Chest Trauma, Pneumothorax, and Pulmonary Embolism Vocabulary

Chest Trauma and Thoracic Injuries

• Epidemiological Significance

  • Traumatic injuries to the chest contribute significantly to traumatic deaths.

  • Injury severity spans a wide clinical spectrum, ranging from simple rib fractures to full cardiorespiratory arrest.

• Mechanisms of Injury

  • Blunt Trauma:

    • Occurs when shearing and compression forces injure internal chest structures.

    • External physical appearance may seem deceptively minor, yet severe underlying internal organ damage and hemorrhage may be present.

    • Examples include a driver's chest slamming against a steering wheel during a motor vehicle collision or direct impact from a baseball bat to the chest.

  • Penetrating Trauma:

    • Occurs when a foreign object impales or passes directly through body tissues, creating an open wound.

Emergency Management of Chest Trauma

• Clinical Assessment for Respiratory Distress

  • Increased respiratory rate ($RR$).

  • Dyspnea (difficulty breathing).

  • Coughing with or without hemoptysis (blood-tinged sputum).

  • Cyanosis, particularly central cyanosis (a severe clinical sign visible on the lips and tongue).

  • Tracheal deviation (indicates a life-threatening emergency).

  • Decreased or absent breath sounds on the affected side.

  • Decreased oxygen saturation ($SpO_2$).

  • Frothy respiratory secretions.

• Clinical Assessment for Cardiovascular Compromise

  • Rapid, thready pulse.

  • Decreased blood pressure ($BP$) accompanied by a narrowed pulse pressure and/or asymmetric blood pressure readings between arms.

  • Distended neck veins (associated with right-sided heart failure or obstructive shock).

  • Muffled heart sounds.

  • Chest pain.

  • Cardiac dysrhythmias.

• Initial Emergency Interventions

  • Prioritization: Establish Circulation, Airway, and Breathing ($CAB$).

  • Oxygenation: Administer high-flow oxygen ($O_2$) to maintain oxygen saturation at $SpO_2 > 90\%$.

  • Vascular Access: Establish IV access with two large-bore catheters ($16\text{--}18\text{ gauge}$) and initiate fluid resuscitation as appropriate using isotonic fluids.

  • Physical Exposure: Remove clothing to perform a comprehensive physical assessment and identify additional hidden injuries.

  • Sucking Chest Wound Management: Cover an open chest wound with a nonporous (occlusive) dressing taped securely on three sides.

    • Mechanism: On inspiration, the dressing pulls tight against the wound, preventing atmospheric air from entering the pleural space. On expiration, the unsealed side opens, allowing trapped air to escape.

  • Impaled Objects: Never remove an impaled object; stabilize the object in place using bulky dressings.

  • Neurological Assessment: Evaluate for disability, including changes in level of consciousness ($LOC$) and acute brain alterations.

  • Patient Positioning: Place the patient in semi-Fowler's position or turn them onto the injured side to maximize full expansion of the unaffected lung (only after completely ruling out cervical spine injury).

  • Analgesia: Administer appropriate pain medications.

  • Emergency Needle Decompression:

    • Indicated as an immediate emergency measure for tension pneumothorax.

    • Procedure: Insert a large-bore IV cannula into the second intercostal space at the mid-clavicular line on the side of the pneumothorax. Withdraw the inner needle, leaving the catheter to release trapped high-pressure air.

• Ongoing Monitoring Requirements

  • Continuous assessment of vital signs.

  • Level of consciousness.

  • Oxygen saturation.

  • Cardiac rhythm.

  • Respiratory status.

  • Urinary output.

  • Preparation for potential endotracheal intubation.

Pneumothorax Pathophysiology and Types

• Pathophysiology

  • Occurs when air enters the pleural cavity.

  • Normally, negative pressure exists within the pleural space between the visceral pleura (lining the outer lung surface) and the parietal pleura (lining the internal chest wall).

  • Air entry converts the negative intrapleural pressure into positive pressure, causing partial or complete collapse of the lung.

  • Accumulation of air in the pleural space directly reduces functional lung volume.

• Classification by External Integrity

  • Open Pneumothorax: An opening in the chest wall allows atmospheric air entry (e.g., penetrating trauma creating a sucking chest wound).

  • Closed Pneumothorax: No external wound is present on the chest wall (e.g., lung rupture caused by a fractured rib).

  • Clinical Rule: Suspect a pneumothorax in any patient presenting with chest wall trauma until diagnostic evaluation proves otherwise.

• Clinical Manifestations

  • Small Pneumothorax: Presents with mild tachycardia and dyspnea; may resolve without requiring chest tube placement.

  • Large Pneumothorax: Presents with acute respiratory distress and complete absence of breath sounds over the affected lung fields.

  • Diagnostic Confirmation: Standard chest X-ray.

• Etiological Types of Pneumothorax

  • Spontaneous Pneumothorax:

    • Caused by the rupture of blebs (small, air-filled sacs on the visceral pleural surface of the lung).

    • Can occur in healthy individuals or those with underlying chronic lung disease (e.g., COPD, asthma, cystic fibrosis, pneumonia).

    • Risk Factors: Tall, thin males, positive family history, cigarette smoking, or history of prior spontaneous pneumothorax.

  • Iatrogenic Pneumothorax:

    • Caused by medical procedures or interventions.

    • Causes: Lung biopsies, subclavian central venous catheter insertion, positive-pressure mechanical ventilation (barotrauma), or esophageal trauma/tearing during enterogastric ($EG$) tube placement.

  • Tension Pneumothorax:

    • A critical medical emergency resulting from rapid air accumulation in the pleural space without a route for escape.

    • Progressive rise in intrapleural pressure causes complete compression of the lung on the affected side and pushes mediastinal structures toward the unaffected side.

    • Mediastinal Shift Impact: Compresses the unaffected lung, heart, and great vessels, causing severe hemodynamic instability due to markedly reduced venous return and decreased cardiac output.

    • Can originate from either an open or closed pneumothorax.

    • Clinical Features: Severe dyspnea, marked tachycardia, tracheal deviation away from the affected side, absent breath sounds on the affected side, neck vein distention, cyanosis, and profuse diaphoresis.

    • Mortality: Rapidly fatal if intrapleural pressure is not relieved immediately. Emergency needle decompression or chest tube insertion must be performed without waiting for chest X-ray confirmation.

Interprofessional Care for Pneumothorax

• Management Considerations

  • Interventions depend on clinical severity, underlying etiology, and hemodynamic stability.

  • Emergency Dressing: For open wounds, apply an occlusive dressing secured on three sides (prevents air entry on inspiration; allows air venting on expiration).

  • Impaled Objects: Secure and stabilize with a bulky dressing; do not remove.

  • Definitive Interventions:

    • Immediate needle decompression (for tension pneumothorax).

    • Chest tube insertion connected to a water-seal drainage system.

    • Surgical options: Partial pleurectomy, video-assisted thoracic surgery ($VATS$) stapling, or chemical pleurodesis.

Chest Tubes and Pleural Drainage Systems

• Purpose and Mechanics

  • Inserted to drain air, fluid, or blood from the pleural space.

  • Reestablishes negative intrapleural pressure, allowing full expansion of the collapsed lung.

• Physical Specifications

  • Standard length: $20\,\text{inches}$ ($50.8\,\text{cm}$).

  • Size range: $12\text{--}40\,\text{Fr}$ (noted historically as $12^\circ\text{ to }40^\circ\text{ F}$ standard sizing scale).

    • Small Catheters ($12\text{--}24\,\text{Fr}$): Used to drain air.

    • Medium Catheters ($24\text{--}36\,\text{Fr}$): Used to drain fluid.

    • Large Catheters ($36\text{--}40\,\text{Fr}$): Used to drain blood (hemothorax, cardiac/thoracic surgery).

    • Pigtail Catheters ($10\text{--}14\,\text{Fr}$): Very small, flexible tubes used for fluid/air.

• Insertion Procedure Details

  • Locations: Emergency Department ($ED$), Operating Room ($OR$), or at the patient's bedside.

  • Pre-procedure: Confirm affected side via chest X-ray if time permits.

  • Standard Insertion Site: Midaxillary line.

  • Positioning: Elevate head of bed ($HOB$) $30^\circ\text{ to }60^\circ$ with the patient's arm raised above their head on the affected side.

  • Surgical Technique: Antiseptic prep, local anesthetic infiltration; administer systemic pain medication and sedatives as clinical time allows. A small incision is made over a rib, and the tube is advanced into the pleural space.

  • Securing: Sutured to the skin, covered with an occlusive petroleum gauze dressing, and connected to a pleural drainage system.

  • Post-procedure: Immediately obtain a chest X-ray to confirm proper tube placement.

  • Anatomical Targeting:

    • Second Intercostal Space: Targeted to remove air (air rises).

    • Lower Intercostal Spaces (above diaphragm): Targeted to drain fluid and blood (gravity-dependent).

• Three-Chamber Drainage System Architecture

  • 1st Compartment (Collection Chamber):

    • Directly receives fluid, blood, and air from the pleural cavity.

    • Fluid and blood remain in calibrated columns for measurement; air vents freely into the second chamber.

  • 2nd Compartment (Water-Seal Chamber):

    • Contains exactly $2\,\text{cm}$ of sterile water acting as a one-way fluid valve.

    • Allows air to enter from the collection chamber and bubble out, but prevents atmospheric air from returning into the patient's pleural space.

    • Intermittent Bubbling: Normal occurrence during exhalation, coughing, or sneezing.

    • Continuous Bubbling: Abnormal in the water-seal chamber; indicates an external or intrapleural air leak.

    • Tidaling: Normal fluctuation of the water column matching respiratory pressure changes (water rises with inspiration, falls with expiration). Tidaling gradually disappears as the lung re-expands. If tidaling stops suddenly, check for tubing occlusions or kinks.

  • 3rd Compartment (Suction Control Chamber):

    • Applies negative pressure to the pleural space, controlled via a water column or mechanical dry regulator.

    • Continuous Bubbling: Normal in a wet suction control chamber.

    • Wet Suction Systems (Ocean Systems): Suction pressure is governed strictly by the depth of water in the chamber (typically $20\,\text{cm}$ of water, generating $-20\,\text{cm H}_2\text{O}$ pressure). The wall suction source is turned up until gentle, continuous bubbling occurs in the third chamber.

    • Dry Suction Systems (Oasis Systems): Contains no water column in the suction chamber (reduces noise). Uses a mechanical rotary dial set to the ordered pressure (e.g., $-20\,\text{cm H}_2\text{O}$) with a visual alert confirming active suction.

Nursing Management of Chest Drainage Systems

• Setup and Insertion Care

  • Verify informed consent and patient awareness.

  • Gather and assemble equipment according to healthcare provider orders.

  • Keep tubing loosely coiled on the bed; avoid dependent loops.

  • Maintain tight, taped, airtight connections throughout the system.

  • Systematically observe for tidaling, air leak bubbling, and fluid levels.

• Clinical Assessments and Interventions

  • Patient Monitoring: Regularly assess vital signs, lung sounds, pain level, and drainage characteristics.

  • Insertion Site: Inspect for localized infection and subcutaneous emphysema.

    • Subcutaneous Emphysema: Air leaking into tissues surrounding the insertion site; produces a characteristic crackling sensation (crepitus) upon palpation.

  • Pulmonary Hygiene: Encourage deep breathing exercises, incentive spirometry (to prevent atelectasis), and range-of-motion exercises for the affected arm/shoulder.

• Drainage System Maintenance

  • Position the unit below chest level at all times to prevent backflow of fluid into the pleural space.

  • Mark output level, color, and consistency on the side of the chamber at regular intervals.

  • Reporting Thresholds: Notify the healthcare provider if drainage exceeds $> 200\,\text{mL/hr}$ within the first hour or $> 100\,\text{mL/hr}$ in subsequent hours. Replace the unit when full.

  • Document drainage as fluid output.

  • Avoid overturning the drainage unit; keep it upright.

  • Management of Unit Breakage: If the drainage unit breaks or loses integrity, immediately submerge the distal end of the chest tube into a container of $2\,\text{cm}$ sterile water to maintain a temporary water seal, then replace the system.

  • Prohibited Practices: Do not milk or strip chest tubes, as this creates dangerously high negative intrapleural pressure.

• Suction Pressure Adjustments

  • Wet Systems: Monitor water levels continuously to offset evaporation; maintain gentle bubbling at $-20\,\text{cm H}_2\text{O}$.

  • Dry Systems: Set dial to ordered pressure. If decreasing suction level, depress the high-negativity relief vent valve and check the water level in the water-seal chamber.

• Dressing Changes and Complications

  • Change site dressings per agency policy using strict aseptic technique and petroleum gauze.

  • Clamping Policy: Clamping chest tubes is not recommended during patient transport or disconnection due to the high risk of converting a simple leak into a tension pneumothorax. Brief manual clamping is permissible only when rapidly changing the drainage unit.

  • Potential Complications: Monitor for reexpansion pulmonary edema, acute hypotension, and severe subcutaneous emphysema.

• Chest Tube Removal

  • Indicated when lungs are fully re-expanded and fluid drainage is minimal.

  • Premedicate the patient with pain medication prior to removal.

  • Instruct the patient to perform the Valsalva maneuver (hold breath and strain) while the physician pulls the tube.

  • Immediately cover the site with an occlusive dressing.

  • Obtain a post-removal chest X-ray and continuously monitor for signs of respiratory distress.

Pulmonary Embolism Etiology and Pathophysiology

• Pathophysiology

  • Occurs when one or more pulmonary arteries are occluded by a thrombus, fat embolus, air embolus, or tumor tissue.

  • A thrombus breaks free from the venous system, travels through the right side of the heart, enters the pulmonary circulation, and lodges in a smaller vessel, completely obstructing downstream alveolar perfusion.

  • Most commonly affects the lower lobes of the lungs.

  • Mortality: $10\%$ of patients with a massive pulmonary embolism ($PE$) die within the first hour of symptom onset.

• Sources and Causes

  • Most $PE$s originate from deep vein thrombosis ($DVT$) in the lower extremities, known collectively as venous thromboembolism ($VTE$).

  • Anatomical Origins: Deep veins of the legs (femoral or iliac veins), pelvic veins, or the right side of the heart (associated with atrial fibrillation).

  • Non-Thrombotic Etiologies: Central venous catheters or arterial lines, fat emboli (secondary to long-bone fractures), air emboli (from IV equipment), heart valve vegetations (endocarditis), amniotic fluid, and cancer emboli.

  • Saddle Embolus: A massive thrombus lodged directly at the arterial bifurcation of the main pulmonary artery trunk into both left and right pulmonary branches.

• Risk Factors for Pulmonary Embolism

  • Immobility or reduced mobility.

  • Surgery within the preceding 3 months (especially pelvic and lower extremity orthopedic procedures).

  • Personal history of prior $VTE$/$PE$.

  • Malignancy (cancer).

  • Obesity.

  • Oral contraceptives or hormone replacement therapy.

  • Cigarette smoking (considered one of the highest overall risk factors).

  • Prolonged air travel or long-distance travel.

  • Heart failure.

  • Pregnancy.

  • Inherited or acquired hypercoagulability/clotting disorders.

Clinical Manifestations and Complications of Pulmonary Embolism

• Clinical Signs and Symptoms

  • Manifestations vary based on the size, number, and location of emboli.

  • Dyspnea: Present in $85\%$ of patients; typically accompanied by mild-to-moderate hypoxemia.

  • Other Associated Features: Tachypnea, cough, chest pain, hemoptysis, lung crackles, wheezing, fever, tachycardia, syncope, and accentuation of the pulmonic heart sound ($P_2$).

  • Massive PE Features: Acute alteration in mental status, severe hypotension, an overwhelming sense of impending doom, and sudden cardiorespiratory collapse/death.

• Major Complications

  • Pulmonary Infarction:

    • Occurs when occlusion of a medium or large-sized pulmonary vessel, lack of adequate collateral bronchial circulation, and preexisting lung disease combine to produce localized alveolar tissue necrosis and hemorrhage.

    • Can lead to secondary lung abscess formation and pleural effusion.

  • Pulmonary Hypertension:

    • Results from severe chronic hypoxemia and vascular bed destruction associated with massive (greater than $50\%$ vessel bed occlusion) or recurrent pulmonary emboli.

    • Progressive pulmonary hypertension causes increased right ventricular workload, ultimately resulting in right ventricular hypertrophy (cor pulmonale).

Diagnostic Studies for Pulmonary Embolism

• D-Dimer Testing

  • Measures cross-linked fibrin degradation products released during clot lysis.

  • Elevated with any active intravascular clot degradation.

  • Limitations: Neither highly sensitive nor specific. Produces false-negative results in small $PE$s. An elevated value confirms clot breakdown somewhere in the body but cannot pinpoint the anatomical location.

• Spiral (Helical) CT Scan / CT Angiography (CTA)

  • The most common diagnostic test for $PE$ confirmation.

  • Requires IV administration of contrast media.

  • Generates a detailed 3-D visualization of the pulmonary vasculature to locate arterial blockages.

• Ventilation-Perfusion (V/Q) Scan

  • Utilized primarily when patients cannot receive IV contrast media (e.g., severe contrast allergy or renal impairment).

  • Consists of two distinct components:

    1. Perfusion Scanning: Injection of a radioisotope to map pulmonary blood circulation.

    2. Ventilation Scanning: Inhalation of radioactive gas to map gas distribution throughout lung spaces.

  • Diagnostic accuracy is highest when both perfusion and ventilation components are successfully completed.

• Adjunctive (Non-Diagnostic) Tests

  • Arterial Blood Gases ($ABG$s).

  • Chest X-ray.

  • Electrocardiogram ($ECG$).

  • Serum Troponin levels.

  • b-type Natriuretic Peptide ($BNP$; elevated in cardiac strain/heart failure).

Interprofessional Management and Nursing Care for Pulmonary Embolism

• Cardiopulmonary Support & Treatment

  • Supportive Interventions: Oxygen administration to treat hypoxemia, IV fluid administration, and strict bed rest in semi-Fowler's position.

  • Immediate Drug Therapy (Anticoagulation):

    • Low Molecular Weight Heparin (e.g., Lovenox / enoxaparin).

    • Oral anticoagulants: Warfarin (Coumadin), Eliquis (apixaban), or Pradaxa (dabigatran).

  • Fibrinolytic Therapy:

    • Thrombolytic agents such as tissue plasminogen activator (tPA / Activase) to dissolve massive occlusive clots.

  • Surgical Procedures:

    • Inferior Vena Cava (IVC) Filter Placement: Preventative placement of a mesh filter in the IVC to trap lower extremity thrombi before reaching pulmonary circulation.

    • Pulmonary Embolectomy: Direct surgical removal of massive pulmonary thrombi.

• Nursing Interventions

  • VTE Prevention:

    • Apply intermittent pneumatic compression ($IPC$) devices.

    • Encourage early patient ambulation.

    • Administer prophylactic anticoagulation (e.g., subcutaneous Lovenox or unfractionated heparin).

  • Immediate Clinical Management:

    • Enforce bed rest in semi-Fowler's position.

    • Continuously evaluate cardiopulmonary status.

    • Administer prescribed supplemental oxygen, IV fluids, and medications.

    • Monitor coagulation blood panels and watch closely for bleeding complications.

  • Patient Psychological Support:

    • Address acute anxiety, chest pain, dyspnea, and fear of death through therapeutic presence and communication.

  • Patient Education:

    • Provide thorough instruction regarding long-term oral anticoagulant therapy.

    • Educate on non-pharmacological measures to prevent $VTE$ recurrence.

    • Emphasize the critical importance of attending regular follow-up appointments and laboratory exams.

Outcome 1: Pathophysiology, Manifestations, and Management of Chest Trauma and Pneumothorax

• Chest Trauma Overview & Mechanisms

  • Epidemiological Significance: Traumatic chest injuries contribute significantly to traumatic deaths, ranging from simple rib fractures to full cardiorespiratory arrest.

  • Blunt Trauma: Occurs when shearing and compression forces injure internal chest structures. External appearance may look deceptively minor, yet severe underlying internal organ damage and hemorrhage may be present (e.g., driver's chest hitting a steering wheel or direct impact from a baseball bat).

  • Penetrating Trauma: Occurs when a foreign object impales or passes directly through body tissues, creating an open wound.

• Pneumothorax Pathophysiology & Classification

  • Pathophysiology: Air enters the pleural cavity, converting normal negative intrapleural pressure between the visceral and parietal pleura into positive pressure. This reduces functional lung volume and causes partial or complete lung collapse.

  • Classification by External Integrity:

    • Open Pneumothorax: An opening in the chest wall allows atmospheric air entry (e.g., penetrating trauma creating a sucking chest wound).

    • Closed Pneumothorax: No external chest wall wound is present (e.g., lung rupture caused by a fractured rib).

  • Etiological Types:

    • Spontaneous Pneumothorax: Caused by rupture of blebs (small air-filled sacs) on the visceral pleura. Risk factors include tall, thin males, family history, smoking, or prior spontaneous pneumothorax. Can occur in healthy individuals or those with chronic lung disease (COPD, asthma, cystic fibrosis, pneumonia).

    • Iatrogenic Pneumothorax: Results from medical procedures (e.g., lung biopsies, subclavian central venous catheter insertion, positive-pressure mechanical ventilation barotrauma, or esophageal tearing during enterogastric ($EG$) tube placement).

    • Tension Pneumothorax: Critical emergency caused by rapid air accumulation in the pleural space with no route for escape. High intrapleural pressure causes mediastinal shift toward the unaffected side, compressing the heart, great vessels, and unaffected lung, drastically reducing venous return and cardiac output.

• Clinical Manifestations

  • Chest Trauma Assessment:

    • Respiratory Distress: Increased respiratory rate ($RR$), dyspnea, coughing with or without hemoptysis, central cyanosis (lips/tongue), tracheal deviation, decreased or absent breath sounds on the affected side, decreased oxygen saturation ($SpO\_2$), and frothy secretions.

    • Cardiovascular Compromise: Rapid thready pulse, decreased blood pressure ($BP$) with narrowed pulse pressure or asymmetric arm readings, distended neck veins, muffled heart sounds, chest pain, and cardiac dysrhythmias.

  • Pneumothorax Assessment:

    • Small Pneumothorax: Mild tachycardia and dyspnea.

    • Large Pneumothorax: Acute respiratory distress and complete absence of breath sounds over affected lung fields.

    • Tension Pneumothorax: Severe dyspnea, marked tachycardia, tracheal deviation away from the affected side, absent breath sounds on the affected side, neck vein distention, cyanosis, and profuse diaphoresis. Rapidly fatal if not relieved.

  • Diagnostics: Standard chest X-ray confirms pneumothorax (tension pneumothorax requires immediate emergency intervention without waiting for X-ray confirmation).

• Nursing and Interprofessional Management

  • Emergency Interventions:

    • Prioritize Circulation, Airway, and Breathing ($CAB$).

    • Administer high-flow oxygen ($O\_2$) to maintain $SpO\_2 > 90\%$.

    • Establish IV access with two large-bore catheters ($16\text{--}18\text{ gauge}$) and initiate isotonic fluid resuscitation.

    • Remove clothing to perform a complete physical assessment for hidden injuries.

    • Sucking Chest Wound: Apply a nonporous (occlusive) dressing taped on three sides (seals on inspiration to block air entry; opens on expiration to release trapped air).

    • Impaled Objects: Never remove; stabilize in place using bulky dressings.

    • Positioning: Place in semi-Fowler's position or turn onto the injured side (after ruling out cervical spine injury) to maximize expansion of the unaffected lung.

    • Analgesia: Administer appropriate pain medications.

    • Emergency Needle Decompression: Immediate measure for tension pneumothorax. Insert a large-bore IV cannula into the second intercostal space at the mid-clavicular line on the affected side to release trapped high-pressure air.

  • Definitive Pneumothorax Care: Chest tube insertion connected to a water-seal drainage system, partial pleurectomy, video-assisted thoracic surgery ($VATS$) stapling, or chemical pleurodesis.

Outcome 2: Purpose, Function, and Nursing Responsibilities for Chest Tubes and Drainage Systems

• Purpose and Physical Specifications

  • Purpose: Inserted into the pleural space to drain air, fluid, or blood, reestablishing negative intrapleural pressure and allowing lung re-expansion.

  • Physical Specifications: Standard length $20\,\text{inches}$ ($50.8\,\text{cm}$); sizing range $12\text{--}40\,\text{Fr}$.

    • Small Catheters ($12\text{--}24\,\text{Fr}$): Drain air.

    • Medium Catheters ($24\text{--}36\,\text{Fr}$): Drain fluid.

    • Large Catheters ($36\text{--}40\,\text{Fr}$): Drain blood (hemothorax, thoracic/cardiac surgery).

    • Pigtail Catheters ($10\text{--}14\,\text{Fr}$): Very small flexible tubes for fluid/air.

• Insertion Procedure and Anatomical Target

  • Procedure: Placed in ED, OR, or bedside. Standard insertion site is the midaxillary line. Elevate HOB $30^\circ\text{ to }60^\circ$ with the patient's arm raised above their head on the affected side. Antiseptic prep, local anesthetic, and systemic analgesia/sedation. Small incision made over a rib, tube inserted, sutured to skin, dressed with occlusive petroleum gauze, and connected to drainage system. Chest X-ray obtained post-procedure to confirm placement.

  • Anatomical Targeting:

    • Second Intercostal Space: Targeted to remove air (air rises).

    • Lower Intercostal Spaces: Targeted to drain fluid and blood (gravity-dependent).

• Three-Chamber Drainage System Architecture

  • 1st Compartment (Collection Chamber): Directly receives fluid, blood, and air from the pleural space; fluid remains in calibrated columns for measurement while air vents to the second chamber.

  • 2nd Compartment (Water-Seal Chamber): Contains $2\,\text{cm}$ of sterile water as a one-way valve. Air bubbles out but cannot re-enter the pleural space. Intermittent bubbling is normal during exhalation, coughing, or sneezing; continuous bubbling indicates an air leak. Tidaling (water level fluctuation matching respiration) is normal until the lung re-expands; sudden cessation indicates tubing occlusion or kinks.

  • 3rd Compartment (Suction Control Chamber): Applies negative pressure to the pleural space.

    • Wet Suction Systems: Suction level controlled by water column depth (typically $20\,\text{cm}$ generating $-20\,\text{cm H}\_2\text{O}$ pressure) with gentle, continuous bubbling.

    • Dry Suction Systems: Contains no water column; uses a mechanical rotary dial set to ordered pressure with a visual alert confirming active suction.

• Nursing Management and Responsibilities

  • Setup & Clinical Care: Verify consent, gather equipment, keep tubing loosely coiled on bed without dependent loops, and maintain tight, taped connections. Inspect site for infection and subcutaneous emphysema (crepitus). Encourage deep breathing, incentive spirometry, and ROM exercises for the affected arm/shoulder.

  • Drainage Maintenance: Keep drainage unit below chest level at all times. Mark and document output level, color, and consistency. Report output $> 200\,\text{mL/hr}$ in the first hour or $> 100\,\text{mL/hr}$ in subsequent hours. Do not milk or strip chest tubes.

  • Unit Breakage: Submerge distal end of chest tube in a container of $2\,\text{cm}$ sterile water to maintain a temporary water seal, then replace the unit.

  • Clamping Policy & Complications: Clamping is not recommended during transport/disconnection due to tension pneumothorax risk; brief manual clamping is permitted only when rapidly changing the unit. Monitor for reexpansion pulmonary edema, acute hypotension, and severe subcutaneous emphysema.

  • Chest Tube Removal: Performed when lungs are fully re-expanded and fluid drainage is minimal. Premedicate patient, instruct to perform Valsalva maneuver during removal, cover site immediately with an occlusive dressing, obtain post-removal chest X-ray, and monitor respiratory status.

Outcome 3: Pathophysiology, Manifestations, Diagnostics, and Management of Pulmonary Embolism

• Etiology and Pathophysiology

  • Pathophysiology: Occlusion of one or more pulmonary arteries by a thrombus, fat, air embolus, or tumor tissue, obstructing downstream alveolar perfusion. Most commonly affects lower lobes. $10\%$ of massive $PE$ patients die within the first hour.

  • Sources & Causes: Most arise from deep vein thrombosis ($DVT$) in lower extremities (femoral/iliac veins), pelvic veins, or right atrium (atrial fibrillation). A saddle embolus is a massive thrombus lodged at the bifurcation of the main pulmonary artery trunk.

  • Risk Factors: Immobility, surgery within preceding 3 months (especially pelvic/lower extremity orthopedic), history of $VTE$, malignancy, obesity, oral contraceptives/hormone replacement therapy, cigarette smoking (one of the highest overall risk factors), prolonged air travel, heart failure, pregnancy, and clotting disorders.

• Clinical Manifestations and Complications

  • Clinical Features: Dyspnea (present in $85\%$), tachypnea, cough, chest pain, hemoptysis, lung crackles, wheezing, fever, tachycardia, syncope, and accentuation of the pulmonic heart sound ($P\_2$). Massive $PE$ causes altered mental status, severe hypotension, an overwhelming sense of impending doom, and sudden cardiorespiratory collapse.

  • Major Complications:

    • Pulmonary Infarction: Occlusion of medium/large vessels without adequate collateral bronchial flow causes localized alveolar tissue necrosis, hemorrhage, abscess formation, and pleural effusion.

    • Pulmonary Hypertension: Results from chronic hypoxemia and vascular bed destruction ($> 50\%$ occlusion), leading to right ventricular hypertrophy (cor pulmonale).

• Diagnostic Studies

  • D-Dimer Testing: Measures cross-linked fibrin degradation products released during clot lysis. Not sensitive or specific; false negatives occur in small $PE$s. Elevated value confirms clot breakdown somewhere in the body but cannot pinpoint location.

  • Spiral CT Scan / CT Angiography (CTA): Most common diagnostic test; requires IV contrast media to generate 3-D visualization of pulmonary vasculature.

  • Ventilation-Perfusion (V/Q) Scan: Used when IV contrast is contraindicated (renal impairment or allergy). Combines perfusion scanning (radioisotope injection) and ventilation scanning (radioactive gas inhalation).

  • Adjunctive Tests: Arterial Blood Gases ($ABG$s), chest X-ray, Electrocardiogram ($ECG$), serum troponin, and b-type Natriuretic Peptide ($BNP$).

• Nursing and Interprofessional Management

  • Cardiopulmonary Support & Medication: Administer oxygen to treat hypoxemia, IV fluids, and enforce bed rest in semi-Fowler's position. Initiate immediate anticoagulation (LMWH/Lovenox, Warfarin, Eliquis, or Pradaxa). Administer fibrinolytics (tPA/Activase) for massive clots. Surgical therapy includes IVC filter placement or pulmonary embolectomy.

  • Nursing Care & Prophylaxis: Prevent $VTE$ using intermittent pneumatic compression ($IPC$) devices, early ambulation, and prophylactic anticoagulants. Enforce bed rest in semi-Fowler's position, monitor coagulation panels and bleeding complications, provide emotional support for anxiety and fear of death, and educate patient on long-term oral anticoagulation and follow-up lab monitoring.