AH3 Exam 1: Chest Trama

What would a nurse specifically look for when assessing a pt with Chest Tube? (5)

1. resp assessment

• crackles?

• symmetrical chest rise?

• tracheal deviation?

• RR?

• hesitant breaths?

2. air leak?

• check seal

3. subQ air? aka emphysema/crepitus

4. tidaling present?

• fluctuation when breathing in water seal chamber

5. bubbling in water seal chamber?

• occasional (normal)

• continuous (BAD = air leak)

What to asses when tidaling’s absent:

What does bubbling in water seal mean?

1. assess obstruction, clot, kink

2. bubbling=air leak → pneumothorax

4 mechanisms of blunt chest trauma and define:

1. acceleration:

• moving object hits chest (punched)

• stationary, then gets thrown into motion

  • fall

  • assault

2. deceleration

• abrupt stop

  • MVC

3. shearing

• tissues/organs get pulled in different directions = tears

  • heart and lungs move at diff speeds even after you are stopped abruptly (MVC)

4. compression

• DIRECT blow to chest

  • construction

  • crushed

Most common penetrating chest trauma: 2

1. GSW

• high velocity

2. stab wounds

• low velocity

What are important initial assessments of chest trauma: (7)

1. How injury occurred

2. Time passed since injury

3. airway, thorax, neck veins

4. breathing effort, stridor, drooling

5. tracheal shift

6. accessory muscles use

7. symmetrical chest rise and fall

8 Complications of Chest Trauma:

1. sternal and rib fractures

2. flail chest

3. closed pneumothorax

4. open pneumothorax

5. tension pneumothorax

6. hemothorax

7. cardiac tamponade

8. pulmonary contusions

Sternal and Rib fx

• tx

• organ involvement

• s/s

1. usually benign, treated conservational (rest, ice, pain meds, heals on its own)

2. fx lower ribs associated w. spleen and liver lacerations

3. diminished ventilation, atelectasis, progress to ARF

ex: MVC complication from direct blow to sternum from steering wheel

Sternal/rib fracture findings: (6)

1. Overlying tenderness

• soft tissue around injured bone

2. ecchymosis

3. crepitus

4. point tenderness

• directly over fractured bone

5. muscle spasms

6. punctured lung

Flail chest findings: (3)

1. 3+ adjacent ribs break in @ least 2+ places each

• free-floating segment of chest wall

2. HALLMARK: Paradoxical mvmt

3. HALLMARK: MEDIASTINUM shifts AFFECTED side

Define paradoxical mvmt:

part of the chest moves OPPOSITE to the normal mvmt of the rest of the chest during breathing

→ normal:

• inhale: chest moves out

• exhale: chest retracts

→ bad:

• inhale: injured part moves IN

• exhale: injured part moves OUT

Closed pneumo findings: (5)

1. air escapes from laceration in lung and enters pleural space

2. sudden pleuritic CP

3. absent breath sounds on AFFECTED side

4. ⬇chest expansion

5. HYPERresonance (air)

Open pneumo: (3)

1. air enters and exits (less dangerous)

2. hallmark: sucking/whistling sound

3. 3-sided occlusive dressing

Tension pneumo findings: (2)

1. air enters pleural space from injured lung gets TRAPPED!!

2. Hallmark: each breath ⬆thoracic pressure, shifting TRACHEA towards UNaffected side!

If chest tube not available for tension pneumo, what do you do?

• Needle decompression!!

• 14/16G (longer better)

  • just over top of 3rd rib, (2nd intercostal space), midclavicular line

hemodynamic compromise in Hemothorax: (3)

1. drainage >1.5L considered massive and pt becomes hemodynamically unstable

2. >0.4 L = may become symptomatic

3. tx: thoracotomy, transfusion

Cardiac tamponade hallmark:

Becks Triad!!!!

1. hypotension (narrowed pulse pressure)

2. muffled heart sounds

3. JVD

Pulmonary contusion findings: (8)

1. bruised lung

2. hypoxemia

3. hemoptysis

4. crackles

5. ecchymosis

6. rib fx

7. Alkalosis: Hyperventilation (⬇PaCO2)

8. MINIMIZE IV fluids!!!

Penetrating

• classified by velocity

  • appearance may be deceptive

  • extent of damage can be wide spread

Blunt (deceleration/shearing)

• Sudden decrease in rate/speed/ velocity

• MVC

rib/sternal fx

• 3+ adjacent ribs break in 2+ sites (free floating ribs)

• chest wall unstable

  • MEDIASTINUM shifts to AFFECTED side

  • PARADOXICAL mvmt

Open pneumo

• chest wall large enough to allow air to pass freely in/out of thoracic cavity

• “sucking” sound

Tension pneumo

• air enters pleural space, TRAPPED

• ⬆thoracic pressure = mediastinum + TRACHEA shifts to UNAFFECTED side

Hemothorax

• rib fractures

• tx w/ thoracostomy (CT) and autotransfusion

• Hemodynamic compromise

  • > 1.5 L = massive hemorrhage

  • < 0.4 L = can be symptomatic

Cardiac tamponade

• fluid/air/blood in pericardial sac

• Becks triad!!!!

• will cause obstructive shock

Pulmonary contusions

• lungs absorb energy from trauma

• capillary blood leaks into lung = edema and inflammation

• Hemoptysis, ecchymosis, ⬇PaCO2

• progress @ 4-6hr; 24-48hr to fully develop