CARDIAC TRAUMA & CARDIAC

TAMPONADE

With Rib Fracture and Flail

ChestPed 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 ringer’s 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)

SaO₂: 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

>SaO₂: 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 patient’s 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

Pedestrian

accident

Explosion

Assault w/ blunt object

Crush injury

Fall

Deceleration injury (sudden

decrease in rate of speed or velocity)

Acceleration injury (moving

object hitting the chest or patient being thrown into an object

Shearing (stretching forces to areas of the chest causing tears, ruptures, or

dissections

Compression (direct blow to

the chest)

Blunt Chest Trauma

2. What clinical presentation will patients with

BCT display?Respiratory Cardiovascular Surface Findings

Dyspnea, respiratory distress

Rapid thready pulse Bruising

Cough w/ or w/o hemoptysis

Muffled heart sounds Abrasions

Cyanosis of mouth, face, nail beds,

mucous memranes

Chest pain Assymetric chest movement

Tracheal deviation Dysrhythmias Subcutaneous emphysema

Decreased breath sounds on side of

injury

Decreased BP Redness across chest

Decreased O₂ saturation Narrowed pulse pressure

Frothy secretions Tachycardia

Tachypnea Crunching sound synchronous with

heart sounds

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. Gardner’s 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?

Cardiac rupture

Air embolus

traumatic aortic injury

Cardiac tamponade

(discussed later)

Heart failure

Tracheal tear

Pneumothorax

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

 

Forceful

penetration to

the skin

Mechanical

stress to the

chest

Penetrating

Chest Trauma

7. What clinical presentation will patients with PCT

display?Respiratory Cardiovascular Surface Findings

Dyspnea, respiratory distress

Rapid thready pulse Bruising

Cough w/ or w/o hemoptysis

Muffled heart sounds Abrasions

Cyanosis of mouth, face, nail beds,

mucous membranes

Chest pain Asymetric chest movement

Tracheal deviation Dysrhythmias Subcutaneous emphysema

Audible air escaping from chest wound

Decreased BP Open chest wound

Decreased breath sounds on side of

injury

Narrowed pulse pressure

Decreased O₂ saturation Asymetric BP values in arms

Frothy secretions Crunching sound synchronous with

heart sounds

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. Gardner’s 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 IV’s 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.

ETIOLOGYBlunt or penetrating trauma

Pericarditis

Cardiac rupture

Post CPR

Rupture of the great vessels

Electrical cardioversion

Malignancy

Radiation therapy

Connective tissue disease

Metabolic disorders

Renal failure

Hepatic failure

Infections (viral, bacterial or

fungal)

Drugs (Procainamide,

Methyldopa, Hydralazine for

example)

Post op mediastinal chest

tube occlusion or removal

Invasive catheters

Cardiac needle biopsy

Myocardial & pericardial

injuryPericardial

tissue damage

Release of inflammatory mediators

Rheumatic fever

Inflammatory response

Formation of exudates

(fibrinous, semi-fibrinous, or

purulent

WBCs amass the site of injury

Collection of exudates in the pericardial sac

Viral infection

Aortic aneurysm

Pericardial effusion

Chest trauma

Rapid build-up of pericardial

fluid

Heart compression

Cardiac tamponade

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

Beck’s 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. Gardner’s 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

Direct blow to the rib/ rib cage

Rib fracture Flail chest

Muscles and ribs cannot stand the

force of the impact

Motor vehicle

accident

Pedestrian

accident

Explosion

Assault w/ blunt object

Crush injury

Fall

Chest trauma

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• Rapid, shallow

breathing• Tachycardia• Unequal chest

expansion• Palpable crepitus• Diminished breath

sounds

Medical

Management• Initial therapy • Airway

management• Adequate

ventilation

• Supplemental O₂ therapy• Careful IV solution administration• Pain control• Mechanical ventilation may be necessary

•Definitive therapy• Reexpansion of the lung • Ensure adequate oxygenation

References

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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

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