Chest Trauma and Thoracic Injuries

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  1. Chest Trauma: The mechanisms of injuries causing chest trauma are speared into two categorigies:

    Blunt and penetrating Trauma
    • => Blunt: when the chest strikes or is struck by an onbject. Rib and sternal fractures can lacerate lung tissue and high volocitly impact may result in tearing of the aorta. COmpressionn of the chesst cmay result in contusion, crush injury and organ rupture.
    • Ex: MVA, fall, crush injury or explosion

    => Penetrating trauma: open injury in which a foreign body impales or passes through dthe body tissues, creating an open wound. Ex: knife wound and gunshots.
  2. **Assessment of Chest Trauma
    Respiratory: dyspnea, resp distress, cough w/ or w/o heoptysis, Cyanosis of mouth, face, nail beds, Tracheal deviation, audile air escaping from chest wound. Decreased breath sounds ON SIDE of injury. Froth secretions.

    Cardiovascular: Rapid, thready plulse. Decreased BP. Narrosed pulse pressure. Asymmetric BP values in arms. Dissstended Neck Veins. Muffled Heart sounds. Chest pain. Crunching sound synvchronous with heart sounds. Dysrhythmias.

    Surface findings: bruising, abrasians, open chest wound. Assymmetric Chest movement, sucutaenous empthysiemia
  3. **Chest Trauma Interventions and Ongoing monitoring
    • Edminister oxygen to keep >90%
    • Establish IV access with two large bore cath. BEgin fluid resuscitation
    • Remove clothing to assess injury
    • Cover sucking chest wound with nonporous dressing taped on THREE sides
    • Stablilize impased objects with bulky dressings. Don't remove object.
    • Assess for other signifcant injuries and treat
    • Stabilized flail rib segment with hand followed by application of large pieces of tape horizontal across the flail segment
    • Place pt in sem folowers or Positon pt on the INJURED side if breathing is easier AFTER cervical spine injury has been ruled out.
    • Prepare for emergency needle decompression if tension pneumothorax or cardiac tampondae present. 

    • Ongoing monitoring:
    • VS, LOC, Ox sat, cardiac rhythms, resp status and Urine Outpute. 
    • Anticipate intubation r resp distress 
    • Release dressing if tension pneumothroax develops after sucking chest wound is covered.
  4. Pneumothroax
    Caused by air entering the pleural cavity

    Usually negative pressure exists between the visceral pleura (surrounding the lung) and the parietal pleura (linking the thoracic cavity) allowing the llung to be filled by chest walle xpainsion. The pleural space has contains only a few mL of lubricaing fluid to reduce friction when the tissue moves.. 

    When air enters this space, the change to positive pressure causes a partial or complete lung collapse. 

    Pneumothorax can be classified as "open" (air enetering through an opeining in chest wall) or closed (no external wound
  5. Types of pneumothorax include:
    Closed pneumothorax has no associated external wound. The most common form is a spontaneous pneumothorax, which is accumulation of air in the pleural space without an apparent antecedent event.

    Open pneumothorax occurs when air enters the pleural space through an opening in the chest wall. Examples include stab or gunshot wounds and surgical thoracotomy.

    Tension pneumothorax is a pneumothorax with rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant tension on the heart and great vessels. It may result from either an open or a closed pneumothorax.

    Hemothorax is an accumulation of blood in the intrapleural space. It is frequently found in association with open pneumothorax and is then called a hemopneumothorax.

    Chylothorax is lymphatic fluid in the pleural space due to a leak in the thoracic duct. Causes include trauma, surgical procedures, and malignancy.
  6. Tension Pneumothrorax
    Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this 'one-way-valve' effect.

    Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest. The classic signs of a tension pneumothorax are deviation of the trachea away from the side with the tension, a hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves little with respiration. The central venous pressure is usually raised, but will be normal or low in hypovolaemic states.

    However these classic signs are usually absent and more commonly the patient is tachycardic and tachypnoeic, and may be hypoxic. These signs are followed by circulatory collapse with hypotension and subsequent traumatic arrest with pulseless electrical activity (PEA). Breath sounds and percussion note may be very difficult to appreciate and misleading in the trauma room.

    Tension pneumothorax may develop insidiously, especially in patients with positive pressure ventilation. This may happen immediately or some hours down the line. An unexplained tachycardia, hypotension and rise in airway pressure are strongly suggestive of a developing tension.

    • XRAY: It illustrates the classic features of a tension:
    • Deviation of the trachea away from the side of the tension.
    • Shift of the mediastinum
    • Depression of the hemi-diaphragm

    With this degree of tension pneumothorax, it is not difficult to appreciate how cardiovascular function may be compromised by the tension, due to obstruction of venous return to the heart. This massive tension pneumothorax should indeed have been detectable clinically and, in the face of haemodynamic collapse, been treated with emergent thoracostomy - needle or otherwise.

    http://www.trauma.org/archive/thoracic/CHESTtension.html
  7. Anatomy of the Thorax:
    THREE cavities: 2 pleural cavities and 1 mediastinum

    PLEURAL MEMBS (From outside to in)

    • Parietal (lines thoracic) ->  Pleural SPACE -> VISCERAL (lines lungs)
    • Space: 5-15 mL: allow expansion and movment
  8. Thorax Physiology
    Lung recoil is inward

    Chest wall moves outward

    Opposing forces create a negative pressure in pleura space

    Negative pressure keeps the visceral and parietal pleurae together

    • Lungs remain partially expanded since parietal pleura is connected to thoracic cage
    • ie.  Two damp suction cups

    Opposing forces = negative pressure => Prevents lungs from collapsing (keeps visceral and pariental membrane together: SUCTION.

    • Any changes inside that space/cavity: that’s when the lungs can collapse.
    • Anything that changes that suction: causes lung collapse.
  9. Chest Drainage Indications
    Pneumothorax

    Tension pneumothorax

    Hemothorax

    Pleural effusion/empyema

    Chylothorax–Lymphatic fluid in the pleural space d/t leak in the thoracic duct (trauma, surgery, malignancy).  Fluid is milky white, and hight in protein

    Mediastinal drainage after heart surgery

    Pleural effusion: accumulation of fluid (more than 15 mL) within that space

    Empyema: pockets of fluid/PUS in the pleural spaces, sometimes requiring going in with thoracentesis to drain out those airways.

    Chylothorax: lymph fluid in pleural space

    Mediastinal drainage: occurs b/c we entered that space due to heart surgery.
  10. Types of Injuries:
    **Penetrating: anything that goes through the chest wall/cage (including a thoracic sx)

    • **Non-Penetrating:
    • -Rib Fractures: Nothing goes through that chest wall but injury can occur b/c internally ribs can fracture and breakoff: like a stick inside the chestà puncturing the wall.

    -Lacerations: Lung cancer. Over inflation of lungs during mech ventilation can cause tears.

    -Pulmonary contusions

    -Flail chest: a life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently.

    -Explosion: change in pressure externally that can resonate internally inside thoracic cage.
  11. Chest Injury Assessment
    Upon assessment: 1st: patient airways. Breathing and circulation

    • THEN:
    • Look at thoracic cage: Is it penetrating or non-penetration
    • -Contusion or abrasion: is something underlying that caused the penetration
    • -look for open wound
    • -LOOK for breathing abnormalities: symmetrical rise ad fall of chest
    • -Listen: breath sounds, anterior, posterior and laterally. Compare to each side. Especially looking in relationship to what you’re inspecting on the outside. Visualizing the chest cage.
  12. Dx:
    Cxr:

    CT scan

    ABG’s

    EKG’s: changes shows.

    Echocardiogram: like an ultrasound off the heart: you can have fluid build up around the heart. Decreased Output/Hypotenson from fluid in pleural space.

    Hgb/hct: are they losing blood
  13. Nursing Managment
    Maintain airway/Ventilation: Suction. May need intubation. Administer Oxygen

    Maintain fluid/electrolyes: especially if in shock.Give fluid resuscitation: blood. Electrolytes

    Acid-Base Balance based on their ABG results.

    Provide pain relief of course.  Acute pain like situation to chest: you’re going to have to give a narcotic. Not going to decrease resp rate…  RR decrease  when you have too much opioids going in.

    First initial pain response: acute phase. NEED TO GIVE MORPHINE and DILAUDID. FENTANYL.
  14. Open Chest Wound
    • Cover with gloved hand
    • Prepare cover with a dressing taped on three sides
    • Assist with ventilation as necessary
    • Set-up for chest tube insertion

    We need to cover the chest wound! Cover only with the dressing that is taped on THREE sides (so we don’t completely occlude it. WHY? We want the air to escape through one side without allowing air to enter or suck in)

    Assist with ventilation

    • Prepare to set up with chest tube insertion. Make sure to ask for premedication: antianxiety. Versed. Opioids. Give in time to work before the procedure start.
    • Think about onset of action: anywhere fro 15-30 mins. Sometimes from using it before or level of anxiety: they may need more than what’s ordered. It can be done at bedside at any med-surge level/floor.

    -Educate pt.

    -Sign the consent.
  15. Locations for PLEURAL CHEST TUBE:
    To remove air
    TO remove fluid 
    Mediastinal Chest Tube
    • To remove air: 
    • Usually upper portion of lung that collapses.
    • -2nd to 3rd intercostal space at midclavicular line.
    • -real possibility of the tube entering the heart if on your left side?! So be careful. Even for quick needle decompression (large bore needle in that space for a tension pneumothorax—trachea deviation) which could open the space until we get a chest tube in place.

    • To remove fluid:
    • 4-6th intercostal and MID-axillary line (The middle of your side)

    Mediastinal chest tube: For pericardial drainage: directly undr sternum: coming from heart sx, small collect of fluid device.

    Through subcutaneous tissue,  cartilage, through muscle, and into pleural spaceUltrasound guided-assisted: tech will come up at bedside to direct doc on where' to go
  16. Pleural Effusion
    • Pathophysiology
    • An accumulation of fluid in the pleural space due to changes in hydrostatic or oncotic pressures.

    Transudate effusion: Non inflammatory, protein-poor/cell-poor fluids (clear/pale in color)

    Exudative effusion Inflammatory reaction (yellow/brown/green/cloudy fluids)

    • Signs and Symptoms
    • Progressive dyspnea
    • Decreased chest wall movement on affected side
    • Pleuritic pain
    • Dullness on percussion
    • Absent or distant breath sounds
    • S/S infection in labs/temp (if exudative)Fluid levels greater that 250mL appear on chest x-ray/CT scan
    • Fluid accumulation in pleural space.

    TREATMENT: Thoracentesis

    Note: Oncotic pressure, or colloid osmotic pressure, is a form of osmotic pressure exerted by proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the circulatory system. It is the opposing force to hydrostatic pressure. It has a major effect on the glomerular filter pressure.

    -Transudate: non inflammatory VS. Exudative: inflammation or basically an infection of bacteria with output: clouded,yellowish which you can see in the collection chamber

    • Hemothorax: you see blood in collection chamber.
    • As that clears: fluid turns bright red dark to a pale color.

    • S/S: Decreased chest wall movement b/c lung can’t expand.
    • -Exudative: labs will show.
    • -Fluid levels: greater than 250.
  17. Thoracentesis
    • May be done at bedside (ultrasound guided)
    • Consent
    • Pre-medicate
    • Pt. positioning
    • Emergency equipment available
    • Only 1000-1200mL should be removed at one time
    • SEND TO LAB
    • F/U with chest x-ray
    • Monitor frequent V/S for 1 hour after

    Recurrent Pleural Effusions may need chest tube and/or Talc therapy (i.e. chemical pleurodesis)

    Just like inserting a chest tube: a thoracentesis:gget through all those levels with a BIG NEEDLE to pull out that fluid. Need conset. Need meds.

    Position pt: sometimes lateral on side. Or sitting on side of bed with arms over table. Sometimes lying flat. Just depends on where fluid is in lungs and location the need to get into it. Minimize amount of fluid to be removed at one time. Removing more than a liter out at onceà reinflation edema can occur. (Going back to square one /: )

    -Some doctors will fill out Liter after Liter volumes.-all of that fluid in the lung. 1-2 L. SO MUCH FLUID. You must send it to the LAB. ALL FLUID TO LAB.

    -ask doctor about c/s and anything else they’re testing for-Maybe they’re testing for TB:  AFB serum.

    ALWAYS FOLLOW UP THORACENTESIS WITH CHEST XRAY. Why? You can puncture lungs -->  pneumo

    Stay with pt. Assess respiratiions/lung sounds. Check oxygenation. Hemodynamic stability. Can be exhausted. Like they ran a marathon.
  18. Pneumothorax
    -Types of Causes
    -SIGNS & SYMPTOMS
    Pathophysiology  Influx of air into the pleural space resulting in increase in intrathoracic pressure.  Cause may be open or closed trauma

    • Closed (Non-penetrating) Causes
    • Spontaneous pneumothorax - cause unknown
    • Mechanical ventilation
    • Insertion of subclavian catheter
    • Perforation of esophagus
    • Broken ribs injure lungs
    • Ruptured blebs or bullae in COPD

    • Open (Penetrating) Causes
    • Gun shot wound, stab wound, or wood
    • Cover with a vented dressing (secured on three sides).  This allows for air to escape to prevents tension pneumothorax
    • Surgical thoracotomies

    S/S:  Pleuritic chest, pain, SOB, Tachypnea, Tachycardia, Asymmetrical chest wall movement, Decreased breath sounds to affected side,, Cyanosis
  19. Treatment of Pneumo:
    • 1. Needle Venting w/ Large bore needle
    • 2. Heimlich Valve
    • 3. Chest tube to water seal drainage
    • 4. Surgery: partial pleurectomy, stapling or plleurodesis 

    Heimlich valves: one way valves. Instead of being trapped to the chest tube, goes in and allows for valve to escape. Looks like a credit card, goes where pneumothorax.-one-way valve used in respiratory medicine to prevent air from travelling back along a chest tube.It is most commonly used to help remove air from a pneumothorax. The valve is usually designed as a rubber sleeve within a plastic case where the rubber sleeve is arranged so that when air passes through the valve one way the sleeve opens and lets the air through. However, when air is sucked back the other way, the sleeve closes off and no air is allowed backwards. This construction enables it to act as a one-way valve allowing air (or fluid) to flow only one way along the drainage tube. The end of the drainage tube is placed inside the patient's chest cavity, within the air or fluid to be drained. The flutter valve is placed in the appropriate orientation (most packages are designed so the valve can only be connected in the appropriate orientation) and the pneumothorax is thus evacuated from the patient's chest.[2]Chest tubes: See videos. 

    Surgery: either prophylactic

    Chest tube- Either prophylactic b/c they took out portion of lung and so then we’re gathering all the fluid associated in that space behind that lung.
  20. Tension Pneumo
    –Occurs when air enters the pleural space and is not able to escape causing compression of the affected lung, major blood vessels and the heart.

    entire lung just collapse, and all that pressure  get shifted over to the great vessels, and moves heart from one side to the other. MEDICAL EMERGENCY. As that heart gets pushed, it’s decreasing cardiac output. We need to be able to reinflate this lung and get pressure of the lung.

    Spontaneous pneumothorax: young, teenage boys.

    • S/S: 
    • HALLMARK SIGN: Tracheal deviation (deviation to the unaffected side)
    • -Hypotension
    • -Compensation: fast breathing and hr.
    • -Subcuatenous emphysema.
    • –Distended neck veins
    • –Compensatory tachycardia & tachypnea
    • –Subcutaneous emphysema
    • –Decreased cardiac output
    • EMERGENT  Must be treated promptly
  21. HEMOthorax

    S/S (additional to Pneumo)
    Causes
    Pathophysiology  Occurs when traumatic injury of the blood vessels causes blood to escape into the chest cavity (with or without pneumothorax)

    • Causes
    • Chest trauma (MVA, fight, fall)
    • Lung malignancy
    • Complications of anticoagulant therapy
    • Pulmonary embolus
    • Tearing of pleural adhesions

    B/V injury inside lug, escaped into chest  cavity.

    • ADDITIONAL SIGNS TO PNEUMO: 
    • Possible subcutaneous Emphysema(crepitus)
    • Tracheal deviation to unaffected side (late sign)
    • Percussion dullness over area of hemothorax

    Subcutaneous emphysema is when gas or air is in the layer under the skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air.

    • -Crepitus: crunching sound; Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Rice Krispies
    • this sensation of air under the skin is known as subcutaneous crepitation.Dullness when percussing.

    • TREATMENT: 
    • Depending on size, location, and clinical findings, may or may not have chest tube
    • If severe blood loss, may need autotransfusion of collected blood, pressers, or fluid resusitation
    • If it’s not too big: the body can reabsorb. Watch via cxr. How much lung compromise is occuring.
    • -If too much compromised, then they can put a chest tube to drain the area.
    • If severe blood looss—fluid resuscitation. Bloods.
    • Vasopressers if cardiac output is low.
  22. Flail Chest
    s/s
    Treatment
    Multiple rib fractures with unstable chest wall.

    -two places within rib itself SO a FLOATING rib.

    -Section isn’t connected to anything. So it’s floating in that space.

    S/S;  Increased RR, HR

    • -The flailed portion does opposing movement of rest of natural chest movement.  On inspiration, it goes IN (abnormal) and on expiration, it moves out (abnormal!)
    • Assess for dyspnea, tachypnea, shallow breathing, tachycardia, crepitus.

    • Diagnostics
    • Chest x-ray, and ABG’s

    • Treatment
    • Prepare for intubation and mechanical ventilation to internally stabilize the floating segment of ribs.
    • May use external stabilization with tape
    • Ventilator will be set to deliver the same tidal volume with each breath and PEEP.
  23. Thoracic Surgery
    Removal of portion of lung due to cancer or disease process

    • Assessment:
    • Pt. positioning after surgeryPain management
    • May or may not have chest tubes post-op

    Reason for chest tube.

    Anticipate lot of fluid afterwards.

    Assessment: make sure we understand what position of the patient will be after surgery.

    -How do we position the patient when they have a good lung to ventilate the patient: Position the bad lung down (where we operated on)-This maximizes the ventilation of the patient. Good lung up to be able to breath and oxygenate. -when they’re positioned on the side.

    -Painful. Medicate!-Do they have PCA. Premedicate. Ice!

    -Make sure to turn the patient but don’t keep them on their good side for too long! Not 2 hours. Think about it, if we’re cutting through thoracic cage..did they have to break through the ribs. What did they have to do to get to the lung.
  24. CHEST DRAINAGE SYSTEM 
    -Collection Chamber
    -Water Seal Chamber
    -Suction Control Chamber
    Normally: The thoracic cavity is a closed space with negative space surrounds each lung to pull the lung towards chest wall

    -stabbing or gunshot or , negative pressure becomes possitive and lung collapses towards mediastium.

    If air or fluid remains in the pleural space, the lung will not be able to expand fully. Thus one or more chest tubes is needed to remove air or flluid from the chest so that lun can expand and the negative pressure can be restablished. Chest tubes also needed after heart surgery to drain fluid from pericardial sac and reduce risk of fluid buildup that could lead to cardiac tampondade.

    Whether the tubes are in pleural space or mediastinum, they are connected by tubing to a chest drain.

    Collection chamber collects drainage

    Water seal chamber allows air to leave pleural space but not return (2 cm H2O)

    Suction control chamber applies suction pressure on pleural cavity (usually  -20 cm H2O)
  25. The Three Chambers of Chest Drainage System
    • Collection Chamber: closes to patient, the patient tubing connects to the the drain.
    • -Fluid types: blood 12-24 hr, Serosanguinesous is post op, Pleural: clear or cloudy depending on infection.
    • -Calibrated up to  200 mL

    • Water Seal Chamber: middle of drain. Allows air to LEAVE chest BUT prevents air fromENTERING the patient. Like straw in glass of milk. You can blow bubbles into it, but when you suck in, you only get fluid.
    • -Like a one way valve.
    • -Monitor bubbling for air.  Continous bubbling means persistent air leak either in thoracic cavity or tube connections.
    • -Intermittent: intermittent air leak. No bubbling indicates there is no leak.
    • Bubbling from Right to left in the air leak monitor  must be present to confirm active airleak.
    • -If no bubbling and the chest tube is IN the pleural space,  check to see water level moves up and down with respiration reflecting pressure changes within the pleural space. This is tidaling. If present means system is functioning properly. BUT if the lung is fully inflated, this will not be visible.
    • - Changes in intrathoracic pressure is determined by observing the level of the float ball in the calibrated water seal column


    • Suction Control Chamber:
    • The third chamber, on the left side of the unit.
    • -Volume and height of water in this chamber  is whatt safely control amount of suction provided for the patient.
    • -Remember: it is the water level in the suction control chamber, NOT the vaccum source level that determines the amount of negative pressure transmitted to the patient's chest.
  26. SAFETY FEATURES of Chest Drainage System
    • High Negativity Float valve: Top of water seal chamber. If you apply too much negative pressure to the glass of milk, you suck up ALL of the fluid, and then you'll suck in air... we never want air to get sucked into chest.
    • -During normal or deep inspiration, the float valve will allow thoracic pt to draw as much intrathoracic pressure as they may require during each respiration cycle, however during prolonged  periods of acuumulating vaccum pressure, float valve will automatically lower high vaccum pressure to a more safe desirable pressure.

    • Filtered Manual Vent: Located on the top of the drain. If there is a condition of high negative interapleural space as seen with maniupulation of tubing or strong coughing, the water level can rise in waterseal chamber. Hard to assess. You can depress this vent when you need to lower the water level in the chamber.
    • -to lower height of water height WHEN CONNECTED TO SUCTION, temporarily depress, untill blue water column lowers to the desired level.
    • -Not recommended to depress the manual vent when suction is NOT operating!

    • Possitive Pressure Protection: Prevents pressure from building up in drain when tubing leaving the drain is blocked. This sasfety valve will vent any pressure buildup to reduce risk of tensiion pneumothorax. Remember: if tubing between the patient or drain is somewho blocked or kinked, this valve can't protect pt b/c no prssure build up in the drain. this valve with automatically vent any positive pressure that builds up in the chest drainage system.
    • Located on top of drain

    • Knock over protection: designed to keep fluid in proper chambers even if drain is kicked or knocked over.
    • -"knock over nozzles."
  27. Nursing Assessment of Chest Tubes
    The patient: 

    Breathing: rate, Regularity,, Depth, Ease, Breath Sounds

    Entry Site: dressing intact, Drainage, Subcutaneous emphysema

    Subj: ease of breathing, anxiety, chest discomfort, Level of understanding

    Tubing: tight, taped connecttions, no kinks, or compressiion, no dependent loops


    Drainage unit chambers: 

    1. Suction
    : Filled to 20 cm line  with gentle continous bubbling

    2. Water seal: filled to 2cm line, Bubbling, fluctuations with inspiration/expiration

    3. Drainage collection: volume, type, rate, chamber below chest level

    Make sure the chamber is below the patient's chest.

    Look to see that the chamber isn’t in a place where it can be knocked over or when it’s under the bed, because it will get smashed when the bed is lowered down D:

    Make sure you get order if the pt has to be disconnected to get up annd go to bathroom or to walk around. You just disconnect and connect back.
  28. Emergency Supplies to Keep at Bedside
    Petroleum: to cover hole if tube comes out accidentally. Cover with nonocclusive dressing, 3 side taped.

    Sterile water: in case it b/comes d/c, the water seal level be directly put into the water so that you don’t change the pressure inside the thoracic cage

    Chest tube clamp: specific clamp that can  go on the tubing itself that will pierce through the tubing. Keep it taped at the bedside or on the wall by bed of pt. If you don’t have that special clamp, use hemostat. Wrap it with gauze and clamp tubing so you don’t damage the tubing.

    When transporting the pt, take these with the patient.
  29. If Chest tube is dislogged
    –No audible air leak, apply occlusive petroleum guaze and notify MD

    –If air leak, apply occlusive petroleum guaze with hand and release periodically so air can escape and notify MD

    If the chest tube is dislogged: apply occlusive dressing.
  30. Absence of drainage
    –Check to confirm system is low enough to facilitate drainage by gravity and turn pt to affected side

    –Check tubing for kinks or compression

    If there is no drainage in the system, there could be resolution of the problem. Then we would anticipate the chest tube coming out. If we notice a lot of drainage the shift before, and all of a sudden, now there’s no drainage. Look for kinks! Is something occluding it?


    –If sudden, check for cardiac tamponade
  31. Full Collection Chambers
    • Change system
    • Maintain sterility at thoracostomy tube & drainage tube connection.
    • Clamp thoracostomy tube & disconnect latex tubing & reconnect new latex tubing & release clamp. 
    • Connect 1 foot latex tubing to suction source.
    • It’s alright to clamp mediastinal tube because it’s not in the pleural cavity.

    If copious drainage, don’t clamp tubing because it may cause cardiac tamponade.

    If all chambers are full, we may need to change the device out itself. Ordder new device from store or distribution dept. When changing out device, do it as sterily as possible. Connect new device with sterile gloves
  32. The H2O seal: Abscence of Bubbling and Continuous Bubbling
    ABSCENCE 

    Turn off suction, because able to see fluctuations better. If no fluctuations suspect occlusion somewhere between pleural cavity and system.No bubbling in mediastinal chest tube.

    No bubbling: look for causes. Maybe turn of suction and give a little time. Is there an air leak?

    Always understand, there is no bubbling ever in mediastinal chest tube.

    There should be continuous gentle bubbling in  SUCTION chamber, NOT water seal.


    Continuous bubbling in H2O seal

    Indicates air leaking into the drainage system.

    Locate and seal the system’s air leak.

    Water seal: tidaling with respiration.

    Intermittent bubbling could mean there is an intermittent air leak.

    Continuous bubbling means there is a continuous leak, somewhere. Look for that possible air leak. Let the physican know cos they could come in, determine where in that system that air leak, and maybe they can cut that air leak out and reattach it, maybe if it’s closes to that device chamber, and if too close to that patient, reinsert a new chest tube.

    Tighten all connections.

    If still bubbles then briefly clamp the tubing starting from proximal end, moving down in 12 inch increments to the drainage system.  Bubbling stops when clamp placed between air leak and water seal.  If continues to bubble then air leak is from system. Change system.

    Note: Bubbling is seen in water seal more during expiration
  33. Water rises to top of Water seal?
    • –Depress high negativity relief valve until you reach desired level
    • You can vent it if water level rises too high
  34. Absence of bubbling in suction control chamber
    Absence of bubbling: look for leak or kink

    • First make sure 1 foot latex tube is connected to suction source.
    • Checked to see if suction source is turned up high enough to draw atmospheric air through water in suction control chamber.  The pleural leak may be too large for the suction to handle.
  35. Suction control chamber overfilled or underfilled
    –There is a resealable rubber diaphragm at the back of chamber. With a needle add or remove sterile water.
  36. System tipped & H2O collection chamber  water entered drainage system
    –Note the amount of water entered chamber and subtract from total drainage.  Make sure water seal and suction control have enough water in them.

    Note the amount of water entered chamber and subtract from total drainage.  Make sure water seal and suction control have enough water in them.

    Calculate the amount of drainage in each chamber and add amounts together for the total drainage.
  37. Planned Chest Tube Removal
    Premedicate per MD order.

    MD may clamp chest tube before removal to check how patient will tolerate not having the chest tube.

    Monitor for respiratory distress

    May indicate reaccumulation of pneumothorax.

    • Taking out chest tube:
    • -Premedicate.
    • -Tell the patient what to expect
    • -Retention sutures that go around the chest tube to hold it in place. Suture removal kit. Take sutures out.
    • -Pull the chest tube out.
    • -Tugging and pulling. It’s painful because the muscles have closed and squished around the chest tube
    • -make sure you have a dressing to place over after the removal.

    -Assess: hemodynamic and Resp status BEFORE and AFTER.
  38. THE NINE ASSESSMENT STEPS:
    Start at patient, work your way down and through the drain

    Check the dressing: make sure it's dry and occlusive. Don't have to be routinely chagned.

    Eliminate dependent loops : make drainage go uphill to get into collection chamber.

    No stripping or milking of chest tubes to enhance chest draiange. This can increase the negative pressure in chest that can damage lung and heart tissue

    Check the drainage in collection chamber: note amt, type of fluid.

    Check for bubbling in water seal chamber: bubbling means air is entering system and being vented out of this chamber.

    If there is NO bubbling, check for tidaling. If there is no bubbling in water seal of pt with pleural tubing,, then look to see if water is going up and down with breathing (tidaling) means normal. Reflects intrapleural pressure changing that occur with normal breathing

    Check level of water in BOTH water seal chamber and suction control chamber, since water will evaporate more quickly if there is more bubbling in one or both of these chambers. Add fluid as needed.

    Adjust the vaccum source so there is gently bubbling in the suction control chamber: once bubbles appear, excess negataivity is vented. Vigrous bubbling doesn't increase negative pressure, but it does make a lot of noise and slows down evaporation

    Check tubing leaving the unit to make sure it's open. FInally follow tubing from the drain across the floor and to the vaccum source ( a regulator on the wall) this tubing should remained open so air can leave the system. It can easily get pinched by wheels of equipment at the bedside. -
Author:
Radhika316
ID:
313853
Card Set:
Chest Trauma and Thoracic Injuries
Updated:
2016-02-03 00:26:24
Tags:
Respiratory CHest Trauma NS4 NS4P1
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Description:
Chest Trauma and Thoracic Injuries
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