Thoracic Injury Management Jan 08

THORACIC INJURY
MANAGEMENT

A GUIDE FOR
EDUCATION & COMPETENCY

Compiled by: Pat Standen,
Grampians Regional Trauma, Emergency and Critical Care Coordinator.

ACKNOWLEDGEMENTS

Thank you to:
Wendy Porteous, Clinical Educator, Emergency Department, Ballarat Health Services,
and Dr Andrew Dean, Director of Emergency Medicine, St John of God Health Care for
reviewing the document and providing their expert advice.

Ballarat Health Services and Rural Ambulance Victoria for so generously allowing their
clinical practice guidelines to be used as a guide.

For information regarding this Guide contact:
Pat Standen
Department of Human Services
PO Box 712
Ballarat 3353
Email: pat.standen@dhs.vic.gov.au
Phone: 03 5333 6026
http://www.dhs.vic.gov.au/regional/grampians/

Version Date Major Changes Page No
1.0 January 2008

Front page image sourced from -
http://images.google.com.au/imgres?imgurl=http://www.24dr.com/reference/pictures/6.jpg&imgrefurl=http://www.24dr.co
m/reference/pictures/lungs_ribs.htm&h=226&w=271&sz=25&tbnid=cbuw7fG0VOhnCM:&tbnh=90&tbnw=108&hl=en&start=
16&prev=/images%3Fq%3Dribs%2Blungs%26svnum%3D10%26hl%3Den%26lr%3D

DISCLAIMER:
Care has been taken to confirm the accuracy of the information presented in this guide, however, the authors,
editors and publisher are not responsible for errors or omissions or for any consequences from application of
the information in the guide and make no warranty, express or implied, with respect to the contents of the
publication.

Every effort has been made to ensure the clinical information provided is in accordance with current
recommendations and practice. However, in view of ongoing research, changes in government regulations
and the flow of other information, the information is provided on the basis that all persons undertake
responsibility for assessing the relevance and accuracy of its content.

Thoracic Injury Management - January 2008 Page 2 of 39

TABLE OF CONTENTS

Page

INTRODUCTION 4

SECTION 1
1.0 Overview Anatomy and Physiology 5
1.1 Bones 5
1.2 Muscles of respiration 6
1.3 Internal organs 6
1.4 The mechanics of breathing 9

SECTION 2
2.0 Assessment 11
2.1 Preparation for arrival 11
2.2 Mechanism of injury 11
2.3 Danger 12
2.4 Response 12
2.5 Primary survey (breathing) 12
2.6 Secondary survey (thorax) 12
Primary Survey Chart 13
Secondary Survey Chart 14

SECTION 3
3.0 Thoracic Injuries 15
3.1 Mechanism of injury 15
3.2 Chest wall injuries 17
3.3 Pulmonary injuries 18
3.4 Mediastinal injuries 23

SECTION 4
4.0 Procedures 25
4.1 Needle thoracentesis 25
4.2 Thoracostomy 26
4.2.1 Indications 26
4.2.2 Sizes 26
4.2.3 Equipment 26
4.2.4 Technique 27
4.2.5 Complications 30
4.2.6 Post Insertion 30
4.2.7 Documentation 30
4.2.8 Chest Drainage System 30
4.2.9 Heimlich Valve 31

SECTION 5
5.0 Pain Management 33
5.1 Thoracic Injury Pain Management 33
5.2 Pain Assessment 34
5.3 Pain Severity 34
5.4 Treatment Choices 34

REFERENCES 38
SUGGESTED FURTHER READING 39

INTRODUCTION

The purpose of this guide is to assist educators in the Grampians Region to design their
own Health Service specific package for Registered Nurses Division 1 & 2 required to
manage patients in an emergency situation. The aim of this guide is to provide generic
information based on principles of care.

It is the responsibility of each individual practitioner and Health Service to ensure
appropriate education for all equipment and that competency in the use of the
equipment is maintained.

The majority of this guide refers to adults. For information regarding paediatric trauma
management it is suggested you refer to the Paediatric Trauma Manual and CD
provided to all trauma services in the Grampians Region.
Bevan, C. and Officer, C. (Editors) 2004 Paediatric Trauma Manual, Practical Trauma
Procedures pp291-311, Royal Childrens Hospital, Melbourne
www.rch.org.au/paedtrauma


SECTION 1

1.0 OVERVIEW OF ANATOMY AND PHYSIOLOGY

1.1 Bones: protector of thoracic contents

1.1.1 Ribs
The first seven (7) ribs are called true ribs. These are attached posteriorly to the
vertebrae and anteriorly, through cartilage, to the sternum
The next three (3) ribs are called false ribs. They are attached posteriorly to the
vertebrae and anteriorly they are attached to the costal cartilage of the ribs
above
The last two (2) ribs are called floating ribs. The posterior end is attached to the
vertebrae and anteriorly they are unattached

1.1.2 Sternum
Sits anterior midline with the thoracic cavity
Manubrium - superior portion
o Articulates with clavicles laterally and first two pairs of ribs
Mesosternum (body) - mid portion
o Bulk of sternum
o Articulates with third to seventh ribs
Xiphoid process - inferior end
o Articulates with body
o Anchors diaphragm and some abdominal muscles
1.1.3 Scapula
Two triangular flat bones located on the dorsal thorax between ribs two to seven
Each has three borders
o Superior shortest border
o Medial parallels with vertebral column
o Lateral abuts the armpit and has small shallow fossa called the glenoid
cavity which articulates with the humerus to form the shoulder joint

1.1.4 Clavicles
Extend horizontally across the upper thorax
The rounded medial sternal end attaches to the sternum manubrium
The flattened lateral acromial end articulates with the scapula

Source of images:
http://images.google.com.au/imgres?imgurl=http://www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_images/15_t.gif&imgrefurl=http:
//www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_car1_crs_lec02.htm&h=144&w=200&sz=11&tbnid=q-
irhPrfGZ_gLM:&tbnh=71&tbnw=99&hl=en&start=56&prev=/images%3Fq%3Dmediastinum%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN

1.2 Muscles of respiration:

1.2.1 Intercostal:
The main muscles of the chest wall are the internal and external intercostal muscles.
Each one extends from one rib to the rib below. They run obliquely and at right angles
to each other
External intercostals
Eleven pairs lie between the ribs
Function is to drawer the ribs together and elevate the rib cage and enlarge the
thoracic cavity horizontally
Internal intercostals
Eleven pairs lie between the ribs
Function is to decrease the dimensions of the thoracic cavity through passive
relaxation

1.2.2 Diaphragm:
The main muscle of respiration. It stretches across the base of the thorax, separating
the thoracic cavity from the abdominal cavity. The diaphragm contracts downwards
during inspiration enlarging the thoracic cavity vertically.

1.3 Internal organs:

1.3.1 Trachea
Half housed in the neck and half in the thorax
Moves up/down 5 cm.
Extends from cricoid cartilage to the level of the carina at the level of the fifth
thoracic vertebrae

1.3.2 Bronchi
The trachea bifurcates into right and left main stem bronchus at the sternal
angle (where the second rib is attached) within the mediastinum
The bronchi leave the mediastinum and enter the lungs at the hilum along with
the great vessels

1.3.3 Bronchioles
Conduct air down into the alveoli, where gas exchange takes place

1.3.4 Great vessels
Aorta, inferior and superior vena cava
Pulmonary vessels

1.3.5 Oesophagus
Muscular tube
Approx 25cms long
Collapses when no food propulsion

Thoracic divisions there are three subdivisions of the space within the thoracic cavity.
The two lateral subdivisions hold the lungs; between the lungs is the mediastinum.

1.3.6 Mediastinum contents
The thymus gland
The thoracic duct
Small lymph nodes
The heart
A branch of the phrenic nerve
Parts of the trachea
Parts of the oesophagus
Great vessels including
o Aortic Arch
o Roots of subclavian arteries
o Roots of brachio-cephalic artery
o Roots of left common carotid arteries
o Superior vena cava
o Pulmonary trunk
o Brachio-cephalic veins
Most of these structures communicate with other parts of the body:
The blood vessels bring blood from the rest of the body and carry it away from
the heart
The phrenic nerve and oesophagus pass through the mediastinum inferiorly and
terminate in the diaphragm and stomach respectfully.

Source of image:
http://images.google.com.au/imgres?imgurl=http://www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_images/15_t.gif&imgrefurl=http:
//www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_car1_crs_lec02.htm&h=144&w=200&sz=11&tbnid=q-
irhPrfGZ_gLM:&tbnh=71&tbnw=99&hl=en&start=56&prev=/images%3Fq%3Dmediastinum%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN


1.3.7 The heart
Size of a persons fist
Weighs 250-350 grams
Sits in mediastinum in thoracic cavity
Extends from second rib to fifth intercostal space
Lies anterior to vertebral column and posterior to sternum
Approx 2/3 extends to left side

Covered by
o Parietal pericardium
Fibrous layer
Serous layer
o Visceral pericardium
o Epicardium
Cardiac muscle
o epicardium
o myocardium
o endocardium

Source of image:
http://images.google.com.au/imgres?imgurl=http://media.wiley.com/assets/8/01/0-7645-5422-
0_0901.jpg&imgrefurl=http://www.dummies.com/WileyCDA/DummiesArticle/id-1211,subcat-
MATH.html&h=367&w=525&sz=40&tbnid=kAIGlawwwoD7JM:&tbnh=90&tbnw=129&hl=en&start=4&prev=/images%3Fq%3Dcardiac%2Banatomy%26svnum%3D10%26hl%3
Den%26lr%3D%26sa%3DX

1.3.8 Lungs
The lungs straddle the heart with the right lung shorter and broader than the left. Each
lungs concave base rests on the diaphragm, and the apex extends slightly above the
first rib. The hilum provides an opening through which the pulmonary and bronchial
blood vessels, lymphatics and nerves pass. The lungs are anchored at the level of the
hilum.
The lungs should never completely collapse as there is always a small amount of air left
in them. This is called the residual volume, air that cannot be exhaled even after
maximal effort.

The pleurae - thin layers that wrap structures in the chest
Parietal pleura
Lines thoracic wall and mediastinum
Folds around the heart, between lungs
Extends as visceral pleura to cover external lung surface
Divides thoracic cavity into three chambers
Produces pleural fluid which
o Allows lungs and thoracic cavity organs to move and slide easily
o Reduces friction
o Holds visceral and parietal pleurae together
Pleural cavity
o Space between the two membranes
Pleural space potential (negative pressure)
Essential for normal lung function


1.4 The Mechanics of Breathing

Respiration is a cycle of active inspiration and passive expiration whereby air moves in
and out of the lungs due to changes in pressure. The lung itself expands because of the
movement of the diaphragm and chest wall.

Pressure relationships in the thoracic cavity:
The intrapulmonary pressure, the pressure within the alveoli of the lungs, rises and falls
with the phases of breathing but will always equalise to the atmospheric pressure
outside the body.
The intrapleural pressure, the pressure within the intrapleural space, also fluctuates
with breathing. However this pressure is always about 4mm Hg less than in the alveoli
and is said to be negative. This negative pressure results from two factors, (a) factors
acting to hold the lungs to the thoracic wall and are opposed to (b) the factors acting to
pull the lungs away from the thorax wall.
Three main factors holding the lungs to the thoracic wall:
1. The adhesive force created by pleural fluid in the pleural space
2. Absorption of gases in the pleural space into the capillary blood creating a partial
vacuum
3. The positive pressure in the lungs
Two factors acting to pull the lungs away from the thoracic wall:
1. The natural recoil tendency of the lungs
2. The surface tension of the fluid film in the alveoli that constantly acts to collapse
the alveoli.

The importance of the negative pressure in the intrapleural space and the tight coupling
of the lungs to the thoracic wall cannot be overemphasised. Any changes to this can
cause the lung to collapse.

Inspiration
On inspiration the diaphragm is stimulated by the phrenic nerve, causing the diaphragm
to contract and move inferiorly and flatten thus increasing the vertical diameter of the
thoracic cavity. Contraction of the external intercostal muscles causing elevation of the
rib cage and thrusting forward of the sternum. This causes an increase in thoracic
cavity volume and hence decreases pressure in the lungs. This volume change makes
the intrapulmonary pressure lower than atmospheric pressure, thus drawing air into the
lungs. Normal inspiration ceases when the atmospheric and intrapulmonic pressure
equalises.


Expiration
When the nerve impulses to the diaphragm cease, the diaphragm returns to its relaxed,
elevated state, the intercostal muscles relax and the chest wall moves back in, the
lungs return to their resting size and position. This passive reduction in the lung size
and thoracic cavity volume causes intrapulmonic pressure to rise above atmospheric
pressure so air leaves the lungs.

Source of inspiration and expiration images:
http://images.google.com.au/imgres?imgurl=http://owensboro.kctcs.edu/gcaplan/anat2/notes/Image250.gif&imgrefurl=http://owensboro.kctcs.edu/gcaplan/anat2/notes/Note
s4%2520Function%2520of%2520the%2520Respiartory%2520System.htm&h=400&w=699&sz=37&tbnid=XXo-
MWmbwHbJhM:&tbnh=78&tbnw=138&hl=en&start=3&prev=/images%3Fq%3Dexpiration%2Batmospheric%2Bpressure%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3D
G

Why the lungs dont collapse
The negative pressure between the two pleurae maintains partial lung expansion by
keeping the lung pulled up against the chest wall. Under normal conditions there is
always negative pressure in the pleural cavity. The degree of negativity changes during
respiration. Under normal conditions the mechanical attachment of the pleurae, plus the
residual volume, keep the lungs from collapsing


SECTION 2

2.0 Assessment

Hypoxia and hypoventilation are the primary killers of trauma patients. Within the
primary survey, breathing is the step that will identify most chest conditions.
Thoracic injuries can cause damage to:
Chest wall: causing fractured ribs, fractured sternum, flail chest or open chest
wounds
Blood vessels: causing ruptured great vessels, haemothorax and contusions to
major organs
Lungs: causing contusion, pneumothorax, tension pneumothorax or surgical
emphysema
The principle aim of the primary survey is to identify and treat life threatening injuries.
In thoracic trauma these include:
Tension pneumothorax
Massive haemothorax
Open pneumothorax
Cardiac tamponade
Flail chest

Patients may present with:
Multiple trauma with involvement of the thorax
Isolated chest injury secondary to blunt or penetrating trauma
Pain
Tachycardia, respiratory distress
Hypotension

Remember:
Use your eyes to look/see
Use your ears to listen/hear
Use your hands to feel/touch
Use your mind to problem solve
Use your experience/intuition to guide you
Use your common sense to know what is right and wrong

2.1 Preparation for arrival
Ensure the Doctor has been notified and his/her expected time of arrival is
known
Call for assistance RNs from other wards or back up staff if required
Delegate and prioritise tasks (person in charge, airway, scribe, procedures etc)
Ensure emergency area clear and accessible
Turn on monitors and set up/check all equipment
Attempt to obtain brief history of events leading to presentation
Commence documentation
Initiate transfer if necessary

2.2 Mechanism of Injury
Consider:
Car occupants involved in high speed MCA; e.g. impact speed >60kph
with major damage to vehicle
Pedestrians hit by vehicles travelling at >30kph
Patients ejected from vehicles following MCA
Patients in car, which has rolled over following MCA

Patients in car where the death of another occupant in that car has
occurred
Patients falling from a height greater than 5-6 metres
Patient hit by an object, which has fallen greater, than 5-6 metres
Motorcyclists, cyclists
Explosions
The injured patient who is trapped, and has remained so for >30 minutes.

2.3 Danger
Ensure your own safety first
Make sure your work area is safe
Assess risks and, if needed, control hazards, seek assistance.

2.4 Response
Can you hear me?
Open your eyes
Whats your name?
Squeeze my hand

2.5 Primary survey (Breathing)
Assessment:
Expose the chest - note rate, rhythm and depth of respiration
Look for chest wall symmetry, equal chest wall movement, paradoxical chest
wall motion
Look for bruising, contusions, penetrating wounds
Feel for tracheal deviation and signs of tension pneumothorax
Feel for tenderness over chest wall and subcutaneous emphysema
Listen for breath sounds equal on both sides. Can patient talk? (words,
sentences)
Percuss both sides of chest for dullness or resonance. Hypo resonance (fluid),
hyperresonance (air)
Management:
Administer oxygen high flow 6-15 l/min
Breathing ineffective bag valve device with high flow oxygen, intubate
Tension pneumothorax needle thoracotomy & chest tube
Sucking chest wound 3 sided non porous dressing
Flail chest consider assisted ventilation
Haemothorax insert chest tube

2.6 Secondary survey (thorax)
Examine the entire chest (front, back and two sides) for injury:
Palpate the clavicle and ribs;
Apply gentle sternal compression to detect sternal fractures or flail segments;
Auscultate breath and heart sounds,
Do ECG.
Think abdominal injuries if lower ribs injured.
Consider cardiac/pulmonary contusion, cardiac arrhythmias, ruptured aorta,
ruptured diaphragm, and perforated oesophagus.
Monitor oxygen saturation if not already started in primary survey
Pay attention to end tidal carbon dioxide if patient intubated

Investigations: (depending on availability)
Chest X-ray
CT scan
Arterial blood gas analysis
Pathology

Enquiries to: Pat Standen 5333 6026 or pat.standen@dhs.vic.gov.au Reviewed Jan 2008

Enquiries to:
Pat Standen 5333 6026 or pat.standen@dhs.vic.gov.au Revised Jan 2008
Adult Retrieval Victoria: 1300 36 86 61

SECTION 3

3.0 THORACIC INJURIES

Mechanical energy is the most common energy source associated with chest injury.
Motor vehicle accidents (MVA) cause 80% of chest trauma
MVA are the contributing factor in 50% of deaths
Death rate in isolated chest injury is approximately four to eight percent
Early deaths are due to
o Airway obstruction
o Flail chest
o Open pneumothorax
o Massive haemothorax
o Tension pneumothorax
o Cardiac tamponade
Later deaths are due to
o Respiratory failure
o Sepsis

3.1 Mechanism Of Injury

Action of forces and energy on the body
Tissues are injured when exposed to excessive amounts of mechanical, electrical,
thermal or chemical energy and/or deprived of heat and oxygen.

Kinetic Energy (energy in motion):
The wounding potential of an event is affected by the amount of kinetic energy that is
transferred to the patient. Kinetic energy (KE) is determined by the mass of the object
in motion and its velocity (speed) or amount of acceleration. KE = mass X velocity
2 .
Speed is more important than mass. Doubling the mass doubles the energy whereas
doubling the speed generates four times the energy

Newtons Laws of Motion:
When a body is set in motion it will remain in motion until acted on by another force
(causes deceleration). Deceleration forces cause deformation of tissue referred to as
strains:
Tensile or stretching
Shear opposing forces across an object
Compressive or crushing
When the deforming force exceeds the tissues ability to regain its original shape
(elasticity) or its ability to resist a change in shape during motion (viscosity) tissue
injury will occur. For example, when a vehicle travelling at a set speed is suddenly
stopped (crashes), the occupant continues to travel at that speed until an outside force
or object causes the occupant to stop (seat belt, steering wheel, air bag, vehicle
interior). There are some internal organs that are not anatomically fixed that will
continue in motion until stopped by a hard structure or the strain on flexible points of
attachment. The first impact is car to tree, the second impact is occupant to steering
wheel and third impact is heart to sternum.

Acceleration and deceleration forces can cause injuries to the thoracic contents. The
first and second ribs and the sternum resist energy forces better than most other
bones. If these bones are fractured you can suspect significant injury to underlying
structures. Mechanical energy applied to the chest can cause fractures along with blunt
cardiac injury and pulmonary contusions. The relative fixation of the descending aorta

makes it susceptible to injury through deceleration forces. Penetrating injury to the
heart usually injures the right ventricle.

Deceleration forces cause heart, aorta and bronchus distal to the carina to tear
from points of attachment.
Compressive forces that cause fractures of relatively strong skeletal structures
can also cause underlying organ damage:
o Ribs pulmonary contusion, injury to pulmonary artery, lacerated liver,
spleen or ruptured diaphragm
o Scapula pulmonary contusion, brachial plexus disruption
o Sternum cardiac contusion, lacerated liver
Ecchymosis or abrasions in areas consistent with the seat belt should alert you
to the potential for pulmonary and/or cardiac contusion or rib fractures with or
without a flail segment.

Blunt injuries:
Blunt forces involve compression, deformation or sudden change in atmospheric
pressure. They result in contusions, lacerations, fractures or ruptures and could involve
a number of structures.

Penetrating injuries
Penetrating forces involve direct contact with an instrument that cuts the skin. Less
force is required to injure and usually result in less structures being involved.


3.2 Chest wall injuries
Chest wall injuries are very common following blunt trauma.

3.2.1 Rib fractures
The most common type of blunt chest injury in adults. Lower rib fractures may be
associated with diaphragmatic tears. Left lower rib fractures may be associated with
splenic injury. Right lower rib fractures may be associated with hepatic injury. Due to
the amount of force required to fracture the first rib close assessment looking for other
injuries should be undertaken.
Symptoms:
Pain on inspiration
Localised tenderness over fracture site
Dyspnoea
Diagnosis:
Usually clinical diagnosis
X-rays may miss a large number of fractures
Management:
Oxygen and airway management
Analgesia
Strapping should be avoided as it can lead to interference with ventilation and
lead to atelectasis
Consider admission to hospital for
o Fractures of 3 or more ribs
o Flail chest
o Those with respiratory co-morbidity
o Those with complications of fracture (pneumothorax etc)
o Uncontrollable pain
o Inability to cope at home

3.2.2 Sternal fractures
Sternal fractures are most commonly associated with steering wheel impact. The most
common fracture site is the manubrium and the body of the sternum (angle of Louis)
that is adjacent to the second intercostal space.
Symptoms:
Localised tenderness and haematoma
Diagnosis:
Chest X-ray, to exclude other injuries
ECG, to exclude myocardial infarction or cardiac arrhythmias
CK/troponin, may be of limited value
Management:
Analgesia
Chest physiotherapy
Consider admission to hospital for
o Presence of obvious cardiovascular sequelae during presentation
o Those with respiratory co-morbidity
o Those with complications of fracture (pneumothorax etc)
o Uncontrollable pain
o Inability to cope at home

3.2.3 Flail chest
Flail chest occurs when a portion of the chest wall becomes isolated by multiple
fractures, or disruption of the cartilaginous costo condral junctions. Usually by multiple
anterior rib fractures of at least two fractures per rib, in at least two ribs (causing a free
segment) or when rib fractures cause a free floating sternum.

The flail segment moves paradoxically or opposite from the rest of the chest wall during
inspiration and expiration. Associated lung contusion is common with a flail segment.
Symptoms:
Bruising, grazes on visible inspection
Localised pain especially on inspiration
Dyspnoea
May be crepitus associated with fractured ribs
Paradoxical chest wall movement
Diagnosis:
Radiology may assist
Paradoxical chest wall movement
Management:
Analgesia
Ventilatory assistance intubation may be required
Consideration of prophylactic ICC insertion

3.3 Pulmonary injuries

3.3.1 Haemothorax
An accumulation of blood in the pleural space, may be caused by blunt or penetrating
trauma
Minimal less than 350mls
Moderate 350 to 1500mls
Massive greater than 1500mls
Signs & Symptoms:
Signs of significant trauma, bruising, lacerations and/or penetrating object
Decreased breath sounds on injured side
Dullness to percussion in dependant areas
Decreased chest expansion
Dyspnoea, tachypnoea
Chest pain
Signs of shock
Management:
Thoracostomy (Insertion of a tube into the pleural space through a small
incision). (Refer Section 4 Procedures)
Thoracotomy (Incision into the chest wall)
Thoracoscopy (Endoscopic examination of the chest cavity)


3.3.2 Pneumothorax
An accumulation of air in the pleural space. This may result in pulmonary and
cardiovascular compromise.
Spontaneous
o Tall thin young males
o Marfans syndrome
Secondary
o Trauma
o Asthma
o Iatrogenic
o TB
o Pneumocystis pneumonia
o Carcinoma
o Sniffing
o IV drug users due to attempts at central vein injection
o Associated with Valsalva, prolonged inspiration in marijuana smokers
Loculated
o In patients with pleural adhesions due to previous pleural inflammatory
conditions or previous intercostal catheter (ICC) insertion

Signs and Symptoms:
Chest pain (in 90%)
Dyspnoea (in 80%)
Decreased chest motion
Cough
On the side of the pneumothorax
o Decreased breath sounds
o Decreased vocal fremitus
o Increased percussion note
Management:
Chest X-ray not always reliable, better in erect films
CT more sensitive than X-ray
Conservative
o In a pneumothorax involving less than 20% of the hemithorax, with no
respiratory compromise
o Repeat CXR in 24 hours and again at 3 5 days
Catheter aspiration
o Approximately 70% success rate
o Use 16G IV cannula or purpose built catheter
o Insert (anterior approach) into 2
nd
intercostal space in the mid clavicular
line or (axillary approach) 5
th
intercostal space, mid axillary line just
above the upper edge of the rib below on the affected side
o Infiltrate with local anaesthesia above the rib below
o Using an extension tubing, 60ml syringe and a three way tap aspirate up
to three litres
o Re X-ray
Thoracostomy (Refer Section 4 Procedures)

3.3.3 Tension pneumothorax
A life threatening injury usually due to a lung laceration. Air enters the pleural space on
inspiration, but the air cannot escape on expiration. Rising intrathoracic pressure
collapses the lung on the side of the injury causing a mediastinal shift, to the other side
of the chest, that compresses the heart, great vessels, trachea and ultimately the
uninjured lung. Venous return is impeded, cardiac output falls and hypotension results.


Tension pneumothorax may develop insidiously especially in patients with positive
pressure ventilation which may exacerbate the one way valve effect. The presence of a
chest tube does not mean a tension pneumothorax cannot develop.

Signs and symptoms:
Severe respiratory distress
Tachycardic
Tachypnoea
Breath sounds and percussion may be difficult to assess and misleading
Hypotension
Distended neck veins, head and upper extremity veins
Hyper expanded chest
Tracheal deviation away from the side with the tension (late)
Cyanosis (late)
Management:
Tension pneumothorax is a clinical diagnosis and immediate decompression should be
performed.
Needle thoracentesis (Refer Section 4 Procedures)
This intervention will convert a tension pneumothorax into a simple
pneumothorax
Follow up with insertion of ICC

3.3.4 Open pneumothorax (sucking chest wound)
A pneumothorax associated with a chest wall defect allowing the pneumothorax to
communicate with the exterior of the body. It results from a wound through the chest
wall which allows air to move in and out of the pleural cavity resulting in impairment to
ventilatory function.

During inspiration when a negative intra-thoracic pressure is generated, air is entrained
into the chest cavity not through the trachea but through the wound in the chest wall.
This is due to the chest wall defect being much shorter than the trachea and providing
less resistance. Once the size of the hole is more than 0.75 times the size of the
trachea, air preferentially enters through the chest cavity. A tension may result if a flap
develops that allows air to move into the chest but not out.

Signs and symptoms:
A wound in the chest wall that appears to be sucking
Reduced breath sounds

Increased percussion note
Reduced expansion of the hemithorax

Management:
Immediate treatment with an occlusive dressing
o Cover the wound with thin flexible paper, defibrillator pads or soft plastic
wrap (glad wrap)
o Seal three sides well, leave one edge free
o Create a valve effect so that air can escape out of the chest on expiration
but not enter on inspiration

With each exhale, air in the chest is pushed out from underneath the occlusive patch.
With each inhale, the patch sticks to the skin, keeping air from coming back into the
chest
Source:http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/Treat
aSuckingChestWound.htm

Analgesia
Insertion of ICC

NB - Never remove any object that is sticking into the chest pack around
the object with gauze pads soaked in normal saline.


3.3.5 Pneumomediastinum
Signs and symptoms:
Subcutaneous emphysema may be present
Hammans sign
o Pericardial or mediastinal crunch sound
o Sounds like the crushing of a foil packet
o Accentuated by heart beat and respiration
Tension pneumomediastinum rare
Management:
Usually conservative

3.3.6 Tracheobronchial injuries
Rare
Usually (65%) related to penetrating trauma
80% of blunt trauma usually occur within 2.5cm of the carina
Signs and symptoms:
Pneumomediastinum
Subcutaneous emphysema
Persistent leak from ICC
Segmental lung collapse
Haemoptysis
Dyspnoea, tachypnoea
Decreased or absent breath sounds
Management:
Primary closure of tear

3.3.7 Air embolism
Air embolism happens when a communication occurs between the pulmonary veins and
lung airways. When airway pressures exceed venous pressures, gas is forced into the
pulmonary venous system. It is then embolised into the systemic arterial tree. It occurs
most commonly following penetrating trauma rather than blunt trauma.
Signs and symptoms:
Focal neurological abnormalities in the absence of head trauma
Air bubbles in the retinal vessels may be visible on fundoscopic examination
Cardiovascular collapse shortly after institution of IPPV in the absence of tension
pneumothorax
Gas or froth in the arterial blood gases if present death is almost certain
Management:
100% oxygen and airway management
IV fluid challenge

3.3.8 Pulmonary contusion
An injury to lung parenchyma, leading to oedema and blood collecting in the alveolar
spaces resulting in loss of normal lung function and structure. Developing over 24
hours, pulmonary contusion leads to poor gas exchange, increased pulmonary vascular
resistance and decreased lung compliance. A large number of patients develop Acute
Respiratory Distress Syndrome (ARDS).

Diagnosis:
Dyspnoea, ineffective cough, haemoptysis and/or hypoxia
Tachycardia
Chest wall contusion or abrasions
Rarely diagnosed on clinical examination.
Suggested by mechanism of injury

Plain X-ray 24 to 48 hours post injury
CT

Management:
Analgesia
Close monitoring
May need ventilatory support

3.3.9 Ruptured Diaphragm
A ruptured diaphragm can be a life threatening injury if the initial diagnosis is missed.
The diagnosis can be difficult without a laparotomy.

In blunt trauma 90% of diaphragmatic injuries are due to motor vehicle accident.
Approximately 50% have pelvic fractures and there is a 33% mortality rate due to
blood loss from associated injuries and delayed diagnosis. In penetrating trauma 85%
are due to knife wounds. If penetration below the level of the nipples occurs,
consideration should be given to diaphragmatic injury.

Injuries to the diaphragm usually affect the left side as the liver cushions the right side.
The majority of diaphragmatic defects will enlarge over time with the organs most likely
to herniate being the:
Omentum
Transverse colon
Stomach
Small bowel and
Spleen
Herniation of abdominal contents into the thoracic cavity may cause respiratory
compromise due to displacement of the lungs and/or mediastinum.

Diagnosis:
Dyspnoea
Abdominal pain
Sharp epigastric pain radiating to left shoulder
Bowel sounds in the lower to middle chest

Management:
Laparotomy and repair of tear

3.4 Mediastinal injuries

3.4.1 Aortic injury:
This is usually caused by high-speed frontal impact motor vehicle accidents and is
frequently fatal pre hospital. The rupture occurs at the junction of the descending aorta
and left brachial artery.

Diagnosis:
Chest pain
Hypotension
Deceased level of consciousness
Deceased quality of femoral pulses compared to upper extremity pulses
Widened upper mediastinum on chest X-ray
CT is approximately 90% sensitive for aortic rupture
A haemothorax which drains bright red blood in ongoing significant amounts
Angiography


Management:
Primary repair
Close observation and management of blood pressure

3.4.2 Myocardial contusion: (rare for patients with myocardial rupture to survive to
hospital)
This is usually caused by high-speed frontal impact motor vehicle accidents from the
steering wheel.

Diagnosis:
Pleural rub
New cardiac murmurs
Signs of low cardiac output
ECG findings may include
o Presence of ST elevation
o Arrhythmia
o Conduction abnormality
o T wave inversion
Transoesophageal Echo (TOE) diagnostic tool of choice
CKMB not reliable
Troponin I
o Only required if ECG abnormal
Coronary angiography if ST elevation on ECG

Management:
Cardiac monitoring may be required

3.4.3 Oesophageal perforation
Occurs infrequently and usually associated with other mediastinal injuries.

Diagnosis:
Dysphagia
Regurgitation of blood
Subcutaneous emphysema
Features of pneumomediastinum
Food/fluid draining from ICC
Chest X-ray
o Mediastinal gas or widening
o Pleural effusion

Management:
Nasogastric tube placed under direct vision by a surgeon
Antibiotics
Acid suppression therapy
Surgical closure
Large bore pleural drainage


SECTION 4

4.0 Procedures

4.1 Needle thoracentesis
o 14g needle inserted (anterior approach) into 2
nd
intercostal space in the
mid clavicular line or (axillary approach) 5
th
intercostal space, mid axillary
line just above the upper edge of the rib below on the affected side
o attach a 10ml syringe to the needle (may help to hold the needle)
o advance the needle until air can be aspirated ( use a 4.5cm minimum
length needle to ensure you can reach the pleural cavity)
o air will escape with a rush from the pleural space under pressure with an
easing of the respiratory distress (in the presence of a tension
pneumothorax)
o if using a cannula, after placement, remove the metal stylet and leave
plastic sleeve in place
o cut a finger from a disposable glove, put a hole in the tip of the finger
and attach base of finger to the cannula to act as a flutter valve.

Source: Clinical Procedures in Emergency Medicine (P136)

This intervention will convert a tension pneumothorax into a simple
pneumothorax
Follow up with insertion of ICC
After the ICC has been inserted, the needle/cannula may be removed

Considerations:
If no rush of air is heard on insertion it may not be possible to determine if there
was a tension present or whether the needle reached the pleural cavity
There is the possibility that the lung may be lacerated during the insertion of the
needle, an air embolism through the laceration is of concern
In the absence of haemodynamic compromise, further assessment and/or
investigation may be warranted prior to needle thoracentesis


Source of images:

http://images.google.com.au/imgres?imgurl=http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/Images/NeedleThoracentesis.jpg
&imgrefurl=http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/NeedleaTensionPneumothorax.htm&h=204&w=252&sz=11&tbnid=
DDCdQl_KL-
niUM:&tbnh=85&tbnw=106&hl=en&start=1&prev=/images%3Fq%3Dneedle%2Bthoracentesis%2Btension%2Bpneumothorax%26svnum%3D10%26hl%3Den%26lr%3D

4.2 Thoracostomy (Insertion of chest drain)

When air and/or blood enters or becomes trapped in the chest causing a pleural space,
the lungs cannot fully expand resulting in respiratory distress.

For information on an audit tool for insertion and removal of a chest drain go to
www.thoracic.org.au/audittools.html

4.2.1 Indications:
Pneumothorax (tension, open or simple)
Haemothorax
Traumatic arrest (bilateral)
Intermittent positive pressure required post trauma
Failed aspiration

4.2.2 Sizes:
Newborn 8 to 12 FG
Infant 12 to 16 FG
Child 16 to 24 FG
Adults:
o Usually 20 FG for air
o 28 to 36 FG for blood, 28 to 32 FG post popular size

4.2.3 Equipment:
Marking pen
Sterile dressing pack
Sterile gloves +/- sterile gown

Gauze
Skin cleaning solution
Local anaesthetic (lignocaine 1%)
10ml syringe, 21g and 25g needles
23 g sterile scalpel blade and handle
Sterile long artery forceps
Sterile suture set
Sterile intercostal catheter
Sterile Heimlich valve or chest drainage device
Suture material (3.0 silk/prolene)
Sterile drainage bag (urinary)
2 large clear dressings eg opsite/tegaderm
Tape

4.2.4 Technique:
Ensure patient has:
o Patent intravenous access
o Oxygen via mask > 8 litres per minute
o Adequate analgesia
o Cardiac and oxygen saturation monitoring
Identify site:
o Injured side
o mid or anterior axillary line behind the pectoralis major
o on inspiration the diaphragm can rise to the level of the fifth rib or nipple
line. Chest drains should be placed above this line
o rib spaces are counted down from the second rib at the sub manubrial
joint
o use the highest rib space that can be felt in the axilla, usually the fourth
or fifth. (the fourth intercostal space is about three fingers below the
armpit)
o mark the site

Source of image:
http://images.google.com.au/imgres?imgurl=http://www.hcmc.org/manualHCMC/Procedure_Lab/thoracostomy_tube_files/image004.jpg&imgrefurl=http://www.hcmc.org/man
ualHCMC/Procedure_Lab/thoracostomy_tube.htm&h=279&w=312&sz=12&tbnid=qpan2WSbJBFOxM:&tbnh=101&tbnw=113&hl=en&start=11&prev=/images%3Fq%3Dthoracos
tomy%26svnum%3D10%26hl%3Den%26lr%3D

set up your equipment (remove the metal trocar from the ICC and discard)
clean the site
infiltrate with local anaesthetic
o put approximately 2ml under the skin
o push the needle down to the level of the inner rib putting in 1 ml at a
time as you go, checking for veins/arteries
o if when you pull back on the syringe you get air you have gone too far
and are in the pleural cavity. Pull back the needle about 2mm and inject
1ml into the pleura
o wait about five minutes for the local to take effect (if patient stable)

Source of image: Clinical Procedures in Emergency Medicine (p157)

insertion of drain
o use scalpel to make 2.5cm superficial skin incision parallel to rib along
the upper border of the rib below the intercostal space to be used to
avoid the vessels lying below each rib
o use the artery forceps to blunt dissect down to the pleura (3 to 4 cm)
o push the forceps in a few millimetres at a time and open them to
separate the muscle, continue until the pleura is reached you will feel a
pop as it goes through

Source: Clinical Procedures in Emergency Medicine (p158)

o open the forceps fully in three or more directions to make space for your
finger
o insert your finger and sweep around gently to clear any tissue (lung,
diaphragm and/or heart may be felt)
o remove your finger and attach forceps to the chest tube
o use the forceps to guide the tube towards the top of the chest (apex of
the lung) through the hole


Blunt dissection occurs by forcing the
closed points of the forceps forward and
then spreading the tips and pulling back
with the points spread.
A rush of air or fluid signifies penetration
into the pleural space.
The chest tube is grasped with the curved
forceps, with the tip protruding from the
jaws.
Using the finger as a guide to ensure entry
into the pleural cavity, the tip of the chest
tube is placed into the pleural cavity.
It can be easy to advance a chest tube
subcutaneously, entirely missing the
pleural space.
Source: Clinical Procedures in Emergency Medicine (p159)

o continue to advance the tube until all the drainage holes along the tube
are inserted. (10 to 12cm) You should not need any force; the tube
should slide in easily. If it is difficult, remove the tube check the hole with
your finger and the cavity and try again
connect the tube to the Heimlich valve (if patient is not being transferred, and it
is appropriate, connect to the underwater seal drainage system that is available
to you)
o connect valve end to the drain and watch the valve flap as air comes out
o connect the drainage bag to the Heimlich valve to collect any blood that
may drain out
o ensure to leave the drainage bag open to allow the air to escape

Source of image:
Council of Rural Area Nurses of Australia (CRANA) 2001 Clinical Procedures Manual for remote and rural
practice


secure the drain
o use a purse string suture to secure the drain or put a suture on each side
of the tube to close the wound then put a suture in the skin above the
tube and tie the long ends around the tube to hold it in place
cover with a clear dressing and tape securely to the chest wall

Consider antibiotic prophylaxis

4.2.5 Complications
malposition
empyema
organ damage
haemorrhage
pulmonary oedema
subcutaneous emphysema
pain (tube in too far)

failure to re expand
o improper connections
o improper position of ICC
o occlusion of bronchi with secretions or foreign body
o tear in larger airway
o large tear of lung parenchyma

4.2.6 Post insertion
immediate observation of air and/or fluid drainage
assess haemodynamic status of patient
assess and manage pain
on a regular, ongoing basis assess
o general patient comfort and anxiety level
o respiratory rate and depth
o work of breathing
o oxygen saturation
o skin colour and peripheral perfusion
o neurological state
o haemodynamic state
o dressing and insertion site
o
Chest X-ray
o Check position of ICC
o Assess lung re expansion
o Detect complications

4.2.7 Documentation
Record:
o Time of insertion
o Patient respiratory and haemodynamic status
o Site/location of ICC
o Size of ICC
o Nature and volume of chest drainage

4.2.8 Chest Drainage System:
The purpose of the chest drainage system is to assist with the re establishment of
normal pressures by removing air and fluid in a closed one-way system. The simple
one-way action of the water seal allows air to escape within a closed system.

Check system:
Observe insertion site for inflammation or infection
Ensure there are no drainage holes in the tube exposed
All connections are secure
There are no dependant loops, kinks or obstructions that may inhibit drainage
Ensure the drainage system is kept below the level of the patients chest

Assess drainage for:
Volume
Colour
Consistence
Air leak
The presence of swinging

Dislodgement of chest tube:
Dislodgement from the patient
o have patient cough or exhale forcibly
o apply a dry sterile dressing taped in three sides
o obtain assistance
o observe patient for respiratory distress
o set up for re insertion of tube

Dislodgement from the drainage system
o Clamp the chest tube (ideally for less than one minute) or place the end
of the drainage tubing (approx 2.5cm) into a container of sterile water
o set up new system
o Do not leave the patient unattended
o Assess for respiratory distress

Observe and document:
o Respiratory assessment
o Site of chest tube placement and size of tube
o Suction applied and amount
o Drainage volume
o Drainage colour and consistence
o Presence or absence of air leak and/or subcutaneous emphysema
o Presence or absence of swinging
o Patient comfort/anxiety level
o Analgesia
o Any procedures, changes in patients condition, interventions and results
of interventions

Transporting with a drainage system
o Ensure the system is below the level of the patients chest at all times
o Do not clamp the tube
o Never leave the patient unattended

4.2.9 Heimlich Valve:
http://www.bd.com/surgical/pdfs/bd_bardparker_heimlich_chest_drain_valve_brochure.pdf

The Heimlich Chest Drain Valve is a specially-designed flutter valve used to replace
underwater bottles in chest drainage.
Constructed of rubber tubing, the valve is compressed at one end to form leaflets that
control unidirectional flow.
The valve is encased in a transparent plastic chamber with tapered ends.

The proximal end of the casing can be attached to most chest catheters and the distal
end to tubing that empties into a plastic bag.
If desired, the distal end can be connected to regulated suction.
The Heimlich Chest Drain Valve is sterile and a single use device.

Because reflux is prevented by its flutter mechanism, the Heimlich Chest Drain Valve
functions even in the event of a disrupted connection beyond the point at which the
valve is attached to the chest catheter. This feature makes it a safe alternative for
patient transfer
When connected to a chest catheter, the Heimlich Chest Drain Valve allows fluid, clots
and air to flow out of the chest without reflux into the pleural cavity. Unlike underwater
drainage bottles, the Heimlich Chest Drain Valve is uncomplicated, and easy to use.
The Heimlich Chest Drain Valve functions in any position, is not restricted to use at a
level below the patients chest, as are underwater drainage bottles. With the valve,
there is no need to clamp the chest catheter during transport of the patient, and
complications arising from interrupted drainage are avoided.


SECTION 5

5.0 ACUTE PAIN MANAGEMENT

Pain is best treated early and effectively because once established it is more difficult to
treat. Multimodal analgesia is an integral part of managing pain. This can include the
use of analgesic drugs, local anaesthetic techniques (eg. nerve blocks) and non-drug
techniques paying attention to psychosocial issues, such as massage, heat and
transcutaneous electrical nerve stimulation. The response to the treatment can be
equally important in pain management especially in the ongoing treatment choices.

Acute pain is described as being of recent onset, usually of short duration and the cause
is generally identifiable. Acute pain has a defined pattern of onset, site, character and
duration. The main reasons for treating acute pain effectively and quickly is to prevent
suffering, reduce negative physiological and psychological effects, assist in rehabilitation
and reduce the ability of acute pain progressing to chronic pain.

5.1 Thoric Injury Pain Management
Source: http://www.adhb.govt.nz/trauma/injury04talks/davis/davis.htm

Treat life threatening Injuries
Assess and decide treatment options early
Pharmacology
o Simple analgesics
o Opiates oral or iv
Invasive techniques
o Intercostal nerve blocks
o Thoracic epidural
o Paravertebral nerve block

Morbidity
Chest trauma causes pulmonary contusions
o Ventilation Perfusion mismatch
o Decreased lung compliance
o Hypoxaemia
Pain Causes
o Decreased coughing
o Shallow hyperventilation
o Reduced FRC
o Sputum retention
The elderly (over 65)
o Mortality 22% vs 10%
o Pneumonia 31% vs 17%
o LOS 15.4 vs 10.7
o Ventilator days 4.3 vs 3.1
o Intensive care days 6.1 vs 4.0
o Each additional # rib increased mortality by 19% and pneumonia by
27%
Effective pain management
o Enables deep breathing and coughing
o Less than 3 #s
oral analgesics, NSAIDs paracetamol, weak opiates
intercostal nerve blocks (ICNB)


o More extensive
intravenous opiates, IV protocol or PCA
Sedation can cause respiratory depression and cough
suppression
Regional techniques shown to be better
Choice of analgesic technique
o Pain relief needs to be individualised
o Less than 3 # ribs oral analgesia +/- ICNB
o Patients requiring immediate surgery are best managed with IV
opiates
o Regional techniques can be added in later
o Head injury and spinal trauma are contraindication for epidural
analgesia

5.2 Pain assessment:
Identify the pain mechanism
Measure the pain severity
Identify any drug and/or alcohol history
Develop a pain management plan including regular reassessment and review at
specific intervals

5.3 Pain severity:
Pain is subjective and cannot be measured directly
Patient self reporting is the best way to assess pain
When using a measure of pain be consistent in its use. Examples include:
o Numerical rating scale, rates pain on a scale from 0 (no pain) to 10
(worst pain imaginable)
o Verbal rating scale, use words to describe the pain eg. None, mild,
moderate, severe, worst possible
o Visual analogue scale, eg. 10cm line with no pain at one end and worst
pain imaginable at the other
o Wong-Baker FACES pain rating scale
For acute pain using a scale provides a way of monitoring intensity and
treatment response.

5.4 Treatment choices:
Treatment should be commenced as soon as possible following identification and when
pain may be predictable, eg prior to invasive procedures. Opioids are the drugs of
choice for severe acute pain. The intra venous route is the most effective and allows for
titration of the dose. Oral analgesics can be used alone or in combination with opioids
depending on the patients condition and cause of pain.

5.4.1 Non-opioid analgesics

Practice points:
Paracetamol is an effective analgesic for acute pain (Level I evidence).
NSAIDs and COX-2 inhibitors are effective analgesics with similar efficacy for acute pain (Level I evidence).
NSAIDs given in addition to paracetamol improve analgesia (Level I evidence).
COX-2 inhibitors and NSAIDs have similar adverse effects on renal function (Level I evidence).
Paracetamol, NSAIDs and COX-2 inhibitors are valuable components of multimodal analgesia (Level II evidence).
COX-2 inhibitors do not impair platelet function (Level II evidence).
Gastric ulceration rates with short-term use of COX-2 inhibitors are similar to those for placebo (Level II evidence).
Adverse effects of NSAIDs are significant and may limit their use (clinical practice point).
The risk of adverse renal effects of NSAIDs and COX-2 inhibitors is increased in the presence of factors such as pre-existing renal
impairment, hypovolaemia, hypotension, use of other nephrotoxic agents and angiotensin-converting enzyme inhibitors (clinical
practice point).
Accessed at - http://www.mja.com.au/public/issues/184_03_060206/mac10793_fm.html

Drug Name Mode of Action Indications Dosages
Acetylsalicylic Acid (Aspirin) Analgesic, antipyretic, anti-
inflammatory and anti platelet
actions. A non selective NSAID,
preventing synthesis of
prostaglandins by
noncompetitively inhibiting both
forms of cyclo-oxygenase
(COX), COX-1 and COX-2
Mild to moderate pain, can be
used in combination with
codeine.
Fever.
Adult:
Orally 300-900mg every 4-6
hours
Paracetamol Analgesic and antipyretic.
May be due to inhibition of
prostaglandin synthesis
centrally, and to a lesser extent
peripherally, where other
mechanisms, which block pain
impulses, may be involved.
Mild to moderate pain, can be
used in combination with
codeine.
Fever
Adult:
Oral/rectal 0.5 to 1g every 3-
6 hours to a maximum 4g daily
IV infusion 1g every 4-6
hours, maximum 4g daily


5.4.2 Opioid analgesics:

Mode of Action:
Opioid analgesics mimic endogenous opioids by activating opioid receptors in the central and peripheral nervous systems to produce
analgesia, respiratory depression, sedation and constipation. They prevent transmission of pain impulses be acting pre and post
synaptically in the spinal cord, and by modulating the descending inhibitory pathways from the brain. Cough suppression occurs in the
medullary centre of the brain. (Australian Medicines Handbook 2006 (AMH) p48)

Clinical practice points:
Morphine is the predominantly used opioid analgesic because of familiarity, availability and cost.
The key advantage of using opioids in pain management is the variety of dosages and routes, they are easily titrated, are very
effective and have low risk to benefit ratios.
Naloxone is used to reverse opioid sedation and respiratory depression.
Dextropropoxyphene has low analgesic efficacy (Level I evidence).
In the management of acute pain, one opioid is not superior over others but some opioids are better in some patients (Level II
evidence).
Tramadol has a lower risk of respiratory depression and impairs gastrointestinal motor function less than other opioids at equi-
analgesic doses (Level II evidence).
Pethidine is not superior to morphine for treating pain of renal or biliary colic (Level II evidence).
In adults, age is a better predictor of opioid requirements than weight, although there is a large interpatient variation (Level IV
evidence).
Assessing sedation level is a more reliable way of detecting early opioid-induced respiratory depression than a decreased
respiratory rate (clinical practice point).
The use of pethidine should be discouraged in favour of other opioids (clinical practice point).
Accessed at - http://www.mja.com.au/public/issues/184_03_060206/mac10793_fm.html

Drug Name Dose suggestions Approximate
duration of action
(hours)
Suggested dose
equivalent to
10mg IM/SC
morphine
Comments
Codeine Adult
Oral.SC/IM 30
60mg every 4 hours
to a maximum
240mg in 24 hours

3 to 4 130mg IM
200mg oral
Mild to moderate pain, do not
exceed 60mg in single dose.
Can be used in combination with
aspirin, paracetamol and ibuprofen.

Drug Name Dose suggestions Approximate
duration of action
(hours)
Suggested dose
equivalent to
10mg IM/SC
morphine
Comments
Fentanyl Dosage varies with
age and clinical
condition of patient
0.1 to 1 50-100 microgram
IV
100 150
microgram SC
Moderate to severe pain. Preferred
in renal impairment.
Duration of action short, making it
useful for painful procedures.

Morphine Titrate to patients
needs; in acute pain
there is no
maximum dose.
Adverse effects limit
the dose.
2 to 3 or 12 to 24
(controlled release)
30mg oral Morphine remains the mainstay of
opioid therapy. There is a direct
relationship between blood
concentration of opioid and pain
relief.
Pain relief is better managed by
shortening the time between
injections rather than increasing
individual dosage.
Oxychodone Initial dose 5
15mg every 4 to 6
hours. Titrate dose
depending on
response.
3 to 4 or 12 to 24
(controlled release)
15 20mg oral Moderate to severe pain
Pethidine Initial IV dose 5
20mg repeated
every 3 to 5
minutes. Titrate
dose according to
response and
adverse effects.
2 to 3 75 100mg IM For use as second line in acute
pain
Tramadol IV/IM 50 100mg
every 4 to 6 hours
up to total daily
dose of 600mg
3 to 6 100 120mg IM/IV
150mg oral
Moderate to severe pain

REFERENCES

Bowers, A.C. and Thompson, J.M. 1988 Clinical Manual of Health Assessment Third
Edition St Louis: CV Mosby Company

Council of Rural Area Nurses of Australia (CRANA) 2001 Clinical Procedures Manual for
remote and rural practice www.crana.org.au

Davis, K. 2007 Pain Management for Patients with Chest Trauma, Acute Pain Service,
Aukland City Hospital http://www.adhb.govt.nz/trauma/injury04talks/davis/davis.htm

Driscoll, P., Skinner, D. and Earlam, R. (Editors) 2000 ABC of Major Trauma Third
Edition London: BMJ Publishing Group

Dunn, R., Dilley, S., Leach, D., Brookes, J., Maclean, A. and Roger, I 2003 The
Emergency Medicine Manual Third Edition Volume 2. Tennyson: Venom Publishing

OH, T.E. (Editor) 1998 Intensive Care Manual Fourth Edition Bath: Butterworth
Heinemann

Proel, J. (Editor) 2004 Emergency Nursing Procedures Third Edition St Louis: Saunders

Roberts, J.R. & Hedges, J.R., 1985, Clinical Procedures in Emergency Medicine Third
Edition, Philadelphia: W.B.Saunders Company

Rural Ambulance Victoria, Clinical Guidelines, www.rav.vic.gov.au

Sheey, S.B., Blansfield, J.S., Danis, D.M. and Gervasoni, A.A. 1999 Manual of Clinical
Trauma Care, The First Hour Third Edition St Louis: CV Mosby Company

The Royal Australian College of General Practitioners, Australian Society of Clinical and
Experimental Pharmacologists and Toxicologists and Pharmaceutical Society of Australia
Australian Medicines Handbook 2006 www.amh.net.au

Tortora, G.T and Grabowski, S.R. 1996 Principles of Anatomy and Physiology Eighth
Edition. Sydney: Harper Collins.

Trauma.Org: Thoracic Trauma (accessed 7 June 2007) www.trauma.org

Victorian Clinical Nursing Consortium, 2003, Trauma Nursing Program: Emergency Care
(Initial Resuscitation) Module Melbourne


SUGGESTED FURTHER READING:

Allibone, L. 2003 Nursing management of chest drains Nursing Standard Vol. 17, Iss,
22; pg 45, 12 pgs
http://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=
4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=6528
0

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine Acute
Pain Management: Scientific Evidence Second Edition 2005
http://www.anzca.edu.au/publications/acutepain.htm (accessed June 2007)

Bevan, C. and Officer, C. (Editors) 2004 Paediatric Trauma Manual, Practical Trauma
Procedures Royal Childrens Hospital, Melbourne www.rch.org.au/paedtrauma

Grey, E. 2000 Pain Management for patients with chest drains Nursing Standard. 14,23,
40-44
http://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-
standard.co.uk/archives/ns/vol14-23/pdfs/p40-
44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6

Salerno, M Sept 2006 John Hunter Hospital Intensive Care Unit: Nursing Management
of a Patient with an Intercostal Catheter, Self Directed Learning Package
http://intensivecare.hsnet.nsw.gov.au/five/doc/education%20packages/jhh_uwsd_sdlp.
pdf


Thoracic Injury Management Jan 08

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Thoracic Injury Management Jan 08

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THORACIC INJURY

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