Chest Trauma Chest Tubes Underwater Seal Drainage By

Chest Trauma, Chest Tubes & Underwater Seal Drainage By: Victoria Murray & Mary Beth Chauder

Objectives v. To review the anatomy and physiology of the respiratory system. v. To identify the various types of trauma associated with the chest, and the nursing management associated with them v. To discuss the mechanics of chest tubes, their uses, and the nursing management associated with them v. To discuss pain management, nursing interventions and nursing diagnosis associated with chest trauma v. To evaluate the understanding of the class with the use of a case study.

The Respiratory System (Day et al. , 2010)

Ventilation Mechanisms (Day et al. , 2010)

What is Chest Trauma? Classified as either: Blunt or Penetrating Trauma

Blunt Trauma Most Common Causes: • MVA (Seatbelt, wheel) • Falls • Bicycle Crashes Generalized Symptoms: • Hypoxemia • Hypovolemia • Cardiac Failure Mechanisms of Blunt Chest Trauma: • Acceleration – moving object impacts chest • Deceleration – sudden decrease in speed/velocity (MVA) • Shearing – stretching forces to areas of chest • Compression – direct blow to the chest

Penetrating Trauma Most Common Causes: • Gunshot • Stab Wound Classified By: Velocity: Stab Wound Low Gunshot High

Initial Assessment of Suspected Chest Trauma VITALS & LOC Temperature, Pulse, RR, BP, SPO 2 & PAIN Inspect Respirations Effort & Depth; Chest Wall Symmetry. Paradoxical Chest Wall Motion; Bruising ; Penetrating Wounds Palpate Trachea for deviation; Adequate and Equal Chest Wall Movement; Chest wall tenderness; Rib 'crunching' indicating rib fractures Percuss Both Sides of the Chest Looking for Dullness or Resonance Auscultate Normal & Equal Breath Sounds (Brown et al. , 2009)

Initial Assessment of Suspected Chest Trauma Trachea Chest Expansion Breath Sounds Percussion Tension Pneumothorax Away from Affected side Decreased (Hyperexpansi on) Diminished Hyper-resonate Simple Pneumothorax Midline Decreased May be Diminished May be Hyperresonate Hemothorax Midline Decreased Diminished (lg) Dull or Normal (sm) Pulmonary Contusion Midline Normal , Crackles Normal Lung Collapse Towards Affected Side Decreased Diminished Normal (Trauma. Org, 2004)

Secondary Assessment of Chest Trauma v. Gather history of event from family, client, and EHS. v. Chief complaint v. In depth medical history v. Allergies v. Pain assessment

Complications Of Chest Trauma • Pneumothoraxes • Simple • Traumatic • Open • Hemothorax • Tension Pneumothorax • • • Pleural Effusion Sternal and Rib Fractures Flail Chest Pulmonary Contusion Cardiac Tamponade Pulmonary Embolism *

Pneumothorax defined & types individually discuss Three Types: • Simple • Traumatic • Open • Hemothorax • Tension (Day et al. , 2010)

Tension Pneumothorax • Air is drawn into the pleural space from a laceration. • Air that enters becomes trapped • Increased positive pressure • Lung collapses and causes a mediastinal shift away from the affected lung (Day et al. , 2010)

Hemothorax 40% of the circulating blood volume can accumulate A small amount of blood (<300) in the pleural space may cause no clinical manifestations and may require no intervention (blood is reabsorbed spontaneously). Massive HTX results from a rapid accumulation of more than 1500 cc of blood in the chest cavity. This may be life threatening because of resultant hypovolemia and tension Rib fractures and pulmonary parenchyma disruption are the most common causes

Pneumothorax-Manifestations Simple/Uncomplicated Sudden onset of pain ↓ Tactile Fremitis Absent breath sounds Hyperresonant Percussion Minimal respiratory distress Large/Tension Air hungry, anxious, dyspnea, diaphoresis, hypotension, tachycardia Central cyanosis may re from severe hypoxemia Acute Respiratory Distress —lung collapses totally

Pleural Effusion Pleural = Pleural Cavity Effusion = abnormal, excessive collection of this fluid

Pleural Effusion Abnormal buildup of fluid between linings of the lung and chest wall result of a disease process or inflammation Normally 5 to 10 m. L of serous fluid in the visceral and parietal pleura. Any more can cause great changes in intrathoracic pressure.

Signs and Symptoms Pleural effusion in itself does not cause symptoms. If effusion expands and presses on lung, patient may develop sharp, localized pain that worsens with coughing, or deep breathing. Dyspnea non-productive cough.

Signs and Symptoms cont. . . Early signs include decreased or bronchial breath sounds on the affected side, dullness to percussion, and decreased fremitus over area of fluid accumulation Auscultation: EGOPHONY Hear “A” over fluid accumulation when patient speaks “E”.

Complications of Pleural Effusion Respiratory compromise and distress from fluid compressing lung. Infection in pleural space---Sepsis/Empyema Fistulas in bronchi or chest wall Inflammation/infection in pleural space leads to increased potential for adhesions. Adhesions isolate effusion to one lung and complicates treatment.

Sternal & Rib Fractures are the most common type of Chest Trauma (60%) Sternal Fractures are most common in MVCs Fractures to the 5 th-9 th Rib are most common site of fracture (Day et al. , 2010)

Sternal & Rib Fractures Manifestations Chest Pain Ecchymosis Crepitus Swelling Interventions: Pain Control Deep Breathing and Coughing Surgery is Rarely Necessary Chest Wall Deformities Patient Must Be Closely Monitored for Underlying Cardiac Injuries!!

Flail Chest v Caused by Blunt trauma http: //www. youtube. com/watch? v=u. JHf. X 1 RFk. F 0

Flail chest trauma

Pulmonary Contusion v. Damage to the lung tissues resulting in hemorrhage and localized edema. v. The client is unable to clear secretions effectively, and the work of breathing is significantly increased v. Primary defect is the abnormal accumulation of fluid (Day et al. , 2010)

Pulmonary Contusion Moderate Pulmonary Contusion: Mucous, Serum and Frank Blood in the Tracheobroncial Tree Persistent Unproductive Cough Severe Pulmonary Contusion Central Cyanosis, Agitation, Combativeness Productive Cough with Frothy Bloody Secretions Treatment priorities are to maintain airway, provide oxygenation and pain management Day et al. , 2010

Cardiac Tamponade Compression of the heart as a result of fluid within the pericardial sac Usually due to chest trauma Manifestations Hypotension Jugular-venous distention Muffled heart sounds Periocardiocentesis to remove fluid from pericardial sac

Pulmonary Embolism Pulmonary embolism occurs when a blood clot becomes lodged in a lung artery, blocking blood flow to lung tissue. Blood clots often originate in the legs.

Pulmonary Embolism Blockage makes it more difficult for the heart to pump blood through lungs. As a result, less oxygen is available to the rest of the body. If the blockage is large enough, tissue death (infarction) occurs in the lung area cut off from circulation. Pulmonary embolisms are commonly misdiagnosed.

Misdiagnosed Why? Easily attributed to other conditions and vary with the size and number of clots. Such as a heart attack Pneumonia Hyperventilation Congestive heart failure Panic attacks.

Who is at risk? Immobilization — Being immobilized puts a strain on the circulatory system. Although the heart acts as the body’s main pump, movement also assists in keeping blood circulating properly. Long periods of inactivity may increase risk of blood clots. Examples include lengthy road trips or flights, or bed rest due to illness or surgery. Blood abnormalities — Some people are born with blood that’s more prone to clotting & those dehydrated, septic, have Ca, those giving birth.

Other Risk Factors for Pulmonary Embolism Advanced age (especially over age 70) Significantly overweight Birth control pills, HRT drugs & the osteoporosis drug raloxifene (Evista) are examples of drugs that list a small risk of developing blood clots.

About 90 % of Pulmonary Emboli Result When a Clot Travels from a Leg to a Lung - often no symptoms Blood tests, a chest X-ray, an electrocardiogram — to help rule out other possible reasons for symptoms. Sometimes a leg blood clot may cause redness, swelling and pain in the calf muscle area. Refer to a physician promptly. A pulmonary angiogram is a more definitive test, although it involves some risk and is more expensive. the CT scan (computed tomography scan) — instead of lung scan or pulmonary angiogram. CT scan is a less invasive test that provides fast and accurate results.

Nursing Diagnosis for Chest Traumas Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Patterns Imbalanced Fluid Volume Decreased Cardiac Output Decreased tissue perfusion Acute Pain Anxiety PC: Bleeding Risk for infection

Chest Tubes Chest Tube

What are Chest Tubes A chest tube is a large catheter inserted through the thorax to remove air, blood, pus or lymph Small Bore (12 -20 Fr) Large Bore (24 -32 Fr) Perry & Potter, 2010)

Indications for Use Pneumothorax Tension Pneumothorax Bilateral Pneumothoraces Hemothorax Post-Operatively (Cardiac Surgery) Pleural Effusion Empyema Chylothorax Esophageal Rupture with Gastric Contents in Pleural Space (Briggs, 2010)

Equipment Required • Chest tube of appropriate size • Underwater seal drainage system • Sterile gloves, gown and drapes • Local anesthetic • Skin Prep solution • Chest Tube Tray • Dressing Material • Chest tube clamps (Briggs, 2010)

Chest Tubes Continued There are two types of Chest tubes: Pleural Mediastinal

Pleural Chest Tube Durai, et al. , 2010; Perry & Potter, 2010

Mediastinal Chest Tubes Perry & Potter, 2010

Pre-Insertion of Chest Tubes Nurse prepares sterile table scalpel, local anesthetic (such as lidocaine), thick silk or polypropylene suture on a cutting needle, a chest tube of appropriate size and the underwater seal with sterile water filled to the mark Opens drain package and prepares drain as per manufacturers instructions Nurse Positions Patient for Procedure Explain Procedure and assure patient Monitor Vital Signs and for Discomfort * MD responsible for admin of analgesic (Durai, 2010)

Methods for Insertion Two Methods for Tube Insertion 1) Trocar based (i. e. the Seldinger technique) Allows for easier insertion Greater Risk Less Painful 1) Blunt dissection More painful for the patient Safest Method Durai, 2010

Chest Tube Insertion

Site of Insertion

Site of Insertion

Digital Exploration

Drain Insertion

Drain Sutured in Place

Underwater Seal Drainage System

Chest Drainage Systems Consist of three parts: • Suction Source • Collection Chamber for pleural drainage • Mechanism to prevent air reentry • Three types of chest drainage systems: • Traditional Water Seal • Dry Suction with a One way Valve (Day et al. , 2010).

Traditional Water Seal Drainage System Contains 3 Chambers: • Collection chamber • Water seal chamber • Wet suction control chamber Additional suction source can be added as needed. Intermittent bubbling indicates proper functioning (Day et al. , 2010).

Dry Suction Water Seal System Contains 3 Chambers: • Collection chamber • Water seal chamber • Wet suction control chamber Suction pressure is set with regulator. Has an indicator to signify suction pressure is adequate. Quieter than traditional water seal system. (Day et al. , 2010).

Dry Suction with One Way Valve System Has a one-way mechanical valve that allows air to leave the chest and prevents air from moving back into the chest. Can be set up quickly in an emergency. Works even if knocked over, ideal for ambulatory patients. (Day et al. , 2010).

http: //www. youtube. com/ watch? v=WVHelc. IIee 8

Post Insertion & Maintenance of Chest Tubes

Management of Chest Tube • The nurse is responsible for managing the chest tube and drainage system including: • Caring for the tube and drainage system when transporting patient • Changing or emptying the drainage container • Monitoring fluid drainage • Monitoring chest tube position • Milking and clamping contraindicated (Durai, Hoque, & Davis, 2010).

Drainage System Assessment Monitor drainage collection System for: • Verify that all connection tubes are patent and connected securely • Assess that water seal is intact when using wet suction system and assess regulator dial in dry suction system • Fluctuations in the water seal chamber for wet suction • Air bubbles in the water seal chamber • Air leak indicator in dry suction systems • Suction set at ordered rate • Keep the system below patient’s chest level • Maintain appropriate fluid in the water seal for wet suction

Monitoring the Water-Seal Chamber There will be an increase in the water level with inspiration and a return to the baseline level with exhalation. This is referred to as tidaling. If your patient’s lung fully expands or the tubing becomes obstructed, you may not see any fluctuations. Bubbling in the bottom of the water-seal chamber indicates an air leak, caused by poor tubing connections. You may notice a small amount of bubbling right after chest tube insertion, or when the patient coughs.

Monitoring Continued Drainage collection Chamber Underwater Seal Chamber TIDALING BUBBLING Yes No No Yes Assessment & Management of Air Leak indicates patient air leak (pneumothorax) No indicates lung reexpansion or obstruction by kinks or clots Yes indicates possible connection or system air leak No observed with pneumonectomy or decreased lung compliance

Patient Assessment Assess client for: • Comfort level • Auscultate lung sounds, and assess for rate, rhythm, and depth. • Monitor HR, BP, Temp, RR, O 2 sats • Drainage for amount, color and consistency • Monitor dressing status and drainage from insertion site • Monitor chest wall at insertion site for subcutaneous emphysema or air leaks • Mark volume and drainage (time, date, initial) every shift. • Mark tube to ensure that it does not become dislodged.

Drainage Assessment • Mediastinal Chest Tube • Less than 50 -200 m. L/hr immediately after surgery • Approximately 500 m. L in the first 24 hours • Pleural Chest Tube • Between 100 -300 m. L may drain 3 hours post insertion • The 24 hour rate is 500 -1000 m. L • Drainage is grossly bloody during the first several hours post-op and slowly changes to serous. • Dark red drainage is expected only during the immediate post-op period… Bright red drainage would indicate active bleeding. • Remember: a sudden gush of drainage may be retained blood/fluid being released during position change. (Perry & Potter, 2010).

Complications of CT drainage systems • Nurse must be aware of the reason for chest tube insertion and what type of drainage to expect. • Tension pneumothorax may occur from incorrect placement of tube. • Tube may become disconnected from drainage system. • Tube may accidentally be pulled out of pleural space. • Occlusion of the chest tube. • Drainage system may be knocked over disrupting seal. • Risk for infection. (Durai et al. , 2010; Sullivan 2008).

What if the Tubing Becomes Dislodged? • Immediately cover the site with a dry, sterile dressing and call the physician. • If air is heard leaking from the site, tape the dressing on only two or three sides to allow air to escape and prevent tension pneumothorax. • Closely monitor the patient and prepare for reinsertion.

What if the chest tube becomes disconnected from the drainage system? • If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent pneumothorax if the chest tube is inadvertently disconnected from the drainage system, a temporary water seal can be established by immersing the chest tube’s open end in a bottle of sterile water. • Or if possible reconnect to the water seal drainage system!

Removal of Chest Tube • Explain Procedure • Administer Analgesics • Remove Drain • Cleanse Wound • Apply Sterile Dressing (Durai, 2010; Sullivan, 2008; Perry & Potter, 2010)

Post Removal Nursing Interventions Respiratory Assessment Assess Vital Signs Chest X-Ray Assess Pain Assess Wound & Dressing

Pain Management Related to: • Insertion – local anesthetic (lidocaine or prilocaine) • In situ – PCA pump (morphine) • Removal – EMLA cream (Eutectic mixture of Local Anesthetics) Overall goal is to provide pain management but not to the extent that respirations are depressed.

Case Study JB is a 25 year old male just arrived to the ER via EHS. Only known hx is that JB was involved in a head on collision with a drunk driver. JB is transferred to trauma stretcher and immediately you notice he is anxious and in pain. He is having difficulty breathing and his seatbelt has left him with bruising across the chest. Vital signs are BP 85/50 mm. Hg, HR 120, RR 30, Temp is 37. o, and Sp 02 is 90%. What type of chest trauma is suspected? What initial assessments would you want to perform?

Following assessment it is determined JB has a hemothorax and a chest tube is required. What equipment would you gather for the physician? What size chest tube did you grab? You notice the physician is landmarking for the 2 nd or 3 rd intercostal space, what do you do? What are some complications of chest tube drainage systems?

Questions & Comments ?

References Briggs, D. (2010). Nursing care and management of patients with intrapleural drains. Nursing Standard. 24(21), 47 -55 Durai, R. , Hoque, H. , Davies, T. W. (2010). Managing a chest tube and drainage system. Association of Perioperative Registered Nurses. (91) 2, 275 -280 Day, R. A. , Paul, P. , Williams, B. , Smeltzer, S. C. & Bare, B. (2009). Textbook of Canadian Medical Surgical Nursing. Philadelphia, PA: Lippincott Williams & Wilkins. Pearce, A. P. (2009). Chest drain insertion: Improving techniques and decreasing complications. Emergency Medicine Australia. (21), 91 -93 Perry & Potter. (2010). Clinical Nursing Skills & Techniques (7 th ed. ). St. Louis: Mosby, . Sullivan, B. (2008). Nursing management of patients with a chest drain. British Journal of Nursing. (17)6, 388 - 393 Trauma. Org. (2004). Chest trauma: Initial Evaluation. Retrieved from http: //www. trauma. org/archive/thoracic/CHESTintro. html