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Assessment1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)2.

Focused
assessmenta. Subjective data collection1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)b) Pain (see Chapter 9)c) Level of consciousness

d) Dyspneae) Vital signs or signs of life observed prior to hospital arrivalf) Cardiopulmonary
resuscitation performedg) Efforts to relieve symptoms

(1) Home remedi(2) Alternative therapies(3) Medications (a) Prescriptionb) Over-the-counter/herbal

2) Past medical history a) Current or preexisting diseases/illnessb) Previous surgeryc) Smoking history

d) Substance and/or alcohol use/abusee) Last normal menstrual period: female patients of
childbearing agef) Current medications (1) Prescription(2) Over-the-counter/herbalg) Allergiesh)
Immunization status

3) Psychological/social/environmental factors a) Extremes of ageb) Possible/actual assault, abuse, or


intimate partner violence situations (see Chapter 3)

b. Objective data collection1) General appearance a) Level of consciousness, behavior, affect

b) Posture, position of comfortc) Vital signsd) Odorse) Level of distress/discomfort

2) Inspection a) Respiratory rate, rhythm, depth, and effortb) Pulse rate, cardiac rhythm, and R-wave
amplitudec) Skin and mucosa: colord) Work of breathing: nasal flaring, accessory muscle use,
retractionse) Neck veins: flat or distendedf) Wounds to chest: open or closedg) Chest wall movement
with respirations: symmetric or asymmetrich) Paradoxical chest motion

3) Auscultation a) Breath sounds: present, absentb) Heart sounds: present, muffled

c) Bowel sounds: present, diminished, absent

4) Palpation a) Skin: temperature and moistureb) Tracheal position: midline or deviated

c) Areas of tenderness, deformity, or bony crepitusd) Subcutaneous emphysema

3. Diagnostic proceduresa. Laboratory studies1) Complete blood count (CBC) with differential

2) Serial hematocrits3) Coagulation profile

4) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine5) Arterial blood gas
(ABG)6) Type and screen, crossmatch7) Serum and urine toxicology screens8) Urinalysis; pregnancy
test in female patients of childbearing age

b. Imaging studies1) Cervical spine radiograph2) Chest radiograph3) Chest computed tomography (CT)
scan4) Focused Assessment Sonography for Trauma (FAST)5) Aortography6) Transesophageal
echocardiography (TEE)7) Multiple-gated acquisition (MUGA) scanc.Other

1) 12- to 15-lead electrocardiogram (ECG)2) Bronchoscopy or laryngoscopy3) Diagnostic peritoneal


lavage (DPL)

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems1. Ineffective airway clearance

2. Ineffective breathing pattern3. Impaired gas exchange4. Decreased cardiac output5. Deficient fluid
volume6. Acute pain7. Anxiety/fear8. Risk for infection9. Deficient knowledge

C. Planning and Implementation/Interventions1. Determine priorities of carea. Maintain airway,


breathing, and circulation (see Chapters 1 and 31)b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood products/medications


d. Obtain and set up equipment and suppliese. Prepare for/assist with medical interventionsf.
Administer pharmacologic therapy as ordered2. Relieve anxiety/apprehension3. Allow significant
others to remain with patient if supportive

4. Educate patient and significant othersD. Evaluation and Ongoing Monitoring1. Continuously
monitor and treat as indicated2. Monitor patient response/outcomes, and modify nursing care plan
as appropriate3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or
plan of careE. Documentation of Interventions and Patient ResponseF. Age-Related Considerations

1. Pediatrica. Growth or development related1) Ribs are more compliant2) Mediastinum thinner,
more mobile) Infants are obligate nose breathers; children depend on their diaphragm for adequate
chest expansion; may exhibit grunting or head bobbing with increased work of breathing (nasal flaring,
accessory muscle use, retractions)) Airways are small and easily obstructed by edema or mucus

5) Children’s metabolic rate and oxygen consumption are much higher than those of adults

b. “Pearls”1) Increased thoracic compliance may result in internal injury without external evidence of
trauma (visual or chest radiograph findings)2) Airway resistance in infants is 15 times greater than in
adults3) Accessory muscles of inspiration tire quickly, owing to less reserve muscle glycogen4)
Obstructive shock and multiple varieties of dysrhythmias are unusual in pediatric patients

2. Geriatrica. Aging related1) Decreased vital capacity, forced expiratory volume, maximum
midexpiratory flow2) Increased residual volume and functional residual capacity3) Decreased static
muscle strength and elastic lung recoil4) Decreased diffusion capacity and arterial oxygenation5)
Increased ventilation-perfusion inequality, alveolar-arterial oxygen gradient

b. “Pearls”1) Pulmonary defense mechanisms are reduced, making older adults more susceptible to
infections2) Diminished ventilatory response to hypoxic and hypercapnic challenge

3) Elderly persons report dyspnea as breathlessness4) Causes of dyspnea in elderly patients may
include the following: a) Functional impairment of pulmonary or cardiopulmonary systemb) Impaired
ventilation secondary to supine positioning5) ECG may be necessary because dyspnea may be
associated with an acute myocardial infarction6) Aspiration mortality rate of 40% to 70%; also
significant cause of pulmonary morbidity7) Concurrent use of medications may mask classic clinical
signs following trauma

II. SPECIFIC THORACIC EMERGENCIES

A. Rib and Sternal FracturesRib fractures are common thoracic injuries, usually resulting from blunt
force or crush injuries during motor vehicle crashes. Rib fractures are not by themselves
life-threatening, but they are especially significant because they may be associated with underlying
lung injury. Fractures of the sternum, first, and second ribs rarely occur; however, because they are
associated with significant force, they are commonly associated with injury to the lungs, aortic arch,
or vertebral column. First rib fractures have a 40% mortality rate because of the frequently associated
laceration of the subclavian artery or vein. Left lower rib fractures are associated with splenic injury in
20% of patients. Right lower rib fractures are associated with hepatic injury in 10% of patients. Sternal
fractures are associated with an increased incidence of blunt cardiac injury. Children’s ribs and
sternum are very flexible, making rib fractures less common in children than in adults, but children
with rib fractures still can present with significant underlying lung injury. The treatment for all age
groups with rib fractures is very similar.

1. Assessment. Subjective data collectioN

1) History of present injury/chief complaint a) Pain (see Chapter 9): localized pain, aggravated by
chest wall movement, palpation, or inspirationb) Onset may be associated with severe coughingc)
Dyspnead) Mechanism of injury (see Chapter 30)2) Past medical history a) Current or preexisting
diseases/illness (1) Pulmonary disease(2) Osteodegenerative processesb) Medicationsc) Allergiesd)
Immunization status

b. Objective data collection1) Physical examination a) General appearance (1) Position intended to
splint injured area(2) Facial expression of pain on movement

(3) Moderate distress/discomfortb) Inspection (1) Chest wall contusion or ecchymosis(2)


Hypoventilationc) Auscultation (1) Breath sounds: diminishedd) Palpation (1) Localized point
tenderness2) Bony crepitus or deformity(3) Subcutaneous emphysema if underlying pneumothorax or
tracheal injury2) Diagnostic procedures a) ABGsb) Chest radiographc) ECG

2. Analysis: differential nursing diagnoses/collaborative problemsa. Ineffective breathing pattern

b. Acute painc. Activity intolerance

3. Planning and implementation/interventionsa. Maintain airway, breathing, and circulation (see


Chapters 1 and 31). Provide supplemental oxygen as indicatedc. Establish IV access for administration
of crystalloid fluids/medications as neededd. Prepare for/assist with medical interventions1) Place in
high Fowler’s position, or position of comfort, to facilitate ventilation2) Institute cardiac and pulse
oximetry monitoring3) Incentive spirometry to help prevent atelectasis during recovery4) Assist with
collection and maintenance of physical and forensic evidence as indicated (see Chapter 43)5) Assist
with possible hospitalization if any of the following:

a) Fractures of more than three adjacent ribsb) Fracture of first or second ribc) Suspected underlying
visceral injury, sternal fracture, or hypoxiae. Administer pharmacologic therapy as orde4) Tetanus
immunization if open wounds.f. Educate patient and significant others1) Importance of analgesia2)
Appropriate splinting techniques) Hydration and breathing exercises, including incentive spirometry4)
Sandbags, strapping, or rib belts are not currently used4. Evaluation and ongoing monitoring (see
Appendix B)a. Hemodynamic statub. Breath sounds and pulse oximetry. Cardiac rate and rhythm

d. Pain relief

B. Flail ChestFlail chest occurs when two or more adjacent ribs are fractured in two or more locations
or when the sternum is detached. The result is a free-floating segment that is drawn inward with
inspiration and outward with expiration, thus causing paradoxical motion during respiration. The flail
segment may not be clinically evident for several hours after injury because of muscle spasms and
splinting of the injured area. Flail chest injuries are painful and cause impaired ventilation. Inefficient
ventilation is caused by the loss of the bellows effect (less negative intrapleural pressure to expand
the lung) and associated pulmonary contusion, dead space, and atelectasis. The patient has increased
respiratory effort, decreased tidal volume, impaired cough, and hypoxia. Associated injuries may
include underlying hemothorax, pneumothorax, pulmonary contusion, and blunt cardiac injury.

1. Assessmenta. Subjective data collection1) History of present injury/chief complaint a) Pain (see
Chapter 9): localized chest painb) Dyspneac) Mechanism of injury (see Chapter 30)

2) Past medical history a) Current or preexisting diseases/illness 1) Osteodegenerative processes

(2) Pulmonary disease(3) Cardiovascular disease

b) Recent thoracic surgery

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection


1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: restlessness or confusion

(2) Position intended to splint injured area

(3) Hypotension, tachycardia, tachypnea

(4) Severe distress/discomfort

b) Inspection

(1) Chest wall contusion or ecchymosis

(2) Paradoxical chest motion

(3) Hyperventilation

(4) Work of breathing: nasal flaring, accessory muscle use, retractions

c) Auscultation

(1) Breath sounds: diminished or absent on injured side

(2) Heart sounds: distinct

d) Palpation

(1) Localized point tenderness

(2) Bony crepitus or deformity

(3) Subcutaneous emphysema if underlying pneumothorax or tracheal injury

2) Diagnostic procedures

a) ABGs

b) CBC with differential

c) Type and crossmatch

d) Urinalysis; pregnancy test in female patients of childbearing age

hest radiograph

f) Cervical spine radiograph

g) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired gas exchange

b. Ineffective breathing pattern

c. Acute pain

d. Anxiety/fear

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)


b. Provide supplemental oxygen

1) Rapid-sequence intubation (RSI) and ventilatory support in patients with respiratory compromise

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluids/blood products/medications

1) Infuse warmed normal saline solutio

d. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Stabilize injured chest wall: place patient on injured side in semi-Fowler’s position, or position of
comfort, to facilitate ventilation

3) Institute cardiac and pulse oximetry monitoring

4) Maintain normothermic body temperature

5) Insert gastric tube and attach to suction

6) Insert indwelling urinary catheter

7) Assist with collection and maintenance of physical and forensic evidence if indicated (see Chapter
43)

8) Assist with hospital admission or transfer to an institution providing a higher level of care

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Non-narcotic analgesics

3) Nrcotics

4) Tetanus immunization if wound opens

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Hemodynamic status

c. Breath sounds and pulse oximetry

d. Cardiac rate and rhythm

e. Intake and output

f. Pain relief
C. PneumothoraxPneumothorax results when air enters the pleural space. It causes a loss of negative
intrapleural pressure and subsequent partial or total collapse of the lung on the affected side.
Pneumothorax may occur following either blunt or penetrating thoracic injury, if a laceration occurs
from either a fractured rib or penetrating object, or when increased intrathoracic pressure produces a
ruptured bleb. In addition, mechanical ventilation or iatrogenic procedures in the trauma patient may
cause pneumothorax. Pneumothorax may be simple or closed (no external opening) or open (wound
through the chest wall present).

1. Assessme

a. Subjective data collection

1) History of present injury/chief complaint

a) Patient may be asymptomatic, especially if pneumothorax is small

b) Pain (see Chapter 9): localized chest pain

c) Dyspnea

d) Mechanism of injury (see Chapter 30)

2) Past medical history

a) Current or preexisting diseases/illness

(1) Pulmonary disease

b) Medications

c) Allergies

d) Immunization status

b. Objective data collection

1) hysical examination

a) General appearance

(1) Position intended to facilitate respiration

(2) Tachypnea

(3) Moderate to severe distress/discomfort

b) Inspection

(1) Chest wall contusion, ecchymosis, or open wound

c) Auscultation

(1) Breath sounds: decreased or absent on injured side

(2) Sucking sound from chest if open pneumothorax

d) Palpation/percussion

(1) Localized point tenderness to injured chest wall

(2) Bony crepitus or deformity

(3) Subcutaneous emphysema


(4) Hyperresonance on injured side

2) Diagnostic procedures

a) ABGs

b) CBC with differential

c) Chest radiograph

d) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired gas exchange

Initial Actions and Primary SurveyLife-threatening injuries associated with thoracic injuries are often
identified in the primary survey by carefully assessing the patient’s ABCs. The injuries to be identified
and treated during the primary surveyare:

1.Airway obstruction

2.Tension pneumothorax

3.Open pneumothorax

4.Flail chest and pulmonary contusion

5.Massive hemothorax

6.Cardiac tamponade

These injuries usually require simple interventions such as intubation, needle decompression, tube
thoracotomy, or pericardiocentesis. These life-threatening injuries and related problems are
resolved as they are discovered. Chest trauma patients can present to the ED via Emergency Medical
Services, in which case they will be back-boarded and collared. They can also present as walk in in
which case it is prudent to apply C-Spine collars and proceed with Advanced Trauma Life Support
Assessment.All trauma patients must be managed in accordance with ATLS algorithms1:

•A (Airway with c-spine protection): Is the patient speaking in full sentences?

•B (Breathing and Ventilation): Is the breathing labored? Bilateral symmetric breath sounds?

•C (Circulation with hemorrhage control): Pulses present and symmetric? Skin appearance (cold
clammy, warm well perfused)

•D (Disability): GCS scale? Moving all extremities?

•E (Exposure/Environmental Control): Completely expose the patient. Rectal tone? Gross blood per
rectum?

•IV – 2 large bore (minimum 18 Gauge) Antecubital IV

•O2 – Nasal cannula, Face Mask

•Monitor: Place patient on monitor.

If patient’s primary survey is intact, the adjuncts to the primary survey and resuscitation begins. The
adjuncts to the primary survey include any of the following as necessary: EKG, ABG, chest X-ray, pelvis
x-ray, urinary catheter, eFAST exam and/or DPL.
Next, a secondary survey must be performed. The secondary survey is the complete history and
physical examination. This is completed after the primary survey and vital functions are returning to
normal. Start by taking an “AMPLE” history. Chest exam should detail exit and entry wounds,
number of wounds, ecchymosis and deformities, paradoxical movement. Bedside sonography should
be used to perform an eFAST exam.

Details of the trauma mechanism are crucial. For motor vehicle accidents (MVAs) speed of collision,
position of colliding car to each other, position of patient in the car, seatbelt use, extent of car
damage (intrusion, wind shield damage, difficulty of extrication, air bag deployment) are important
elements to elicit. With respect to falls, height of fall is very important. With respect to gun shot
wounds, kind of gun, distance from the shooter, number of shots heard are all relevant. For stab
wounds, it is prudent to obtain information on kind of weapon used.

Chest trauma can lead to several serious injuries. Chest trauma patients usually present with chest
pain and shortness of breath, but can also present in shock (altered mental status) or in traumatic
arrest. Presenting vital signs tend to range from slightly abnormal to floridly unstable. Thoracic
injuries are identified by primary survey signs: tachypnea, respiratory distress, hypoxia, tracheal
deviation, breath sounds, percussion abnormalities, and chest wall deformity 1Chest trauma injuries
can range from simple pneumothorax (PTX) to flail chest to cardiac tamponade. Any injury within the
“box” described as the region in between the nipple lines, inferior neck line and diaphragm result in
injury to underlying organs.

Tension PTX typically presents with shortness of breath chest pain in the setting of trauma and in
certain cases traumatic arrest. Presenting clinical findings include absent breath sounds ipsilateral to
the PTX, tracheal deviation opposite to the PTX, crepitus and jugular venous distension. Bedside
sonogram can be used to confirm the absence of lung sliding on the site of suspicion. Once the
diagnosis is made patients should undergo prompt needle decompression followed by tube
thoracostomy. Tension pneumothorax is a clinical diagnosis and there should be no delays in
obtaining portable chest x rays to make this diagnosis.

PneumothoraxThe presentation for this entity is typically less dramatic than tension pneumothorax.
Patients present with chest pain and shortness of breath, tachycardia, tachypnea, hypoxia. On
physical exam they often have bilateral breath sounds, although typically asymmetric with decreased
noted on the site of the PTX. Chest X-ray (figure 1a) and bedside ultrasonography (figure 1b) is useful
in making the diagnosis.

Figure 1a. Simple traumatic left sided pneumothorax.4Figure 1a. Simple traumatic left sided
pneumothorax.4Figure 1b: Ultrasound image including M Mode demonstrating a pneumothorax.
Image courtesy of Creagh Boulger MD, The Ohio State University Wexner Medical Center. Figure 1b:
Ultrasound image including M Mode demonstrating a pneumothorax. Image courtesy of Creagh
Boulger MD, The Ohio State University Wexner Medical Center.

Open pneumothorax is a sucking chest wall wound from penetrating injury, usually with a big defect
in the chest wall. Patients present with chest pain shortness of breath with sonorous breath sounds
on physical exam, sucking air from wound and shallow respirations. It is treated by placement of a
square dressing tape on three sides to create an escape valve. If this is not performed, this injury can
turn into a tension PTX. Ultimately a chest tube is placed ipsilateral to the side of the wound but at a
different anatomic location than the wound.

HemothoraxPatients present with shortness of breath, chest pain or occasionally asymptomatic.


Typically presents with decreased breath sounds, dullness to percussion on exam. Although vital signs
typically indicate tachycardia, tachypnea or hypoxia, occasionally they can present as completely
normal. The diagnosis can be confirmed with a bedside ultrasound which can reliably reveal the
presence of a hemothorax. Although chest Xray can be utilized, the sensitivity of an upright chest Xray
exceeds that of a portable. The typical treatment is placement of a chest tube. If the hemothorax is
retained despite the chest tube then a video assisted thorascopic surgery is recommended.
Indications for emergent surgery are greater than 1500 ml of blood on initial chest tube placement
and if there is greater than 200 ml/hour of blood for 2-4 hours. Diagnosis can also be made using
bedside ultrasonography (figure 2).

Figure 2: Shows a collection of blood above (to the left on the figure) the diaphragm on this
Hepatorenal view ultrasound (courtesy of Creagh Boulger MD, The Ohio State University Wexner
Medical Center).Figure 2: Shows a collection of blood above (to the left on the figure) the diaphragm
on this Hepatorenal view ultrasound (courtesy of Creagh Boulger MD, The Ohio State University
Wexner Medical Center).

Flail ChestOccurs when patients suffer multiple rib fractures (3 or more ribs in 2 places). Pulmonary
contusion is a frequent complication. Patients present with chest pain, dyspnea, painful respirations
and are tachycardic, tachypneic and hypoxic. Clinical findings are pertinent for a visible or palpable
deformity, bruising or crepitus, paradoxical movement and splinting with secondary hypoventilation.
Chest X-Ray can be used to make the diagnosis (figure 3). Early intubation is advocated in elderly
patients, those with multiple rib fractures or if patients are in respiratory failure. The treatment goal
is to re-expand the lung with CPAP (positive pressure) or physiotherapy, and to avoid atelectasis. For
patients with less severe injuries pain control and incentive spirometry can be attempted. All patients
need admission for observation.

Figure 3. A patient with flail chest and pulmonary contusions on the chest X ray.5

Figure 3. A patient with flail chest and pulmonary contusions on the chest X ray.5

Pulmonary ContusionSevere blunt chest trauma causes leakage of blood and proteins into alveoli
causing atelectasis and that can lead to ARDS (figure 3). Patients with pulmonary contusions can be
occasionally asymptomatic but often present with shortness of breath, chest pain, hemoptysis and
cough. On exam tachypnea, tachycardia, hypoxia is common. In severe cases ecchymosis can be
evident over chest wall and decreased breath sounds on auscultation. Although CXR is typically
performed the initial CXR can be relatively normal especially within the first 6-12 hours. CT has a
greater sensitivity and specificity for diagnosis of pulmonary contusions. For large pulmonary
contusions patients need to be intubated. Smaller contusions can be managed with conservative
management that includes incentive spirometry, pulmonary toilet, pain control and careful fluid
administration.

Cardiac ContusionThe right atrium/ventricle are most commonly injured in blunt chest trauma. This
injury is closely associated with sternal fractures. Patients may present with lack of any specific signs
or symptoms however most report some chest pain. Physical exam may be completely normal. Some
patients can have chest wall contusions. Those with sternal fractures will have obvious sternal pain.
40% of patients with cardiac contusions can develop signs of decreased cardiac output. Diagnosis
requires a high clinical suspicion. EKG usually shows non-specific findings. First-degree AV block, PVCs,
RBBB can sometimes be seen. Cardiac enzymes can be sent but these have no role in making the
diagnosis. Patients with suspected cardiac contusions need to have formal echocardiograms
(2D-ECHOs) for evaluation of EF. They should be observed for at least 23 hours on telemetry as they
are at risk of developing dysrhythmias and cardiogenic shock. If the 2D-ECHO shows a reduced EF
(new from prior) patients should undergo a dobutamine stress test. Elderly individuals are high risk
for this entity and it is important to note that frequently they may present to the ER 12-72 hours after
injury with signs of cardiac compromise.

Cardiac TamponadePenetrating injury to the heart (penetrating cardiac injury) with subsequent
tamponade. Patients present with chest pain shortness of breath, with air hunger, frequently altered
mental status. On exam Beck’s triad (hypotension JVD and distant heart sounds) is sometimes present.
More frequently patients present hypotensive in shock, with pulsus parodoxus and narrowing of pulse
pressure. Diagnosis is clinical however can be made with bedside sonogram while performing the
eFAST exam (figure 4). Although EKG can show electrical alternans, it is not frequently seen in
traumatic tamponade. CXR can show an enlarged cardiac silhouette. In hemodynamically stable
patients pericardiocentesis is indicated. Unstable patients need emergency surgical intervention in
the OR. If patients lose their vitals while in the ED, ED thoracotomy is indicated.

Figure 4. Pericardial Tamponade on bedside eFAST exam.6Figure 4. Pericardial Tamponade on


bedside eFAST exam.6

Blunt Aortic InjuryUsually seen in sudden deceleration type injuries secondary to abrupt
deceleration from > 30 mph or > 40 ft fall. Majority of injuries are proximal aortic injuries. Patients fall
into three categories: A) dead on scene – presumed complete aortic transection on impact. B)
hemodynamically unstable – full thickness transection with active hemorrhage from aorta (look for
non sustained improvement in BP on fluid bolus). C. Hemodynamically stable patients – partial
thickness transection with possibility of pseudoaneurysm aorta with vague complaints including
chest/back pain and lower extremity complaints. In unstable patients apart from hemodynamic
instability, patients can present with a left sided hemothorax. In stable patients physical findings are
nonspecific, however look for chest wall contusion, pulse and blood pressure discrepancy in
extremities. Diagnosis is suggested is the mediastinum is widened on a CXR (figure 5). A CTA (spiral CT)
is diagnostic. Angiography is considered the gold standard and only performed if the spiral CT is
unequivocal. TEE can be used for unstable patients however they need to be intubated prior to this
test. The treatment for hemodynamically unstable patients is emergent surgery to cross clamp the
aorta. For stable patients aggressive BP control to a SBP< 120 mmHg followed by eventual surgical
correction is advocated.

Figure 5. Widened mediastinum in a patient with blunt chest injury.7Figure 5. Widened mediastinum
in a patient with blunt chest injury.7

Great Vessel InjuryGreat vessels include the aorta, vena cava and pulmonary trunk. Patients present
with unstable and hypotensive with minimal improvement in blood pressure on fluid challenge. Most
patients present in frank hypovolemic shock. Physical findings suspicions for great vessel injuries
include an expanding hematoma, acute superior vena cava syndrome, hematoma compressing
trachea. Diagnosis is primarily clinical. If patient is stable enough for advanced imaging, a CTA or
Angiography are helpful, however most patients are unstable and need emergent surgical
intervention (OR thoracotomy). Treatment consists of initial fluid resuscitation followed by
transfusion of packed RBC.

Traumatic Arrest Secondary to Penetrating Chest TraumaA traumatic arrest from penetrating chest
injury can occur due to penetrating cardiac injury and great vessel injury leading to massive
hemorrhage. In these situations, closed CPR is futile. Management requires stabilization of airway via
endotracheal intubation, bilateral chest tubes and ED thoracotomy which allows open heart CPR,
pericardiotomy and cross clamping of the aorta. If a pulse is obtained after said interventions,
patients need STAT surgical intervention in the OR. Patients with a penetrating injury and PEA within
5 minutes of arrival are appropriate candidates for resuscitative thoracotomy. Important caveats
include the fact that a qualified surgeon must be present at the time of the patient’s arrival to
determine the need for and potential success of an emergency department resuscitative
thora-cotomy (ATLS 9th Edition).

Diagnostic Testing1.Chest X-ray: All chest trauma patients should receive a portable chest radiograph.
However, the sensitivity of a chest radiograph is only 65% for detection of acute traumatic injuries
such as pneumothoraxes/hemothoraxes. Chest CTs have a much higher sensitivity for detection of
acute traumatic chest injuries, however in unstable patients Chest CTs may not be an immediate
option.
2.eFAST Ultrasound: Recent studies8 have also established the utility of bedside ultrasound –
specifically the eFAST exam in the diagnosis and management of several acute chest injuries such as
hemo and pneumothorax as well as tamponade.

3.EKG: May be helpful in patients with blunt chest trauma or single car MVA’s to help elucidate a
cause of the accident.

4.Pulse Oximetry: To assess adequacy of oxygenation and need for supplemental O2.

5.Blood work including ABG does not have utility in making the diagnosis of any of the conditions
listed above. As a general rule for all trauma patients a type and screen must always be requested. In
cases where massive transfusion is expected, a massive transfusion protocol should be activated.

TreatmentThe goal of treating patients with chest injuries is to establish normal gas exchange and
normal hemodynamics. That said, the specific treatment depends on the actual traumatic condition:

•Hemodynamically unstable patients: Packed RBC (O-Neg) transfusion), consideration of STAT OR for
surgical intervention.

•Pneumothorax: Tube thoracostomy. Please see video:


http://www.nejm.org/doi/full/10.1056/NEJMvcm071974.9

•Open Pneumothorax: Tape wound and tube placement at site separate from injury

•Hemothorax: As above, except if greater than 1500 cc of blood obtained on initial chest tube
placement or more than 150-200cc/hr x 4 hours, patient needs to go to the OR under Cardiothoracic
surgery.

•Flail Chest: Symptomatic Support, intubate and ventilate as needed. Incentive spirometry. In
extreme cases patient may need cardiothoracic surgical intervention.

•Pulmonary Contusion: Symptomatic support, high flow oxygen, early intubation if needed, incentive
spirometry.

•Cardiac Contusion: Monitoring if any significant changes in ejection fraction

•Cardiac Tamponade: Pericardiocentesis followed by OR thoracotomy. Please see video:


http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841.10

•Blunt Aortic Injury: If stable blood pressure control followed by close observation and delayed aortic
repair. If unstable, massive transfusion protocol, transfuse pRBC and stat emergency aortic repair by
Cardiothoracic and Vascular surgery.

•Great Vessel Injury: Typically unstable shock like presentation: Massive transfusion with concurrent
OR thoracotomy.

Resuscitative Thoracotomy Indications 1,11

•Patients with a penetrating injury and PEA, especially if the loss of signs of life is recent, are
appropriate candidates for resuscitative thoracotomy.

•A qualified surgeon must be present at the time of the patient’s arrival to determine the need and
potential for success of an emergency department resuscitative thoracotomy.

•Once the chest is opened, bleeding must be controlled.


ughes Classification of Ocular Burns

Grade 2 (Good prognosis)


Grade 1 (Very good prognosis)
 Corneal haze but iris details are clear.
 No corneal opacity nor limbal ischemia.
 Less than 1/3 cornea limbus ischemia.

Grade 3 (Guarded prognosis) Grade 4 (Poor prognosis)

 Sufficient corneal haze to obscure iris  Opaque cornea without view of iris or
details. pupil.
 1/3 to 1/2 of cornea limbus ischemia.  More than 1/2 of cornea limbus ischemia.

ALIKEurn due to contact with concentrated anhydrous ammonia in an industrial accident. Note the
necrotic tissue, small area of inferior limbal ischemia, and epithelial defect of the cornea. There was
good iris and pupil details on examination. This was a grade 2 ocular burn.

MANAGEMENT OF CHEMICAL BURNS


Grading helps to determine the aggressiveness and course of treatment. Treatment modalities include
some or all of the following depending on the severity of the burn:

 Debride necrotic tissue


 Bandage contact lens
 Quinolone: 1 drop 4-6x/day (prevents infection)
 Prednisolone phosphate: 1 drop every 1-2 hr while awake to reduce inflammation
 Vitamin C: 1-2 gm orally daily to reduce corneal thinning/ulceration
 10% sodium citrate: 1 drop every 2 hr while awake (chelates calcium and impairs
polymorphonuclear leukocyte (PMN) chemotaxis)
 Scopolamine 0.25%: 1 drop three times daily (reduces pain/scarring with anterior chamber
inflammation)
 10% Mucomyst® (n-acetyl-cysteine): 1 drop 6x/day (mucolytic agent and collagenase
inhibitor)
 Doxycycline 100 mg orally twice daily (collagenase inhibitor)
 Glaucoma drops/oral acetazolamide (Diamox®) if IOP elevated
 Significant injury may require admission

ENDOPHTHALMITISpatient with endophthalmitis presenting with decreased vision,


pain, redness, and layered white blood cells in the anterior chamber (hypopyon).

The Endophthalmitis Vitrectomy Study (EVS) [2] applies only to post-cataract endophthalmitis. The
study states that patients did better with a vitrectomy and injection of intravitreal antibiotics when
the vision is light perception or worse. If vision is hand motions or better, then patients with a TAP
(vitreous biopsy and culture) and intravitreal injection of antibiotics did as well as patients who had a
vitrectomy and injection of intravitreal antibiotics.
If referral doctor suspects endophthalmitis, ask about penicillin allergy before patient is enroute.

Order intravitreal antibiotics immediately.

Call the senior resident so they can help you set up the minor room for a tap and inject. This can be
difficult if the patient does not have a hospital number. In the past, I have given the patient's name and
birthdate to the pharmacist, and they can look up the patient after they check in. The intravitreal
injections only have a shelf life of about 2 hours, so do not order them too early.

Obtain gram stain and culture media (plates & liquid culture media) for aqueous and vitreous (1 set for
each).

INTRAVITREAL ANTIMICROBIAL CONCENTRATIONS

Intravitreal vancomycin: 1 mg/0.1 ml in 1 cc syringe.

Intravitreal ceftazidime: 2.25 mg/0.1 ml in 1 cc syringe.

Penicillin Allergy: Intravitreal gentamycin: 100 µg/0.1 ml in 1 cc syringe or amikacin 200-400


µg/0.1 ml in 1 cc syringe. Some attending physicians prefer amikacin, due to its somewhat better
toxicity profile.

Be sure there is at least 0.5 ml of antibiotic in syringe so you can transfer to a sterile syringe and still
have enough left for your injection.

Suspect Bacillus cereus: Intravitreal clindamycin: 0.5 mg/0.1 ml (optional). To date, B. cereus is
sensitive to Vancomycin.

Suspect fungus: Intravitreal amphotericin B: 5-10 µg/0.1 ml.

References

Nerad, JA. Oculoplastic Surgery. The Requisites in Ophthalmology. Mosby 2001. 348--386.

Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of
intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis
Vitrectomy Study Group. Arch Ophthalmol. 1995. Dec; 113 (12): 1479-96.

Thach, Allen B. Ophthalmic Care of the Combat Casualty. Textbook of the Military Medicine Series.
Office of The Surgeon General, United States Army. June 1, 2003.

Virtual Naval Hospital. Ocular Trauma Manual. http://www.vnh.org/Providers.html (noted on review,


Jan 2011, this resource has been discontinued by the US Government, an archived copy may be found
at http://web.archive.org)

Wagoner, MD. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv
Ophthalmol. 1997 Jan-Feb; 41 (4): 275-313.

last updated: 1-28-2008; reviewed 2-11-2011