Pulmonary Embolism, Chest Trauma, Chest Tubes

What is a saddle pulmonary embolism?

Large clot that obstructs the bifurcated pulmonary artery so that there is no bloodflow to right or left lung, very deadly!

What is a PE usually caused by? Where does the clot come from in patients with Afib? Where does the clot come from after childbirth? What procedures can also cause PE?

DVT. Right side of heart for afib. Pelvic veins after childbirth. Central venous catheter and art line can cause PE

What states increase risk for PE? What are the three aspects of this?

Virchow's Triad. Venous stasis due to prolonged immobility, hypercoagulability, vascular injury

What is included in venous stasis for risk factors of virchow's triad?

Surgery, prolonged air travel

What is included in hypercoagulability for risk factors of Virchow's Triad?

Tumor, clotting disorders, cigarette smoking, oral contraceptives, pregnancy, cancer, obesity, history of VTE

What is included in vascular injury for risk factors of Virchow's Triad?

Trauma, heart disease, surgery (especially pelvic/lower extremity surgery)

What are the clinical manifestations of PE?

Dyspnea, tachypnea, cough, chest pain, hemoptysis, syncope, hypotension, sense of impending doom

What manifestations does the hypoxemia cause in PE?

Tachycardia and LOC changes

What is the lung assessment in PE?

Normal (because it is a bloodflow issue, not an airway obstruction issue)

What are the complications of PE?

Pulmonary infarction caused by abscess and pleural effusion, pulmonary HTN, RV hypertrophy/cor pulmonale

What are the clinical manifestations of RV hypertrophy/cor pulmonale? What does it lead to?

JVD and hepatosplenomegaly. Cardiogenic shock

What is the first thing we do to diagnose PE and why? What is the gold standard for diagnosis of PE? What is the V/Q scan?

Spiral CT scan because it is quick. Gold standard is pulmonary angiography, but this takes longer than spiral CT. Ventilation (V) perfusion (Q) scan

What is the supportive therapy of PE?

Supplemental O2, sit patient up in semi or high Fowler's, CV support because it leads to cardiogenic shock

What treatment does not work in saddle PE?

Supplemental O2

What is the drug therapy for PE?

Low molecular-weight Heparin, Heparin, Warfarin, Fibrinolytics

What is required for the patient who is on Heparin? How do we measure the effectiveness of Heparin?

Need 2 therapeutic levels taken 6 hours apart. Measure aPTT levels

How is Warfarin measured?

INR

What are the two options for surgical therapy for PE?

Pulmonary embolectomy or IVC filter which is an umbrella that catches the DVT in the leg before it gets to the lung

What are the two types of chest trauma?

Blunt trauma, something hitting against the chest and penetrating trauma, something entering the chest wall such as knife or bullet

What is important to remember about blunt trauma? What is important to remember about penetrating trauma?

How the injury looks on the outside does not always match the injury on the inside. Never pull out the object in penetrating trauma other than in the OR

What are the populations at risk for chest trauma?

Elderly and pre-existing disease

Rib fractures are most common with what kind of chest trauma? What are the CMs?

Blunt trauma. Pain, shallow breaths, atelectasis, pneumonia

What is the treatment of rib fractures? What is no longer recommended?

Pain control w/ NSAIDs, opioids, nerve blocks, incentive spirometry, breathing exercises. Binding

What causes flail chest? What kind of chest movement does this lead to?

2+ consecutive ribs in 2 or more places leads to an unstable segment. Causes paradoxical chest movement

What happens during inspiration during pardoxical chest movement? Where is the mediastinal shift?

Flail segment moves inward (should usually be outward). Mediastinal shift to uninjured side

What happens during expiration during pardoxical chest movement? Where is the mediastinal shift?

Flail segment bulges outward. Mediastinal shift to injured side

What are the CMs of flail chest?

Tachypnea, tachycardia, crepitus near fracture

What is the interprofessional care of flail chest?

Airway management, ventilation, O2, pain meds, surgical care

What happens in a pneumothorax? They can be what or what?

Air enters the pleural cavity. Can be open or closed

What happens in a spontaneous pneumothorax?

Rupture of small blebs which are air-filled blisters at the apex of the lung

How do blebs form in a spontaneous pneumothorax? How do blebs form in a secondary spontaneous pneumothorax?

Spontaneous is when they form in healthy, young individuals. Secondary spontaneous is when they form due to lung disease such as COPD, asthma, CF, pneumonia

What increases risk for bleb formation?

Smoking

What are other risk factors of spontaneous pneumothorax?

Tall and thin, male gender, family history, previous spontaneous pneumothorax

What is iatrogenic pneumothorax? What is the leading cause?

Laceration or puncture of the lung during medical procedure. Transthoracic needle aspiration

What is barotrauma? What else can cause iatrogenic pneumothorax?

Excessive ventilatory pressure causing pneumothorax. Esophageal procedures

What is a tension pneumothorax? What do we see in these patients when it happens?

Air enters the lungs but can't escape, leads to suppression of the SVC/IVC and decreased CO which is life threatening. Trachial deviation and mediastinal shift

What is a hemothorax?

Blood fills pleural space

What is a chylothorax? What drug is used for it?

Milky fluid high in lipids from lymph system in the pleural space. Octreatide which decreases lymphatic flow

What kind of dressing is used in an emergency chest trauma where there is a wound?

Cover wound with occlusive vented dressing, which is secured on all three sides. Never secure on all four sides because this will cause a tension pneumo

How should we communicate with the patient who has a pneumothorax?

Ask yes/no questions, do not ask them to speak in long sentences

What is the main treatment of pneumothorax/chest traumas?

Chest tube

Large chest tubes (36-40) are used for what? Medium chest tubes (24-36) are used for what? Small chest tubes (12-24) are used for what?

Large for blood. Medium for fluid. Small for air

For the insertion of a chest tube, how is the arm on the affected side positioned? What is the HOB at? Where is the incision? What kind of dressing is placed? How do we confirm the placement? What is the tube connected to?

Arm above head to expose mid-axillary area. 45 degrees. Incision over rib, tube advanced up and over rib and sutured in place. Occlusive dressing. Confirm placement with chest xray. Tube connected to CDU (chest drainage unit)

What happens in the collection chamber of the CDU?

Receives air and fluid from pleural or mediastinal space, drained fluid stays in this chamber and air goes to the second compartment

What is in the water-seal chamber of the CDU? What happens here?

2cm of water and a one-way valve. Incoming air enters and bubbles up through the water

What is not a normal sign in the water-seal chamber?

Constant bubbling, this indicates a leak

What does the suction control chamber of the CDU do? What is the suction regulated by? What is the normal range of suction in the CDU? What are the two types of suctions available?

Applies suction to chest drainage system. Suction regulated by amount of H20 in the chamber, not by the amount of suction. Suction pressure usually around -20cm H20, normal is -10 to -40cm H20. Water and dry suction

How do we initiate suction in a water-suction CDU? What about for dry suction?

Turn up vacuum until gentle bubbling present. For dry suction, there is no water so turn up the vacuum until the visual alert indicates suction

How do we prepare the CDU in wet suction?

Add sterile water to 2cm mark in water-seal chamber (second compartment) and add to 20cm mark or as ordered in suction-control chamber (third compartment)

How do we prepare the CDU in dry suction?

Add sterile water to fill line of air leak meter, attach suction tubing and increase suction until visual cue on display window

Fluid pulled off from a chest tube should follow what? What should the volume be?

Normal progression, sanguinous, serosanguinous, then serous. Volume should decrease over time, random increase is abnormal

What is a heimlich/flutter valve? When are they used? What do they increase? What must be done to the drainage bags?

One way valve attached to external end of chest tube that opens only when intrathoracic pressure greater than atmospheric pressure. Used for emergency transport and small to moderate sized pneumos. Increase patient mobility. Attached drainage bag must be vented (taped only on 3 sides not 4 to avoid tension pnuemo)

In a Heimlich valve, what happens during inspiration? What happens during expiration?

During inspiration the valve is closed to prevent air from going back into the pleural space. In expiration the valve opens due to increased intrathoracic pressure

What should be closely monitored with a chest tube? What should be reported?

Assess amount of drainage. Report over 200mL in the first hour

Never do what to a chest tube and why? What are the two exceptions?

Clamp a chest tube, this causes a tension pneumo. Changing drainage unit or sclerosing (destroyal) agent insertion in the pleural space

What should we encourage with the patient who has a chest tube?

Intermitted breathing exercises, ROM

What are the possible complications of a chest tube?

Rapid removal of pleural fluid causing hypotension, subcutaneous emphysema, bleeding, atelectasis, infection, dislodgment/disconnection

What are the indications for removing a chest tube?

When lung is re-expanded or when fluid drainage is minimal or has ceased

What must be done for 24 hours before a chest tube can be removed? When should pain meds be given? What should the patient do when the tube is pulled out? What kind of dressing is applied? What do we follow up with?

Put chest tube to gravity without suction for 24 hours. Pain meds 30-60 minutes before. Patient should hold breath while the tube is pulled out. Apply an occlusive petroleum dressing. Follow up with chest xray to ensure the lung has expanded

What are the two options for chest surgery?

Thoracotomy or video-assisted thoracoscopic surgery (VATS) which is a minimally invasive option and decreases risk for complications, pain, and morbidity

What must be done to the patient before chest surgery? What must the patient stop doing before surgery?

PFTs, ABGs, ECG, cardiac workup. Patient must stop smoking

What is used for pain management for chest tubes? What assessment is extremely important? What should the patient do post-op?

PCA and nerve blocks. Respiratory assessment important. Incentive spirometry, cough and deep breathe

What is a pleural effusion? What is it indicative of?

Abnormal collection of fluid in the pleural space. Indicative of disease

What are the 4 causes of pleural effusion?

Increased pulmonary capillary pressure, increased pleural membrane permeability, decreased oncotic pressure, obstructed lymphatic flow

What are the three types of fluid in pleural effusion?

Transudative, exudative, empyema

What is transudative fluid in pleural effusion?

Non-inflammatory, low in protein, made of mostly plasma

What is exudative fluid in pleural effusion?

Caused by infectious process, cancer

What is empyema? What clinical manifestation is specifically seen with it?

Collection of pus. Weight loss

What are the CMs of pleural effusion? What does the lung assessment sound/look like?

Sharp chest pain that worsens with inhalation, dyspnea, cough, fever, night sweats. Decreased chest movement and breath sounds

Other than treating the underlying cause, what procedure is done to treat pleural effusion? What should be done afterwards? What chemical procedure can be done?

Thoracentesis. Do chest xray post-procedure. Chemical pleurodesis, which is a chemical sclerosing agent

What is the maximum amount of fluid that should be drained in thoracentesis? What is the risk if more is drained?

1.2L. Hypotension and hypovolemia

What should be assessed post-procedure because of what complication?

Lungs. Pneumothorax (needle could nick the lungs and cause them to collapse)