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02.03 Penetrating Thoracic Trauma

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Overview

With penetrating thoracic traumas, even though we can see the external injuries, we can not forget the possible concurrent injuries that can occur.

Nursing Points

General

  1. What is a penetrating injury?
  2. Mechanism of injury / clinical history
    1. Possible injuries
      1. Open Peumothorax
        1. Penetrating chest wound that enters pleural space. Air enters and exits the chest through the wound.
      2. Hemothorax 
        1. Build up of blood within the chest cavity
      3. Aortic disruption 
        1. Any tear or seperation of the aorta
      4. Myocardial rupture
        1. Any punture or tear of the myocardium
      5. Diaphramagitc puncture
        1. Any puncture or tear of the diaphragm

Assessment

  1. Similar for all
  2. Where is the blood coming from?
    1. A, B, C’s
    2. Inspection, Auscultation, Percussion, Palpation
    3. Vital signs, most important is blood pressure
    4. Radiology
      1. X-Ray
      2. FAST
      3. CT / CT Angio

Therapeutic Management

  1. Control Life Threatening Hemmorhage!
  2. Open Pneumothorax (Sucking chest wound)
    1. Control bleeding
    2. Cover with occlusive dressing
    3. Manage airway
  3. Hemothorax
    1. Control Bleeding
    2. Replace blood
    3. Chest tube
    4. Surgery?
  4. Aortic disruption
    1. Control bleeding
    2. Replace blood
    3. Beta Blockers
    4. OR
  5. Myocardial rupture
    1. Load and go!
    2. Open thoracotomy in ED
    3. Immediate OR
  6. Diaphramagitc puncture
    1. Maintain ABCs
    2. OGT or NGT
    3. OR

Nursing Concepts

  1. Anatomy & Physiology
    1. Need to know proper anatomy to help identify concurrent injuries
  2. Oxygenation
    1. Maintain O2 saturation especially in cases where airway is compromised
  3. Perfusion
    1. In cases of severe bleeding, shock and tissue hypoxia can set in
  4. Tissue/Skin Integrity
    1. Penetrating injuries disrupt tissue

Patient Education

  1. Understand that any penetrating injury to the chest should be treated as an emergency.
  2. If the patient is injured with an object that is still present… do not remove the object!

Reference Links

Video Transcript

Welcome everyone to our  continuing series on trauma care. Today we are going to talk about penetrating thoracic trauma.

In penetrating trauma, something has entered the body that shouldn’t have. We need to work quickly to identify the injuries and stop the bleeding in order to even have a chance and saving these patients. 

So what is a penetrating trauma. Well like i said, something from the outside has broken the skin and gotten inside. This doesn’t mean it is still there, just that it had been at one point, and you can be sure it caused some damage.

There are numerous instruments that can cause penetrating traumas. The most common are gunshots and stabbings. That being said, anything that can pierce the skin can cause a penetrating injury. Pencils, nails, sticks, spikes, fence posts, even a dull spoon if used with enough force. In fact, penetrating traumas can even be cause by air compressors. With enough force behind it, the concentrated stream of air can break through the skin and cause internal injuries. If you dont believe me, search for air compressor death on youtube and watch the first video. There have been numerous instances of air compressors causing internal perforations of hollow organs and subsequent deaths.

When we think of penetrating injuries, we try to keep 2 things in mind.. the ballistics and the kinematics. The ballistics refers to the weapon used, the projectile, the flight of the projectile, and the science behind these items. Kinematics deals with the force and energy transferred during the injury.

There are a whole lot of injuries that can be cause by penetrating trauma but we are going to focus on these. Open pneumothorax, hemothorax, aortic disruptions, myocardial rupture and diaphragmatic ruptures.

When we have penetrating injuries, it is very likely we are going to have a lot of bleeding. It is cases like this where we may adjust our ABCs a little bit and change to CABC. This stands for Control Life Threatening Hemorrhage, then airway, breathing and continuing circulation, The thought here is that if someone is truly hemorrhaging through an open wound, it’s possible that they could bleed out before we even are able to establish an airway. 

But let’s be honest. In a well oiled trauma team, someone is going to be applying pressure or tourniquets or clamping vessels, while someone else is trying to secure the airway. In a real trauma lots of things happen simultaneously. 

Watch the vitals, especially blood pressure and get the patient to radiology to really determine how much internal damage there is. Many times, we can bring radiology to us. Portable X-rays and FAST or a Focused Assessment with Sonography in Trauma, can be done right at the bedside. The FAST exam is a quick ultrasound that can be done in seconds to give us a picture of internal bleeding. Unfortunately, most places don’t have portable CT, so we still have to bring them there.

An pneumothorax is when there is an opening in the lung causing an air leak into the pleural space. With an open pneumo, the air is entering and exiting the chest through a hole. The usual negative pressure in the chest cavity is altered and each breath the patient takes in actually causes more and more pressure to build.

Here we would apply an occlusive dressing over the wound. usually a dressing that resembles saran wrap. We put the dressing over the wound and tape it down on 3 sides. This allows for air to exit through the wound but does not allow air to enter through the hole in the chest.

These patients, and our hemothorax patients, who were going to talk about ina minute, usually will have a chest tube inserted in an effort to allow air and fluid to escape the chest in a controlled and closed system while maintaining the proper pressure. While we dont insert the tubes ourselves, it is our responsibility to monitor the system and address any issues that come up. I highly reccomend getting familiar with the type of chest tube device your facility uses.

A hemothorax is a buildup of blood in the chest cavity. Again we need to control bleeding. We also need to replace the blood our guy is losing. Sometimes in cases like this, the doc will know that the patient is bleeding from an internal injury that may not make it to the OR. This is when they might perform a thoracotomy in an effort to visualize and gain access to the heart, lungs and great vessels, usually in order to throw a clamp on something so they can stop the bleeding and get the patient to the OR.

An aortic disruption is just that, a tear or separation in the aorta. If we think about the amount of blood that travels through the aorta you can imagine how much we would need to replace if its leaking all over the body and the floor. This is where we might start our MTP’s or massive transfusion protocol. Check with your facilities to see if they have something like this and what is involved.

If the disruption is not causing an immediate death scenario, the docs might give beta blockers like labetalol in an effort to lower the BP and reduce the pressure being pushed against the disruption. Either way, we need to probably get these guys to the OR.

Myocardial ruptures are some of the worst injuries. Think of someone being stabbed or shot right in the heart. In the field, if EMS suspects this, they Load and go, meaning they don’t spend time at the scene. A good crew knows there is only so much they can to in the field and that getting these patients to the trauma center as fast as possible is the best chance they have for survival.

ED thoracotomies and immediate transfer to the OR are pretty standard if these patients are alive when they get to the ED.

Diaphragmatic ruptures are concerning especially if something in the abdomen has been punctured. The diaphragm keeps everything in the abdomen that should be kept there. If there is a hole in the abdomen, we risk those organs and their contents leaking into the thoracic cavity causing all kinds of issues. 

If we are at all concerned about the stomach coming through the diaphragm, we would insert an orogastric or nasogastric tube and attach to suction. The goal here is to decompress the stomach, maybe shrink it a little in the hopes that it would recede back into the abdominal cavity.

From airway compromise to sepsis, a puncture in the diaphragm is something that is going to need repair fairly quickly.,

We have to know our anatomy in order to know how many possible injuries could occur from these traumas.

Obviously with the possible injuries to the heart and lungs, oxygenation and perfusion become our priorities.

And it goes without saying that any sort of penetrating trauma is going to cause issues with tissue and skin integrity.

So we want to try our best to find out how our guy was injured, If the knife still isn’t in his chest, does anyone know what it looked like, how big it was, how deep did it go?

These patients are going to be losing blood and we need to give it back to them.

This is the first time we approach the idea of CABC. Control that life threatening bleeding.

With any traumas we need to keep concurrent injuries in mind and

We need to avoid tunnel vision. Just becuse you see a gunshot wound to his chest, dont forget he might have 12 more to his back.

So thanks so much for hanign with me for this lesson and as always…

Happy nursing!

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