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Blunt chest trauma

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•Sudden compression or positive pressure against the chest wall strucked in the chest, normal is negative pressure, motor vehicle crash and hit the steering wheel, aggravated assault to the chest can cause hematoma in greater vessel, lungs to collapse, cause blood to fill in the pleural cavity, diaphragm to rupture, bleeding, stomach and spleen can herniate to the diaphragm

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Penetrating chest trauma

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•Foreign object penetrates chest wall

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Pathophysiology, hypoxemia

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•Hypoxemia •Disruption of the airway •Injury to lung parenchyma •Injury to rib cage & resp muscles •Pneumothorax- (penetrating trauma)] •Collapsed lung impair gas exchange, cant expand lungs because of the damage

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Pathophysiology , hypovolemia

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•Hypovolemia •massive fluid loss •Massive hemorrhage •Cardiac rupture (hit heart itself and cause bleeding)

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Pathophysiology, cardiac failure

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•Cardiac failure -Tamponade- , impair CO, blood in the cardiac sac, puts pressure on the heart, smothers the heart -Cardiac contusion -increased intrathoracic pressure (puts pressure on heart)

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Tamponade s&S

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Becks Triad (1 of 3) •JVD •Muffled Heart Sounds- something is in the airway •Hypotension (decrease CO) Leads to PEA- pulseless electrical activity, patient in cardiac arrest, can have a sinus rhythm but no pulse

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Nursing Assessment

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-Time - when injury happened -Mechanism of Injury -LOC- do they still have a LOC afterwards -Obvious injuries -Estimated blood loss (EBL) (fist method MAR, each fist 20 ml) -ETOH or Drugs -Pre-hospital treatment - EMS or home

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Collaborative management

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Priorities -ABC's -Establish an airway -Potential for large blood loss Bp, Map, to determine if theyre internally bleeding -Re-establish chest wall integrity

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Rib Fractures

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can interfere with patient being able to take deep breath •Most common type of injury •Fracture of 1st three ribs (punctured lug and heart) -High mortality (rare) -Laceration of subclavian artery or vein •Fracture 5th-9th ribs -most common site for fractures •Lower ribs -injury to spleen/liver, very vascualr •Fx ribs heal in 3-6 weeks (hurt like hell, prob with breathing, splint their rib which is no longer recommended)

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Diagnostics

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•CXR/CT Scan •Lab Values- look for liver disease, put you at greater risk for bleeding CBC, Coags (clotting factor), Type ; Screen (to see if they need more blood), BMP (electrolyte disturb •ABG (oxygenation) •EKG fast exam- focused exam (ultrasound) tonography, rapid ultrasounds look for bleeding.

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Signs and symptoms

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•Severe pain - chest area •Point tenderness - at site of fx •Muscle spasm over area of fracture •Bruising over injured area •Crepitus- air escaped, and trapped, feels like rice crispies (sub tissue of chest neck and shoulders, air escaped sub tissue from lungs, sign of pneumothorax) •Chest wall deformity- •Unequal chest expansion

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Nursing interventions

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•Pain Management •Splint chest - shallow breathing, but still take deep breaths to keep expanding the lung (but splint when coughing) •Avoid deep sighs/cough •Avoid over sedation/ resp suppression •Ice fx site •Pain decreases 5-7 days •Chest binder - support (don't use often anymore b/c of secondary complications) •Nurs DX: Ineffective breathing pattern give pain med to decrease pain

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Flail chest description and pathophysiologic presentation

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Description: •Multiple adjacent ribs are fractured at two or more sites causes in free floating rib segments Pathophysiologic Presentation: •Chest wall loses stability •Unequal chest expansion •Paradoxical chest movement •Resp impairment - resp distress •Hypoxemia - resp acidosis •Decreases cardiac output

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Flail chest pathophysiology

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multiple rib fractures, great areas of disconnect in ribs, impair movement of chest bc the ribs are fractured. Pathophysiology multiple rib ractures, chest wall loses stability in the chest movement, chst moves in uneven manner, can affect CO, and introduce positive pressure to chest cavity, •During inspiration, chest expands, & detached segment ( flail segment) moves in paradoxical manner, pulled inward during inspiration, reducing air to drawn into lungs, sucks in •On expiration, intra-thoracic pressure exceeds atmospheric pressure, bulge out •Flail segment bulges outward, impairing ability to exhale •Reduces alveolar ventilation

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Flail chest collaborative management

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Collaborative Management -Ventilatory support (may be mechanical) -Clearing secretions from lungs -Control Pain -May require surgery- fix areas that are

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What are the signs and symptoms of tymponade

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Jvd, muffled heart sounds, increased thoracic pressure, decreased oxygenation, increased pressure of the heart

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Penetrating trauma

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•Gunshot- check enter and exit •Stab wounds- don't remove it because its temponade bedside ultra sound crack it from side

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Chest trauma

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•Pneumothorax: Air in the pleural space, collapsed lung tissue (open or closed), penetrating trauma, blunt chest trauma •Hemothorax: Blood in the pleural space, lungs at top open or closed, blunt or penetrating •Hemopneumothorax: Air and blood Caused by surgery, disease or trauma (penetrating or blunt)

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Trauma patient priority care

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Establish an airway •Examine patient for other injuries •Undress the patient! •Large bore IV- 18 guage may need blood may need pressure (give u blood pressure fluids packed rbcs •Diagnostics •CXR •Labs ( CBC, CMP, T;S), ABG rapid ultra sound •continuous Pulse Ox/EKG, every 5-15 bp every 5 mins

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Pneumothorax

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Description- open space, collapsed lung tissue, change in intrathor pressure, put pressure on lungs and it drops and the air escaped into subcu tissue and you can see crepitus -Parietal/visceral pleura is breached ; pleural space exposed to positive atmospheric pressure, pushes the lung -Three types •Simple = Spontaneous •Traumatic •Tension

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Three types of pneumothorax

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•Simple = Spontaneous (tall, skinny guy, playing ping pong) •Traumatic •Tension (cause drop lung inside), put spressure on the heart itself

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Pneumothorax

answer

Trachia deviates to good side , absent diminished lung sound, air, puts pressure on the lung and causes it to collapse

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Signs and symptoms

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•Unequal chest expansion •Dyspnea •Sudden pain Collaborative Management: -Evacuate air or blood from pleural space -Pain control -Chest tube management

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Tension Pneumothorax

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patient on positive air ventilation Description -Occurs when air is drawn into pleural space from a lacerated lung or through a small hole in chest wall -Mediastinal shift to unaffected side, affect heart and put pressure on it, trauma to heart -PEA-pulseless electrical activity ; cardiac rhythm on monitor but no pulse lead to cardiac arrest

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Tension Pneumothorax sign and symptom, Collaborative management

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Signs ; symptoms Air hunger •Agitation •Hypoxemia (test abgs) •Cyanosis •Hypotension •Tachycardia (heart trying to compensate) •Diaphoresis Collaborative Management •High flow oxygen •Needle decompression, release air out of space •Chest tube

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Needle decompression picture

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the physician sterilely insert needle guided by ultra sound, they'll hear a rush of air, positive pressure is being released,

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Hemothorax

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Description •Collection of blood in pleural space •After chest surgery or injury Assessment •Same as pneumothorax •Mediastinal shift may occur, tracheal deviation Diagnostics •CXR •Thoracentesis (additional accumulation of fluid)

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Subcutaneous emphysema

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Description (bubbles escaping your body) •Air enters the tissue planes & passes under skin •Crackling sensation "rice krispies" •Air can be absorbed if treated or spontaneously stops •http://www.youtube.com/watch?v=H036SlCqUYo

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Misaligned trach, diminished lung sounds,

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need an order to get an xray, order for oxygen, may have pneumothorax

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Thoracic Surgery

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Types of Thoracic Surgery: •Thoracotomy-thoracic space is opened up, for flail chest so they need bridging, tumor and need a biopsy, part of lung had to be removed for cancer, just needed a lobe of lung removed •Biopsy- removal of small piece of tissue for laboratory examination •Pneumonectomy- entire lung removed •Lobectomy •Segmentectomy- segment of the lobe or lung •Wedge Resection- area of the lung damaged removed or tissue

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Nursing diagnosis

answer

ineffective breathing patterns, pain, ineffective perfusion, anxiety

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Nursing Pre-Operative Interventions

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•Chest auscultation •History & Physical •Pulmonary function tests •ABGs •Improving airway clearance, ABC's •Relieving anxiety- worsen symptoms •Patient Ed: splint incision when cough (post op)

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Post-Operative Nursing Interventions

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VS every 4 hours typically/ pre protocol •O2 depends on how well they're oxygenating •HOB 30-45 degrees promote lung expansion •Turn q 1 hr to promote lung expansion, prevent ulcers •Pain meds make sure patient is safe on meds, if not safe utilize non narcotics

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Mechanical Ventilation

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Post-operatively patient maybe intubated (ETT) based upon: (endotracheal tube), critical care unit after surgery •Type of surgery •Underlying condition •Intra-operative course •Anesthesia

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Chest Tube

answer

Superior position for air removal (tube placed high), 3rd or 4th intercostal space Inferior position primarily for fluid removal (tube placed low) air rises (pneumothorax) , fluid drops (hemothorax)

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Chest Tube

answer

goes into pleural space not the lung blood drains by gravity into the collecting system can be suction or no suction air that escapes gets trapped into the water seal so that it cant return make sure there's no loops or kinks so place it on the floor, when draining fluid if connected to suction increase rate of evacuation of fluid and air room air vent helps to vent air •Tube is sterile, flexible, nonthrombogenic composed of vinyl or silicone (can not form clots in the tubing) •Typically packaged with aluminum trocar (help to place the tube) •Measures 20 inches in length (50 cm) •Proximal end is fenestrated (so you can evacuate air and or blood) •Indications and patient size dictates size •Pneumothorax: 20-24 Fr (not as heavy so you wont need as much diameter) •Fluid: 28 Fr •Average adult/teen male: 28-32 Fr •Average adult/teen female: 28 Fr

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Chest Drainage Systems

answer

Goals of Therapy: monitor the environment •Chest drainage system used to re-expand lung •Improves gas exchange •Improves breathing post op •Removes excess fluid, blood, ; air

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Chest Drainage Systems

answer

Requirements •Suction source, may need suction •Collection chamber for drainage, •Mechanism to prevent air from re-entering the chest with inhalation •Two types -H2o Seal, most common -Dry

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Water Seal

answer

•Water seal chamber = NO bubbles •Sterile H2O for water seal and suction chamber •Aseptic technique •Dressing placed at site to seal so air wont enter (occlusive dressing) •Sealed connections w/ tape (prevent any disconnect) may be fluctuations bubbling means air leak , =1 severe bubble -5

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Two disposable chest tube units

answer

Pleura evac Atrium - document I and os, mark the date time initials, next time measure do the math and document, because it cannot be emptied note the blood, too much, too fast is a problem

question

Nursing Interventions for Chest Tube Set Up

answer

•Check orders •Medicate patient if applicable •Obtain sterile water to fill chamber •Fill water seal to line •If suction ordered, fill suction chamber •Connect wall suction ;80 mmHg prescribed by physician

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Chest Tube Drainage System(p. 527) picture

answer

dry vs wet is referring to the suction both of them have water seal suctioning is usually set at -20 and youll turn the knob, needleness too measure output just write it on the front so you squeeze water into it, if you see constant bubbling than there is a problem constant bubbling is a problem

question

Clarification on bubbles in the water seal chamber

answer

When the patient's CT (chest tube) is initially connected to the CT drainage system, there will be bubbles (likely) in that water seal chamber, as the air (from the pneumothorax) will escape into the drainage system. This is only initially, and should then stop.

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Filling the chamber pic

answer

http://www.youtube.com/watch?v=w65OgC3mVBk&list=PL41ADB25B2523B574 (Ocean) http://www.youtube.com/watch?v=GWxKZbKAxe8 (Oasis

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Evaluating Air Leaks

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•The water seal is a window into the pleural space •If air is leaving the chest, bubbling will be observed in the water seal window •Calibrated air leak monitor (1 low to 5 high) provides clinician with a method to trend the patient's air leak •Oscillation (swing), not abnormal to see ball rise when patient exhales and inhales water fluid rise when they inhale which is normal to see bubbles means there's a leak which is bad •http://www .bing.com/videos/search?q=chest+drainage+with+an+air+leak&FORM=HDR SC3#view=detail&mid=0B514E222D2477AE0B760B514 222D2477AE0B76

question

The suction control

answer

•Vigorous bubbling is loud and disturbing •Cause rapid evaporation in the suction control chamber -Lowers the suction level •Too much bubbling is not needed clinically- more is not better •Too much bubbling in scx control -turn down the vacuum source until a constant, moderate bubbling need a good constant tide in the suction control chamber

question

Chest tube drainage systems without water

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Dry Suction Equipment: •Spring or dial mechanism in place of the H2O column to control the suction level Advantages •Easy to set-up, no noise, and more precise suction •Evaluate the suction indicator frequently to be operating properly

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Secure Chest Tube picture

answer

Wrap xerofoam or pertroleum guaze wrap around chest tube, tape the fenestrated guaze, and put silk tape to seal it

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Nursing care

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•Keep drain below the chest for gravity drainage (put on floor) •Promotes drainage •Fluid moves from higher pressure to lower pressure •Same principle as raising an IV bag to increase flow rate

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Nursing care

answer

•Routine Assessments •Assess site, equipment •Monitor drainage •HOB 30 degrees •TCDB •IS •Flutter Valve- break up secretions, exhale and blows .Advocate ambulation & position changes

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nurse put in chest tube just 30 mins ago and there is already a lot of blood what should we do?

answer

Call the doctor

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Nursing Interventions

answer

•Auscultate breath sounds Q4H •Reinforce occlusive dressing •Tape all connecting points,

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Nursing Considerations

answer

•Sudden drainage increases = hemorrhage •Consistency changes could = evolving infection •Decreased drainage may = tube displacement, kinked tubing, or a clot (if its new), or they don't need it anymore (if its been in there for a while)

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Patient

answer

•Breathing and coughing techniques •Position •Addressing pain and discomfort, may need to splint when cough •Promote mobility ; arm/shoulder exercises, could be sore from injury and from the chest tube •Diet •Prevention of infection, encourage nutrition •S/sx to report

question

Accidental removal pictures

answer

chest tube is removed by incident need an occlusive dressing for 24 hours

question

will Fluid fluctuation in the water seal chamber or air leak indictor area stop` when the lung has re expanded ?

answer

yes, lung has re expanded (less negative pressure), You may have clots, kinks, or the suction isn't working properly

question

Accidental removal

answer

Get a occlusive dressing on insertion site immediately, tape 3 sided, 3 quarter taped on open side, to prevent air from entering but allow any expired air to escape.

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Indications CT removal

answer

•Xray shows full lung re-expansion •Drainage <200 ml/ 24 hrs •No air leaks •Improved patient s/sx •MD applies gentle pressure take deep breath and during exhale physician remove tube and apply gentle pressure pain before tube is removed give pain management

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Nursing Interventions

answer

Before Tube Removal by MD: •X-Ray Confirmation •Medicate Firm occlusive dressing applied to site taped and sealed on all sides •Post tube removal: -Check for subcutaneous emphysema -Check for air leaks around wound(s) -Check VS especially respiration quality and depth - Listen to breath sounds

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CT site dressing

answer

•Do not remove the occlusive dressing for 24 hours •Date the CT site dressing when changed •Document and don't write on the patient just write on a piece of tape.

question

nurse noticed chest tube is disconnected from the atrium chest drainage what intervention should you do? if tube comes out what should you do?

answer

2 cm of H2O proper seal Occlusive dressing

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Summary

answer

•Chest traumas can be spontaneous or related to an injury/disease •Traumas to the chest cause an alteration in oxygenation •The nurses priority is the ABC's •Two common complications of chest trauma is hemothorax and pneumothorax •Both of these complications may require a chest tube •CT's are also required after thoracic surgery •The nurse is responsible for CT set up and Maintenance

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