CARDIAC TRAUMA & CARDIAC TAMPONADE

With Rib Fracture and Flail Chest

Ped Silvestre,RN (in progress) Kia Marie Mandalupa, RN (in progress) Joey Albert Ongtagalog, RN (in progress)

CASE PRESENTATION
Jennifer Gardner, a 16-year-old 54 kg (120 lb) white female, is brought to the emergency department by

ambulance following a motor vehicle accident.

Emergency workers found her strapped into the passenger seat. It took workers more than 45 minutes to extricate her from the vehicle.

She is awake, alert, and oriented to person, place, and time when admitted via spinal board with cervical collar intact, on 2 L/min nasal cannula, with 16-guage intravenous (IV) lactated ringers at 100 cc/hr. She is complaining of midsternal chest pain nonradiating of 2 to 3 on pain scale

of 1 to 5. The only visible marking are ecchymosis and

redness across chest from seatbelt. History reveals a healthy teenager who plays high school soccer.

VITAL SIGNS ON ADMISSION:

BP: 140/80 mm Hg HR: 110 bpm Respirations: 26 breaths/min Temperature: 98.6F (37C)

SaO: 97%-98%

Routine lab values reveal normal hemoglobin and hematocrit. Chest X-ray (CXR) was completed and reveals sinus tachycardia

with no other abnormalities. Computed tomography (CT) scan and

C-spine are completed and rule out any neurologic involvement. Morphine 2 mg and spinal board are removed and patient is admitted for 24 hour observation. After the initial 24 hours, it was decided that the patient should be admitted to the intensive care unit (ICU) for further monitoring and evaluation.

ADMISSION TO ICU
The patient is awake, alert, and oriented, pain level is now a 1 with vital signs as noted: >BP: 110/70 mm Hg >HR: 118 bpm >Respirations: 20 breaths/min >Temperature: 98.6 F >SaO: 97%

When assessing heart sounds the nurse notes distant, muffled heart sound with the PMI slightly shifted to the left.

Serial lab values 4 hours post- ICU admission reveal

hemoglobin 11 and hematocrit 33. The nurse contacts the physician regarding physical findings and lab results. The physician orders stat CXR, which reveals enlarged heart shadow. A subsequent echocardiogram reveals

cardiac tamponade.

Emergency pericardiocentesis is performed in the patients

room. Ms. Gardener is taken for emergency chest exploration to repair a small right ventricular tear and remove rib fragments. She has an uneventful recovery and is discharged home on the eight postoperative day.

QUESTIONS:
1. Define blunt cardiac trauma (BCT). State the etiology and pathophysiology of BCT.

Blunt cardiac trauma is defined as a blunt trauma injury to the chest/heart that causes either ecchymosis or petechiae to develop on the myocardium (heart muscle).

Blunt cardiac trauma is most often caused an acceleration/deceleration injury that is sustained during a motor vehicle collision (MVC). Usual mechanism of injury is either the seat belt or from striking an object inside the vehicle (usually the steering wheel or dashboard). Other common mechanisms for sustaining a blunt cardiac trauma include: Motor vehicle accident Being kicked by a large animal (a horse for example) Being assaulted with a blunt instrument Industrial crushing injuries (explosions for example) Rigorous cardiopulmonary resuscitation

Motor vehicle accident

Crush injury

Assault w/ blunt object

Fall

Pedestrian accident

Explosion

Deceleration injury (sudden decrease in rate of speed or velocity)

Shearing (stretching forces to areas of the chest causing tears, ruptures, or dissections Compression (direct blow to the chest)

Acceleration injury (moving object hitting the chest or patient being thrown into an object

Blunt Chest Trauma

2. What clinical presentation will patients with BCT display?

Respiratory Dyspnea, respiratory distress Cough w/ or w/o hemoptysis Cyanosis of mouth, face, nail beds, mucous memranes Tracheal deviation Decreased breath sounds on side of injury Decreased O saturation Frothy secretions Tachypnea Cardiovascular Rapid thready pulse Muffled heart sounds Chest pain Dysrhythmias Decreased BP Narrowed pulse pressure Tachycardia Crunching sound synchronous with heart sounds Surface Findings Bruising Abrasions Assymetric chest movement Subcutaneous emphysema Redness across chest

3. Discuss appropriate nursing diagnoses for a patient with BCT.

Decreased cardiac output related to heart failure

Potential for cardiac tamponade secondary to bleeding Altered tissue perfusion (cerebral, cardiac or peripheral) Impaired gas exchange secondary to pulmonary edema Activity intolerance Pain Knowledge deficit

4. Outline Ms. Gardners collaborative plan of care related to a diagnosis of BCT.

Ineffective breathing pattern

BED REST Monitor ABGs and oxygen saturation Administer oxygen, as ordered Administer analgesics, as ordered, on a regular schedule, not allowing pain to get intense Monitor chest x-ray reports

5. What complications may develop from BCT?

Pneumothorax Cardiac rupture Air embolus traumatic aortic injury Cardiac tamponade (discussed later) Heart failure Tracheal tear Hemothorax Pulmonary contusion Acute Respiratory Distress Syndrome (ARDS) Rib fractures

Flail chest
Sternal fractures Esophageal injuries

6. Define penetrating cardiac trauma (PCT). State the etiology and

pathophysiology of PCT.
PENETRATING TRAUMA

Penetrating Cardiac Trauma is defined as anything that causes the myocardium to sustain a puncture wound from a sharp object. ETIOLOGY: Fractures (rib most commonly) Force inflicted injuries (knife, gunshot, ice pick) Industrial injury (usually falling on a sharp object) Motor vehicle collision that causes some sort of impalement Sports injuries Crushing injuries

7. What clinical presentation will patients with PCT display?

Respiratory Dyspnea, respiratory distress Cough w/ or w/o hemoptysis Cyanosis of mouth, face, nail beds, mucous membranes Cardiovascular Rapid thready pulse Muffled heart sounds Chest pain Surface Findings Bruising Abrasions Asymetric chest movement

Tracheal deviation
Audible air escaping from chest wound Decreased breath sounds on side of injury Decreased O saturation Frothy secretions

Dysrhythmias
Decreased BP Narrowed pulse pressure Asymetric BP values in arms Crunching sound synchronous with heart sounds

Subcutaneous emphysema
Open chest wound

8. Discuss appropriate nursing diagnosis for a patient with PCT. Decreased cardiac output secondary to decreased contractility or hypovolemia

Fluid volume deficit secondary to hemorrhage

Impaired gas exchange Activity intolerance Risk of infection related to foreign body Acute Pain Anxiety Knowledge Deficit

9. Outline Ms. Gardners collaborative plan of care related to a diagnosis of

PCT.

Provide adequate analgesia to promote breathing, coughing and movement Intercostal nerve blocks or continuous epidural analgesia may be employed to manage pain assoc. with flail chest

Endotracheal intubation and mechanical ventilations as necessary

Repeated bronchoscopy may be done to remove secretions and cellular debris Mechanical ventilation with positive end-expiratory pressure to maintain open alveoli and adequate gas exchange

 Control hemorrhage (apply direct pressure if bleeding from the wound). DO NOT REMOVE the impaled object (controlled surgical intervention will be required). Stabilize impaled object with IV bags and dressings Chest tube for hemothorax or pneumothorax will more then likely be required. Pericardiocentesis for cardiac tamponade

Improve oxygen delivery with supplemental O2 (patient will likely require

intubation). Keep SaO2 greater the 95%

Insert at least 2 large bore IVs for fluid resuscitation

Type and cross match for blood transfusion Prepare patient for surgical intervention (thoracotomy)

10. What complications may develop from PCT?

Common complications include:

Hemorrhagic shock Pulmonary Embolism Cardiogenic Shock Pneumothorax Hemothorax Cardiac Tamponade

11. Define cardiac tamponade. State the etiology and pathophysiology of cardiac tamponade.

Cardiac tamponade is defined as the accumulation of blood, effusion fluid and or pus into the pericardial space. This fluid accumulation compromises cardiac filling and cardiac output as a result of increasing pressure on the

myocardium.

ETIOLOGY
Blunt or penetrating trauma Pericarditis Cardiac rupture Post CPR Rupture of the great vessels Renal failure Hepatic failure Infections (viral, bacterial or fungal) Drugs (Procainamide, Methyldopa, Hydralazine for example)

Electrical cardioversion
Malignancy Radiation therapy Connective tissue disease Metabolic disorders

Post op mediastinal chest tube

occlusion or removal Invasive catheters

Cardiac needle biopsy

Rheumatic fever

Viral infection

Myocardial & pericardial injury Pericardial tissue damage

Aortic aneurysm

Release of inflammatory mediators Inflammatory response WBCs amass the site of injury Formation of exudates (fibrinous, semi-fibrinous, or purulent Collection of exudates in the pericardial sac

Pericardial effusion

Chest trauma

Heart compression

Rapid build-up of pericardial fluid

12. What clinical presentation will the patient with a diagnosis of cardiac tamponade display?

Complaints of pericardial fullness Complaints regarding feelings of doom Pain Dyspnea Tachycardia Pulseless Electrical Activity (PEA) in severe cases Becks Triad (hypotension, distended neck veins and muffled heart sounds) Increased right atrial pressure Increased Pulmonary artery diastolic pressure Decreased cardiac output and cardiac index

13. Discuss appropriate nursing diagnoses for a patient with cardiac tamponade.

Decreased cardiac output secondary to decreased contractility or hypovolemia Fluid volume deficit secondary to hemorrhage Pain Anxiety Knowledge Deficit

14. Outline Ms. Gardners collaborative plan of care related to a diagnosis of cardiac tamponade.

Intubation and mechanical ventilation (in most cases) Replacement of circulating volume (Normal Saline or Albumin) Inotropes as necessary

15. How should the nurse prepare Ms. Gardner for pericardiocentesis?

Performing a Pericardiocentesis is often a life saving measure for the patient who has developed cardiac tamponade. If Pericardiocentesis is required, the nurse can assist with the following preparations: Place patient in semi-Fowlers position ECG pads should be placed on limbs and away from the chest wall if possible Monitoring of ST-segment elevation is required and will be seen when the needle touches the epicardium. Pain medication and sedation should be given when possible. Monitoring for other complications (pneumothorax, cardiac rupture or cardiac laceration).

16. What complications may occur during a pericardiocentesis?

Complications may occur like:

Dysrhthymias Further cardiac tamponade Pneumomediastinum Pneumothorax Myocardial laceration Coronary artery laceration

RIB FRACTURE AND FLAIL CHEST

Motor vehicle accident

Crush injury

Assault w/ blunt object

Fall

Pedestrian accident

Explosion

Direct blow to the rib/ rib cage Muscles and ribs cannot stand the force of the impact Chest trauma

Rib fracture

Flail chest

Flail Chest frequently a complication of blunt chest trauma from a steering wheel injury; occurs when two or more

consecutive ribs are fractured in multiple places resulting to a

free-floating segment of the chest wall Clinical manifestations Paradoxic movement
The physiologic function of the chest wall is impaired as the flail segment is sucked inward during inhalation and moves outward with exhalation

 Dyspnea Medical Management Rapid, shallow breathing Initial therapy Tachycardia Airway management Unequal chest expansion Adequate ventilation Palpable crepitus Diminished breath sounds

 Supplemental O therapy Careful IV solution administration Pain control Mechanical ventilation may be necessary

Definitive therapy
Reexpansion of the lung Ensure adequate oxygenation

 References

Marini, J., J. & Wheeler, A., P. (2006). Critical care medicine: the essentials. (3rd ed.). Lippencott, Williams and Wilkes. Philadelphia American Lung Association. (November 2003). Fact Sheet: Adult Respiratory Distress Syndrome. Retrieved on January 10, 2006 at: www.lungusa.org/diseases.ards_factsheet.html Cohen, S., S. (2003). Trauma nursing secrets. Questions and answers reveal secrets to safe and effective trauma nursing. Hanley & Belfus. Philadelphia. Critical Care Medicine Tutorials. (2003). Key points of acute lung injury. Retrieved on January 10, 2006 at: http://www.ccmtutorials.com/rs/ali/09_alikp.htm Melander, S., D. (2004). Case studies in critical care nursing: A guide to application and review. (3rd ed.). Saunders. Philadelphia