Emergency Nurse Orientation 3.0: Thoratic Trauma

Which injury should you suspect in a patient with abrasions or bruising on the anterior chest and cardiac dysrhythmias? A. Pneumothorax B. Blunt cardiac injury C. Tracheal injury D. Esophageal injury

B Although trauma to the anterior chest can cause all of these injuries, the presence of dysrhythmias increases the likelihood of blunt cardiac injury. Patients with chest injuries between the midclavicular lines, clavicles, and costal margins require aggressive evaluation for cardiac involvement. Pneumothorax, tracheal injury, and esophageal injury do not cause dysrhythmias.

A patient with a suspected aortic disruption is likely to display which finding? A. A crunching, rasping sound heard over the pericardium B. A discrepancy between the blood pressure in the right and left arms C. Decreased pulses in the arms D. Increased blood pressure in the legs

B Aortic disruption causes a discrepancy between the blood pressures in the right and left arms, increased blood pressure and pulses in the arms, and decreased or absent blood pressure and pulses in the legs. Bronchial and esophageal injuries produce Hamman's crunch (a crunching, rasping sound heard over the pericardium when air accumulates in the mediastinum).

A spontaneously breathing patient with a pneumothorax undergoes a chest tube insertion. The chest tube is connected to a closed drainage system. Which finding should you expect to observe in the chest tube drainage system? A. The water level in the water-seal chamber rises with expiration. B. The bubbles in the water-seal chamber fluctuate with respirations. C. The water level in the water-seal chamber falls with inspiration. D. No fluctuations occur in the water-seal chamber.

B Bubbling in the water-seal chamber that fluctuates with respirations indicates an air leak, which continues until the lung is re-expanded. For a patient who is breathing spontaneously, the water level in the water-seal chamber should rise with inspiration and fall with expiration. For a patient receiving mechanical ventilation with positive end-expiratory pressure (PEEP), this pattern is reversed because breaths are delivered under positive pressure. Fluctuations stop when the lung is fully re-expanded or when the chest tube is kinked or compressed.

Which mechanism is the most likely cause of a fractured larynx? A. Falling backward and injuring the neck B. Receiving a karate blow to the neck C. Being a restrained passenger in a rear-end motor vehicle collision D. Striking the chest against the handlebars of a bicycle

B Fracture of the larynx is a rare, life-threatening injury. Common mechanisms of injury include striking the anterior neck on a steering wheel or dashboard and sustaining a karate blow or "clothesline" injury, which involves direct impact on the anterior neck. All other answer options do not affect the anterior neck.

Hemoptysis is a finding in which injury? A. Diaphragmatic injury B. Pulmonary contusion C. Tension pneumothorax D. Esophageal injury

B Hemoptysis is a finding in pulmonary contusion, bronchial injuries, open pneumothorax, and aortic disruptions. It is not associated with diaphragmatic injury, tension pneumothorax, or esophageal injury.

Which injury causes decreased cardiac output? A. Pulmonary contusion B. Tension pneumothorax C. Flail chest D. Laryngeal injury

B Tension pneumothorax is a life-threatening condition that occurs when air accumulates in one pleural space and forces the thoracic contents to the opposite side of the chest. The resulting vena caval compression impairs venous return to the heart, which worsens diastolic filling and further decreases cardiac output. With a pulmonary contusion, airways collapse, followed by loss of ventilation, pulmonary shunting, and hypoxemia. With flail chest, the flail segment moves in with inhalation and out with exhalation, resulting in hypoventilation of both lungs followed by atelectasis and hypoxia. With laryngeal injury, subcutaneous emphysema and crepitus can affect respiratory effort.

A patient stabbed in the right lower thorax sustains a liver laceration. Based on the mechanism of injury, you should know that the patient may also have sustained which injury? A. Cardiac tamponade B. Diaphragmatic injury C. Aortic disruption D. Bronchial injury

B Diaphragmatic injuries rarely occur alone and usually appear with other blunt thoracic injuries, trauma to the liver or spleen, or pelvic or long bone fractures. Most injuries affect the left side of the diaphragm. When injuries do occur on the right, they may be difficult to identify because of the liver. Based on the mechanism of injury, the patient is not likely to have sustained injury to the heart, aorta, or bronchi.

Which injury involves bilateral detachment of the sternum from costal cartilage? A. Flail chest B. Sternal fracture C. Traumatic asphyxia D. Pneumothorax

A Flail chest is defined as fractures in two or more adjacent ribs in two or more places, or bilateral detachment of the sternum from costal cartilage. This creates a free-floating, unstable segment that moves in opposition to normal chest wall movement. Sternal fractures occur when tremendous force is applied to the chest and can lead to heart or great vessel injuries. Traumatic asphyxia results from a severe, prolonged crush injury to the thorax. Its pathophysiology involves a direct increase in thoracic and superior vena cava pressure and closure of the glottis. Pneumothorax refers to air accumulation in the pleural space that results in partial or complete lung collapse as negative intrapleural pressure is lost.

Which injury is likely to produce bowel sounds in the chest on auscultation? A. Diaphragmatic injury B. Esophageal injury C. Bronchial injury D. Laryngeal injury

A In diaphragmatic injuries, large tears cause herniation of the abdominal contents into the thorax, allowing bowel sounds to be heard in the chest. Esophageal injury, bronchial injury, and laryngeal injury do not produce this finding.

Assessment may reveal subcutaneous emphysema in a patient with which injury? A. Laryngeal injury B. Diaphragmatic injury C. Hemothorax D. Tension pneumothorax

A Subcutaneous emphysema is an assessment finding in laryngeal and bronchial injuries. It is not an expected finding in a diaphragmatic injury, hemothorax, or tension pneumothorax.

Which injury may require the insertion of a 14- or 16-gauge needle with a catheter into the second intercostal space at the midclavicular line on the injured side if a chest tube is not immediately available? A. Tension pneumothorax B. Hemothorax C. Cardiac tamponade D. Open pneumothorax

A Tension pneumothorax requires immediate needle decompression, which involves insertion of a 14- or 16-gauge needle with a catheter into the second intercostal space at the midclavicular line on the injured side. Chest tube insertion must follow needle decompression because it is the definitive treatment for tension pneumothorax. If the physician was immediately available, a chest tube would be the first line of treatment. Hemothorax requires chest tube insertion and possibly autotransfusion. Cardiac tamponade requires pericardiocentesis (blood evacuation from the pericardial sac) as a lifesaving, temporizing procedure to improve cardiac function while the patient waits for surgery. Open pneumothorax requires the initial application of a three-sided occlusive dressing followed by chest tube insertion.

Which heart chamber is the most vulnerable to blunt and penetrating trauma? A. Right ventricle B. Right atrium C. Left ventricle D. Left atrium

A The right ventricle sits beneath the sternum, making it the heart chamber that is the most vulnerable to trauma.

Hypotension is a likely finding in which injury? A. Laryngeal injury B. Diaphragmatic injury C. Tension pneumothorax D. Pulmonary contusion

C In tension pneumothorax, the lung injury lets air enter the pleural space with inspiration but does not let it escape. This air accumulation forces the thoracic contents away from the injured side and causes a mediastinal shift towards the uninjured side, which results in hypotension. This finding does not occur in diaphragmatic injury, laryngeal injury, or pulmonary contusion.

Which injury can cause pain that radiates to the left shoulder? A. Laryngeal injury B. Tension pneumothorax C. Diaphragmatic injury D. Bronchial injury

C A diaphragmatic injury results from large tears that cause herniation of the abdominal contents into the thorax. It causes abdominal or epigastric pain that radiates to the left shoulder (Kehr's sign). This type of pain is not a finding in tension pneumothorax, laryngeal injury, or bronchial injury.

Which intervention is appropriate for a patient with blunt chest trauma? A. Assist with chest tube insertion. B. Initiate rapid infusion of an isotonic crystalloid solution. C. Place the patient in a semi-Fowler's position. D. Prepare the patient for surgery.

C Because a patient with blunt chest trauma may have a pulmonary contusion, plan to place the patient in the semi-Fowler's position to promote lung re-expansion, suction the airway, perform chest physiotherapy, possibly use continuous positive airway pressure (CPAP), and expect intubation and mechanical ventilation. To prevent pulmonary overload (fluid in the pleura), restrict fluids when no evidence of hypovolemia exists. No information suggests that this patient has a pneumothorax or hemothorax, which would require chest tube insertion or surgery.

A patient with a sternal fracture is at increased risk for developing which complication? A. Esophageal tear B. Fracture of the larynx C. Ruptured diaphragm D. Cardiac tamponade

D A sternal fracture has a significant potential for underlying cardiac and pulmonary injury, including pulmonary contusion, blunt cardiac injury, and cardiac tamponade. A sternal fracture does not cause injury to the larynx, diaphragm, or esophagus.

Which injury poses the greatest risk of exsanguination? A. Esophageal injury B. Cardiac tamponade C. Blunt cardiac injury D. Aortic injury

D Although all of these injuries may be fatal, injuries that disrupt the structural integrity of the heart and aorta commonly lead to rapid exsanguination. Esophageal injury results in mediastinitis due to contamination from saliva and gastric contents. Cardiac tamponade occurs when blood rapidly accumulates in the pericardial sac, which decreases ventricular filling. As the pericardial sac fills, blood presses on the ventricles and impairs ventricular filling and the heart's pumping ability, which decreases cardiac output. With blunt cardiac injury, the myocardium may sustain a mild contusion or concussion or may have a severe injury that mimics acute myocardial infarction.

Autotransfusion after chest tube insertion is contraindicated for which patient? A. A patient with religious objections to blood transfusions B. A patient with immediate chest drainage of 650 mL of blood C. A patient with chest drainage of 500 mL after 3 hours D. A patient with a ruptured diaphragm

D Autotransfusion is not appropriate when enteric contamination has occurred or is suspected (as in a ruptured diaphragm), infection is present, the patient has coagulopathies or hepatic or renal insufficiency, or the blood has been in the autotransfuser for more than 6 hours. Autotransfusion is indicated for wounds that are less than 4 to 6 hours old or are associated with significant intrathoracic blood loss (more than 350 mL in an adult). It is also indicated when homologous blood is not available and when a patient's religious convictions (Jehovah's Witnesses, for example) forbid homologous transfusion.

Fracture of the first rib is associated with injury to which structure? A. Liver B. Spleen C. Heart D. Trachea

D Fractures of the first and second ribs are rare because the clavicles protect these ribs. Because significant blunt force is needed to fracture these ribs, expect associated injuries to underlying structures, such as the great vessels, brachial plexus clavicles, scapulae, trachea, and lungs. Left lower rib fractures are associated with spleen and left kidney injuries. Right lower rib fractures are associated with liver and right kidney injuries. Sternal fractures can cause heart or great vessel injuries.

The focused assessment with sonography for trauma (FAST) examination is highly reliable for detecting which injury? A. Blunt cardiac injury B. Hollow viscus injury C. Retroperitoneal injury D. Hemothorax

D The focused assessment with sonography for trauma examination is highly reliable for detecting pericardial effusion and hemothorax. It is a poor diagnostic tool for identifying hollow viscus or retroperitoneal injury. It cannot identify the source of bleeding or the injuries that may cause hemoperitoneum and is limited in detecting less than 250 mL of peritoneal fluid. It cannot identify blunt cardiac injury but can be used to detect cardiac tamponade.