THORACIC AND NECK TRAUMA

THORACIC AND NECK TRAUMA OBJECTIVES

Upon completion of this chapter/lecture, the learner should be able to:
1. Identify the common mechanisms of injury associated with thoracic and neck
trauma.
2. Describe the patho physiologic changes as a basis for the signs and symptoms.
3. Discuss the nursing assessment of patients with thoracic and neck trauma.
4. Based on the assessment data. Identify appropriate nursing diagnoses and expected
outcomes associated with patients with thoracic and neck trauma.
5. Plan appropriate interventions for patients with thoracic or neck trauma.
6. Evaluate the effectiveness of nursing interventions for patients with thoracic or neck
trauma.

INTRODUCTION
Epidemiology
Patients with trauma to the chest and neck present some of the most life-threatening conditions in
emergency care. Thoracic injuries are second only to brain and spinal cord injuries as the leading
causes of traumatic death.
Improvements in the overall provision of trauma care have contributed to a continued decline in
mortality
related to neck injures. Most studies have reported a 2 to 6% mortality rate from neck injuries'
The increase in interpersonal violence has had an impact on the pattern of injuries to the chest
and neck.

Mechanisms of Injury and Biomechanics

Mechanical energy is the most common energy source associated with chest and neck injuries.
Acceleration and deceleration forces may be responsible for injuries to intrathoracic contents.
The first and second ribs and the sternum tend to resist energy loads better than other bones of
the body; therefore, if these bones are fractured, suspect significant injury to underlying
structures. Mechanical energy applied to the chest can lead to fractures as well as blunt cardiac
injury and pulmonary contusions.. Forces that cause penetrating cardiac injury most often injure
the right ventricle.
Motor vehicle crashes account for an estimated two-thirds of all chest trauma-related deaths
Additional mechanisms of injury commonly associated with thoracic injuries are falls, crush
injuries, Assaults, use of firearms, stabbings, and motor vehicle versus pedestrian incidents.
Injuries to the neck are most commonly associated with motor vehicle crashes. Other mechanisms
include strangle or choke holds, hangings, assaults, falls, and sudden neck hyperextension, such
as with a "clothesline-type" of injury.3

Types of Injuries
The most common type of injury associated with chest trauma is blunt; the most common cause
of blunt chest trauma are motor vehicle crashes, accounting for approximately 70%. Penetrating
injuries to the chest are commonly the result of firearm injuries or stabbings.
Neck injuries also result in blunt and penetrating injuries. Penetrating injuries to the neck may
appear benign based on the appearance of the wound, but. Because of the number and variety of
vital structure in a small anatomic region, the potential for underlying organ injury is si,

1
onificant.4 Slashing or cutting wounds are less likely to cause injury to underlying structures than
penetrating wounds that puncture the platysma muscles of the neck.

Usual Concurrent Injuries

Injuries to the neck and chest are frequently associated with immediate life-threatening
conditions. Life-threatening injuries of the neck may include upper airway trauma, vascular
injuries, or cervical vertebra'. and spinal cord trauma. Chest and/or neck trauma may disrupt the
airway, impair breathing, and/or result in serious alterations in circulation.
Isolated blunt thoracic injury is uncommon. Head. Extremity, and abdominal injuries frequently
occur concurrently. Penetrating trauma to the thorax, particularly gunshot or shotgun injuries, are
frequently associated with abdominal trauma because of the anatomical proximity of the chest
and abdomen. Patient; with penetrating injuries to the lower thoracic region should be assumed to
have both chest and abdominal injuries until proven otherwise.

PATHOPHYSIOLOGY AS A BASIS FOR SIGNS AND

SYMPTOMS
Ineffective Ventilation
Ineffective ventilation can be a result of thoracic or neck trauma. The resulting pathophysiology
is related to the loss of integrity of anatomical structures as well as compromises to the normal
physiologic process of respiration. Blunt or penetrating neck injuries can directly damage or
destroy anatomical structures or indirectly occlude the airway through localized hematonna
formation. Tears or lacerations in the tracheo-bronchial tree interrupt the integrity of the lower
airway. Patients with these injuries manifest dramatic symptoms early during resuscitation with
massive air leaks into the subcutaneous tissue.

Ineffective ventilation may also result from rib fractures and/or sternal fractures, which injure
underlying organs. Pain resulting from these fractures may impair the patient's ability to
adequately ventilate.

Penetrating injury of the chest wall and/or laceration of lung tissue affects the patient's ability to
maintain negative intrapleural pressure. Air or blood leaking into the intrapleural space collapses
the lung. The degree of the lung collapse is dependent on the severity of the underlying lung
injury.
Interstitial and alveolar edema may occur, in addition to hemorrhage and laceration, when the
lung is contused or punctured. The interstitial and alveolar edema results in impaired diffusion of
gases across the alveolar membrane. Damaged alveoli and/or capillary injuries produce
abnormalities in the ventilation to perfusion ratio.'

Ineffective Circulation
Injury to the heart and thoracic great vessels reduces the amount of circulating blood volume,
leading to hemorrhage, hypovolemia. and shock. Direct trauma to the heart may lead to a
reduction in cardiac output because of reduced myocardial contractility.
Air or blood that continues to accumulate in the thoracic cavity will increase the intrapleural
pressure. If the pressure rises to an abnormally high level, the heart and great vessels will shift,
causing compression of the vena cava. obstruction of venous return, and collapse of the lung.
Compression of the vena cava with obstruction of venous return will result in a decreased cardiac
output. The patient may present with respiratory distress, tachycardia, hypotension, tracheal

2
deviation, unilateral absence of breath sounds, and neck vein distention because of increased
intrathoracic pressure. Rapid accumulation of even small amounts of blood in the pericardial sac
(pericardial tamponade) which result in compression of the heart and inability of the heart to fill
during diastole. This results in decreased cardiac output. The patient may exhibit hypotension,
tachycardia, muffled heart sounds, and neck vein distention.

Neurological Deficits
Paraplegia associated with aortic injuries is related to ischemia or infarction of the spinal cord
because of hematoma formation or occlusion of the blood flow from the aorta to the spinal
arteries. Injuries in the neck region may also cause spinal cord or brachial plexus injuries,
impairing motor or sensory function. Neck injuries may also produce cerebral ischemia or
cerebral infarction resulting in motor or sensory impairment.

SELECTED THORACIC AND NECK INJURIES

Rib and Sternal Fractures
Rib fractures are the most common type of blunt chest injury, the injured area of lung underlying
the fracture is usually of more clinical significance than the fracture. Fracture of the sternum,
first, and/or second rib requires significant force and, therefore, may be associated with serious
injuries of underlying structures. Left lower rib fractures may be associated with splenic injury,
right lower rib fractures with hepatic injury, and stemal fractures with heart and/or great vessel
injury. '' Stemal fracture is associated with a blunt injury (e.g., the chest impacting with the
steering wheel). The most common fracture site is the junction of the manubrium and the body of
the sternum (angle of Louis) which is adjacent to the 2nd intercostal space.
SIGNS AND SYMPTOMS
• Dyspnea
• Localized pain on movement, palpation, or inspiration
• Patient assumes a position intended to splint the chest wall to reduce pain
• Chest wall ecchymosis or sternal contusion
• Bony crepitus or deformity

Flail Chest
Flail chest is defined as a fracture of two or more sites on two or more adjacent ribs or when rib
fractures produce a free-floating sternum. The unsupported chest wall or flail segment moves
paradoxically or opposite from the rest of the chest wall during inspiration and expiration. Flail
segments may not be clinically evident in the first several hours after injury' because of muscle
spasms that splint the flail segment. Once positive pressure is initiated, paradoxical chest
wall movement ceases. A flail chest may be associated with the following:
• Ineffective ventilation
• Pulmonary' contusion
• Lacerated lung parenchyma
SIGNS AND SYMPTOMS
• Dyspnea
• Chest wall pain
• Paradoxical chest wall movement—the flail segment moves in during inspiration and out
during expiration

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Pneumothorax
A simple pneumothorax results when an injury to the lung leads to accumulation of air in the
pleural-space with a subsequent loss of the negative intrapleural pressure. Partial or total collapse
of the lung may cause: An open pneumothorax results from a wound through the chest wall. Air
enters the pleural space both through the wound and the trachea.

SIGNS AND SYMPTOMS OF PNEUMOTHORAX

• Dysonea. Tachyonea
• Tachycirdia
• Hyperresonance on injured side
• Decreased or absent breath sounds on the injured side
• Chest pain
• Open, sucking wound on inspiration (open pneumothorax)

A tension pneumothorax is a life-threatening lung injury. Air enters the pleural space on
inspiration, but the air cannot escape on expiration. Rising intrathoracic pressure collapses the
lung on the side of the injury causing a rnediastinal shift that compresses the heart, great vessels,
trachea, and ultimately, the uninjured-lung. Venous return is impeded, cardiac output falls, and
hypotension results.'Tension pneumothorax is a clinical diagnosis and immediate decompression
should be performed. Do not delay to perform more definitive diagnostic tests.
SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX
• Severe respiratory distress
• Hypotension
• Distended neck veins, head and upper extremity veins
• Tracheal deviation—shift toward uninjured side (late)
• Cyanosis (late)

Hemothorax
A hemothorax is an accumulation of blood in the pleural space. A massive hemothorax is a rapid
accumulation of 1,500 ml or more in the intrapleural space. Massive, intrapleural hemorrhage
may result in a mediastinal shift, decreased venous return, and hypotension.
SIGNS AND SYMPTOMS
• Dyspnea, tachypnea
• Chest pain
• Signs of shock
• Tracheal. deviation
• Decreased breath sounds on the injured side

Pulmonary Contusion
Pulmonary contusions may occur as a result of direct impact, deceleration, or high velocity bullet
wounds.' Pulmonary contusions are seen on chest radiographs as consolidation and pulmonary
infiltration. A pulmonary contusion may be demonstrated on a CT scan as a "pulmonary
laceration surrounded by intraalveolar hemorrhage without significant interstitial injury."'4 The
degree of respiratory insufficiency is related to the size of the contusion, the severity of injury to
the alveolar-capillary membrane, and the development of aleleciasis. The subtle signs and

4
symptoms of respirator}' insufficiency associated with pulmonary contusion usually develop over
time rather than have immediate onset. 12
SIGNS AND SYMPTOMS
• Dyspnea
• Ineffective cough
• Hemoptysis
• Hypoxia
• Chest pain
• Chest wall contusion or abrasions

Ruptured Diaphragm
A ruptured diaphragm is a potentially life-threatening injury that may result from forces that
penetrate the body, such as gunshot wounds, or from acceleration or deceleration forces, such as
motor vehicle crashes.
Blunt injuries are more likely to injure the left leaf of the diaphragm since the right leaf is
somewhat protected by the liver. A rupture or tear of the diaphragm may allow hemiation of
abdominal contents, such as the stomach, small bowel, or spleen into the thorax. Herniation may
result in respiratory' compromise because of impairment of lung capacity and displacement of
normal lung tissue. Mediastinal structures may shift lo the opposite side of the injury.

SIGNS AND SYMPTOMS

• Dyspnea or orthopnea
• Dysphagia
• Abdominal pain
• Sharp epigastric or chest pain radiating to the left shoulder (Kehr's sign)
• Bowel sounds in the lower to the middle chest
• Decreased breath sounds on the injured side

Tracheobronchial Injury
Blunt ruptures or tears of the lower trachea or mainstem bronchus may be caused by such
mechanisms of injury as striking the dashboard or steering wheel, karate-type blows, or
"clothesline-type" injuries. The a~Luhii uifferencc in the incidence of penetrating wounds
versus b'iunL injuries varies geographically.ls It has been reported that the majority of
tracheobronchial ruptures (>80%) occur within 2.5 cm of the carina.
The majority of penetrating injuries to the trachea and bronchi (75%) occur in the proximal
trachea.l666 Patients with injuries causing large defects in the trachea or bronchial tree require
bronchoscopy or bronchogram and immediate surgical intervention.
SIGNS AND SYMPTOMS
* Dyspnea, tachypnea
• Hemoptysis
• Potential airway obstruction
• Subcutaneous emphysema in the neck, face, or suprastemal area
• Decreased or absent breath sounds

Blunt Cardiac Injury

Formally called "cardiac contusion or concussion," the phrase blunt cardiac injury has become
preferred to describe the spectrum of potential blunt injuries to the heart, including more

5
 specific descriptions of associated structures and cardiac injury involvedl' (e.g., blunt cardiac
injury, with septal rupture). Blunt cardiac injury should be suspected following an associated
mechanism of injury or in patients that exhibit an abnormally poor cardiovascular response to
their injury. 18 It is most commonly associated with motor vehicle crashes,l7 especially with
direct impact of the chest with the steering wheel, or falls from heights
On autopsy, minor blunt cardiac injuries are clearly delineated, without the zones of ischemia
associatec with myocardial infarction. 9
SIGNS AND SYMPTOMS
• ECG abnormalities ranging from dysrhythmias (premature ventricular coniractions and
atrioventricular (AV) blocks are most common) to ST and T wave changes'
• Chest pain
• Chest wall ecchymosis

NURSING CARE OF THE PATIENT WITH A THORACIC AND NECK

INJURY

Assessment
HISTORY
Refer to Chapter ' Initial Assessment, for a description of general information that should be collect
regarding every trauma victim. Only pertinent questions specific lo patients with thoracic or neck injury
are described below.
• What was the mechanism of injury?
• What was the type of motor vehicle collision? _-
Head-on collision or impact with a stationary object, such as a tree or cement wall, will
result in deceleration forces that may be associated with chest and neck injuries, such as
a trauma, aortic rupture.
•What was the damage to the exterior and interior of the vehicle?
A bent steering wheel or steering column imprint on the patient's chest may be
associated with sternal fractures, blunt cardiac injury, or a transected aorta. The amount
of structural intrusion into the passenger compartment may be useful to identify
patterns of injury, such as lateral rib fractures.
• What arc The patient's complaints?
• Dyspnea
• Dysphagia
• Dysphonia
• What were the patient's vital signs prior to admission?
Were vital signs or signs of life observed by prehospital care personnel or another reliable
source? If cardiopulmonary resuscitation is being performed, when was it started? When
did the patient lose signs of life? This information is important in determining the
indications for performing a thoracotomy in the emergency department.
PHYSICAL ASSESSMENT
Refer to Chapter , Initial Assessment, for a description of the assessment of the patient's airway,
breathing,
Inspection
• Observe the chest wall for injuries that may severely impair the adequacy of breathing, such
as open chest wounds. This requires the removal of debris or blood to avoid overlooking any
wounds.
• Assess breathing effectiveness and rate of respiration

6
 • Observe the chest wall for symmetrical movement
The presence of a flail segment may produce paradoxical movement.
•Inspect the neck for signs of trauma, such as ecchymosis, swelling, or hematomas, that may
result in airway obstruction. Listen for noisy air movement. Swelling of the face and/or neck
may indicate a mediastinal. esophageal. or tracheobronchial injury.
• Inspect the jugular veins
Distended neck veins may indicate increased intrathoracic pressure as a result of a tension
pneurnothorax or pericardial tamponade. Flat external jugular veins may reflect
hypovolemia.
* Identify the zone of neck injury
• Inspect the upper abdominal region for evidence of blunt or penetrating injury
Percussion
Percuss the chest
Dullness is associated with hemothorax, and hyperresonance suggest a
pnemothorax.

Palpation
• Palpate the chest wall, clavicles, and neck for:
• Tenderness
• Swelling or hematoma
• Subcutaneous emphysema (esophageal, pleural. tracheal, or bronchia] tear)
• Note the presence of bony crepitus (possible fractured ribs and/or sternum)
• Palpate central and peripheral pulses and compare quality between:
• Right and left extremities
• Upper and lower extremities
• Palpate the trachea
. Palpate the trachea above the suprasiemal notch. A shifted trachea may indicate a tension
pneurnothorax or massive hemothorax.
• Palpate extremities for motor and sensory function
Lower extremity paresis or paralysis may indicate aortic inj ry.7 Hemiplegia may occur with
vascular injury of the neck. A motor and/or sensory deficit in the upper extremities may
indicate ulnar or radial nerve damage secondary to a brachial plexus injury.4
Auscultation
• Auscultate and compare blood pressure in both upper and lower extremities
• Auscultate breath sounds
Decreased or absent breath sounds may indicate the presence of a pneumothorax or
hemothorax.
Diminished sounds may result from splinting. Shallow respirations may be because of pain.
• Auscultate the chest for the presence of bowel sounds
Bowel sounds present in the middle to lower lung fields may occur with diaphragmatic
rupture.
• Auscultate heart sounds
Muffled heart sounds may be associated with pericardial tamponade.
• Auscultate the neck vessels for bruits. which may indicate vascular injury

7
DIAGNOSTIC PROCEDURES
Refer to Chapter , Initial Assessment, for frequently ordered radiographic and laboraior)' studies.
Additional studies for patients with thoracic and neck injuries are listed below.
Radiographic Studies
• Chest
After the potential for spinal cord injury has been ruled out an upright chest radiograph
may be necessary to evaluate the presence of a hemothorax, especially if blood
accumulation is less than 300ml. Chest radiograph is the primary diagnostic screening
tool for diagnosis of blunt aortic injuries, with loss of the aortic knob contour as the most
reliable marker.
• Arteriography
• Arteriography is used to evaluate suspected vascular injuries in the neck 3 and chest.
• Aortography may be done if there is a mechanism of injury, or physical or radiographic
signs that result in a high index of suspicion for aortic injury.
• Esophagoscopy ;
• Bronchoscopy and laryngoscopy
• CT scan
A thoracic CT evaluates pulmonary parenchymal injuries, pulmonary contusions, and
aortic injuries.
Other
• Electrocardiogram
Premature ventricular contractions (PVCs) and AV blocks are most frequently observed
following blunt chest injury. 99
• Central venous pressure (CVP)
Patients with cardiac tamponade or tension pneumothorax may have an elevated CVP.
Patients with hypovolemia may have a decreased CVP. Normal CVP is 5 to 10 cm H?O.
• Echocardiography

Analysis, Nursing Diagnoses, Interventions and Expected

Outcomes
In addition to the nursing diagnoses outlined in Chapter , Initial Assessment, the following nursing
diagnoses are potential problems for the patient with thoracic and/or neck injury. Once a patient has been
assessed, diagnosis can be defined as either actual or risk. An actual nursing diagnosis is one derived from
a decision based on the patient's presenting signs and symptoms. A risk nursing diagnosis is ajudgment the
nurse makes based on a particular patient's risk and potential for developing certain problems.
Nursing diagnosis intervention Expected outcome
Airway clearance, Stabilize cervical spine The patient will maintain a
ineffective, Position the patient patent airway, as
related to: Open and clear the airway evidenced by:
• Presence of an artificial Insert oro- or nasopharyngeal • Regular rate, depth, and
airway airway pattern ot
• Edema of the airway, Assist with endotracheal breathing
intubation or surgical airway • Bilateral chest expansion
vocal cords,
epiglottis, and upper • Effective cough and gag
airway reflex
• Direct trauma • Absence of signs and
symptoms of

8
• Irritation of the respiratory
tract
• Altered level of
consciousness
• Tracheobronchial secretions
or obstruction
• Aspiration of foreign matter
• Inhalation of toxic fumes or
siihstRncpaa
Breathing pattern, ineffective, Administer oxygen via a
related to: non-rebreather mask
• Pain Prepare lor ventilatory
• Musculoskeletal impairment support
• Unstable chest wall with either bag-valve-mask
segment device or endotracheal
• Lack of intact thoracic cavity intubation and mechanical
wall ventilation
• Lung collapse • Obtain blood sample for
ABGs
as indicated
' Cover open wounds with
sterile, nonporous dressing
' If signs and symptoms ol a
tension pneumothorax
develop:
• After application of the
dress-
ing, remove the dressing
and
re-evaluate the patient
• Immediatelv Dreoare for a
airway obstruction: stridor,
dyspnea,
hoarse voice
• Clear sputum ot normal
amount
without abnormal color or
odor
• Absence of signs and
symptoms of
retained secretions:
fever, tachycardia,
tachypnea
The patient will have an
effective breathing
pattern, as evidenced by:
• Normal rate, depth, and
pattern of
breathing
• Symmetrical chest wall
expansion
• Absence of stridor, dyspnea.
or cyanosis
• Clear and equal bilateral
breath sounds
• ABG values within normal
limits:
• Pa0g 80-100 mm Hg (10.0-
13.3 KPa)
• SaO, >95%
• PaCOg 35-45 mm Hg (4.7
- 6.0 KPa)
• pH between 7.35 - 7.45
• Trachea midline

Gas exchange, impaired, Administer analgesic The patient will experience

related to: medication, as prescribed adequate gas
• Ineffective breathing Prepare for ventilatory exchange, as evidenced by:
pattern: loss support, • ABG values within normal
as necessary limits:
of integrity of thoracic
Prepare for/assist with chest • PaOg 80 -100 mm Hg
cage, tube insertion
impaired chest wall (10.0 -13.3 KPa)
Administer high flow oxygen • SaO~ >95%

movement, Monitor oxygen saturation with • PaCC)2 35-45 mm Hg (4.7

loss of negative
intrathoracic
pressure
• Retained secretions
• Accumulation of blood in
thoracic cavity
• Decrease in inspired air
• Pulmonary contusion
• Altered blood flow,
oxygen-
continuous pulse oximetry - 6.0 KPa)
AHrTiinic+or hlnnrl ac • pH between 7.35 - 7.45
\nrlir~arii • Skin normal color, warm, and
dry
• Level of consciousness,
awake and
alert, age appropriate
• Regular rate, depth, and
pattern of
breathing

9
 carrying capacity of the
blood,
oxygen supply
• Aspiration of foreign
matter
• Hypo- or hyperventilation
• Inhalation of toxic fumes or
Fluid volume deficit, related
to:
• Hemorrhage
• Impaired cardiac filling
and
ejection
* Mechanical compression of
heart and great vessels
• Alteration in capillary
normoahi]ih/
Cardiac output, decreased,
relatei
to:
• Hypovolemic shock
secondary
to acute blood toss
• Compression of heart and
great vessels
• Impairment of cardiac filling
nnrl oi~rtinn
Tissue perfusion, altered
renal,
• Control any uncontrolled The patient will have an
external bleeding effective circulating
• Cannulate two veins with volume, as evidenced by:
large- • Stable vital signs
bore catheters and appropriate for age
initiate • Urine output 1 ml/kg/hr
infusion of lactated • Strong, palpable peripheral
Ringer's pulses
solution or normal saline • Level of consciousness,
awake and alert
• Stabilize impaled objects
• Prepare for definitive care age appropriate
if • Skin normal color, warm,
control of internal and dry
bleeding is • Maintains hematocrit of 30
indicated mt/dl or
• Consider autotransfusion hemoglobin of 12 to
for a 14g/dl or greater
patient with a • Control of external
hemothorax hemorrhage
• Position patient with legs
elevate)
• Ariminiftor hiring ac inrliraierl
IMMEDIATELY prepare for a The patient will maintain
needle thoracentesis if a adequate
tensio circulatory function, as
pneumothorau is suspected evidenced by:
• Prepare for • Strong, palpable
pericardiocentesis peripheral pulses
as indicated • Apical pulse rate age
• Monitor and treat cardiac
appropriate
dsyrhythmias
• Normal heart sounds
• Assist with emergency
• EGG with normal sinus
thoracotomv. as indicated rhythm
• Absence of jugular vein
distension,
deviated trachea
• Skin normal color, warm, and
dry
• Level of consciousness,
awake and aler
age appropriate
Control any uncontrolled The patient will maintain
bleeding adequate tissue
10
cardiopulmonary, cerebral,
gastro-
inlestinal, peripheral
(specify type),
related lo:
• Hypovolemia
• Interruption of flow: arterial
anri/nr uonniic
Pain, related to:
• Effects of trauma
• Pleural irritation
• Experience during invasive
Drocedures/diaanostic tests
Cannulate two veins with
large-
bore catheters and initiate
infusion of lactated
Ringer's
solution or normal saline
Administer blood, as
indicated
Prepare for definitive care
Administer analgesic
medication,
as prescribed
techniques to
qive comfort
Stabilize impaled objects
Use touch, positioning, or
relaxation
periusion, as evidenced by:
• Vital signs within normal
limits for age
• Level of consciousness,
awake and alert,
age appropriate -—---
_____-
• Skin normal color, warm, and
dry
• Strong and equal peripheral
pulses
• Urine output of 1 ml/kg/hr
The patient will experience
relief of pain, as
evidenced by:
• Diminishing or absent level
of pain
through patient's self-report
• Absence of physiologic
indicators of pain
that include: tachycardia,
tachypnea,
pallor, diaphoretic skin,
increasing
blood pressure
• Absence of nonverbal
cues of pain:
crying, grimacing,
inability to assume
position of comfort
• Ability to cooperate with
care, as
appropriate

Planning and Implementation

Refer lo Chapter, Initial Assessment, for a description of the specific nursing interventions for patients
with compromises lo airway, breathing, circulation, and disabling.
• Ensure patent airway
• Suction airway to maintain patency, as needed
• Prepare for endotracheal intubation or surgical airway with cervical spine stabilization if
the patient has severe neck or chest trauma
• Intubation of the patient with a tracheobronchial injury in the emergency department is
contra versial. Attempts at intubation may cause further injury. The use of a flexible
bronchoscope may be helpful in guiding the ET tube distal to the injury. More definitive
control of the airway may need to be achieved in the operating room. 16
• Administer oxygen via a nonrebreather mask at a flow rate sufficient to keep the reservoir
bag inflated; usually requires 12 to 15 liters/minute.
• Prepare for ventilatory support, as necessary. Administer 100% oxygen using either a bag-
valve-mask device with an attached reservoir system or a mechanical ventilator

11
 • Management of a patient with a chest drainage system
• Maintain the chest drainage unit below the level of the chest lo facilitates the flow of
drainage and prevent reflux into the chest cavity. With water seal chest drainage units, keep
the unit upright to prevent the loss of the water seal.
• The tubing should be gently coiled without dependent loops or kinks.
• Assess and document fluctuation in the water seal chamber, output, color of drainage,
and air leak (FOCA)
• Notify the physician if initial chest drainage output is > 1,500 ml or if there is continued
blood loss of >200 ml/hour
• During patient transport, clamping of chest tubes is NOT necessary and is contraindicated.
Clamping of chest tubes before the patient's lung is fully re-expanded may lead to the
development of a tension pneumothorax.
• Prepare for aggressive ventilatory support if a major bronchial air leak exists after chest tube
insertion
• A tracheobronchial laceration can result in persistent bubbling in the chest drainage unit. and
the involved lung will not re-expand despite suction.24
• Prepare for surgical intervention if a tracheobronchial injury' is suspected
• Prepare for transport to the operating room for emergency thoracotomy if there is an initial
output of 1,500 ml or more of blood from the chest tube. or if there is continuing blood loss of>
200 mi/hour'
• Prepare for autotransfusion, as indicated
• Consider autotransfusion if a large blood loss is anticipated or > 500 ml of blood is collected.
Blood contaminated with abdominal contents is a relative contraindication to
autotransfusion.
• Indications: To transfuse patients with their own blood. In the emergency department, auto-
transfusion is usually limited to blood drained from a hemothorax. In significant chest
trauma, autotransfusion should be anticipated and the collection device prepared before
chest tube insertion, if possible.
• Precautions/contraindications:
• Blood contaminated with bowel contents or infection at the site of blood retrieval. Blood
salvaged from a bacteria-contaminated cavity is considered in dire emergencies or when
no alternative source of blood is available.
• Blood potentially contaminated with malignant cells
• Injuries > six hours old
• Autotransfusion > 50% of patient's estimated blood loss
• Carefully consider autotransfusion in patients with hepatic or renal dysfunction.
• Stabilize impaled objects
•Cannulate two veins with large-bore, 14- or 16-gauge catheters, and initiate infusions of
lactated Ringer's solution or normal saline
If pulmonary contusion is suspected, and, if no signs of hypovolemic shock are present,
restrict fluid administration to prevent pulmonary complications.
• Prepare for pericardiocentesis, as indicated Pericardiocentesis is an emergency procedure to
relieve cardiac tamponade. The patient is placed with head and torso elevated at a 45° angle. A
16- or 18-gauge, 6-inch (15 cm) or longer, over-the-needle catheter is attached to a 60 ml
syringe. The needle is inserted at a 45° angle, lateral to the left side of the xiphoid. I to 2 cm
inferior to the xiphochondral junction. Blood is aspirated during introduction of the needle
until as much nonclotted pericardial blood is withdrawn as possible." 7
Blood removed from the pericardial sac will generally not clot (because blood is defibrinated

12
 from agitation during systole), and the hemaiocrit will be lower than venous blood.6 Blood
clots may be present in the pericardial sac and require operative removal.
• Assist with an emergency thoracotomy
The indications for this procedure have been subject to considerable controversy. The use of
an emergency department thoracocomy for patients with no documented vital signs and/or
with blunt injuries has been demonstrated to have questionable benefit. The best results are
obtained in patients with a single penetrating injury of the anterior or precordial thoracic
area. and in patients who had deteriorating vital signs. In such patients, especially those with
stab wounds, a Umely thoracotomy may lead to complete recovery.' This procedure is
recommended only in situations where physicians are experienced in the technique
and surgical resources are available for continuing surgical therapy.
• Monitor and treat cardiac dysrhythmias or dysfunction if significant blunt cardiac injury is
suspected
• Administer analgesic medication, as prescribed
Pain control helps to prevent hypoventilation. Prepare to assist with an intercostal nerve
block, if ordered.

Nursing Interventions for the Patient with a Neck Injury

• Monitor for progressive airway edema
• Control external bleeding with direct pressure
• Monitor for continued bleeding and expanding hematomas

Evaluation and Ongoing Assessment

Refer to Chapter , Initial Assessment, for a description of the ongoing evaluation of the patient's
airway, breathing, circulation, and disability'. Additional evaluations include:
• Monitoring airway patency, respiratory effort, and arterial blood gases
• Monitoring respiratory effort after covering a wound since this may lead to the development
of a tension pneumothorax
• Monitoring vital signs
• Monitoring chest tube drainage to determine the amount and any change in drainage
characteristics

SUMMARY
Trauma to the neck and chest may result in life-threatening injuries because of catastrophic
compromises in breathing and circulation. Knowledge of anatomy, mechanism and pattern of
injury, and the physiologic consequences of any disruption of the pulmonary and cardiovascular
systems are the foundations of the trauma nursing process for patients with an injury to the chest
or neck.
Early, identification of all injuries requires a collaborative team approach to conduct the
necessary diagnostic and therapeutic interventions. Determining the patients need for operative
management and/or transfer to a comprehensive trauma center is a major consideration for
members of the trauma team.

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