Trauma nursing: Blunt chest injuries
RN/DREXEL Home Study Program
CE credit is no longer available for this article. Expired July 2005
Originally posted March 2004
A motor vehicle crash. A missed stair that results in a fall. A soccer game that ends with a fractured bone. A drive-by shooting. The common denominator? Trauma.
According to the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control (NCIPC), more than 29.7 million nonfatal injuriesand more than 157,000 fatal injurieswere reported in 2001. Motor vehicle crashes (MVCs), falls, overexertion, and being cut, stabbed, or struck are among the leading causes of nonfatal injuries, and MVCs, gunshots, and falls are among the leading causes of fatal injuries.
MVCs and falls are particularly common sources of injury. In 2002, approximately 2.9 million people were injured and 42,000 killed as a result of MVCs, while 7.4 million were injured and 15,000 killed due to falls in 2001, according to the NCIPC.
Regardless of whether their injuries are caused by a fall, MVC, or attack, trauma patients require your immediate attention. Knowing how to quickly detect and treat specific injuries is crucial. As part of our Trauma Nursing series, we'll examine several types of trauma and in some cases, their effect on unique patient populations. We begin here with a look at blunt chest injuries.
Future installments will cover head injuries, penetrating injuries, pediatric trauma, dismemberment, and domestic violence. We'll tell you what you need to know to deliver the very best care when every moment counts.
Trauma nursing: Blunt chest injuries
JAMES F. VERONESI, RN, MSN, CNAA, CHE
JAMES VERONESI is director of nursing resources and systems at Pennsylvania State University Milton S. Hershey Medical Center in Hershey, Pa.
KEY WORDS: blunt chest trauma, pneumothorax, hemothorax, flail chest, "brown paper bag effect", pericardial tamponade, aortic tear, commotio cordis
Blunt chest trauma leads to a wide range of injuries, from relatively minor soft tissue wounds to fatal pulmonary and cardiac damage. A quick and accurate assessment can significantly improve your patient's odds of survival.
Marilyn Greene, 26, has just graduated from law school. After her graduation ceremony, she and a few close friends go out on the town. While driving herself home, she rounds a sharp curve, loses control of her car, and hits a tree at approximately 35 miles per hour. A passerby calls 911 immediately.
The front and interior of Ms. Greene's car were severely damaged. Ms. Greene had been wearing her seat belt and the front and side air bags had fully deployed.
The local emergency medical services (EMS) team responds and calls in to tell you her vital signs are stable with a heart rate of 92, respiratory rate of 20, and blood pressure 136/92. A cardiac monitor shows a sinus rhythm without ectopy. She's alert and oriented and says she did not lose consciousness. The only abnormal finding is tenderness on palpation of the left chest wall. Because of the mechanism of injury, she is immobilized on a backboard, and estimated time of arrival at the hospital is eight minutesapproximately 32 minutes from the reported time of the crash.
This initial report could lead to a false sense of security regarding Ms. Greene's condition. Although she may seem "stable," she may, in reality, have internal injuries from blunt chest trauma. Even without obvious sign or symptoms initially, impact to the chest wall can lead to significant injury, including severe damage to the lungs, heart, and great vessels, and even death. Understanding how blunt chest trauma occurs, how to assess a patient who has sustained it, and how to effectively treat it will help you provide patients like Ms. Greene with the lifesaving care they may need.
Assess chest trauma in two phases
There are two types of chest trauma: penetrating and blunt. (We will cover only blunt chest trauma here. Look for our article on penetrating chest trauma in May.) As many as 80% of serious blunt chest injuries are caused by motor vehicle crashes (MVCs).1 Other causes of blunt chest trauma include falls, sports injuries, violent acts, and crush and blast injuries.1
The injuries seen in blunt chest trauma typically result from a combination of three mechanismsdirect transfer of energy, rapid deceleration, and compression of the heartwhich are described in the "Mechanisms of injury in blunt chest trauma" box. Knowing which mechanisms were involved in your patient's case can help guide your care.
You'll assess a patient with suspected blunt chest trauma in two phases: You'll do a primary survey to check for life-threatening conditions, and then a secondary survey to assess for other injuries.
Begin by checking the patient's airway, breathing, and circulation (ABCs) to determine if she needs cardiopulmonary resuscitation. If she's yelling or moaning, you know the airway is open and she's moving enough air to create sounda good sign. If the patient is breathing on her own, watch her chest wall to assess the rate, depth, and symmetry of her respiration. Determine if she's using accessory muscles to breathe; this could indicate airway obstruction.2 Inspect the chest wall to see if it's intact or if there are visible bruises or deformities that could indicate a serious underlying injury. Assess circulation by checking for obvious bleeding and by palpating pulses. If your ABC assessment indicates the patient is unstable, deliver emergency care according to advanced trauma life support (ATLS) protocols before continuing with your assessment.2
Once the patient is stable, begin your secondary survey by obtaining as detailed a clinical history as possible. Find out the time and mechanism of injury, how fast the car was going (if it's an MVC injury), and whether there's evidence of injury to other systems.1
In the case of a fall, determine how far the patient fell and onto what surface or object. You can get this information from the EMS crew, police, family members, or, ideally, the patient himself. Also try to obtain a medical history, including information about current medication use, allergies, and any chronic medical condition, such as chronic obstructive pulmonary disease (COPD), that may make the patient more likely to experience injury when forces are applied to the chest.
Carefully inspect the patient's chest for bruises, lacerations, and abrasions. If the patient was in an MVC, look for bruises from the seat belt or redness or bruising over the sternum. Ms. Greene had red marks and abrasions at mid-sternum, and bilaterally over the anterior iliac spinae. Any of these signs might indicate that the crash was strong enough to cause myocardial contusions.2
To assess the stability of the chest wall, palpate it using firm, even pressure. Note any areas of tenderness or crepitus or any spots that feel unstable, which might indicate underlying injury. Move onto percussion, noting any hollow sounds; they could indicate pneumothorax, an accumulation of air or gas in the pleural space that can interfere with lung expansion.2 Auscultate the chest to help detect underlying lung injury, such as pneumothorax, or a ruptured diaphragm. Listen to the patient's heart sounds, too, as muffled and distant tones may signal pericardial bleeding or tamponade.2
Because most of the injuries commonly associated with blunt chest trauma can be diagnosed by chest radiography alone, all patients with suspected chest trauma should have a chest X-ray.3 Chest computed tomography (CT) may also be necessary; it's more sensitive than X-ray when used to detect certain injuries such as pneumothorax and pulmonary contusion.1
Patients will need a 12-lead electrocardiogram (EKG) to help identify cardiac abnormalities, the most common of which are tachyarrhythmias and conduction disturbances.1 Other tests used in the evaluation of blunt chest trauma include angiography, to detect blunt aortic injury;4 thoracic ultrasound, to help diagnose pericardial effusion, tamponade, and hemothorax; and transesophageal echocardiogram (TEE), to assess the descending thoracic aorta and evaluate other cardiac structures and function.1,3
Treatment is based on type of injury
Treatment for blunt chest trauma varies widely depending upon the type of injury. For the purpose of this article, we'll categorize blunt chest trauma into soft tissue, orthopedic, pulmonary, and cardiac injuries. In reality, though, patients with blunt chest trauma frequently have multiple injuries, and it's rarely possible to compartmentalize them. (Details of specific injuries are also included in the "At-a-glance: Blunt chest injuries" box.)
Soft tissue injuries
These injuries are the result of the direct transfer of force to an area of the chest wall where skin overrides bony structures. Soft tissue injuries include ecchymosis, hematoma, and lacerations.
Ecchymosis and hematoma result when blood vessels under the skin rupture. Lacerations occur when energy to the chest wall is applied at an angle to the skin. Severe lacerations can result in partial or complete avulsion of a portion of the chest, particularly with higher energy injuries.
Soft tissue injuries are rarely life-threatening. If you note them, however, suspect that there's damage to underlying structures until such damage is ruled out. Remember that soft tissue injuries from seat belts are usually red for the first few hours after impact, and not the typical black-and-blue or ecchymosis that you might expect from a seat belt. Ms. Greene was evaluated for underlying injuries to her ribs, chest, lungs, and heart, based on the chest bruises that her nurse had observed.
Rib fractures are the most common type of blunt chest injury.1 They typically occur following a direct, high-energy impact to the chest wall, as might happen if, for example, a person is kicked in the chest during an assault. Keep in mind, however, that even relatively low-energy impacts can cause rib fractures in patients with osteoporosis.
Rib fractures may be simple or compound. A simple fracture consists of a single break in a rib; a compound fracture is diagnosed when the skin is damaged and an open wound extends all the way down to the fracture site. Sharp bone ends or fragments can puncture the lung and cause a pneumothorax.
If your patient has a fractured rib, expect to administer non-steroidal anti-inflammatory drugs (NSAIDs) to control the pain. Surgical intervention is rarely necessary. In the past, rib belts or binders have been used to treat rib fractures. Although these devices are beneficial for pain control because they limit movement of the chest wall, they're no longer recommended because the limited movement often leads to hypoventilation and can contribute to pneumonia.
Flail chest, which is also called flail segment, occurs when there are multiple fracture of the ribs or sternum, resulting in a "free floating" unstable segment of the chest wall. Typically, it occurs when a high level of energy is transferred to the chest wall.
The classic sign of flail chest is paradoxical movement of the chest wall. To assess for it, observe the patient's chest for several breathing cycles. During inspiration, the affected area of the chest wall appears to "sink," while the rest of the chest wall rises. Conversely, during exhalation, the affected chest wall appears to rise slightly as the recoiling chest wall reaches maximum deflation.
The flail segment will also be obvious when the chest wall is palpated. Because the lung tissue beneath the flail segment is typically contused and nonfunctional, ventilation and oxygenation may be affected.
Surgery is rarely performed to stabilize flail chest. But because flail chest can cause hypoventilation and the underlying contusion causes ventilation/perfusion mismatch, intubation and mechanical ventilation may be necessary.
The patient needs careful monitoring to detect respiratory insufficiency and the need for mechanical ventilation. Pain control is best achieved with regional anesthesia, such as an intercostal block, IV patient-controlled analgesia, epidural pain control, or a combination of these measures.
Fractures of the clavicle can occur when a patient falls directly onto the shoulder or tries to break a fall and lands on an outstretched arm. This type of fracture can also result from a direct blow to the clavicle. The hallmark signs of a clavicle fracture are tenderness, crepitus, edema, and deformity at the injury site.
Like rib fractures, a fractured clavicle can produce sharp bone ends, which can damage underlying structures, including the lungs, the jugular vein, and the subclavian vessels. Clavicular fractures in children are common and generally heal well; in adults, however, these fractures take longer to heal and carry a higher risk of complications.5 Treat a clavicular fracture by applying ice to the area, immobilizing the affected arm with a sling (and often a swathe), and providing pain relief.5
Fracture of the sternum is also possible following blunt chest trauma, particularly after MVCs, which account for up to 90% of sternal fractures.6 While the increased use of seat belts and shoulder restraints has reduced the severity of MVC injuries overall, it has increased the incidence of sternal fractures.6 Fortunately, sternal fractures are rarely life threatening. Ms. Greene's chest X-ray showed a small one, which was treated with NSAIDs.
Pulmonary contusion occurs when high velocity blunt force is applied to the chesta person is struck with a bat, for example. The blow disrupts the microvasculature in the lung parenchyma, and blood and other inflammatory mediators invade the tissue. Typically, patients are asymptomatic at first. As the pulmonary contusion progresses, expect to note crackles during chest auscultation and, typically dyspnea, tachypnea, and tachycardia as well.
Pulmonary contusion is diagnosed with a chest X-ray, which will show opacity in the peripheral lung near the injured chest wall; however, this finding may not show up until 12 24 hours after the injury.7 If the contusion is small, supplemental oxygen by nasal cannula may be all that's needed. In severe pulmonary contusion, the patient may need intubation and mechanical ventilation to allow the lung time to recover.7
Pneumothorax can occur as a result of direct transfer of energy to the chest wall or rapid deceleration, in which the lung hits something inside the body, like the ribs. It can also result from what's called the "brown paper bag effect": A patient who's aware of an impending accident will often instinctively gasp just before impact. In an MVC, the body will move forward rapidly until it hits the steering wheel, and this can cause a rapid increase in intrathoracic pressure. With the lungs holding air and the glottis closed, there's no opportunity for pressure relief, so either a portion of the alveoli or the tracheobronchial tree ruptures.
Either simple or tension pneumothorax is possible with blunt chest trauma. Simple pneumothorax is generally not life threatening. It occurs when an alveolar tear allows air to enter the pleural space, but the air does not build up under pressure.
Signs and symptoms of simple pneumothorax are mild shortness of breath, often caused by shallow breaths taken to compensate for pleuritic chest pain. Treatment for simple pneumothorax is determined by its size and by the patient's condition.
A pneumothorax involving 10% or less of the lung isn't likely to result in lung collapse, so the patient may only require observation with serial X-rays.2 A patient with a larger pneumothorax may need chest tube thoracostomy to allow the air to leave the pleural space.8 A chest tube thoracostomy is also called for in any patient with simple pneumothorax who will be receiving positive pressure ventilation. This chest-tube placement is necessary to prevent a simple pneumothorax from becoming a life-threatening tension pneumothorax.
In tension pneumothorax, air escapes into the pleural space, but this time it is under pressure, so it results in lung compression. Tension pneumothorax is far more common in patients receiving positive pressure ventilation, either from a manual resuscitation bag or ventilator. As the volume of air builds, the external pressure on the lung increases, collapsing the lung. Pressure moves on to the mediastinum, shifting the trachea and great vessels toward the unaffected side. The pressure surrounding the mediastinum restricts the heart's ability to expand and accept venous return. Ultimately, stroke volume is reduced, leading to hypotension and subsequent hypoperfusion.
Other signs and symptoms of tension pneumothorax include cyanosis, tachypnea, tachycardia (usually greater than 135 beats per minute), paradoxical pulse (pulse that markedly decreases during inspiration), markedly diminished lung sounds on the affected side, and hyperresonance or tympany on percussion.8 With a mediastinal shift, deviation of the trachea and tracheal tug during inspiration may be present.
Tracheal deviation is best assessed by palpating the trachea at the suprasternal notch. Keep in mind, though, that you can't have a tracheal shift if the patient is intubated; the endotracheal tube holds the trachea in place.
Treatment for tension pneumothorax consists of immediate needle decompression with a large gauge needle (ideally, 12 14 gauge) placed in the intercostal space in the midclavicular line, followed by chest tube insertion.2 Pneumothorax is typically accompanied by some degree of blood in the chest, which can also be managed with a chest tube.2 If breath sounds are diminished on the left, remember that a displaced endotracheal tube in the right mainstem bronchus can mimic a large pneumothorax.
Myocardial contusion, or bruising of the heart, occurs as a result of direct force to the chest; for instance, an unrestrained driver hits the steering wheel during an MVC. The force disrupts the vasculature in the heart, leading to accumulation of blood and inflammatory mediators in the myocardium. The greatest risk to the patient following myocardial contusion is cardiac dysrhythmia.9
Suspect myocardial contusion any time there's been a direct blow to the chest, regardless of the velocity of the impact, and make sure your patient has a 12-lead EKG on admission to establish a baseline. Because myocardial contusion affects the right ventricle more frequently than the left, it may not be evident on a single-lead EKG, which typically examines electrical activity through the left ventricle. In Ms. Greene's case, her initial 12-lead EKG was normal, ruling out cardiac injury.
Blunt chest trauma can also result in pericardial tamponade, a life-threatening condition. Also know as cardiac tamponade, it occurs when blood (alone or in combination with other fluids) fills the pericardial sac, compressing the heart. As the pressure on the heart increases, the heart doesn't refill sufficiently and cardiac output rapidly drops. If the pericardial sac fills quickly, it may take only 100 200 ml of blood to cause death.
A patient with pericardial tamponade typically presents with Beck's triad: marked hypotension, diminished heart sounds, and distended jugular veins. Cardiac monitoring usually reveals sinus tachycardia with low-voltage QRS complexes.10
A patient with pericardial tamponade will need oxygen, as well as intravenous infusions of crystalloid solutions or blood products to maintain preload and perfusion. Pericardiocentesissurgical puncture of the pericardial cavity to aspirate fluidis the lifesaving emergency treatment.10
An aortic tear is another type of cardiac injury that can occur with blunt chest trauma. During rapid deceleration, the heart moves toward the front of the chest; however, its movement is somewhat restrained by the ligamentum arteriosum, which tethers the aorta to the heart. When the force exerted is significant, the forward movement of the heart can stretch the ligamentum arteriosum beyond its limits, causing an incomplete or complete tear in the aorta. If the tear is complete, meaning that all layers of the aorta are disrupted, blood rushes into the chest, leading to exsanguination and death.
In a patient with an aortic tear, skin color and temperature may differ above and below the nipple line, depending on where the tear occurs. If the tear occurs beyond where the subclavian artery comes off the aorta, skin below the nipple line will generally be pale and cool or clammy; above the nipple line, it will remain normal.
Radial and carotid pulses will be stronger than femoral pulses. On chest X-ray, the mediastinum will appear wide. The definitive treatment is surgical repair of the tear.
Myocardial rupture can occur with blunt chest trauma if the heart hits the sternum or is compressed between the sternum and the spine. The right ventricle is the most frequently ruptured chamber.11 As with gross aortic tear, the vast majority of patients with myocardial rupture die before they reach a hospital. Patients who do make it to a hospital alive will be in profound shock. They may have pulmonary edema and ventricular dysrhythmias, as well. An immediate consultation with a thoracic surgeon is essential and takes precedence over attempts at medical stabilization.11 Rapid infusion of fluids may help increase preload until the patient can get to the OR.
Commotio cordis is the sudden, unexpected death that occurs when a projectile, such as a baseball, strikes the precordium during the vulnerable period of the cardiac cycle10 to 30 milliseconds before the peak of the T wave.12 It occurs most frequently in young peoplethose under the age of 18during sports activities, particularly baseball, softball, or hockey.12 About half of the time, victims collapse right away; in some cases, however, there's a brief period of consciousness before collapse. Despite resuscitative efforts, which are often begun almost immediately, survival is rare.
Blunt chest trauma can result in serious injury, so early identification and treatment is a must. In Ms. Greene's case, attention to key findings during assessment uncovered her sternal fracture, a relatively minor consequence of blunt chest trauma. Not all patients will fare as well, but your close assessment and quick intervention may improve their chances.
1. Sawyer, M. A. "Blunt chest trauma." 2003. www.emedicine.com/med/topic3658.htm (4 Dec. 2003).
2. Carroll, P. (1999). Chest injuries. RN, 62(1), 36.
3. Sako, E. Y. "Lesson 18, Volume 15Blunt chest trauma." 2001. www.chestnet.org/education/online/pccu/vol15/lessons17_18/lesson18.php (4 Dec. 2003).
4. Nagy, K., Fabian, T., et al. (2000). Guidelines for the diagnosis and management of blunt aortic injury: An EAST Practice Management Guidelines Work Group. J Trauma, 48(6), 1128.
5. Brilliant, L. C. "Fractures, clavicle." 2003. www.emedicine.com/emerg/topic190.htm (17 Nov. 2003).
6. Slabinski, M. S. (2002). "Fractures, sternal." www.emedicine.com/emerg/topic206.htm (17 Nov. 2003).
7. New York Emergency Room RN. "Chest trauma." 2003. www.nyerrn.com/er/t/c.htm (17 Nov. 2003).
8. Bascom, R., Seema, J., & Iyriboz, T. "Pneumothorax." 2003. www.emedicine.com/med/topic1855.htm (17 Nov. 2003).
9. Orliaguet, G., Ferjani, M., & Riou, B. (2001). The heart in blunt trauma. Anesthesiology, 95(2), 544.
10. Yarlagadda, C., Hout, W., & Habib, S. "Cardiac tamponade." 2002. www.emedicine.com/MED/topic283.htm (17 Nov. 2003).
11. Shirani, J., & Alaeddini, J. "Myocardial rupture." 2003. www.emedicine.com/med/topic 1571.htm (17 Nov. 2003).
12. Link, M. S., Maron, B. J., et al. (2002). Reduced risk of sudden death from chest wall blows (commotion cordis) with safety baseballs. Pediatrics, 109(5), 873.
Internal injury, particularly to the heart and lungs, occurs as a result of one of three mechanisms, or some combination of the three. The first is the direct transfer of energy following a direct impact to the thoracic wallfor example, the chest wall strikes the steering wheel during a motor vehicle crash (MVC) or hits the ground during a fall.
The second mechanism is rapid deceleration, which also typically occurs during an MVC. Although the body stops moving forward after it hits an object, the internal organs continue to move until they hit somethingthe heart strikes the sternum, the lungs hit the ribs, or the aorta presses against the spine. All of these scenarios can result in contusion, bleeding, and rupture.
The third mechanism, unique to heart injury, is compression of the heart between the sternum and the spine. It could occur, for example, if someone were crushed by a large, heavy object or if the chest is subjected to a blast force from an explosion.
Any of these mechanisms can lead to significant injury, depending upon the level of energy that's transferred from an object to and through the chest wall. This energy level is determined primarily by the object's velocity, and also by its mass.
Generally, the higher the velocity, the higher the energy, and the greater the potential for injury. However, the transfer of relatively low-level energy can lead to significant injury, and even death, depending on the timing of the impact in relation to the cardiac cycle. For example, even a low-energy impact to the chest wall can cause sudden cardiac death if it occurs 10 30 milliseconds before the T-wave peak.
Sources: 1. Carroll, P. (1999). Chest injuries. RN, 62(1), 36. 2. Flynn, M. B., & Bonini, S. (1999). Blunt chest trauma: Case report. Crit Care Nurse, 19(5), 68. 3. Link, M. S., Maron, B. J., et al. (2002). Reduced risk of sudden death from chest wall blows (commotion cordis) with safety baseballs. Pediatrics, 109(5), 873.
The wide range of injuries from blunt chest trauma can make diagnosis and treatment challenging. The following review of the mechanisms of injury, signs and symptoms, and typical tests can help to simplify things.
|Mechanism of injury||Clinical signs & symptoms||Typical tests|
|Fractured ribs||Direct impact||Inspiratory chest pain and discomfort over the fractured ribs. Local tenderness and crepitus over the site of the fracture||Chest X-ray|
|Fractured clavicle||Direct impact||Tenderness over the fracture site. Pain with movement of the shoulder or arm. Crepitus. Edema||Chest X-ray|
|Fractured sternum||Direct impact||Pain around the injured area. Local tenderness and swelling. Initially redness, then ecchymosis in the area around the fracture. Possibly, inspiratory pain, dyspnea, a palpable defect, fracture-related crepitus||Chest X-ray|
|Flail chest (flail segment)||Direct impact||Pain and tenderness at the fracture sites. Inspiratory pain. Paradoxical motion of the flail segment (affected segment of the chest wall appears to move inward with inspiration and outward with expiration). Dyspnea, tachypnea, tachycardia||Chest X-ray|
|Pulmonary contusion||Direct impact or rapid deceleration||Dyspnea, tachypnea, tachycardia, crackles||Chest X-ray, chest CT scan|
|Pneumothorax (simple and tension)||Direct impact or rapid deceleration||Simple: Mild shortness of breath, often pleuritic (stabbing)
chest pain on deep inspiration
Tension: Cyanosis, tachypnea, tachycardia, hypotension, paradoxical pulse, markedly diminished lung sounds on the affected side, and hyperresonance of the chest to percussion
|Chest X-ray, chest CT scan|
|Hemothorax||Direct impact or rapid deceleration||Decreased breath sounds on the affected side. Dullness to percussion. Shock||Chest X-ray, thoracic ultrasound|
|Myocardial contusion||Direct impact||Dysrhythmia. Tachycardia. Friction rub. Accumulation of pericardial fluid||Chest X-ray, 12-lead EKG, serum troponin I, transesophageal echocardiogram (TEE)|
|Pericardial tamponade||Direct impact||Becks triad: hypotension, diminished heart sounds, and distended jugular veins. Sinus tachycardia||Chest X-ray, 12-lead EKG, serum troponin I, TEE, thoracic ultrasound|
|Aortic tear||Rapid deceleration||Skin above the nipple line will be relatively normal while skin below the nipple line will be pale and cold or clammy. Radial and carotid pulses will be stronger than femoral pulses.||Chest X-ray, chest CT scan, TEE|
|Ruptured myocardium||Direct impact, rapid deceleration, or compression||Profound shock, pulmonary edema, ventricular dysrhythmias||Chest X-ray, TEE|
|Commotio cordis||Direct impact||Sudden death||N/A|
Sources: 1. Sawyer, M. A. "Blunt chest trauma." 2003. www.emed icine.com/med/topic3658.htm (4 Dec. 2003). 2. Carroll, P. (1999). Chest injuries. RN, 62(1), 36. 3. Sako, E. Y. "Lesson 18, Volume 15Blunt chest trauma." 2001. www.chestnet.org/education/online/pccu/vol15/lessons17_18/lesson18.php (4 Dec. 2003). 4. New York Emergency Room RN. "Chest trauma." 2003. www.nyerrn.com/er/t/c.htm (17 Nov. 2003). 5. Bascom, R., Seema, J., & Iyriboz, T. "Pneumothorax." 2003. www.emedicine.com/med/topic1855.htm (17 Nov. 2003). 6. Yarlagadda, C., Hout, W., & Habib, S. "Cardiac tamponade." 2002. www.emedicine.com/MED/topic283.htm (17 Nov. 2003). 7. Shirani, J., & Alaeddini, J. "Myocardial rupture." 2003. www.emedicine.com/med/topic1571.htm (17 Nov. 2003).
Kathleen Moore, ed. James Veronesi. Trauma nursing: Blunt chest injuries. RN Mar. 1, 2004;67:47.
Published in RN Magazine.