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In 1934, Alfred Blalock, a pioneer in the field of
cardiac surgery, was the first American surgeon to
successfully repair an aortic injury. Thoracic trauma
was still in its infancy when treatment guidelines
were established during World War II.
In 1957,
Klassen became the first surgeon to successfully
repair a traumatic blunt aortic injury (BAI).
that time, prominent medical journals advised sur-
geons to avoid blunt chest trauma surgery. Since
then, however, advances in trauma and cardiac
surgery, surgical intensive care unit (SICU) resuscita-
tion, critical care, and perioperative nursing have
improved the care and recovery of the chest trau-
ma patient.
Trauma is the leading cause of all deaths, morbidity,
hospitalizations, and disability from the first year of
life through middle age, and results in over 100,000
deaths annually.
According to the 2006 National
Trauma Data Bank report (NTDB), motor vehicle
collisions (MVC) accounted for 41.3% of all injured
patients, falls comprised 27.2%, and firearm injuries
caused 5.6% of trauma injuries between 2001 and
Chest trauma accounts for 25% to 50% of all
traumatic injuries and is a leading cause of death in
all age groups; MVCs account for 70% to 80% of all
chest trauma injuries. Aortic injury is the second most
common cause of death in blunt trauma patients,
and an estimated 8,000 deaths per year are caused
by BAI.
chest trauma patient
Team management of the
32 ORNurse2008 March www.ORNurseJournal.com
Anne Ravdin Taylor, RN, BSN
Rosalyn P. McGrath, RN, BSN
Team management of the
chest trauma patient

What is chest trauma?
While perioperative nursing care follows specified
standards, and policies and procedures,
it’s never
routine. The individual circumstances of a patient’s
condition influences care, especially for chest trauma
patients. Due to the initially unknown details and the
need for immediate care, perioperative nurses must
have an overall understanding of the intricate nature
of the chest injury and the tissue and organ damage
that may have been caused.
Assessment findings will
vary according to the extent and the type of trauma.
Chest trauma is divided into two categories: blunt
and penetrating. Closed or blunt chest trauma
patients arrive in the OR intubated or awake, anaes-
thetized or medicated for pain. They may also have
cardiac and thoracic injuries that must be further
assessed after the initial triage and addressed rapidly.
Blunt chest trauma, an injury to the thoracic cavity
without penetration, is often caused by a severe blow
from a fall, a weapon (for example a baseball bat or
club), or from impact in a MVC. Vascular, cardiac, or
pleural space injuries may be present. In a MVC, the
blunt injury is caused by rapid deceleration and the
production of sheering forces that may result in a tran-
section of the aorta, causing a massive hemorrhage
and interruption of blood flow to the lower extremities
and vital abdominal organs.
Penetrating chest trauma
is an open injury to the cardiothoracic region that may
affect the cardiopulmonary system. The injury may be
caused by high-velocity, such as rifles and other high-
powered weapons that damage structures surrounding
the affected penetrated sites, medium-velocity (hand-
guns, which may impact surrounding areas), or low-
velocity weapons (knives that damage the involved
These patients deteriorate more rapidly
and their injuries may require operative intervention;
however, they tend to recover faster than those with
blunt or closed chest injury.
On arrival to the ED, the patient is initially assessed for
life-threatening problems involving airway, breathing,
and circulation (ABCs). Diagnostic tests are done
based on the patient’s condition and type of trauma.
A patient with a life-threatening injury may go directly
to the OR before a diagnostic workup is completed.
Arterial blood gas analysis may be done to evaluate
respiratory and metabolic status. Complete blood cell
count will help determine the amount of blood loss
and coagulation studies evaluate clotting ability. A
comprehensive metabolic profile may indicate the
presence of electrolyte imbalance.
Chest X-ray is the initial imaging study to detect rib
and sternal fractures, pulmonary contusion, mediasti-
nal hemorrhage, pneumothorax, and hemothorax in
the patient with chest trauma. Many blunt chest
injuries can be medically managed but may be too
complex for diagnosis via chest X-ray, and may
require additional studies, such as a computerized
tomography (CT) scan.
The helical CT scan is used
to diagnosis aortic injury in blunt chest trauma.
The transesophageal echocardiogram (TEE) is a
useful tool to evaluate traumatic aortic injury (TAI).
Cardiac anesthesiologists who are TEE-certified, or
cardiologists, may perform the TEE. Quickly initiated
once the patient is anesthetized, the probe is inserted
down the esophagus to deliver an ultrasound picture
of the heart structures. TEE’s advantages are the rapid
diagnosis of a hemodynamically unstable patient, its
portability, the lack of contrast needed, and the ability
to continually evaluate during operative procedures.
The disadvantages are its weakness in identifying
descending aortic injuries and that it requires an
experienced operator. While the risks of the proce-
dure are low, contraindications include cases of C-
spine, oropharyngeal, esophageal, or severe maxillofa-
cial injury. The results of the echocardiogram allow
the surgical and anesthesia teams to better manage
the patient intraoperatively.
Transthoracic echocardiography (TTE) is used to
detect pericardial effusion and diagnose cardiac tam-
Closed or blunt chest injury
A closed chest injury may result from a MVC, fall,
blast injuries, or blows to the chest causing injury to
the structures of the thoracic cavity. Examples of blunt
chest trauma injuries include fractured ribs, pneumoth-
orax, hemothorax, and BAI. The trauma team will
assess the patient in the trauma bay using the ABCs,
a patient
www.ORNurseJournal.com March ORNurse2008 33
a patient
Team management of the chest trauma patient
34 ORNurse2008 March www.ORNurseJournal.com
auscultation, percussion, and chest X-ray, and will pro-
ceed with further studies, such as a CT scan, in a stable
closed chest injury. These patients are most likely to be
treated via chest tube insertion, though a patient may
proceed rapidly to the OR for surgical intervention; the
cardiothoracic team will be placed on alert for a possi-
ble cardiac injury, such as cardiac tamponade. (See
Cardiac tamponade.) If blood is present when the peri-
cardium is opened, there may be trauma to the heart
or surrounding tissue. The trauma team may then con-
sult the cardiothoracic surgeons or proceed to a medi-
an sternotomy to further assess the injury(s).
If the injury is in the pleural cavity causing pneu-
mothorax or hemothorax, a chest tube insertion to
drain blood, fluid, and air may be warranted.
If surgi-
cal repair and thoracotomy are indicated, the cervical
spine (C-spine) must be cleared by the traumatolo-
gists. If the injuries warrant a surgical thoracotomy
approach, the patient is carefully placed in a lateral
decubitus position. Positioning devices, such as gel
pads, beanbags and pillows, lateral armrests, and
shoulder rolls are used, and the head, neck, shoulders,
arms, and legs should be properly aligned. Positioning
with appropriate padding to reduce pressure on the
bony prominences is important for the patient’s tissue
integrity through the recovery process. A padded safe-
ty belt is applied to the upper thigh to keep the
patient secure, and the table is flexed for proper
access to the open thoracic cavity.
Blunt injuries of the thoracic aorta
Thoracic aortic injury management continues to evolve.
If the desired treatment is intraoperative stenting, the
team may decide to slightly delay the repair, allowing
for a preferred, more controlled situation.
The cardiac
nursing staff, trained in endovascular procedures, assists
the cardiothoracic and vascular surgeons. The nursing
staff’s knowledge and efficiency during the procedure
is crucial to maintain a stable patient.
For BAIs that require stenting, it’s crucial to have all
of the necessary supplies and equipment readily avail-
able. At the Hospital of the University of Pennsylvania,
the OR Endovascular Suite is the pre-
ferred setting due to the special radiol-
ogy table, C-arm, and supply set-up.
The table is mobile and can move
horizontally and vertically on its base.
C-arm fluoroscopy is attached to the
floor, and is able to access the full
length of the table and circumference
of the patient. (See C-arm unit on base.)
When a BAI patient is imminent,
the suite is rapidly set-up. A full array
of introducers, dilators, wires, bal-
loons, and vascular stents are housed
in the room. The patient is assessed,
positioned, and prepped. Contrast
media and heparin are added to the
sterile field in labeled cups. The
choice of contrast medium depends
on the patient’s creatinine level if
available; in a trauma case, the least
Cardiac tamponade
Cardiac tamponade is an emergency condition in
which blood or fluid fills the pericardial space,
compressing the heart, increasing intracardiac
pressure, and obstructing venous return.
blood flow to the ventricles decreases, cardiac
output is reduced and can be fatal without prompt
treatment. Traumatic causes for cardiac tampon-
ade include penetrating trauma or blunt chest
trauma involving the pericardium, and can be
diagnosed via echocardiography.The echocardiog-
raphy often demonstrates an enlarged pericardi-
um or collapsed ventricles. A pericardial window
is the preferred procedure to drain the collected
fluid. Cardiac tamponade should be suspected
whenever hypotension is associated with a pene-
trating lesion in the chest or epigastrum.
C-arm unit on base
renal toxic choice is made. The circulating RN keeps
the surgical and anesthesia team apprised of the
amount of contrast medium used throughout the
procedure. Due to the C-arm radiation, the room
staff all need to wear protective lead shields and
aprons. A defibrillator and paddles, emergency cart,
and heart instruments are also brought into the room.
(See Defibrillation in the OR.)
Open chest to the OR
Patients with immediate life-threatening injuries may
proceed to the OR without a thorough work-up. The
immediate establishment and maintenance of the
ABCs is crucial to resuscitate chest trauma patients.
The patient may arrive in the OR with an open chest,
a chest retractor in place, and open cardiac massage in
progress. In a Level 1 trauma center, the critical chest
trauma patient may be directly admitted to the OR
from the helipad, bypassing the ED trauma bay.
If the chest trauma patient arrives with an open
chest and cardiac massage is in progress, the surgeon’s
hand performing the massage will be prepped along
with the open chest. A sterile field must be main-
tained while draping the open chest and a rapid
exploration and repair is initiated within minutes. I.V.
antibiotic therapy should begin as early as possible to
avoid a later infection.
If the injury is solely a cardiac injury and doesn’t
include the surrounding pleural cavity, the cardiac
scrub person may prefer to use a heart set for the
repair unless the trauma set is comprehensive to
cover basic cardiac procedures. At the Hospital of the
University of Pennsylvania, the trauma set allows the
patient to be placed on cardiopulmonary bypass
(CPB) and accommodates basic cardiac repairs.
The chest is then prepped and draped, and a
subxiphoid or substernal incision is made. The items
needed include: a suction device to remove the col-
lected blood, a small self-retaining retractor for expo-
sure, a clamp to grasp the pericardium, a scissor, for-
ceps, and a cautery device. Based on the results of
the exploration, the team may proceed to a full ster-
notomy for repair or simply insert a chest tube and
close the wound.
Cardiopulmonary bypass (CPB)
At a Level I trauma center, the ability to quickly place
the patient on CPB allows the surgeons to safely
repair a difficult chest injury.
The perfusionists, who
are responsible for operating the CPB machine, and
the cardiac anesthesiologists must be notified and
available. Cannulation sutures, surgical ties, cardiovas-
cular sutures, and suture tourniquets are added to the
trauma set-up. A specific side-biting clamp and cross-
clamp may also be requested. The perfusionists add
the necessary cannulas, cell saver tubing, tubing con-
nectors, bypass lines and suction tips. At the authors’
Level I trauma center, a bypass pump, cell saver, and
a rapid infuser are readily available, and the perfusion-
ists are in-house at all times, as are anesthesiologists
with trauma and cardiac experience.
Open repair: Aortic transection
A rapid and correct diagnosis and timing of the
proper care are crucial when treating a chest trauma
patient. Acute rupture is generally fatal, but the aorta is
rarely completely transected. (See The aorta and Rapid
decelerative injury causing a tear in the thoracic aorta.)
When the diagnosis of transected aorta is made,
the OR is placed on alert. Repairing the injury will
likely require a variety of vascular grafts. If the injury
isn’t entirely transected, the repair may be made by
over-sewing the tear with a vascular suture. If the
transaction is complete or nearly complete, the repair
will likely be made with a vascular graft(s).
In addi-
tion to the fundamental supplies needed for CPB,
www.ORNurseJournal.com March ORNurse2008 35
Defibrillation in the OR
The defibrillator supplies an electric current
through the heart causing the myocardial cells to
depolarize simultaneously, converting the abnor-
mal heart rhythm to a normal sinus rhythm.
Biphasic defibrillators using an alternating
pulse current direction complete a full cycle of
current in 10 milliseconds, requiring lower joules
to regulate and revive a heart rhythm. Biphasic
defibrillators are now used in many settings,
though monophasic defibrillators are still accept-
able. Cardiothoracic and trauma ORs should be
set-up with a biphasic defibrillator and external
and internal paddles. During defibrillation, exter-
nal defibrillating pads or external paddles are
used to deliver 150 to 200 joules. When defibrilla-
tion is necessary during an open chest case, the
sterile internal paddles are typically used to deliv-
er 30 to 50 joules.
Defibrillators and the integrity of the sterile
paddle packages should be checked daily. Con-
ductive jelly or external conductive pads must
also be available.
items needed for a repair may include various sized
vascular grafts, vascular suture, cross-clamps, and vari-
ous patch and pledgetted sutures.
Bypass versus off-bypass
A superficial wound to the heart, such as from a stab-
bing, can generally be repaired via over-sewing with
vascular suture. Due to the high velocity projectile
versus the lower velocity of a stabbing, gunshot
wounds are more likely to be fatal. If a more compli-
cated repair and greater visualization are necessary,
CPB will be necessary. In the case of BAI, limiting
cross-clamp and bypass time will benefit spinal cord
protection, decreasing the possibility of paralysis.
Clinical presentation
A 46-year-old man, in an apparent suicide attempt, shot
himself in the heart with a pneumatic nail gun. He came to
the trauma bay with a large nail imbedded in his heart, just
above the left nipple. The posterior-anterior and lateral
chest X-rays showed the nail was in the right ventricle, and
the tip had penetrated the septum to the left ventricle. The
patient remained hemodynamically stable and
was transported emergently to the OR. The
perfusionists remained on standby while the
procedure plan and the need for CPB were
discussed. The OR team rapidly prepared for
the patient, ready to proceed with the prep
and sternotomy when the patient arrived. The
TEE located the nail and an operative plan
was discussed. The sternum and pericardium
were opened, revealing a blood collection. The
nail was surgically removed and the ventricle
was repaired with a pledgeted vascular suture
(see Cardiac repair). A second patch suture
ensured adequate hemostasis. Two chest tubes
(angled and straight) were placed in the medi-
astinal and diaphragmatic chest sites. The
patient remained stable throughout the proce-
dure and was transported, intubated, to the
The team approach
Tasks may be divided among the nursing
staff, but it’s important that one RN circu-
lator is primarily responsible for the
patient and the overall activities in the
OR. A well-trained, collective team
approach, with cooperation between the
36 ORNurse2008 March www.ORNurseJournal.com
Team management of the chest trauma patient
Rapid decelerative injury causing
a tear in the thoracic aorta
From Harwood-Nuss A, Wolfson AB, et al. The Clinical Practice of
Emergency Medicine, 3rd Edition. Philadelphia: Lippincott Williams
& Wilkins, 2001.
The aorta
www.ORNurseJournal.com March ORNurse2008 37
ED/trauma bay, the OR, and the SICU, and pre-
paredness for emergencies are the key components
to the successful care of a chest trauma patient. OR
1. University of Pennsylvania Health System. UPHS mission and vision
statement. Philadelphia: UPHS; 2007. Available at http://www.uphs.
upenn.edu/about_uphs/mission.html. Accessed January 15, 2008.
2. Brinkman WT, Szeto WY, Bavaria JE, et al. Overview of great vessel
trauma. Thorac Surg Clin. 2007; 17(1): 95-108.
3. Sawyer MAJ, Sawyer EM, Jablons D, et al, Blunt chest trauma.
Emedicine. June 30, 2006. Available at http://
www.emedicine.com/ med/topic3658.htm.
Accessed January 15, 2008.
4. National Trauma Data Bank. American
College of Surgeons National Trauma Data
Bank Annual Report. 2006: Version 6.0. Avail-
able at: http:// www.facs.org/trauma/ntdb/
ntdbannualreport2006.ppt. Accessed Febru-
ary 4, 2008.
5. Hunt PA, Greaves I, Owens WA. Emergency
thoracotomy in thoracic trauma—a review. Injury.
January 2006; 37(1): 1-19.
6. Association of PeriOperative Registered Nurses.
AORNs standards, recommended practices and
guidelines 2007. Denver: AORN; 2007.
7. Longmore M, Wilkinson IB, Rajagopalan S.
Oxford handbook of clinical medicine. 6th ed.
Oxford: Oxford University Press; 2004.
8. Hudson K. Chest trauma: nursing care and
management. Dynamic Nursing Education.
December 4, 2004. Available at: http://
php?class_id=33&pid=11. Accessed January
15, 2008.
9. Shahani R, Galla JD. Penetrating chest trauma.
Emedicine. May 24, 2006. Available at http://
www.emedicine.com/med/topic2916.htm. Accessed January 15,
10. American Heart Association: Defibrillation. Available at: http://
www.americanheart.org/presenter. jhtml?identifier=4540.
Accessed January 15, 2008.
11. Acker MA, Gracias V. Cardiac surgery: Trauma and surgical critical care
clinical presentation. Philadelphia: Hospital of the University of Pennsylva-
nia; 2006.
Anne Ravdin Taylor is a perioperative trauma coordinator and Rosalyn P.
McGrath is a perioperative cardiac coordinator at the Hospital of the
University of Pennsylvania, Philadelphia.
The author has disclosed that she has no financial relationship related to
this article.
Cardiac repair
Team management of the chest trauma patient
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Your certificate is valid in all states.
1. What are the two main categories of chest
a. penetrating and thoracic
b. blunt and closed
c. blunt and thoracic
d. penetrating and blunt
2. The best definition of blunt chest trauma
a. any injury to the pleural space.
b. an injury to the thoracic cavity without
c. a chest injury involving the aorta.
d. a closed injury to the heart.
3. All of the following injuries may require
chest tube insertion for treatment except?
a. rib fracture without pleural injury
b. pneumothorax
c. penetrating pleural injury
d. hemothorax
4. Which position is most likely for a patient
undergoing a surgical thoracotomy?
a. supine
b. prone
c. lateral flank
d. lateral decubitus
5. Which statement best applies to an
emergency open chest trauma prep with
cardiac massage in progress?
a. The surgeon stops cardiac massage during
the prep.
b. The open chest is prepped, not the surgeon’s
c. A sterile field is maintained while prepping
the open chest.
d. In emergency surgery, the sterile field isn’t
a concern.
6. A cardiac tamponade diagnosis is most
often made using
a. chest X-ray.
b. echocardiography.
c. sternotomy.
d. CT scan.
7. The preferred procedure to treat cardiac
tamponade is a
a. thoracotomy.
b. sternotomy.
c. pericardial window.
d. chest tube.
8. Which diagnostic tool best assists in
evaluating a TAI?
a. magnetic resonance imaging
b. TEE
c. chest X-ray
d. arterial blood gas analysis
9. Which is an advantage of TEE?
a. no contrast needed
b. safe for use with C-spine injuries
c. rapid identification of pulmonary injuries
d. safe for use with severe maxillofacial
10. What equipment is added to the trauma
set up specifically for CPB?
a. suction
b. transesophageal probe
c. cannulation sutures
d. chest retractor
11. Which feature of a biphasic defibrillator
is accurate?
a. the paddles must be activated twice in
rapid succession
b. requires higher joules than a monophasic
c. completes a full cycle of current in 100
d. uses an alternating pulse current direction
12. Internal defibrillator paddles deliver
a. 5 to 10 joules.
b. 30 to 50 joules.
c. 70 to 90 joules.
d. 100 to 120 joules.
13. Who is responsible for keeping the team
appraised of how much contrast medium is
used during stenting?
a. circulating RN
b. scrub person
c. anesthesia provider
d. perfusionist
14. A superficial stab wound to the heart
can be treated using
a. CPB.
b. cross-clamping of the aorta.
c. a vascular graft.
d. over-sewing with vascular suture.
15. In the OR, spinal cord protection is
improved by
a. increasing cross-clamp time.
b. limiting cross-clamp and bypass time.
c. placing larger vascular grafts.
d. using a transesophageal probe.
16. Which team member is primarily
responsible for the patient and OR activities?
a. surgeon
b. anesthesiologist
c. perfusionist
d. RN circulator
ENROLLMENT FORM OR Nurse 2008, March, Team management of the chest trauma patient
B. Test Answers: Darken one circle for your answer to each question.
a b c d
1. H H H H
2. H H H H
3. H H H H
4. H H H H
a b c d
5. H H H H
6. H H H H
7. H H H H
8. H H H H
a b c d
9. H H H H
10. H H H H
11. H H H H
12. H H H H
a b c d
13. H H H H
14. H H H H
15. H H H H
16. H H H H
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Team management of the chest trauma patient
GENERAL PURPOSE: To provide the registered professional nurse with a review of the required care given by the OR team for victims of chest
trauma. LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to 1. Discuss mechanisms, injury patterns, and
diagnostic modalities of chest trauma. 2. Identify various treatments and the roles within the surgical team.
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