chest trauma and chest tubes

What is the primary core concept of Advanced Trauma Life Support (ATLS)?

Treat the greatest threat to life first without delaying urgent treatment for a definitive diagnosis or detailed history

Who founded Advanced Trauma Life Support (ATLS)?

Dr James Styner

What is the number one preventable reason for death in trauma patients?

Exsanguinating external hemorrhage

What does X stand for in the Primary Survey of trauma assessment?

Exsanguinating External Hemorrhage Control using tourniquets direct pressure or wound packing

What does A stand for in the Primary Survey of trauma assessment?

Airway with cervical spine precautions assessing for obstruction and inserting oral airway or ETT if needed

What does B stand for in the Primary Survey of trauma assessment?

Breathing assessment including rate effort obstruction need for ventilation assistance and open chest wounds

What does C stand for in the Primary Survey of trauma assessment?

Circulation assessment evaluating skin color temperature moisture central capillary refill and administering blood products

What initial blood product is given during massive transfusion protocols before type and cross is available?

Uncrossmatched O-negative whole blood

What does E-FAST stand for in trauma circulation evaluation?

Extended Focused Assessment with Sonography for Trauma

What four targeted diagnoses does an E-FAST exam look for in the chest and abdomen?

Hemoperitoneum - Hemothorax - Pericardial Effusion - Pneumothorax

What does D stand for in the Primary Survey of trauma assessment?

Disability involving a basic neurological assessment of GCS and pupil response

What does the AVPU scale stand for in trauma neuro assessment?

A for Alert - V for responds to Verbal - P for responds to Painful stimuli - U for Unresponsive

What does E stand for in the Primary Survey of trauma assessment?

Exposure and Environmental Control undressing the patient completely to inspect for injuries while preventing hypothermia

Why is hypothermia dangerous in trauma patients?

Hypothermia alters blood coagulation and impairs the body ability to clot

When is the Secondary Survey performed in trauma care?

Only after the primary survey is completed life-threatening injuries are addressed and the patient is stabilized

What does F stand for in the Secondary Survey acronym?

Full set of vital signs

What does G stand for in the Secondary Survey acronym?

Give comfort through pain management

What does H stand for in the Secondary Survey acronym and what history components are included in AMPLE?

Head-to-toe examination and AMPLE history: Allergies - Medications - Past medical history - Last oral intake - Events surrounding injury

What does I stand for in the Secondary Survey acronym?

Inspection of the back and all hidden body surfaces

What does the MIVT prehospital assessment acronym stand for?

M for Mechanism of injury - I for Extent of injury - V for Vital signs in field - T for Treatment in field

What differentiates penetrating chest trauma from blunt chest trauma?

Penetrating trauma breaks the skin and enters the chest cavity while blunt trauma involves an impact without skin breakdown

What common injuries result from a blunt steering-wheel injury to the chest?

Rib fractures - Flail chest - Pneumothorax - Hemopneumothorax - Myocardial contusion - Pulmonary contusion - Cardiac tamponade - Great vessel tears

What common injuries result from shoulder-harness seat belt trauma?

Fractured clavicle - Dislocated shoulder - Rib fractures - Pulmonary contusion - Pericardial contusion - Cardiac tamponade

What common injuries result from thoracic crush injuries?

Pneumothorax - Hemopneumothorax - Flail chest - Great vessel tears and rupture - Decreased cardiac output

What common injuries result from penetrating gunshot or stab wounds to the chest?

Open pneumothorax - Tension pneumothorax - Hemopneumothorax - Cardiac tamponade - Esophageal damage - Tracheal tear - Great vessel tears

What mechanism causes cardiac tamponade in chest trauma?

Accumulation of blood in the pericardial sac surrounding the heart restricting cardiac filling and reducing stroke volume

What classic clinical triad of signs indicates cardiac tamponade?

Beck Triad: Jugular vein distention - Muffled or distant heart sounds - Abnormal blood pressure or hypotension

What other clinical signs occur in cardiac tamponade?

Chest pain or pressure - Palpitations with electrical alternans - Dyspnea - Sudden sweating nausea and anxiety - Tachycardia

What obstructive shock emergency develops if cardiac tamponade is not treated?

Cardiovascular collapse treated emergently with pericardiocentesis or surgical window

What is the most common type of blunt chest trauma injury?

Rib fractures diagnosed by chest X-ray

Which rib fractures carry a high risk of underlying liver spleen or diaphragm injury?

Fractures of ribs 9 through 12

What are the main nursing priorities for managing simple rib fractures?

Pain control and pneumonia prevention through pulmonary hygiene

What defines flail chest?

Fracture of 3 or more contiguous ribs in 2 or more places creating an unstable free-floating chest segment

What classic physical sign characterizes flail chest during breathing?

Paradoxical chest movement where the flail segment moves inward during inhalation and outward during exhalation

What initial therapies are indicated for flail chest?

Airway management - Adequate ventilation - Supplemental oxygen - Careful IV fluid administration - Pain control

What normally keeps the lungs expanded inside the pleural space?

Negative intrapleural pressure in the thin fluid-filled space between the parietal and visceral pleura

How does intrapleural pressure change during normal respiration?

Intrapleural pressure becomes more negative during inhalation and less negative during exhalation

What defines a pneumothorax?

Air entering the pleural space resulting in partial or complete collapse of the lung

What clinical symptoms occur with a pneumothorax?

Pleuritic chest pain - Dyspnea - Tachypnea - Air hunger - Agitation - Diminished or absent breath sounds - Hypoxemia - Tachycardia - Chest asymmetry

What differentiates an open pneumothorax from a closed pneumothorax?

An open pneumothorax allows air to move in and out through a chest wall hole while a closed pneumothorax has no external opening and traps air inside

What is the immediate emergency intervention for an open sucking chest wound?

Cover the wound with a 3-sided vented occlusive dressing that lets air escape on exhalation but prevents air entry on inhalation

What is a tension pneumothorax?

A medical emergency where air enters the pleural space on inhalation but cannot escape building severe pressure

What late physical finding confirms a tension pneumothorax?

Tracheal deviation away from the affected side along with mediastinal shift compressing the opposite lung heart and great vessels

What hemodynamic collapse occurs during a tension pneumothorax?

Obstructive shock caused by compression of the vena cava and heart resulting in decreased venous return decreased cardiac output severe hypotension and tachycardia

What is the immediate emergency treatment for a tension pneumothorax before chest tube insertion?

Needle decompression with a 14-gauge needle placed perpendicular in the 2nd intercostal space at the midclavicular line

What is the purpose of a pleural chest tube?

To drain air fluid blood or pus from the pleural space and restore negative intrapleural pressure to re-expand the lung

What is the purpose of a mediastinal chest tube?

To drain blood and fluid from the mediastinal space to prevent pericardial tamponade after cardiothoracic surgery

Where are pleural chest tubes inserted to remove air versus fluid?

Tubes inserted higher in the 2nd intercostal space remove air while tubes placed lower in the 4th to 6th intercostal spaces remove fluid or blood

What position should a patient be placed in for chest tube insertion?

Semi-upright position with the arm on the affected side raised over the head

What essential diagnostic test must be performed immediately after chest tube placement?

Chest X-ray to confirm tube placement and lung re-expansion

What are the three core chambers of a chest drainage collection system?

Collection chamber - Water seal chamber - Suction control chamber

What is the primary function of the water seal chamber in a chest tube system?

Acts as a one-way valve allowing air to escape from the pleural space without letting outside air re-enter

What water level must be maintained in the water seal chamber for proper function?

Sterile water filled to the 2 cm mark

How does dry suction differ from wet suction in a chest drainage system?

Dry suction uses a mechanical dial regulator and orange bellows indicator while wet suction relies on the height of a sterile water column in the suction chamber

What determines the actual amount of suction applied to the patient chest tube?

The suction regulator dial or water level set on the chest drain unit not the wall vacuum regulator gauge

What does continuous bubbling in the water seal chamber usually indicate?

A system air leak in the tubing or connection points requiring immediate troubleshooting

When is intermittent bubbling in the water seal chamber considered normal?

Intermittent bubbling is normal during exhalation or coughing in a patient with an active pneumothorax and resolves as the lung re-expands

What is tidaling in a chest drainage system?

Normal fluctuation of the float ball in the water seal chamber rising on inspiration and falling on expiration during spontaneous breathing

What does a sudden absence of tidaling in the water seal chamber signify?

Either the lung has completely re-expanded or the chest tube is obstructed kinked or clamped

What volume of hourly chest tube drainage is considered excessive and requires immediate provider notification?

Drainage greater than 100 mL per hour

What is subcutaneous emphysema and how is it assessed?

Air leaking into subcutaneous tissue around the chest tube insertion site causing a crackling rice krispies feeling called crepitus

What nursing actions are required if subcutaneous emphysema is detected?

Palpate around the site mark the outer borders with a pen monitor for spreading and notify the healthcare provider

How should the chest tube drainage system be positioned relative to the patient chest?

Always keep the drainage system below chest level on the floor and avoid dependent loops in the tubing

Why should chest tube stripping be avoided and milking strictly limited?

Stripping generates high negative pressures that cause severe tissue trauma and pleural bleeding

When is clamping a chest tube acceptable in clinical practice?

Only briefly when changing the drainage collection unit checking for an air leak location or per explicit provider orders prior to removal

What immediate action must a nurse take if a chest tube disconnects from the drainage system?

Submerge the open end of the chest tube in 1 to 2 inches of sterile water to re-establish a water seal while preparing a new drainage unit

What immediate action must a nurse take if a chest tube is accidentally pulled out of the chest wall?

Immediately cover the insertion site with a gloved hand and apply an occlusive dressing (3-sided if an active air leak is suspected) then notify the provider