Chapter 30: Chest Trauma and Thoracic Injuries

Chest Trauma and Thoracic Injuries: Significance and Range

• 75% of all traumatic deaths

• Range of injuries:

  • Simple rib fractures → life-threatening organ rupture

• Can be life-threatening.

Chest Trauma: Blunt Mechanism of Injury

• Deceleration injuries

• Acceleration injuries

• Shearing injuries

• Compression injuries

Chest Trauma: Penetrating Mechanism of Injury

• Open wound through the pleural space

Rib Fractures: Common Location and Potential Damage

• Most commonly affect ribs 5 through 9.

• Can damage the pleura and lungs.

Rib Fractures: Clinical Manifestations and Complications

• Clinical manifestations:

  • Pain and splinting

  • Shallow respirations

• Complications:

  • Atelectasis

  • Pneumonia

Rib Fractures: Treatment

• No strapping or binding of the chest

• NSAIDs

• Opioids

• Nerve blocks

Rib Fractures: Patient Education

• Deep breathing and coughing

• Incentive spirometry

• Appropriate use of analgesics

Flail Chest: Movement Shown During Respiration

• Inspiration:

  • Affected chest-wall segment moves inward while the remaining chest wall moves outward.

• Expiration:

  • Affected chest-wall segment moves outward while the remaining chest wall moves inward.

Flail Chest: Management

• Adequate airway and ventilation

• Oxygen therapy

• IV fluids

• Pain control

• Surgical fixation

Chest Trauma Emergency Management: Respiratory Distress Findings

• Dyspnea

• Cough with or without hemoptysis

• Cyanosis

• Tracheal deviation

• Decreased breath sounds

• Decreased O2 saturation

• Frothy secretions

Chest Trauma Emergency Management: Cardiovascular Compromise Findings

• Rapid, thready pulse

• Decreased BP with:

  • Narrowed pulse pressure and/or

  • Asymmetric readings

• Distended neck veins

• Muffled heart sounds

• Chest pain

• Dysrhythmias

Cardiac Tamponade

• Secondary to collection of blood in the pericardial sac

• Prevents filling of the ventricles

Cardiac Tamponade: Clinical Manifestations

• Muffled, distant heart sounds

• Narrowed pulse pressure

• Hypotension

• Neck vein distention

• Increased CVP

Cardiac Tamponade: Emergency Treatment

• Emergent pericardiocentesis

Open Pneumothorax

• Air enters through an opening in the pleural space.

• Also called a sucking chest wound.

• Associated with penetrating trauma.

Closed Pneumothorax

• No obvious external wound

• Types:

  • Iatrogenic

  • Spontaneous

Tension Pneumothorax: Open or Closed

• May occur with an open or closed pneumothorax.

Fluid Entering the Pleural Space

• Hemothorax:

  • Blood

• Chylothorax:

  • Lymphatic fluid

Hemopneumothorax

• Blood and air enter the pleural space.

Pneumothorax

• Caused by air entering the pleural cavity

• May be open or closed.

Pneumothorax: Clinical Manifestations

• Clinical manifestations vary.

• Mild tachycardia and dyspnea

• Chest pain

• Cough

• Absent breath sounds over the affected area

• Severe respiratory distress

Pneumothorax Diagram: Sources of Air

• Outside air rushes in due to disruption of the chest wall and parietal pleura.

• Lung air rushes out due to disruption of the visceral pleura.

Open Pneumothorax: Course and Initial Treatment

• Treatment depends on severity.

• May resolve spontaneously.

• Administer oxygen

Open Pneumothorax: Emergency Vent Dressing

• Cover the open wound with an occlusive dressing secured on three sides.

• Inspiration:

  • Dressing seals, blocking air entry.

• Expiration:

  • Trapped air can exit through the untaped section of the dressing.

Open Pneumothorax: Additional Treatment

• Stabilize an impaled object with a bulky vent dressing.

• Thoracentesis

• Chest tubes

• Pleurodesis

Iatrogenic Pneumothorax

• Opening into the pleural space caused by a medical procedure

• Complication of invasive procedures

• Patient-safety issue for insertion of subclavian central lines:

  • Quality indicator for hospitals

Iatrogenic Pneumothorax: Clinical Presentation

• Decreased breath sounds on the affected side

• Concern for tension pneumothorax

Iatrogenic Pneumothorax: Treatment

• Supplemental oxygen

• Physician intervention:

  • Needles aspiration

  • Chest tube

  • Surgical repair

Spontaneous Pneumothorax

• Rupture of blebs

• Closed:

  • No obvious opening

• Can occur in healthy or chronically ill persons.

Spontaneous Pneumothorax: Risk Factors

• Tall and thin male

• Lung disease

Spontaneous Pneumothorax: Clinical Presentation

• Chest pain on the side of the collapsed lung

• Shortness of breath

Spontaneous Pneumothorax: Treatment

• Observation:

  • Resolve with time

• Chest tube:

  • Heimlich valve or Pneumostat

• Pleurodesis

Tension Pneumothorax

• Accumulation of air in the pleural space that does not escape

• Causes:

  • Mediastinal shift

  • Hemodynamic instability

• Can occur with an open or closed pneumothorax.

Tension Pneumothorax: Clinical Presentation

• Dyspnea

• Marked tachycardia

• Tracheal deviation

• Decreased or absent breath sounds on the affected side

• Neck vein distention

• Cyanosis

• Profuse diaphoresis

Tension Pneumothorax: Emergency Treatment

• Medical emergency

• Urgent needle decompression or chest tube

Hemothorax

• Blood in the pleural space

• Treat with a chest tube.

Hemopneumothorax: Treatment

• Blood and air in the pleural space

• Treat with a chest tube.

Chylothorax

• Lymphatic fluid in the pleural space

• Treat:

  • Conservatively

  • With medications

  • With surgery

  • With pleurodesis

Chest Trauma: Recognizing Cues

• Common causes of chest trauma

• Clinical manifestations or symptoms

• Patient history:

  • Subjective data

  • Objective data

Chest Trauma: Analyzing Cues

• Pathophysiology:

  • Lungs and pleural cavity

  • Changes to the pulmonary system

• Clinical presentation:

  • Open versus closed pneumothorax

• Diagnosis:

  • Pertinent test results of concern

• Complications:

  • Respiratory distress

  • Cardiovascular compromise

Chest Trauma: Prioritize Hypotheses

• Organize assessment findings/cues.

• Prioritize patient needs.

Chest Tube Insertion: Patient Safety Alert

• Obtain a chest X-ray to check for pneumothorax.

Wet-Suction Pleural Drainage System: Labeled Chambers

• Water-filled suction-control chamber

• Water-seal chamber

• Collection chamber

Dry-Suction Pleural Drainage System: Labeled Chambers

• Dry suction-control regulation

• Water-seal chamber

• Collection chamber

Flutter (Heimlich) Valve

• One-way valve that opens only when intrathoracic pressure is greater than atmospheric pressure

• Used for:

  • Emergency transport

  • Small-to-moderate-sized pneumothorax

• Increases patient mobility.

• Any attached drainage bag must be vented.

Chest Tube Nursing Assessment: ABCs

• Monitor ABCs:

  • A: Check airway.

  • B: Assess breathing patterns and breath sounds.

  • Tracheal deviation must be reported.

  • C: Assess skin color, blood pressure, and heart rate.

Chest Tube Nursing Assessment: Affected Side

• Monitor the affected side:

  • Breath sounds?

  • Chest expansion?

  • Breathing comfortable?

Chest Tube Nursing Assessment: Patient Feedback

• Seek patient feedback regarding:

  • Severe chest pain

  • Dyspnea

  • Local pain

Chest Tube Nursing Assessment: Drainage and Site

• Check drainage color and amount.

• Drainage averages 70–100 mL/hr and will decrease over time.

• Call MD for significant bright-red bleeding greater than 100 mL/hr.

• Monitor for:

  • Signs of infection

  • Subcutaneous emphysema

Chest Tube Water-Seal Chamber: Bubbling

• Bubbling indicates an air leak.

• A large air leak is initially expected with pneumothorax.

• Bubbling eventually disappears as air in the pleural space decreases.

• Continuous or intermittent bubbling is not normal:

  • Problem with system setup or patient

Chest Tube Water-Seal Chamber: Tidaling

• Reflects normal changes with inspiration and expiration.

• Investigate sudden cessation:

  • May signify an occluded chest tube

• Disappears as the lung re-expands.

If the Chest Tube Is Pulled Out of the Patient

• Immediately cover the insertion site:

  • Ideally with petroleum gauze

  • If unavailable, use a gloved hand.

• Call for help.

• Cover the site with a gauze dressing and tape to complete the dressing.

If the Chest Tube Disconnects from the Drainage System

• Quickly insert the end of the chest tube 1–2 cm into a bottle of sterile water to create a water seal.

• Call for help.

• Reconnect to a chest drainage system.

Chest Tube Care: Do

• Position the patient in Semi- or High-Fowler’s.

• Maintain an occlusive dressing.

• Encourage:

  • Deep breathing

  • ROM

  • IS

• Coil excess tubing on the mattress next to the patient.

• Adjust tubing to hang in a straight line to the system.

• Monitor drainage color and amount.

• Assess and address pain level.

Chest Tube Care: Do Not

• Do not strip or milk the chest tube unless ordered by the MD:

  • Be gentle.

• Do not clamp the chest tube except under certain circumstances.

• Do not elevate the drainage system above the chest.

• Keep the system stable and do not let it overturn.

Chest Tube Care: Appropriate Reasons for Clamping

• To assess for an air leak

• To quickly change or empty the collection system

• To assess whether the patient is ready to have the chest tube removed

Chest Tube Clamping: Danger

• Leaving the chest tube clamped can cause:

  • Tension pneumothorax

  • Mediastinal shift

Rapid Removal of 1–1.5 L: Chest Tube Complications

• Reexpansion pulmonary edema

• Vasovagal response

Chest Tube Complications

• Subcutaneous emphysema:

  • Air leak into tissue

• Air leak:

  • Evidenced by continuous or intermittent bubbling in the water-seal chamber

• Tension pneumothorax

• Severe respiratory distress or chest pain

• Absence of breath sounds on the affected side

• Monitor the chest-tube site for signs of infection.

Chest Tube Removal

• Remove when:

  • Lungs are reexpanded.

  • Drainage is minimal.

• Premedicate before removal.

• Perform the Valsalva maneuver during removal.

• Apply an occlusive dressing.

• Monitor for respiratory distress.

• Obtain a chest X-ray 30–60 minutes after removal.

Chest Tube Care: Problem-Solving Assessment

• Patency of chest tube

• Presence of drainage

• Presence of fluctuations

• Patient vital signs

• Chest-drainage status

• Type of suction

• Level of comfort

Open Thoracotomy: Approach

• Traditional long, open posterior lateral chest-wall approach or revised midaxillary smaller vertical incision

• Open chest with surgical rib separation

• Skin closure with:

  • SQ sutures or

  • Staples

Open Thoracotomy: Uses and Outcomes

• Best for:

  • Lobectomy

  • Pneumonectomy

  • Large thoracic/mediastinal masses

• Therefore:

  • Longer hospitalization

  • Longer recovery time

  • Higher morbidity

  • More painful

Video-Assisted or Robotic Thoracic Surgery: Approach

• Performed through 2–3 small incisions approximately 2 cm each

• Camera inserted between the ribs for thoracic-cavity or lung evaluation

• Closed with SQ sutures and Steri-Strips

• Robotic approach is now replacing certain VATS procedures.

Video-Assisted or Robotic Thoracic Surgery: Uses

• Perform biopsies

• Remove lung tissue

• Repair chest trauma

Post-Thoracic Surgery: Nursing Care

• Assess respiratory function.

• Provide adequate pain management.

• Maintain chest-tube drainage and function.

• Encourage incentive spirometry.

• Advance nutrition/bowel regimen.

• Provide incision and wound care.

• Encourage ROM exercises and ambulation.

Chest Trauma: Generate Solutions

• Nursing management

• Collaborative plan of care

Chest Trauma: Take Actions

• Perform nursing actions based on client needs.

• Coordinate efforts with the health care team.

• Document care.

• Provide education.

Chest Trauma: Evaluate Outcomes

• Reassess the patient.

• Determine whether outcomes were met.

• Modify the plan of care as indicated.

Pulmonary Diseases: Obstructive

• COPD:

  • Emphysema

  • Chronic bronchitis

• Cystic fibrosis

• Bronchiectasis

Pulmonary Diseases: Cancers

• Laryngeal:

  • Upper

• Lung:

  • Lower

Pulmonary Diseases: Trauma

• Pneumothorax

• Thoracic injuries

Pulmonary Diseases: Restrictive

• Pleural effusion

• Pleurisy

• Atelectasis

Pulmonary Diseases: Interstitial

• Idiopathic pulmonary fibrosis

• Sarcoidosis

Clinical Interventions: MS Essentials/Quiz 1

• Chest tubes

• Oxygen