Chest Trauma, Chest Tubes & Underwater Seal Drainage By: Victoria Murray & Mary Beth Chauder
Objectives • To review the anatomy and physiology of the respiratory system. • To identify the various types of trauma associated with the chest, and the nursing management associated with them • To discuss the mechanics of chest tubes, their uses, and the nursing management associated with them • To discuss pain management, nursing interventions and nursing diagnosis associated with chest trauma • To evaluate the understanding of the class with the use of a case study.
The Respiratory System (Day et al., 2010)
Ventilation Mechanisms (Day et al., 2010)
What is Chest Trauma? Classified as either: Blunt or Penetrating Trauma
Blunt Trauma • Most Common Causes: • MVA (Seatbelt, wheel) • Falls • Bicycle Crashes • Generalized Symptoms: • Hypoxemia • Hypovolemia • Cardiac Failure • Mechanisms of Blunt Chest Trauma: • Acceleration – moving object impacts chest • Deceleration – sudden decrease in speed/velocity (MVA) • Shearing – stretching forces to areas of chest • Compression – direct blow to the chest
Penetrating Trauma Most Common Causes: • Gunshot • Stab Wound Classified By: Velocity: Stab Wound Low Gunshot High
Initial Assessment of Suspected Chest Trauma VITALS & LOC Temperature, Pulse, RR, BP, SPO2 & PAIN Inspect Respirations Effort & Depth; Chest Wall Symmetry. Paradoxical Chest Wall Motion; Bruising ; Penetrating Wounds Palpate Trachea for deviation; Adequate and Equal Chest Wall Movement; Chest wall tenderness; Rib 'crunching' indicating rib fractures Percuss Percuss Both Sides of the Chest Looking for Dullness or Resonance Auscultate Normal & Equal Breath Sounds (Brown et al., 2009)
Initial Assessment of Suspected Chest Trauma (Trauma. Org, 2004)
Secondary Assessment of Chest Trauma • Gather history of event from family, client, and EHS. • Chief complaint • In depth medical history • Allergies • Pain assessment
Complications Of Chest Trauma • Pneumothoraxes • Simple • Traumatic • Open • Hemothorax • Tension Pneumothorax • Pleural Effusion • Sternal and Rib Fractures • Flail Chest • Pulmonary Contusion • Cardiac Tamponade • Pulmonary Embolism *
Pneumothorax defined & types individually discuss • Three Types: • Simple • Traumatic • Open • Hemothorax • Tension (Day et al., 2010)
Tension Pneumothorax • Air is drawn into the pleural space from a laceration. • Air that enters becomes trapped • Increased positive pressure • Lung collapses and causes a mediastinal shift away from the affected lung (Day et al., 2010)
Hemothorax 40% of the circulating blood volume can accumulate A small amount of blood (<300) in the pleural space may cause no clinical manifestations and may require no intervention (blood is reabsorbed spontaneously). Massive HTX results from a rapid accumulation of more than 1500cc of blood in the chest cavity. This may be life threatening because of resultant hypovolemia and tension Rib fractures and pulmonary parenchyma disruption are the most common causes
Pneumothorax-Manifestations Simple/Uncomplicated • Sudden onset of pain • ↓ Tactile Fremitis • Absent breath sounds • Hyperresonant Percussion • Minimal respiratory distress Large/Tension • Air hungry, anxious, dyspnea, diaphoresis, hypotension, tachycardia • Central cyanosis may re from severe hypoxemia • Acute Respiratory Distress—lung collapses totally
Pleural Effusion Pleural = Pleural Cavity Effusion = abnormal, excessive collection of this fluid
Pleural Effusion • Abnormal buildup of fluid between linings of the lung and chest wall • result of a disease process or inflammation • Normally 5 to 10 mL of serous fluid in the visceral and parietal pleura. • Any more can cause great changes in intrathoracic pressure.
Signs and Symptoms • Pleural effusion in itself does not cause symptoms. • If effusion expands and presses on lung, patient may develop • sharp, localized pain that worsens with coughing, or deep breathing. • Dyspnea • non-productive cough.
Signs and Symptoms cont... • Early signs include decreased or bronchial breath sounds on the affected side, dullness to percussion, and decreased fremitus over area of fluid accumulation • Auscultation: EGOPHONY • Hear “A” over fluid accumulation when patient speaks “E”.
Complications of Pleural Effusion • Respiratory compromise and distress from fluid compressing lung. • Infection in pleural space---Sepsis/Empyema • Fistulas in bronchi or chest wall • Inflammation/infection in pleural space leads to increased potential for adhesions. Adhesions isolate effusion to one lung and complicates treatment.
Sternal & Rib Fractures Rib Fractures are the most common type of Chest Trauma (60%) Sternal Fractures are most common in MVCs Fractures to the 5th-9th Rib are most common site of fracture (Day et al., 2010)
Sternal & Rib Fractures Manifestations • Chest Pain • Ecchymosis • Crepitus • Swelling • Chest Wall Deformities Interventions: • Pain Control • Deep Breathing and Coughing • Surgery is Rarely Necessary Patient Must Be Closely Monitored for Underlying Cardiac Injuries!!
Caused by Blunt trauma Flail Chest http://www.youtube.com/watch?v=uJHfX1RFkF0
Damage to the lung tissues resulting in hemorrhage and localized edema. The client is unable to clear secretions effectively, and the work of breathing is significantly increased Primary defect is the abnormal accumulation of fluid Pulmonary Contusion (Day et al., 2010)
Pulmonary Contusion Moderate Pulmonary Contusion: Mucous, Serum and Frank Blood in the Tracheobroncial Tree Persistent Unproductive Cough Severe Pulmonary Contusion Central Cyanosis, Agitation, Combativeness Productive Cough with Frothy Bloody Secretions Treatment priorities are to maintain airway, provide oxygenation and pain management Day et al., 2010
Cardiac Tamponade • Compression of the heart as a result of fluid within the pericardial sac • Usually due to chest trauma • Manifestations • Hypotension • Jugular-venous distention • Muffled heart sounds • Periocardiocentesis to remove fluid from pericardial sac
Pulmonary Embolism • Pulmonary embolism occurs when a blood clot becomes lodged in a lung artery, blocking blood flow to lung tissue. Blood clots often originate in the legs.
Pulmonary Embolism • Blockage makes it more difficult for the heart to pump blood through lungs. As a result, less oxygen is available to the rest of the body. If the blockage is large enough, tissue death (infarction) occurs in the lung area cut off from circulation. Pulmonary embolisms are commonly misdiagnosed. Nurses need to watch for it!
Misdiagnosed Why? Easily attributed to other conditions and vary with the size and number of clots. • Such as a heart attack • Pneumonia • Hyperventilation • Congestive heart failure • Panic attacks. Misdiagnosed for
Who is at risk? • Immobilization — Being immobilized puts a strain on the circulatory system. Although the heart acts as the body’s main pump, movement also assists in keeping blood circulating properly. • Long periods of inactivity may increase risk of blood clots. Examples include lengthy road trips or flights, or bed rest due to illness or surgery. • Blood abnormalities — Some people are born with blood that’s more prone to clotting & those dehydrated, septic, have Ca, those giving birth.
Other Risk Factors for Pulmonary Embolism • Advanced age (especially over age 70) • Significantly overweight • Birth control pills, HRT drugs & the osteoporosis drug raloxifene (Evista) are examples of drugs that list a small risk of developing blood clots.
About 90 % of Pulmonary Emboli Result When a Clot Travels from a Leg to a Lung - often no symptoms • Blood tests, a chest X-ray, an electrocardiogram — to help rule out other possible reasons for symptoms. • Sometimes a leg blood clot may cause redness, swelling and pain in the calf muscle area. Refer to a physician promptly. • A pulmonary angiogram is a more definitive test, although it involves some risk and is more expensive. • the CT scan (computed tomography scan) — instead of lung scan or pulmonary angiogram. CT scan is a less invasive test that provides fast and accurate results.
Nursing Diagnosis for Chest Traumas Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Patterns Imbalanced Fluid Volume Decreased Cardiac Output Decreased tissue perfusion Acute Pain Anxiety PC: Bleeding Risk for infection
Chest Tubes Chest Tube
What are Chest Tubes • A chest tube is a large catheter inserted through the thorax to remove air, blood, pus or lymph • Small Bore (12-20 Fr) • Large Bore (24-32 Fr) Perry & Potter, 2010)
Indications for Use (Briggs, 2010) Pneumothorax Tension Pneumothorax Bilateral Pneumothoraces Hemothorax Post-Operatively (Cardiac Surgery) Pleural Effusion Empyema Chylothorax Esophageal Rupture with Gastric Contents in Pleural Space
Equipment Required • Chest tube of appropriate size • Underwater seal drainage system • Sterile gloves, gown and drapes • Local anesthetic • Skin Prep solution • Chest Tube Tray • Dressing Material • Chest tube clamps (Briggs, 2010)
Chest Tubes Continued There are two types of Chest tubes: Pleural Mediastinal
Pleural Chest Tube Durai, et al., 2010; Perry & Potter, 2010
Mediastinal Chest Tubes Perry & Potter, 2010
Pre-Insertion of Chest Tubes * MD responsible for admin of analgesic (Durai, 2010) • Nurse prepares sterile table scalpel, local anesthetic (such as lidocaine), thick silk or polypropylene suture on a cutting needle, a chest tube of appropriate size and the underwater seal with sterile water filled to the mark • Opens drain package and prepares drain as per manufacturers instructions • Nurse Positions Patient for Procedure • Explain Procedure and assure patient • Monitor Vital Signs and for Discomfort
Methods for Insertion Durai, 2010 Two Methods for Tube Insertion Trocar based (i.e. the Seldinger technique) Allows for easier insertion Greater Risk Less Painful Blunt dissection More painful for the patient Safest Method