CHEST INJURIES

Dr Rodwell Gundo
Medical/Surgical Nursing Department
Learning outcomes
By the end of the session, learners should be able to:
• Explain the common chest injuries

• Describe the pathophysiological states that occur in chest injuries

• Describe the assessment of patients with chest injuries

• Describe the chest drainage systems

• Explain the nursing care of a patient with chest drains

Review - Anatomy
Blunt trauma
• Caused by motor vehicle
accidents (trauma from steering
wheel, seat belt)

• Mechanism of injury
• Acceleration
• Deceleration
• Compression
Blunt trauma
• Injuries lead to the following pathologic states:
Hypoxaemia
• Disruption of the airway
• Injury to the lung parenchyma, rib cage and respiratory
musculature
• Massive haemorrhage
• Collapsed lung
• Pulmonary contusion
• Pneumothorax
Blunt trauma
Hypovolemia
• Massive fluid loss from the great vessels, cardiac rupture or
hemothorax

Cardiac failure
• From cardiac tamponade
• Cardiac contusion
• Increased intrathoracic pressure
Gunshot and stab wounds
Gunshot and stab wounds
Stab wounds
• Appearance of the external wound may be deceptive

• Pneumothorax, hemothorax, lung contusion and cardiac tamponade

along with haemorrhage can occur from any small wound
Gunshot and stab wounds
Gunshot wounds
• Factors that determine extent of damage include distance from which
the gun was fired, the calibre of the gun and size of the bullet

• A bullet can cause damage at the site of penetration and along its
pathway

• The bullet may ricochet off bony structures and damage chest organs
and great vessels or can travel into the abdomen
Assessment
• Rapid assessment involves the use of the Advanced Trauma Life
Support (ATLS) – ABCDE
• Airway – stridor, cyanosis, nasal flaring
• Breathing – symmetric movement, entrance or exit wounds. The chest
also palpated for tenderness and crepitus (subcutaneous emphysema)
• Circulation – vital signs and skin colour
• Disability – level of consciousness; concurrent head and spinal cord
injuries
• Exposure – exposure injuries: hypothermia and hyperthermia
Assessment
• Many patients have associated injuries that require attention

• Ongoing assessment is essential to:

• monitor patient’s response to treatment

• detect early signs of clinical deterioration

Diagnosis
• Chest x-ray
• CT scan
• Complete blood count
• Blood grouping and x-matching
• Electrolytes
• Oxygen saturation
• Arterial Blood Gas analysis
Medical management
• Management of penetrating and blunt chest trauma are similar
• Immediate management is to restore and maintain cardiopulmonary
function
• Insert large-bore IV line
• Insert indwelling catheter to monitor urinary output
• Insert NGT and connect to low suction to prevent aspiration, minimize
leakage of abdominal contents and decompress the gastrointestinal
tract
• Treat shock with colloids solution, crystalloids or blood
Medical management
• Chest tube is inserted into the pleural space in patients with
penetrating wounds
• to achieve rapid and continuing re-expansion of the lungs – restores
the negative intrathoracic pressure
• results in complete evacuation of the blood and air
• allows recognition of continuing intrathoracic bleeding

• Patients with penetrating chest wound require exploratory surgery

Sternal and rib fractures
• Caused by direct blow to the sternum

• Fractures of the first three ribs are rare but can result in high mortality
because of laceration of the subclavian artery

• Fifth through ninth rib – common

• Fractures of the lower ribs associated with injury to the spleen and
liver
Clinical manifestations

• Sternal fractures – anterior chest pain, overlying tenderness, crepitus,

swelling and possible chest wall deformity

• Rib fractures – severe pain, tenderness and muscle spasm over the area
of the fracture, aggravated by coughing and deep breathing
Clinical manifestations

• The patient splints chest, breaths in a shallow manner, avoids sighs,

deep breaths, coughing and movement

• The reluctance to move or breathe results in diminished ventilation,

atelectasis (collapse of unaerated alveoli), pneumonitis and
hypoxaemia
Diagnostic investigation
• Chest x-ray

• ECG

• Arterial blood gas analysis

Medical and nursing management
• The goals are to control pain and to detect and treat the injury

• Narcotics are used to relieve pain and allow deep breathing and
coughing

• Care should be taken to avoid oversedation and suppression of the

respiratory drive

• Alternative strategy – use of ice over the fracture

Flail chest
• Usually a complication of blunt
chest trauma from a steering
wheel injury

• Occurs when three or more

adjacent ribs (multiple
contiguous ribs) are fractured at
two or more sites resulting in
free-floating rib segments
Flail chest
• May also occur as a combination fracture of ribs and costal cartilages
or sternum

• Chest loses stability causing respiratory impairment and usually

respiratory distress

• There is an underlying pulmonary or cardiac contusion

Chest tubes
• A chest tube is a drain which is
used to remove air, fluid or blood
from the pleural space

• Most chest tubes are

multifenestrated transparent
tubes with distance and radio-
opaque markers
Chest tubes
• There are two types of chest tubes namely: pleural and mediasternal
depending on the location of the tip of the tube

• Large tubes (20-36 French) are used for blood or thick pleural
drainage while small tubes (16 -20 French) are used to remove air.
Equipment for chest tube insertion
• Chest tube insertion tray (with • Large hemostasis
scapel blade) • Suture material (2-0 silk) on a
• Chest tube cutting needle
• 1% Lidocaine • Gauze swabs
• Syringe for lidocaine infiltration • Chest drainage system and
• Antiseptic solution suction
• Sterile gloves • Sterile water for water seal
systems
• Medication for pain and sedation
Drainage system
• To promote intrapleural negative pressure, a seal for the chest tube
which prevents air from outside entering into the system is required

• An underwater drainage system is commonly used

• Knowledge of the drainage system allows nurses to safely manage

complicated chest drains
Types of chest drainage systems
• One chamber system

• Two chamber system – has a water seal and a collection chamber

• Three chamber system – includes a suction control chamber

Two chamber system
• First chamber is collection
receptacle and the second is
water seal

• Sterile water is added to the

second chamber to the 2 cm level
to achieve a seal
Two chamber system
• Represents the negative pressure that is exerted on the pleural space
while the water closes the chest drain to prevent air from outside,
which acts as a one way valve

• The water seal allows air to escape while preventing air from outside
to enter the pleural space

• Fluid levels above 2 cm of water exerts great negative pressure on the

pleural space
Two chamber system
• The fluid level in the water seal fluctuates during respiration.

• During inspiration pleural pressures become more negative, making

the fluid level in the water seal chamber to rise

• During expiration pleural pressures become more positive causing the

fluid levels to descend
Two chamber system

• Bubbling is only seen in the underwater seal chamber during

expiration as air and fluid drain from the pleural cavity

• Continuous bubbling may indicate air leak in the system or broncho-

pleural fistula
Three chamber system
• A suction is added to the two
chamber system
• It is the safest way to regulate the
amount of suction
• Suction can be achieved by
adding water to the prescribed
level in the suction chamber
normally -20cm of water
Three chamber system
• Once the wall suction exceeds the force necessary to lift the column of
fluid, any additional suction simply pulls air from a vented cap atop
the chamber up through the water

• The amount of wall suction applied to the chamber should be adequate

to create ‘gently rolling’ bubble in the suction control chamber

• Vigorous bubbling lead to loss of water through evaporation, changing

the suction pressure and increasing noise level in the room.
Three chamber system

• Caregivers should check water loss and add sterile water as required to
maintain the prescribed level of suction

• The bubbles should be assessed for gentle suction and the water level
(-20 cm of water) is assessed every 8 hours and when condition
changes
Assessment and nursing management
• Nurses should ensure patency and proper function of the chest tube
drainage system

• Effective nursing care can reduce complications in patients with chest

drainage system

• The latex tubing frequently drains into the collection container

Assessment and nursing management
• The patient should not lie of the tube

• The chest tube drainage system is never raised above the chest to
prevent backflow into the chest

• Check the chest tube for drainage regularly

• Inspect all connections on the tubing for leak and secure them with a
tape to prevent accidental disconnection
Observations
• Monitor cardiopulmonary status and vital signs 2 hourly/PRN
• Check and maintain patency of the tube 2 hourly
• Monitor the amount and type of drainage
• Check and maintain patency of the tube every 2 hours/PRN
• Mark amount of drainage every shift and document
• Refill water systems with sterile water to the water seal level and
prescribed suction level
Observations
• Assess the patient for pain and treat accordingly

• Assess the chest tube insertion site for signs of infection and
subcutaneous emphysema with dressing changes

• Change dressing daily/PRN

Drainage monitoring
• The nurse should assess and document the colour, amount, consistency
and note any changes

• A sudden increase indicate bleeding/patency of blocked tube

• A sudden decrease indicate obstruction of the chest tube or failure of

the chest tube or drainage system
To re-establish tube function

• Proper position of the tube and the patient

• If a clot is visible, straighten the tubing between the chest and drainage
unit and raise the tube to enhance the effect of gravity
Water seal monitoring
• Monitoring the water seal of the chest drain is important

• Visual checks should be done to ensure water seal chambers are filled
to the 2-3cm water line

• Make sure the water line is at the recommended level (-20 cm of

water).
Water seal monitoring
• The tubing should never be left clamped to avoid pneumothorax or
fluid building in the chest

• Respiratory fluctuations should be observed in the water seal chamber

• Absence may indicate re-expansion of the lungs or the tube is blocked

• Check tubings for disconnection

Positioning
• Semifowlers position is most suitable
• Change of position 2 hourly enables air and fluid evacuation
• Teach the patient to splint the chest wall near the tube site insertion
using a pillow/arms
• Encourage coughing, deep breathing and ambulation
• Administer pain medication before exercises to decrease pain and
enhance lung expansion
Transporting a patient with chest tubes
• Critically ill patient require close assessment to prevent tube
disconnections resulting in pneumothorax
• Maintain chest drain system integrity by positioning the drainage
system below the level of the chest.
• Secure the system to the foot of the bed with no kinking
• Frequent assessments are necessary for the patient and drainage
system.
• Check for air leaks, dressing integrity, water level and drainage
Complications
• Tension pneumothorax

• Chest tube may fall accidentally, immediately seal with gauze and
plaster to prevent air entry into the pleural
Assignment - Pneumothorax
• Types of pneumothorax

• Clinical manifestations

• Medical and nursing management

References
• Morton, P.G. & Fontaine, D. (2009). Critical care nursing: A holistic
approach (9th ed.), Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins

• Pellico, L.H. (2013). Focus on adult health medical-surgical nursing,

Philadelphia: Lippincott Williams & Wilkins