Chest injuries

Often life threatening

Sucking wounds, (pneumothorax)

Stab injury, part of fractured rib, gun shot, spontaneous.

Air entering the chest via wound, look for wound - listen for air entry.

Tell patient to exhale and cover wound with air tight dressing.

Prepare for insertion of chest tube - X ray, area of hyper-resonance

Tension pneumothorax

Air in pleural cavity displaces heart and mediastinum to uninvolved side.

Cardiac embarrassment.

Observe for ; Dyspnoea, Chest pain, Tachycardia

Diminished or absent breath sounds on involved side

Emergency conversion into an open pneumothorax followed by insertion of chest tube.

Haemothorax

Blood in the pleural cavity, lung collapse and hypovolaemia

Observations BP, pulse, reduced chest movements, dull percussion

Interventions Chest drainage, fluid replacement, pre-op care

Chest drainage

Pneumothorax 2nd or 3rd intercostal space, anterior.

Haemothorax 7th or 8th intercostal space, posterior.

Indications

Allow the lung to re-inflate following thorocotomy

Facilitate the removal of material from the pleural space, e.g. serous fluid, blood, pus or air.

Physiological importance of the pleural space

Why does the lung collapse with penetrating chest injuries

Principles of drainage

Water prevents air re-entering the pleural space

Drainage depends on gravity and the mechanisms of respiration.

If suction is required to aid drainage a vacuum pump may be attached to outlet tube

Aims of treatment

Increase the effectiveness of respiration, allowing full lung expansion.

Prevent damage to the collapsed lung.

How much fluid is put in the bottle before connection to the chest tube

Pre-set amount

Same volume used consistently

Submerge the drainage tube by 2.5 cm

In most systems the volume of sterile water used will be 500 ml

The fluid level should be carefully checked before being connected to the patient.

Two pairs of chest drain clamps to hand

In case of tube disconnection or breakage of the bottle

Do not leave on or forget - a tension pneumothorax may develop

Never leave unattended when the clamps are in place.

How to prevent accidental disconnection

Sutured in place

Looped round and held in place with strong adhesive tape

Well fitted connections - may be secured with transparent adhesive tape

Keep drainage bottle at floor level

Prevents water and drained fluid from running back into the pleural space

Nursing observations

Systemic condition

Presence of bubbles should be monitored

Swinging fluid level in the tube

The amount of fluid swing should reduce as the lung nears full re-expansion

Assess amount of fluid draining from the chest

Volumes should be measured and recorded

Record quantity and type of fluid drained

Risk of infection

Normal wound care and observation carried out locally

Strict asepsis maintained when changing the down tube and drainage bottle

Keep the system as closed as possible

Frequent turning, deep breathing and coughing should be encouraged to prevent development of chest infections

Analgesia

Pyrexia may indicate infection

Tube removal and further management

Purse-string suture

Plastic spray dressing

Airtight dressing applied with a firm pressure and secured with airtight tape

Chest X ray

Observe respiratory function

Removal of sutures is common at 10 -14 days.

Flail chest

Resulting from multiple rib fractures

Paradoxical movement

Prepare for positive pressure ventilation

Cardiac tamponade

Compression of heart from excessive fluid in pericardial space.

Observations

falling BP pulsus paradoxus patient reluctant to lie down ECG

Management

CVP Prep for thoracotomy Blood cross match Prep for pericardiocentesis.