2.1 Respiratory, Chest Trauma Flashcards by jodi Trethewey

Describe and give example of a penetrating chest injury

Penetrating trauma:
Foreign object enters the body
-gunshot, stab wound, impalement

Common chest trauma injuries
Hemothorax
Pneumothorax
Pulmonary or myocardial contusion
Cardiac tamponade
Esophageal and diaphragm injury
Tracheal tear
Great vessel tear

How well did you know this?

Not at all

Perfectly

Describe and give example of a non-penetrating chest injury and types of force involved

Blunt trauma:
No communication between damaged tissue and the outside environment
-motor vehicle crash, fall, assault, sports injury

Type of force involved:
Deceleration
Acceleration
Shearing
Compression
Crushing

Contrecoup trauma (think whiplash):
Blunt trauma caused by impact of body parts against another object. Injury occurs on side of impact and also on opposite side
*rib fraction is the most common chest injury
*fractions of scapula, sternum or first rib suggests massive force of injury

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Spontaneous

Spontaneous pneumothorax:
Closed pneumothorax
Ruptured bleb on lung surface (most common)
Common with tall, thin, young men
S/S:
Sharp, pleuritic pain, worse with inspiration r/t air irritating the parietal pleura
Decreased breath sounds over affected area
Increase HR and resp, dyspnea, unequal chest expansion
TX:
Monitoring, supplemental O2, chest tube placement, surgery

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Open

Open pneumothorax):
External wound, air enters the pleural space
Sucking chest wound- penetrating trauma (stab wound, gunshot wound, impalement)
S/S:
Pain
Decreased breath sounds over affected area
Increased HR and resp, dyspnea, unequal chest expansion
Audible air movement
TX:
Cover with sterile, occlusive, nonporous dressing
Tape 3 sides which allows air to escape
-inhalation sucks dressing to skin so outside air does not enter
-exhalation allows air to escape
Decreases risk of tension pneumothorax
Do not remove object in chest, stabilize with bulky dressing

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Closed

Closed pneumothorax (negative pressure):
No external wound, air in pleural space

2 Types:

Spontaneous

ruptured bleb on lung surface (most common)
common in tall, thin, young men

Traumatic
-rib fractures
Iatrogenic (medical procedure)
-procedures such as central line placement (CVC)
-mechanical ventilation

S/S:
Sharp, pleuritic pain, worse with inspiration r/t air irritating the parietal pleura
Decreased breath sounds over affected area
Increase HR and resp, dyspnea, unequal chest expansion
TX:
Monitoring, supplemental O2, chest tube placement, surgery

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pneumothorax Tension

Tension pneumothorax:
Any cause (any type of pneumothorax), air overfills pleural space
Rapid accumulation of air with no escape
Open or closed
Pleural pressure becomes positive
Medical emergency!
Increased pressure on heart, great vessels, esophagus and trachea

S/S:
Cyanosis
Air hunger
Agitation
Tracheal deviation toward unaffected side
Subcutaneous emphysema
Neck vein distension
Absent breath sounds on affected side
Hyperresonance to percussion on affected side
Tachypnea, tachycardia

TX:
Surgical emergency
Emergency decompression “band aid” until chest tube is placed. Insert large bore needle (14 g) in 2nd intercostal space, midclavicular line, to release air
Insertion of chest tube
Chest x-ray to confirm placement and re-expansion

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Hemothorax

Hemothorax:
Blood enters pleural space
Causes:
Blunt or penetrating trauma
Surgery/procedure
S/S:
Dyspnea
Decreased breath sounds
Dullness to percussion
Tachypnea, tachycardia
Hypovolemia, shock
TX:
Chest tube
Transfusion
May require surgery

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Rib Fracture

Rib fracture: Chest wall injury
Most common chest wall injury
-ribs 5-10 most common r/t least protected by chest muscles
-ribs 1-3, clavicle or scapula- suspect vascular injury
-ribs 7-10 suspect injury to liver (right side) or spleen (left side)
Rib fractures may injure pleura causing pneumothorax or hemothorax
S/S:
Pain with inspiration
Crepitus
Shallow tachypnea
Splinting
TX:
Analgesia, intercostal nerve block
Push pulmonary rehab- inspirex, cough and deep breathing, ambulate
Avoid binding or taping (leads to resp complications)
Imaging to exclude other injuries

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Flail Chest

Flail chest wall injury:
Multiple adjacent rib fractures may produce a mobile fragment which moves paradoxically with respiration
Significant force required, often associated with other underlying injuries
S/S:
Paradoxical chest wall movement
Respiratory distress
Pain, dyspnea, crepitus, diminished breath sounds
Associated hemothorax, pneumothorax, pulmonary contusion (bruising of lung tissue)
TX:
Stabilize flail segment- occasionally need surgery/plating
Possible intubation and ventilator
Oxygen/PEEP
Aggressive analgesia
Treat other injuries

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pulmonary Contusion

Pulmonary Contusion:
Lung tissue (parenchyma) is fragile- shock wave of force causing alveoli and capillaries rupture leading to hemorrhage and inflammation
Poor gas exchange
S/S:
May be delayed up to 24 hours
Tachycardia, cyanosis, agitation
Copious sputum- may be blood tinged
TX:
Supportive
Ventilation and oxygenation
Mechanical ventilation
Bronchoscopy to clear secretions
**Inflammation leads to vasodilation and capillary leaks

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Cardiac Tamponade

Cardiac Tamponade:
Fluid fills the pericardial sac around heart
Compressed heart muscle cannot pump
Medical emergency!
Causes:
Trauma
Surgery
Pericardial effusion
Cardiac rupture or hemorrhage
S/S:
Pulses paradoxus (BP drops/pulse diminishes during inspiration)
Beck's Triad- distended neck vein, muffled heart sounds, hypotension, tachycardia, tachypnea
TX:
Pericardiocentesis
Surgery- pericardial window (piece of paracardial sac is cut out which allows fluid to continually drain)
Volume resuscitation

How well did you know this?

Not at all

Perfectly

Assessment findings, interdisciplinary care, nursing interventions and rationale for:
Pulsus Paradoxus

Pulsus Paradoxus:
Blood pressure drops
Pulse diminishes during inspiration
Hallmark to cardiac tamponade

How well did you know this?

Not at all

Perfectly

Discuss why narcotics are administered cautiously to chest injured patients

Narcotics lower respiratory rate

How well did you know this?

Not at all

Perfectly

Identify changes in ABGs that are expected in chest trauma patients

How well did you know this?

Not at all

Perfectly

Chest tubes

PNEUMOTHORAX (AIR)

Spontaneous: blebs, COPD

Traumatic: stabbing, gunshot, broken rigs, ventilator injury, procedural

Tension: life threatening progression of pneumothorax, shifts trachea and mediastinum to unaffected side

How well did you know this?

Not at all

Perfectly

Chest tube
PLEURAL EFFUSION (FLUID)

Transudate (clear, thin fluid): heart failure, cirrhosis, open heart surgery

Exudate (protein rich fluid): pneumonia, kidney disease, cancer, inflammatory disease

Other less common causes: autoimmune, TB

Hemothorax: blood drainage
Surgical drainage: fluid drainage
Chylothorax: lymph fluid in pleural space

How well did you know this?

Not at all

Perfectly

Discuss types of airways: Oral

Oropharyngeal airway
Inserted through mouth
Measured corner of lip to mandibular angle
For unconscious patients only due to gag reflex

Discuss types of airways: Nasal

Nasopharyngeal airway
Inserted through nose
Measured nare to tragus of ear
May be used for conscious patients
Contraindicated with facial trauma
Facilitates nasotracheal suctioning

Discuss types of airways: Esophageal

Esophageal tracheal airway (combitube):
Temporary airway
Easy to insert
Common for stabilization in the field
Not used with mechanical ventilation

Discuss airways: Tracheostomy, indications, advantages, complications

Tracheostomy:
Bedside or OR
Tube allows passage of air and removal of secretions

Indications:
Facilitate vent weaning
Manage secretions
Upper airway obstruction

Advantages:
Stable airway
Enables swallowing, speech, oral hygiene

Complications:
Bleeding
Infection
Dislodgement
Cuff necrosis

Discuss types of airways: Endotracheal

Endotracheal tube:
More stable (days to weeks)
Technically more difficult to insert
Balloon inflated to prevent secretions from entering into lungs
Anesthesia or respiratory failure

Review suctioning: Oral

Review suctioning: Nasal

Review suctioning: Trach

Review suctioning: Endotracheal

Review tracheostomy care

Care of the patient post-thoracotomy

Teaching: | Prevention of further complications???

Assessment findings, interdisciplinary care, nursing interventions and rationale for: Cardiac Contusion

``` Cardiac Contusion: Cardiac tissue (myocardium) bruising damages contractile fibers, decreases strength of contraction and cardiac output S/S: Low BP may be delayed up to 24 hours Dysrhythmias Low cardiac output TX: Supportive Monitor for myocardial infarctions ```

Respiratory assessment

``` Decreased breath sounds on side of injury Dyspnea Hemoptysis Cyanosis Audible air from wound Frothy secretions Tracheal deviation ```

Pain assessment

Tachypnea= decreased ventilation= increased atelectasis Diminished ability to cough= increased secretions= pneumonia Hypercarbia, hypoxemia= respiratory failure results

Cardiovascular assessment

``` Rapid, weak pulse Decreased blood pressure Narrow pulse pressure- diff between systolic and diastolic Distended neck veins Chest pain Arrythmias ```

Chest trauma general treatment

``` Ensure airway Supplemental O2 IV access Removed clothing Semi fowlers Monitor vital signs Manage pain Labs and imaging ```

Chest tube propose and insertion

Purpose: Remove fluid and/or air Prevent fluid and/or air from returning Restore negative pressure in the pleural space/re-expand lung ``` Insertion: Confirm consent Assist with positioning Administer medications Monitor patient Setup drainage system Label and send specimens ```

Chest tube complications and removal

Complications: tube malposition Re-expansion pulmonary edema (>1-1.5 liters removed) Vasovagal response (brady, syncope) Infection Pain- decreased shoulder mobility, shallow respirations Removal (requires special training): Once lung re-expands and drainage is minimal Discontinue suction prior to removal Final check for air leak before removal Cover site with airtight dressing for 24 hours

Chest drainage systems: | WET/DRY

Wet vs Dry suction Regulation of suction Wet: regulated by fluid level adjustment Dry: regulated by a dial

Chest tube nursing care assessment

Assessment: Respiratory rate, depth, effort, symmetry, pulse ox Output amount, quality, color Site/dressing, changed daily Tube connection and patency Verify order and suction settings (bellow should be out) Presence of air leaks (bubbling in water seal chamber) or crepitus Pain Signs of distress: increased HR, JVD, tracheal deviation, anxiety

Chest tube maintenance

Keep system below insertion site No clamping tubes, keep clamp at bedside Maintain connections, correct kinks/depend loops Tube dislodged, cover with occlusive, 3 sided dressing Tube disconnected, place tube in sterile water until system can be reestablished

Chest tube drainage systems: NO WALL SUCTION

NO WALL suction chest tubes (water sealed): ``` Heimlich Valve: Small device, one way valve to release air No fluid collection chamber Often in emergency pneumothorax kits Can discharge home Can drip pleural fluid ``` ``` PneumoStat: Small device, one way valve to release air 35mL collection chamber Can discharge home No pleural fluid drip ``` Mini500: Medium size, one way valve to release air 500mL collection chamber Can discharge home Accordion Drain: Medium size, one way valve to release air 500mL collection chamber Compress accordion for suction, narrow tube Can discharge home

Intubation indications and nursing care

``` Intubation indications: Upper airway obstruction apnea Decreased LOC Increased risk of aspiration Ineffective clearance of secretions Respiratory distress ``` Nasal vs Oral: Oral preferred r/t easier insertion and can use larger tube for decreased work of breathing Nursing care: Maintain correct tube placement Maintain proper cuff inflation -collaborate with respiratory therapy -high volume, low pressure cuffs prevent tracheal trauma -check cuff pressure using MOV (min occluding volume) or MLT (min leak technique Monitor oxygenation and ventilation Maintain tube patency Frequent oral care, suctioning, brushing teeth Frequent repositioning and ROM, protect skin Foster comfort and communication

Lung Surgery What is it? Post op care

Wedge resection: small section of lung removed for biopsy Lobectomy: full lobe removal Pneumonectomy: entire lung removed, space fills with fluid Thoracotomy: incision through the chest wall Thoracoscopy (VATS): small scope incision through the chest wall ``` Post op care: Monitor resp status, O2 Pain control Pulmonary rehab, IS, flutter, ambulate Chest tubes: usually start on suction, then water seal, air leaks are common Telemetry Encourage nutrition, increased protein ```