrease for 24 hours and continuously monitored by electrocardiogram or the risk of accidents and injuries. The National Institute of Health ECG to strictly check the functioning of the heart. During Emergency recommends taking precautionary measures including wearing treatment, the patient will be given oxygen support specifically if protective gears upon driving and working in heights. [58]

C. Traumatic arrest

Chest trauma is one of the most life-taking condition and source of has ABCDE principles (Airway, Breathing, Circulation, Disability morbidity and mortality all over the world that may lead to cardiac and Exposure). The victim must be assessed immediately and must be arrest. Cardiac arrest refers to the sudden stoppage of the function provided with a patent airway by stabilization of neck and head where of the heart to pump cardiac output and good circulation. When this there is a possible good passageway of air. When there is patency of happens, the delivery of oxygenated blood and the removal of carbon airflow, clear the mouth from blood or fluids. Breathing pattern should dioxide stop as well. The metabolism of tissue cell becomes anaerobic be checked. If it is absent, shallow or there is an abnormal breathing and respiratory and metabolic acidosis ensues. It is either ventricular pattern, manual ventilation is required by using a ventilation device or fibrillation happens in which the fibers of the muscle have a fast bag-mask device. [64] irregular twitching or periodic impulses which signals the heart muscle The rescuer also must decrease the visible bleeding of the victim by to stop. [62] applying direct compression and proper application of dressing. Pulse If the condition is associated with trauma leading to arrest, immediate must be checked and if the rescuer does not feel any pulse within 10 attention must be given. This happens when blunt and penetrating seconds, he/she must start to do cycles of chest compressions and trauma to the chest wall, pelvis, or abdomen occurs as an example. ventilation. If Automated External Defibrillator is available, use it. In certain cases, this kind of trauma may cause a clot to form inside This helps the provider to monitor the cardiac rhythm of the victim. a coronary artery or causes the artery to tear which makes blood flow [64] to the heart decrease. [60] Patients with penetrating trauma who had All throughout the management, the patient must be observed carefully an absent pulse should be seen immediately especially when they on his/her response. Know the extent of injury by removing the clothes are relatively close to a hospital with full and complete materials for ( must maintain privacy) and when all the injuries are seen, prevent survivability. They may be experiencing pericardial tamponade or low hypothermia by covering the victim. [64] blood volume (hypovolemia) due to a leaking vessel that they may survive with extensive surgical procedure. [61] ACLS is done when the patient is being transferred to the hospital. Certain interventions were also being done. This is for the continuous Patients who had blunt trauma and has an absent pulse are quite monitoring of the victim. Immediate intubation is done when there is difficult to assess. It is usually hard to identify if the medical respiratory failure (hypoxemia or hypoventilation despite of oxygen occurrence proceeded to severe trauma or not that caused the arrest. therapy) and respiratory arrest or apnea. Loss of gag reflex, depressed There must be a broad information gathering and history of the level of consciousness, thoracic injuries (trauma or contusion) and event. A cardiac arrest that is due to traumatic mechanism is called injuries associated with possible airway obstruction such as neck and “Commotio cordis” or sudden heart death which is manageable with facial injuries must also be considered to give immediate attention. CPR and AED, the same way as non-traumatic cardiac arrest. [61] Administration of medications varies on the extent of injury and Traumatic arrest usually happens outside the facilities by the condition of the victim. [64] occurrence of vehicular accident and action must be taken with basic The best management of traumatic arrest is having a focused mind and management. Basic Life Support (BLS) is used to prolong the victim’s efficiency. There must be a fast assessment for medical cause if there is life while waiting for the arrival of the rescuers with their materials absence of breathing or pulse, quickly observe for treatable reversible and ambulance to transfer to a hospital; and to prevent arrest. This causes. [61]

VII. BLOOD VESSEL INJURIES

A. Aortic rupture/ injury/ dissection

Injuries to the chest wall can cause damage to the vital organs that are and blunt injuries should be given proper attention and care, hence encased by it. This can cause impairment of respiration and circulation, proper assessment and diagnosis should be kept in mind. This will aid thus, becoming the origin of complications, and worse, leads to in able to gave appropriate management and treatment regimen, and death of a victim. That is why patients who suffer from penetrating

Nursing.EliteCME.com Page 17 also be able to identify the other underlying injuries that cause further mediastinum, following the left course of the vertebrae column, to impediment to one’s system. the esophagus and diaphragm just at the twelfth level of thoracic Any blunt or penetrating injury to the chest wall inflicts damage to the vertebrae. [64] organs such as heart and lungs. It can also damage other adjacent body On the other hand, the sphlanchnic artery originates from the structure such as pleura, bones, and major and minor blood vessels. abdominal aorta, which extends from the descending aorta to the Damages to these can contribute to the impediment of circulation and junction that lies on the fourth lumbar vertebrae. The combination of respiration. the descending part of the thoracic aorta and the abdominal aorta is Pertaining to the circulatory system, it includes the heart and the termed as the thoracoabdominal aorta. [64] different distribution of blood vessels that provides the circulation The injury to the aorta depends on the location and the layer involved. of blood all over the body, transport oxygen and nutrients, removes Typically, any portion of the aorta is at risk when blunt injury occurs, body wastes, and promotes homeostasis of the body. Whatever is but it mostly takes place at the thoracic aorta. Thus, the shearing pumped by the heart should be evenly distributed by the blood vessels forces, side and front impacts, or falls are the risks present for an aortic throughout the different body organs and the whole body. That is why injury. Patients can be classified into three major classifications when damage to a major blood vessel is a big impediment to the circulation suffering from blunt aortic injury: [65] those who contain aortic injury of blood that provides the need of different body organs. can be classified as hemodynamically stable, and can be managed There are two major blood vessels that are essential in the circulation though blood pressure monitoring and control; hemodynamically of blood. They play a crucial role in the circulatory system. The aorta unstable patients suffer from aortic hemorrhage or hemorrhage from carries the oxygenated blood that will be distributed throughout the another organ. These can be managed through control of hemorrhage; body, while the vena cava carries deoxygenated blood back to the lastly, those who suffer from worse case scenarios of aortic transaction heart, and will be oxygenated when passed through the lungs. Both and rupture can result in death. [65] major blood vessels are essential to the blood circulation. Damage to One of the aortic injuries that are caused by a blunt trauma is the the aorta can impede the circulation of oxygenated blood throughout dissection of the aorta. Aortic dissection is defined as the separation of the body. [66] the layer of the aorta, usually the intima part. Once the aortic wall is The aorta is composed of three layers: intima, media, and adventitia. exposed to sheering stress or high pulsatile pressure, causing tension The innermost layer, called intima is lined by endothelium, a delicately that result in injury or trauma, thus, rupturing and causing partition thin layer that is easily traumatized. The middle layer called media and splitting to the media of the aorta and tear connected to the consists of coated intertwining sheets of elastic tissue, smooth muscles, intima. This forms an exit tear that creates a double-barreled aorta by that is crucial for the strength of the aorta. The outermost layer, which a true lumen and a false lumen. [64] This dissection may also cause largely consists of collagen, is responsible for the blood supply of the pseudoaneurysms, or resulting in effusion of blood to the pericardial outer wall of the vessel and the production of pain is called adventitia. sac called hemopericardium, and obstructions to the coronary arteries [64] and occlusion of the arteries supplying other organs including spinal cord, kidneys, gastrointestinal tract and lower extremities. [41][66] There are two regions that disseminate the aorta: the thoracic and the abdominal. The thoracic aorta is then divided into parts. The ascending Manifestations include tearing or ripping-like chest pain that is aorta is made up of an upper tubular segment and the aortic root that is determined depending on the location of the dissection. The onset of approximately five centimeters long. Its upper tubular segment starts pain may be sudden and severe, thus, may radiate to the anterior chest, at the sinotubular junction and ends at the beginning of the aortic to the back and to the shoulders. Increased heart rate, elevation of arch. [64] Coronary arteries, aortic valve and the three sinuses of blood pressure may be present. Dyspnea and hemoptysis occurs when valsalva lie on the aortic root. In addition, its location to the midline there is obstruction to the trachea, or rupture of dissection happens to is slightly to the right, with the pericardial cavity at its proximal the pleura. Other manifestations include flank pain if the involvement portion. Meanwhile, another part of the thoracic aorta, the arch, lies of renal artery occurs, abdominal pain if the dissection happens in initially in front of the trachea and ends to the back of the left trachea the abdominal aorta, and dysphagia from the compression of the and esophagus. The arch of aorta curves between the ascending and esophagus. [64][66] descending aorta. This is where the brachiocephalic arteries originate; Dissection of the aorta can lead to serious complications. A rupture other sub-arteries that arise from this arch that carries blood to the of the aorta can cause hypotension and shock. Hemopericardium brain. This is also the origin of the pulmonary arch bifurcation, the can also result in pericardial tamponade. Regurgitations can also be pulmonary artery, to the left lung. The aortic isthmus, which is the present, depending on the affected part of the aorta. An obstruction to common site of trauma, is the term called for the junction of the the carotid artery may lead to neurologic deficits such as hemiplegia ascending and descending aorta. On the other hand, from the area of and ischemic cerebrovascular accident. Other complications are due to the left subclavian artery to the twelfth intercoastal space lies the third compression and impediment of circulation. [64] part of the aorta, the descending part. Its origin lies at the posterior

VIII. OTHER TRUNK INJURIES

Blunt and penetrating injuries can cause serious damage to the and blood vessel may impede circulation of blood; any fracture to the different organs and parts of the body. It may cost one person’s life, bones or chest wall injuries may obliterate stability. depending on the severity of trauma inflicted to him/her. It is important Trunk injuries do not only pertain to the damages inflicted to the heart to identify and assess the injury that the patient suffered. Otherwise, and lungs, but also to the adjacent body structures such as vertebrae correct diagnosis will not be identified; proper management and and gastrointestinal parts. For instance, vertebrae and thoracic spine treatment regimen will not be implied correctly, and recovery will not fracture can result in spinal cord injury and may cause neural deficits. be obtained easily. It is important to know the details of the injury and mechanism of All organs and body structures are at risk in obtaining serious injury trauma in able to identify the forces and to know the extent of injury inflicted by a trauma. Any parts that are damaged can interfere with the inflicted to the possible affected body part. The injury depends on the mechanism of system that is affected. An injury to the lungs may cause part that is affected resulting in specific injuries of the anatomical and abnormalities in oxygenation and ventilation; injuries to the heart functional features. [66] Back pain is the significant sign that there can

Page 18 Nursing.EliteCME.com be a suspected sign of the said injury. Development of neural deficits presence of air in the space in the middle of the chest between the from a thoracic vertebrae fracture and spinal cord injury can cause lungs, or called pneumomediastinum. Surgical management may symptoms such as numbness and tingling feeling, and weakness. [66] involve chest cavity drainage at the site of perforation, debridement of Injury to the esophagus during trauma can be rare and under- necrotic tissue, delineation of the degree of injury, closure of defect by diagnosed. But there are two possible mechanisms of an esophageal pedicle buttressing, and decortications of soiled pleural space. [67] injury. First, it can be a compression injury that affects crushing Other massive trunk injuries may involve the diaphragm that results between the sternum and thoracic vertebrae. Secondly, it could be an from a tear or pelvic injury; intraperitoneal organ injuries such as increase in luminal pressure on a closed glottis, resulting in blow- retroperitoneal duodenal rupture, spleen or pancreatic injury from a out damage. The patient usually shows signs of difficulty and pain blunt trauma that can cause rupture of small blood vessels, leading on swallowing. Meanwhile, classic presentation of the spontaneous to hemorrhage; liver injury that may lead to bile obstruction and also rupture of the esophagus involves severe vomiting followed by acute, hemorrhage; ureteric and renal injuries that may be also associated severe epigastric and chest pain. [69] Through palpation on the neck, with intraabdominal injuries; and pelvic fracture that may be followed an identified crepitus may be present. Chest x-ray may also show by intraperitoneal bladder and urethra rupture. [68]

IX. Types of Injuries

A. Blunt chest trauma

Blunt chest trauma can be diagnosed by the initial inspection of the to get a complete idea of the type of injury that occurred to the patient. patient along with careful history taking of the patient. The clinical Management of blunt chest trauma requires high amount of experience presentation of the patient with blunt chest trauma varies from simple and observational skills to detect early signs of the underlying injury reporting of pain in the chest to severe dyspnea along with signs of since the blunt chest trauma is a tricky case to handle due to its hidden shock. The clinical presentation depends mainly on the mechanism nature of the damage. Appropriate management starts with thorough of injury and the organs affected due to the trauma. It is extremely physical examination. [2] important to obtain a detailed history of the incidence of the accident

Physical examination

First of all, irrespective of the type of chest the trauma patient should Grading of bruising [71]: be evaluated for ABC’s for the vital status to determine whether the Bruise severity grading score patient requires cardio-pulmonary resuscitation. It should be followed Harm score Severity Notes by visual inspection. 0 Light bruise No damage 1. Visual inspection 1 Mild bruise Little damage Make the patient lie down on the examination bed. Patient should be undressed in an appropriate area for careful inspection with 2 Moderate bruise Some damage assurance of missing no important data. 3 Serious bruise Dangerous ○○ Breathing and thoracic cage signs 4 Extremely Dangerous During a careful inspection of the patient we should look for serious bruise type of breathing, the movement of the thoracic cage and look for any abnormal signs. Usually the blunt chest trauma patients 5 Critical bruise Risk of death are presented with chest pain which leads to shallow breathing Risk of death due to the underlying multiple rib fractures or contusions. ○○ Bruising graze and seatbelt signs b. Graze is one type of wound occurring due to superficial We should look for any alteration in skin color of the chest, damage to the skin without affecting the deeper layers any marks, injuries, lacerations, abrasions or bruises on the of skin. It is characterized by mild abrasions, scrapes or chest. It will give you the idea of depth and severity of the minor scratches. They usually do not produce any scar and chest trauma. If the chest trauma has occurred due to a motor do not bleed as well. Graze are a very mild degree of an vehicle accident, we should look for bruises from the seatbelts abrasion skin injury of lesser intensity than the lacerations. such as redness in the area of seatbelt, bluish discoloration, It can be seen throughout the body area where the and scratches especially in the sternal region. The depth of patient has suffered from blunt injuries or motor vehicle bruises and severity of the grazes and seatbelt signs provide accidents. Grazes are suggestive of minor degree of injury very important data to determine the severity of the injury that and suggestive that there is no underlying tissue, muscle would have affected underlying vital organs such as the heart, or organ damage that has occurred due to the chest trauma. lungs and the other bony structures. [71] a. Bruise is type of tissue hematoma in which extravasations c. Seat belt sign is the bruising occurring in the region of of blood occur into surrounding interstitial tissues like the horizontal or the diagonal strap of the seatbelt in the veins, venules and capillaries. It is clinically evident by chest or abdominal region. Presence of seat belt sign is black or bluish discoloration of the skin. It does not blench itself indicative that the victim has come across severe on pressure. Bruises are usually occurring due to internal blunt trauma and need thorough examination, evaluation bleeding from the interstitial tissues which is not seen as and may require intensive care therapy. It usually of external bleeding. Main reason for bruises are physical high severity in the high speed MVCs. Seatbelt sign compression and deceleration pressure effects which is suggestive of the severity of the collision. This sign happens as a result of blunt injuries. So a patient with signifies the underlying severe intra-abdominal injuries bruises on the chest confirms the blunt chest trauma. [71] along with the other evident injuries. Sudden increase in

Nursing.EliteCME.com Page 19 intra-abdominal pressure due to seat belt injury causes spinal injuries, diaphragmatic injuries etc in very selected thoracic duct rupture and chylo-thorax as its complication. circumstances. [74] [72] The severity of seat belt sign favors the diagnosis of 3. Treatment sternal fracture, clavicle fracture, shoulder dislocation, Treatment of blunt chest trauma starts even before the diagnosis aortic rupture etc. One should not overlook the seat belt has been made because most of the patients arrive at the sign. On the contrary the absence of seat belt sign does not emergency trauma center and require life care support irrespective rule out visceral injury. [73] of the type of injury. So initial emergency management requires Thus, visual inspection gives initial quick assessment multifunctional team work through which we can provide effective which is very helpful in determining the quick diagnosis treatment to the chest trauma victim. and plan of care for the critically ill patient. a. Analgesics 2. Diagnosis More than 90% of patients with blunt chest trauma have Diagnosis of blunt chest trauma often requires thorough physical got rib fractures. Most of the time 4 to 10 ribs are involved examination along with radiological imaging in order to evaluate with multiple rib fractures. The patient usually complains of and confirm the status of the underlying visceral injuries. Here intense pain with difficulty in breathing due to pain. Apart we have incorporated the X-ray, CT scan and MRI’s role in the from the fracture of other bony structures like the clavicle, diagnosis of blunt chest trauma. The radiological findings of sternum fracture is also a common occurrence in case of chest trauma are varied, diverse and consist of musculo-skeletal, blunt chest trauma. [2] Morbidity and mortality increases pulmonary, pleural, cardiac and mediastinal manifestations. It with those having blunt chest trauma and more than 3 rib helps in early diagnosis and quick decision making for effective fractures. Pain related to the bony fractures is one of the causes management of the patient. of poor outcome of the management of blunt chest trauma a. X- ray patients. Pain leads to poor breathing efforts, inadequate lung X-ray is a most basic radiological study required for the expansion, poor mobility and often results into complications evaluation of any type of chest trauma. Antero-posterior chest like pneumonia, venous thrombo-embolism, respiratory x-ray is a standard part of any chest trauma workup at most of distress and increase the hospital stay with poor overall the level –I trauma centers all over the world. The chest x-ray therapeutic outcome of the case. Effective pain management to facilitates in evaluating the multitude of the injury due to the facilitate deep breathing, chest physiotherapy for lung toileting blunt chest injury. The injuries like musculo-skeletal injuries and improvement of mobility are very necessary for the such as rib or sterna fracture, pulmonary injury, aortic rupture, effective blunt chest trauma management and helps to prevent hemothorax, pneumothorax, extra-pulmonary hematoma, any unlikely complications. [74] So, the primary goal of initial diaphragmatic rupture, tracheobronchial rupture etc can be treatment is to make the patient pain free with the use of easily diagnosed from the chest x-ray. [74] analgesics. For almost all the patients, this therapy comprises of administration of oral and/or parenteral analgesics. Since Apart from this, usually the patient with blunt chest trauma has the pain is always of high intensity local anesthetic agents are multiple other injuries too and are usually intubated and have often used such as bupivacaine. Those who have a singular other neck lines inserted. So the x-ray also helps to exclude rib fracture and are having severe pain can be treated with an any mal-positioning of these lines. But the x-ray provides very intercostal nerve block. Patients with multiple rib fractures and basic information. There are all the chances that x-ray may having ineffective pain control can be treated with epidural miss many injuries that can lead to mismanagement of the analgesia. [2][75] case. [74] b. Intubation b. CT Scan On arrival of the victim of blunt chest trauma, the primary goal For advance analysis and for accuracy one cannot rely alone lies to establish the ABC. Those are known as: on the x-ray findings. Patient needs to be evaluated by advance A- Airway- Look for airway, radiological diagnostic procedures. There are many incidences B- Check for breathing, that injuries which are often missed in the chest radiographs C- Establishment of circulation [2] are easily detected in the CT-Scan. Due to multiple injuries occurring at the same time with the patients, there are chances Without establishing the airway, breathing and circulation of overlying the injuries to one-another. In such cases CT further treatment may not prove to be as effective as expected. scan is very useful to detect each and every minute injury Most of the patients of blunt chest trauma often require with a clear picture. Experience suggests that CT scan mechanical aid in establishment of ABCs. To maintain assessment of the chest trauma patients also helps in deciding the adequate oxygenation to the vital organs the patient the management plans in a better way than the chest x-ray may require artificial respiration which starts with placing assessment because of more accuracy . [74] the endotrachial tube which facilitates the breathing by establishment of an adequate passage for the breathing. [2] So CT scan has become a gold standard imaging in detection Intubation is done by placing a size appropriate breathing tube of blunt chest trauma. It is specially used in the suspicion of into the trachea of the patient with the help of bronchoscope. chest trauma with thoracic spinal injuries. [74] It facilitates the breathing by avoiding blockage of trachea- c. MRI bronchial passage due to bleeding, tissues, leaking of air etc. MRI is a less frequently used imaging study in evaluation of In the victim of blunt chest trauma having lung contusions, blunt chest trauma. Unlike x-ray, CT scan it is not possible parenchymal lung injuries, trachea-bronchial injuries, massive to acquire quick images of MRI’s. It may take up to 1 hour hemo-pneumothorax, and/or flail chest often prove to be life- or more in the development of images. So this becomes very threatening due to improper oxygenation of the tissue requiring difficult since most of the trauma patients are critically injured endo-tracheal intubation in the early stage of management. and require basic or an advanced life support system which Arterial blood gas analysis (ABG) is a predetermining test are not always MRI compatible. There are limited uses of which measures the extent of ventilation, oxygenation, acid- MRI in the assessment of cardiac or pericardial injuries,

Page 20 Nursing.EliteCME.com base status of the body and helps in deciding the need of the multiple chest tube insertion. The collected material is closely endo-tracheal intubation as well as the extubation. [2] observed in terms of its quantity and quality because the initial hours following chest tube insertion decides the need for c. Mechanical ventilation surgery. [2] Mechanical ventilation, as the name suggests is an artificial respiration provided to the patient with poor functioning If the contents of the chest tube drainage remain very high in lungs with external mechanical aids. The patient with blunt volume and continuous without any improvement or there is chest trauma often fails to establish adequate breathing and presence of blood clots it is indicative that the patient may subsequently fails to provide adequate oxygenation to the body require surgical intervention. [2] parts due to injuries to the lung and the adjacent tissues. In 4. Recovery such patients, endotracheal intubation followed by mechanical Patients with blunt chest trauma are most of the time seriously ventilation through advanced computerized ventilators is injured with multiple vital organs involved. Such patients often warranted. Most of the patient requires positive pressure require prolonged hospitalization and post discharge care even mechanical ventilation. Mechanical ventilation maintains from days to months together. Usually patents are kept in the sufficient oxygenation of the blood and allows time for the intensive care units with the mechanical aids supporting the lung to recover. [2][17] life system. The patient gradually recovers his vital function d. Chest tube with normal establishment of cardio-respiratory functions. The Chest tubes are the tubes placed into the pleural space by initial recovery phase is predominated by extubation following doing a tube thoracostomy procedure. It allows the drainage withdrawal of all other life support systems. Gradually the chest of the blood, fluid or air around the lungs and facilitates lung tubes, ventilator supports and life supportive drugs are withdrawn recovery. [76] In patients of blunt chest trauma injuries to the but the patient may require a little more time to recover completely lung parecnchymal tissue is very common and often leads to from the other musculo-skeletal injuries. Follow up chest pneumothorax, hemothorax or hemopneumothorax. These radiographs is one of the proven markers used for the evaluation patients always require doing pulmonary toileting with the of the recovery of the patient from the blunt chest injuries. [2][77] help of chest tube drainage. Insertion of chest tube is done by Chest physiotherapy like vibration, suction, incentive spirometry tube thoracostomy following it the tube is connected to the and forced expiratory exercises, coughing exercise, thoracic collection system which is always of negative suction with expansion exercises, positioning, diaphragmatic breathing, pursed pressure approximately of -20cm water. The tube sucks the air, lip breathing etc helps in the fast recovery of the patient with blunt blood or fluid from the lungs. It is kept inserted till it detects chest trauma and significantly decreases the hospital stay. [77] On any such material to be sucked. Once the lungs seem to be discharge from the hospital the patient needs to be monitored for clear, the tubes are disconnected and the site is closed with wound healing and regular assessment sessions are performed in water seal. In case of hemothorax, the patient may require order to detect any developing complications in the early stage. [2]

B. Penetrating chest trauma

Penetrating chest trauma and related organ injuries are relatively easy 2. Treatments to diagnose then the blunt chest trauma due to the confined location of Treatment of penetrating chest injuries comprise of a very specific the penetrating wound which helps in initial management of the patient approach depending on the type of organ damage. But the primary with penetrating chest trauma on the basis of suspicion. treatment always starts with management and reestablishment of 1. Diagnosis ABCs followed by aggressive pain management and intensive care Diagnosis of the penetrating chest trauma starts with appropriate therapy with strict pulmonary/cardiac function evaluation. The history taking along with the physical examination followed by protocols for analgesics, ventilator supports, need of intubation specific radiological investigation depending upon the severity and and chest tube insertion remains the same as in the management of the suspicion of the organ damage. It gives primary diagnosis and blunt chest trauma as discussed earlier. [5] the emergency management can be performed. Specific treatment approach is often helpful to minimize the a. Physical examination: Physical examination is often quick in morbidity and mortality and also the hospital stay of the patient. its approach and confined to the area of injury. It comprises of The penetrating chest trauma produces massive damage to the rapid evaluation of ABCs, consciousness, cardio-respiratory organs within the chest cavity but at the same time may leave functions followed by examination of the area of injury. If the other organs functioning normally. Multiple chest penetrating vitals of the patient are within normal limits without serious traumas which is also seen leads to multiple organ damage. Such injury requiring immediate surgery, a patient is fully evaluated organ damage many times require surgical therapy for its effective with various diagnostic tests. [5] management. b. Radiological imaging: Chest radiography is one of the most basic investigations done for all cases of penetrating chest Surgical treatment trauma. Presently the multi-detector CT scan is taking its a. Chest wall injury: place as a primary diagnostic tool due to its higher efficacy Patient with chest wall injury rarely requires any surgical to image a variety of intra-thoracic structures which can be interventions. It can usually be treated with pain management, missed in the chest radiographs. [5][78][10] Echocardiography aggressive pulmonary care, intubation and mechanical is often required since the deep penetrating chest injury mostly ventilation aid along with ICU care except in certain involves cardiac injuries. [5] complicating chest wall injuries like: c. Laboratory investigation: Diagnosis of penetrating trauma ■■ Flail chest with poor pulmonary response rarely requires any laboratory findings but lab investigations ■■ Failure to wean from ventilator support are often helpful in diagnosis of any other existing illnesses ■■ Indication of thoracotomy due to other organ damage like diabetes, blood anomalies, infections or any other ■■ Secondary infection etc [5] systemic illnesses which can play a contributing role in treatment of the penetrating chest trauma. [5]

Nursing.EliteCME.com Page 21 b. Lung injuries: management of cardiac injury with timely surgical intervention Usually lung injuries due to penetrating chest trauma leads leads to a good outcome of the case. Pericardiocentesis is a to hemo-pneumothorax which can be easily treated with tube very common surgical procedure useful in a diagnostic as thoracostomy with drainage via chest tube which is most well as a therapeutic procedure. Any foreign body within the commonly used surgical treatment for the pleural space injury. heart has to be removed by emergency thoracotomy followed Pulmonary parenchymal injuries such as laceration require by intensive post-operative care. More commonly involved surgical intervention like lobar bisection and thoracostomy great vessels liable for injuries due to penetrating chest and can be easily managed by using stapling, oversewing or injuries are carotid, subclavian, aorta and the major pulmonary tractotomy. Very few patients requires pneumonectomy. [5] arteries. The surgical point of entry depends on the vessel that acquired injuries. In case of subclavian artery involvement c. Tracheo-bronchial injuries: median sternotomy is recommended. In case of involvement Almost all the patients with trachea-bronchial injuries require of descending thoracic aorta postero-lateral thoracotomy is the surgical intervention. Since the trachea-bronchial injuries are choice of incision. [5] always life-threatening in nature and emergency surgical treatment such as tracheal or bronchial repair the primary goal 3. Recovery of the surgery is end to end anastomosis with preservation of Recovery time and the scope of complete recovery of vital the blood supply. [5] function in the case of penetrating chest trauma depends upon the extent of the injury, vital organs involved and timeliness of d. Esophageal injuries: medical intervention available to the patient. Those who acquire an Injuries to the esophagus due to chest penetrating trauma are isolated organ injury may recover completely with the appropriate very uncommon. Although the surgical approach remains to management. But patients with multiple penetrating chest traumas achieve the surgical correction of the esophageal tear with end having multiple organs involved take relatively more time to to end anastomosis. recover and even may suffer from residual symptoms due to the e. Cardiac and great vessels injuries: injury. [5] Traumatic penetrating injuries to the heart may turn to be very lethal, with mortality rate of 70 to 80%. [5] Still the aggressive

X. Conclusion

Modernization and urbanization have given lots of benefits to In patients of chest trauma the presentation is varied from minor mankind but is also taking its reward through producing dangerous abrasions to deep penetrating lung or heart injuries or even sudden co-effects like increased rates of motor-vehicle accidents, terrorism, cardiac arrest. [3] So the management is totally dependent on the time uncontrolled use of fire arm, war etc. They have been producing of availability of the medical help and the extent of the vital organ significant morbidity and mortality in the form of inflicting traumatic injury. Advancement in the radiological imaging and various newer injuries, mainly the chest trauma due to injuries to the vital organs diagnostic procedures lend a hand in early diagnosis and medico- such as lungs and heart. surgical treatment of the chest trauma patient. Currently Chest trauma is the 3rd highest cause of mortality and Timely medical help, life care support, appropriate diagnosis and morbidity in the USA. Due to the emergency nature of the situation medico-surgical correction of the acquired chest trauma have surely emergency medicine has failed to develop a gold standard approach made revolution in the emergency care medicine and have led to of management of the chest trauma patient. Although health care reduction in the mortality and disability resulting from chest trauma. providers with many years of experience and expertise have Though there is scope for improvement by addressing the prevention significantly improved the therapeutic outcome of chest trauma of chest trauma in the form of taking adequate steps to minimize the patients. [3] external etiological factors contributing to the chest traumas.

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Nursing.EliteCME.com Page 23 CHEST TRAUMA Final Examination Questions Choose the best answer for questions 1 through 10 and mark your answers online at Nursing.EliteCME.com.

1. A trauma that is inflicted by a positive pressure, resulting in sudden compression of a body part (e.g., chest wall) is known as Blunt trauma.

¨¨ True  False

2. Chest wall maintains the stability of the arms and shoulder in addition to providing protection to the vital organs like heart and lung.

¨¨ True  False

3. There are a variety of means to categorize a fall injury. This helps to determine the extent of injury inflicted to a victim. International Classification of Diseases 10 Clinical Modifications (ICD-10) categorization is included in the formulation by Morse.

¨¨ True  False

4. Still pertaining to the categorization of blast injury, Secondary blast injury comprises of all other injuries caused by explosions, including chemical or thermal burns, injury from falling debris, crush injuries from collapsed structure or buildings and displaced heavy objects, toxic, dust or gas inhalations, or exposure to radiation?

¨¨ True  False

5. The volume of air that is moved with each breath but does not participate in gas exchange is termed as “Atelectasis”.

¨¨ True  False

6. Hemothorax is the consequence of blunt or penetrating chest trauma that is simply defined as the presence of blood in the pleural space.

¨¨ True  False

7. Sternum is a bone that lies in the middle of the chest wall. Any break to the sternum that is caused by a trauma is called sternal fracture ONLY when there is devision of a part of the xiphoid process of sternum

¨¨ True  False

8. The injury to the aorta depends on the location and the layer involved. Typically, any portion of the aorta is at risk when blunt injury occurs, but it mostly takes place at the thoracic aorta.

¨¨ True  False

9. Tube-thoracostomy is required to treat the Hemo-pneumothorax.

¨¨ True  False NMA05CTI15 10. Lungs consists of two layers which are separated by serous fluids. The spaces between these two layers are termed as “Mediastinum”.

¨¨ True  False

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