Chest Trauma

Is it considered a medical emergency? & life threatening?

Chest Trauma
Precisely, because the chest houses the heart, the lungs, & great vessels Therefore chest trauma frequently produces lifethreatening disruptions of cardiopulmonary function.

Chest Traumas
Causes: Falls Use of machinery Employment of lethal weapons Motor vehicle crashes

Chest Traumas
Classifications: Penetrating Chest Injury

Non-Penetrating Chest Injury

Penetrating Chest Traumas

-involves break in the skin, chest wall, & pleural cavity -often result from bullets, knives, impaled objects, or flying shrapnel or splinters. -may cause an open chest wound, disrupting the normal ventilation mechanism.

Penetrating Chest Traumas

may seriously damage the lungs, heart & other thoracic structures

Non-Penetrating Chest Injury

-AKA Blunt Injuries -are not as obvious as penetrating wounds & may, therefore, be more difficult to diagnose. -most commonly are deceleration injuries associated w/ motor vehicle crashes

Assessment of & Therapeutic Intervention for the Chest Trauma Victim

Maintain Airway, Breathing, & Circulation!

Obtain a quick history

What happened? What was the mechanism of injury? How long ago did it happen? Where is the pain? Does it radiate?

Obtain a quick history

Is there anything that makes the pain better or worse? What does the pain feel like? How severe is the pain on scale of 1-10? Is there any medical history?

Perform a quick (1-minute) evaluation

 for SOB & cyanosis  VS  skin color & temperature  wound size & location for paradoxical chest movement  distended neck veins

Perform a quick (1-minute) evaluation

Listen for respiratory stridor. Listen for breath sounds. Look for epigastric & supravicular indrawing. Give rough estimate of tidal volume.  for tracheal deviation.

Perform a quick (1-minute) evaluation

Assess intercostal muscle use. Assess accessory muscle use. Check for subcutaneous emphysema. Look & listen for sucking chest sounds. Listen to heart sounds.

Provide Therapeutic Intervention

Maintain airway Ensure adequate air movement Administer O2 Cover any chest wound Control flail segment Insert needles or chest tube into anterior chest wall if tension Pneumothorax is present

Provide Therapeutic Intervention

Initiate IV line Do pericardiocentesis, if indicated. Get CXR Frequently recheck VS Monitor for dysrhythmias

Complications
Pneumothorax Tension pneumothorax & mediastinal shift Open pneumothorax & mediastinal flutter Hemothorax Fractured ribs Fractured sternum Flail chest

Pneumothorax
Presence of air or gas in the pleural space, causing a lung to collapse. Occurs when the parietal or visceral pleura is breached & the pleural space is exposed to positive atmospheric pressure

Pneumothorax

What are the possible causes?

Open chest wound Rupture of an emphysematous vesicle Severe bout of coughing

Pneumothorax

Types of Pneumothorax
Tension Pneumothorax

Open Pneumothorax

Pneumothorax

Tension Pneumothorax
Air that enters the pleural space w/ each inspiration, becomes trapped, & is not expelled during expiration (one-way valve effect). Most commonly occurs w/ blunt traumatic injuries

Pneumothorax

Air enters the pleural space during inspiration Air Trapped Air is not expelled during expiration Air pressure build-up in the pleural space Lung collapse Mediastinal shift heart Compression Cardiac insufficiency lung compression great vessels compression tracheal deviation

respiratory collapse

Pneumothorax

Great vessel compression Impairment of blood return in the heart Decrease in CO & BP

Pneumothorax

Tracheal deviation Airway obstruction

Pneumothorax

Clinical Manifestations
Marked, severe dyspnea Tachypnea Crepitus Progressive cyanosis Acute pleuritic chest pain Hyperresonance (on percussion)
Pneumothorax

Clinical Manifestations
Tachycardia Assymetric chest wall movement Diminished or absent breath sounds (on affected side) Extreme restlessness/agitation

Pneumothorax

Clinical Manifestations
(Other) Neck vein distention Laryngealt/ tracheal deviation Feeling of tightness/pressure w/n the chest PMI shift laterally/ medially Severe hypotension

Pneumothorax

Diagnostic Exams
X-ray study ABGs

Pneumothorax

Medical Management
*Immediate intervention is to convert tension pneumothorax into open pneumothorax Prompt thoracenteis Insertion of water-seal drainage system (CTT)

!Nursing Alert Relief of tension pneumothorax is considered an emergency measure

Pneumothorax

Nursing interventions
Restore/promote adequate respiratory function. Give supplementary O2 Assist with thoracentesis and provide appropriate nursing care. b. Assist with insertion of a chest tube to waterseal drainage and provide appropriate nursing care. c. Continuously evaluate respiratory patterns and report any changes.

Pneumothorax

Nursing interventions
3. Provide relief/control of pain. a. Administer narcotics/analgesics/sedatives as ordered and monitor effects. b. Position client in high-Fowlers position.

Pneumothorax

Open Pneumothorax
Occurs w/ sucking chest wound / penetrating chest trauma A traumatic opening in the chest wall is large enough for air to move freely in & out of the chest cavity during ventilation

Pneumothorax

Penetrating chest trauma Opening on the pleura Air move freely in & out the chest cavity Mediastinal flutter Fluttering back-&-forth of the mediastinal structures & collapsed lung w/ each inspiration & expiration Severe cardiopulmonary embarassment
Pneumothorax

Management
Immediately cover the wound w/ anything available. (Ideally: sterile gauze petrolatum dressing) Ask to perform valsava s maneuver Assess carefully for presence of tension pneumothorax & mediastinal shift.

Pneumothorax

Management
Provide supplemental O2 Prompt thoracentesis Insertion of water-seal drainage system (CTT)

Pneumothorax

Hemothorax
An accumulation of blood & fluid in the pleural cavity, usually the result of trauma Also may be caused by the rupture of small blood vessels that results from inflammation.

Hemothorax

Diagnostic Exam/s
CXR

Hemothorax

Management
Aspiration of blood in the pleural space (thoracentesis ) Insertion of water-seal drainage system (CTT) Thoracotomy (if there is a large amount of drainage *200ml or more per hour) Provide supplemental O2 WOF development of hypovolemic shock
Hemothorax

Flail Chest
Consists of fractures of two or more adjacent ribs (multiple-contiguous ribs) are fractured at two or more sites, resulting in free-floating rib segments. Frequently, a complication of blunt chest trauma/

Flail Chest

Blunt chest trauma Rib fracture Tearing of the pleura & lung surface Hemopneumothorax dead space flail segment paradoxical movement of the thorax compliance chest pain

Hypoxemia hypoventilation Respiratory Acidosis

Flail Chest

Diagnostic Exams
CXR ABG Analysis Pulse Oxymetry Pulmonary Fxn Monitoring

Assessment findings
1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will move INWARDS on inhalation and OUTWARDS on exhalation. 2. Cyanosis, possible neck vein distension, tachycardia, hypotension 3. Excruciating Pain 4. Diagnostic tests reveals
a. PO2 decreased b. pCO2 elevated c. pH decreased

Management
it includes: Providing ventilatory support - endotracheal intubation -mechanical ventilation Purposes: -restore adequate ventilation - paradoxical motion thru the use of +pressure to stabilize chest wall internally -relieve pain by decreasing movement of the fxd ribs -provide an avenue for secretion removal

Management
Pain Management thru Drug therapy -narcotics -sedatives -muscle relaxants/musculoskeletal paralyzing agents (pancuronium bromide)

Nursing interventions
1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotracheal tube; note changes in amount, color, and characteristics. 2. Monitor mechanical ventilation 3. Encourage turning, coughing, and deep breathing. 4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA

Pleural Effusion
Defined broadly as a collection of fluid in the pleural space A symptom, not a disease; may be produced by numerous conditions:  Complication of heart failure  TB, Pneumonia, pulmonary infections  Nephrotic syndrome  Neoplastic tumors (bronchogenic ca)

General Classification
Transudative effusion Exudative effusion

Transudative effusion
-are substances that have passed thru a membrane or tissue surface -occur w/ conditions w/ CHON loss & low CHON content (cirrhosis, nephrosis) -also referred as hydrothorax

Exudative effusion
Substances that have escaped from blood vessels. They contain an accumulation of cells, have high specific gravity, high LDH May occur in response to malignancies, infections, or inflammatory processes.

Assessment findings
1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over affected area, pleural pain, dry cough, pleural friction rub 2. Pallor, fatigue, fever, and night sweats (with empyema)

Diagnostic tests
a. Chest x-ray positive if greater than 250 cc pleural fluid b. Pleural biopsy may reveal bronchogenic carcinoma c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive for specific organism in empyema.

Nursing interventions: In general:

1. Assist with repeated thoracentesis. 2. Administer narcotics/sedatives as ordered to decrease pain. 3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to distribute the drug within the pleurae).`Pleurodesis 4. Place client in high-Fowlers position to promote ventilation.

Medical management
1. Identification and treatment of the Underlying cause 2. Thoracentesis 3. Drug therapy
a. Antibiotics: either systemic or inserted directly into pleural space b. Fibrinolytic enzymes: trypsin, streptokinase-. streptodornase to decrease thickness of pus and dissolve fibrin clots

Medical management
4.pleurectomy (pleural stripping) 5. pleurodesis- installation of sclerosing substance(unbuffered tetracycline, nitrogen mustard, & talc.) into the pleural space. 6. Closed chest drainage 7. Surgery: open drainage

Treatment Modalities

Chest Tubes
Definition 1. Use of tubes and suction to return negative pressure to the intrapleural space; a water seal maintains a closed system 2. To drain air from the intrapleural space, the chest tube is placed in the second or third intercostal space; to drain blood or fluid, the catheter would be placed at a lower site, usually the eighth or ninth intercostal space

Chest Tubes: Purposes

Foster & permit the drainage of air & or serosanuineous fluid form the pleural space & to prevent their reflux Help reexpand the the lung tissue by reestablishing normal negative pressure in the pleural space Prevent mediastinal shift & lung tissue collapse by equalizing pressures on both sides of the thoracic cavity

Types of drainage systems

1. One, Two, Three-chamber system: includes one chamber that serves to collect drainage, one that acts as a water-seal, and one that has levels of water to control the amount of suction regardless of the amount of negative pressure applied 2. Commercially prepared plastic unit designed for closed chest suction: combines the features of the other systems and may or may not be attached to suction (e.g., PleurEvac)

Nursing care
1. Ensure that the tubing is not kinked; tape all connections to prevent separation 2. Gently milk the tubing, if ordered, in the direction of the drainage system to maintain patency; milking can cause a pneumothorax 3. Maintain the drainage system below the level of the chest; mark and monitor drainage

Nursing care
4. Turn the client frequently, making sure the chest tubes are not compressed 5. Report drainage on dressing immediately, because this is not a normal occurrence 6. Observe for fluctuation of fluid in tube; the level will rise on inhalation and fall on exhalation; if there are no fluctuations, either the lung has expanded fully or the chest tube is clogged

Nursing care
7. Palpate the area around the chest tube insertion site for subcutaneous emphysema or crepitus, which indicates that air is leaking into the subcutaneous tissue 8. Situate the drainage system to avoid breakage 9. Place two clamps at the bedside for use if the underwater-seal bottle is broken; clamp the chest tube immediately to prevent air from entering the intrapleural space, which would cause pneumothorax to occur or extend; clamps are used judiciously and only in emergency situations

Nursing care
10. Encourage coughing and deep breathing every 2 hours, splinting the area as needed 11. After lung reexpansion is verified by chest x-ray, instruct the client to exhale or strain (Valsalva's maneuver) as the tube is withdrawn by the physician; apply a gauze dressing immediately and firmly secure with tape to make an airtight dressing 12. Encourage movement of the arm on the affected side 13. Evaluate client's response to procedure; length of time for lung expansion depends on etiology

Thoracentecis

Thoracentecis
Invasive procedure that entails the insertion of o trocar into the pleural space for removal of fluid or air Done for both diagnostic & therapeutic purposes.
Therapeutically, it is done to relieve pain, DOB, & other sx of pleural pressure. Diagnostically, performed whenever pleural effusion of unknown etiology is recognized

Thoracentecis
The pleural fluid is evaluated for gross appearance; CHON; LDH; glucose; Gram stain & bacteriologic cultures; M. Tuberculosis & fungus; cytology; CEA levels;

Contraindications
Patients w/ significant

thrombocytopenia

Potential Complications
Pneumothorax Interpleural Bleeding Hemoptysis Reflex bradycardia & HPN Pulmonary Edema Seeding of the needle tract w/ tumor Subcutaneous Emphysema

Thoracentecis
No more than 1000 ml of fluid should be removed at a time; fluid withdrawn should be sent to the laboratory for culture and sensitivity tests

Procedure & Patient Care

Patient Care: Before

Explain procedure to the client Obtain an informed consent Ensure that chest x-ray examination is done before and after the procedure Inform the patient that movement or coughing should be minimized Administer coughed suppressant before the procedure in occureence of troublesome cough

Patient Care: During

The patient is usually placed in an upright position w/ the arms & shoulders raised & supported on an padded overhead table.

Position

Patient Care: During

Pts. Who cannot sit upright are placed in a sidelying position on the unaffected side w/ the to be tapped uppermost. It is performed under strict sterile technique The needle insertion site is aseptically cleansed & anesthetized locally.

Patient Care: During

Also, large volumes of fluid may be collected by connecting the catheter to a gravitydrainage system Monitor the patient s pulse for reflex bradycardia, & evaluate the pt. for diaphoresis & the feeling of faintness during the procedure.

Patient Care: After

Place a small bandage over the needle site. Place the client on opposite side for approximately 1 hour to prevent leakage of fluid through the thoracentesis site After the procedure, label and send specimens for laboratory tests

Patient Care: After

Note and record the amount, color, and clarity of the fluid withdrawn Observe the client for coughing, bloody sputum, and rapid pulse rate and report their occurrence immediately

Patient Care: After

Obtain CXR study as indicated to check for the complication of pneumothorax Evaluate the patient for s/sx of pneumothroax, tension pneumothorax, SQ emphysema, & pyogenic infection If pt. has no complaints of DOB, normal acts. Can be resumed after 1 hr.