1 Pneumothorax, Hemothorax, Tension Pneumothorax, Flail Chest

spontaneous pneumothorax

A ___ typically occurs due to the rupture of small blebs (air-filled blisters) located on the apex of the lung. Can occur in healthy, young individuals (primary). Or as a result of lung disease such as COPD, asthma, cystic fibrosis, and pneumonia (secondary).

higher

A chest tube will be placed __ in the lung with the presence of a *pneumothorax* (approximately 2nd intercostal space) *air rises*

Open Pneumothorax

An open wound to the chest that allows air to enter the pleural space and cause lung collapse.

MVA

Are responsible for 80% of blunt chest traumas:

thoracostomy

Creation of an opening in the chest, usually to insert a tube

arrhythmias

For nonsurgical cardiac contusions, treatment focuses primarily on

12 lead Cardiac biomarkers

How is cardiac contusion diagnosed?

blunt trauma, penetrating trauma

Mechanisms of injury: (two categories)

benzos (lorazepam) opioid agonists

Medications for chest trauma: *monitor respirations*

Pneumothorax

Occurs when air leaks into the space between your lung and chest wall. The air pushes on the outside of your lung causing it to collapse. *Collapsed lung*

5-9

Rib fractures are the most common type of chest injury resulting from blunt trauma. Ribs ___ are most commonly fractured because they are the least protected by chest muscles.

breath

Tell the patient to hold their __ when pulling chest tubes so the patient does not suck in air.

thoracentesis

The pleural space can be aspirated with a large-bore needle.

pericardiocentesis (draining the fluid from the pericardial sac)

Treatment for cardiac tamponade:

Chest drainage Bowel rest Parenteral nutrition Octreotide has been used to reduce the flow of lymphatic fluid with some success Surgery Pleurodesis is the artificial production of adhesions between the parietal and visceral pleura, usually done with a chemical sclerosing agent, such as talc or doxycycline

Tx. of Chylothorax:

hemopneumothorax

When hemothorax occurs with pneumothorax, it is called a _____.

positive

Whenever fluid or air accumulates in the pleural space, the pressure becomes ___ instead of negative, and the lungs collapse.

C

Which of the following is a LATE sign of the development of a tension pneumothorax?* A. Hypotension B. Tachycardia C. Tracheal deviation D. Dyspnea

C

You're providing care to a patient with a pneumothorax who has a chest tube. On assessment of the chest tube system, you note there is no fluctuation of water in the water seal chamber as the patient inhales and exhales. You check the system for kinks and find none. What is your next nursing action?* A. Keep monitoring the patient because this is a normal finding. B. Increase wall suction to the system until the water fluctuates in the water seal chamber. C. Assess patient's lung sounds to assess if the affected lung has re-expanded. D. Notify the physician.

b, c, d, e

a nurse in the ED is assessing a client with suspected flail chest. which of the findings should the nurse expect? a. bradycardia b. cyanosis c. hypotension d. dyspnea e. paradoxic chest movement

b, e

a nurse is assessing a client with a GSW to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? a. tachypnea b. deviation of trachea c. bradycardia d. decreased use of accessory muscles e. pleuritic pain

chest trauma

account for 75% of all traumatic deaths:

Muffled, distant heart sounds Hypotension Tachycardia Neck vein distention Increased CVP paradoxal pulse

cardiac tamponade s/s

atelectasis

collapsed lung

rapid, shallow respirations tachycardia visual examination asymmetric splinting palpation of abnormal respiratory movements crepitus near the rib fractures hypotension dyspnea cyanosis anxiety chest pain

flail chests s/s

blunt chest trauma penetrating trauma closed/occluded chest tube decreased pulmonary reserves due to normal lung changes COPD

hemothorax/pneumothorax risk factors:

chest tube with water seal drainage autotransfusion of collected blood treatment of hypovolemia as necessary

tx. of hemothorax:

Needle decompression Chest tube insertion

tx. of tension pneumothorax:

Cardiac Tamponade

Acute compression of the heart caused by fluid accumulation in the pericardial cavity The heart can no longer fill completely, less blood is ejected with each beat, and the heart has to work harder to supply the body's needs. The blood trying to enter the heart will back up producing congestion in the lungs and veins.

gunshot or stab wounds blunt trauma to the chest from a car or industrial accident accidental perforation after cardiac catheterization, angiography, or insertion of a pacemaker punctures made during placement of a central line cancer that has spread to the pericardial sac, such as breast or lung cancer pericarditis, an inflammation of the pericardium high levels of radiation to the chest kidney failure infections that affect the heart

Causes of Cardiac Tamponade

negative pressure

Normally, ___ exists between the visceral pleura (surrounding the lung) and the parietal pleura (lining the thoracic cavity), allowing the lung to be filled by chest wall expansion. This space contains only a few milliliters of lubricating fluid to reduce friction when the tissues move.

anxiety and restlessness low blood pressure weakness chest pain radiating to your neck, shoulders, or back trouble breathing or taking deep breaths rapid breathing discomfort that's relieved by sitting or leaning forward

Signs and symptoms of cardiac tamponade (occurs very quickly/medical emergency):

Blunt

__ trauma occurs when the chest strikes or is struck by an object. The resultant impact can cause deceleration, acceleration, shearing, and compression of thoracic structures. The external injury may appear minor, but internally the organs may have severe injuries. The injuries can occur on both the same side as the impact and the opposite side as the tissue moves in a back-and-forth manner. Rib and sternal fractures can lacerate lung tissue. In a high-velocity impact, the shearing force may result in laceration or tearing of the aorta. Compression of the chest may result in contusion, crush injury, and organ rupture.

Iatrogenic pneumothorax

___ can occur due to laceration or puncture of the lung during medical procedures.

B

Which statement is CORRECT about a tension pneumothorax?* A. This condition happens when an opening to the intrapleural space creates a two-way valve which causes pressure to build up in the space leading to shifting of the mediastinum. B. A tension pneumothorax is a medical emergency and is treated with needle decompression. C. Tracheal deviation is an early sign of a tension pneumothorax D. An open pneumothorax is the only cause of a tension pneumothorax.

C

While caring for a patient with a suspected pneumothorax, you note there are several areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are located on the patient's neck, face, and abdomen. On palpation on these areas, you note they feel "crunchy". When charting your findings you would refer to this finding as?* A. Subcutaneous paresthesia B. Pigment molle C. Subcutaneous emphysema D. Veisalgia

Traumatic pneumothorax

__ can occur from either penetrating (open) or nonpenetrating (closed) chest trauma.

CT

__ scanning of the chest is the gold standard for the diagnosis of pneumothorax.

Nonpenetrating

___ chest trauma (blunt trauma), such as rib fractures, can lacerate the lung and cause air to enter the pleural space. Blunt trauma can also cause alveolar rupture secondary to sudden chest compression.

Tension pneumothorax

___ may result from either an open or a closed pneumothorax. In an open chest wound, a flap may act as a one-way valve. Thus air can enter on inspiration but cannot escape. Can occur with mechanical ventilation and resuscitative efforts. It can also occur if chest tubes are clamped or become blocked.

Tension pneumothorax

___ occurs when air enters the pleural space through a one way valve but cannot escape. The continued accumulation of air in the pleural space causes compression of the lung on the affected side and pressure on the heart and great vessels, pushing them away from the affected side. >>>> The mediastinum shifts toward the unaffected side, compressing the 'good' lung, which further compromises oxygenation. >>>> As the pressure increases, venous return is decreased, and cardiac output falls.

Chylothorax

____ is the presence of lymphatic fluid in the pleural space. The thoracic duct is disrupted either traumatically or from a malignancy, and the lymphatic fluid fills the pleural space. This milky white fluid is high in lipids. Normal lymphatic flow through the thoracic duct is 1500 to 2500 mL/day. This amount can be increased up to tenfold after ingestion of fats.

Penetrating

____ trauma allows air to enter the pleural space through an opening in the chest wall. Examples include stab or gunshot wounds and surgical thoracotomy. "sucking chest wound" because as you inhale, you are taking air into chest wall- Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides (vent dressing). If the penetrating object is present still, leave it in place!

penetrating

____ trauma is an open injury in which a foreign body impales or passes through the body tissues, creating an open wound. Examples include knife wounds, gunshot wounds, and injuries with other sharp objects. Severity depends on location of penetration and affected organs/vessels.

d

a nurse is reviewing discharge instructions for a patient who experienced a pneumothorax. which of the following statements should the nurse use when educating the patient? a. notify your provider if you experience weakness b. you should be able to return to work in 1 week c. you need to wear a mask when in crowded places d. notify your provider if you experience a productive cough

b

a nurse is reviewing the prescriptions for a client who has a pneumothorax. which of the following actions should the nurse preform first? a. assess the clients pain b. obtain a large bore IV needle for decompression c. administer lorazepam d. prepare for chest tube insertion

pericardiocentesis

surgical puncture to aspirate fluid from the sac surrounding the heart

dyspnea marked tachycardia tracheal deviation to unaffected side decreased/absent breath sounds on the affected side neck vein distention cyanosis air hunger profuse diaphoresis inadequate cardiac output severe hypoxemia death hyperresonance to percussion

tension pneumothorax s/s:

pericardiocentesis surgical repair BiPAP, bilevel positive airway pressure CPAP, continuous positive airway pressure

tx. of cardiac tamponade

airway management adequate ventilation supplemental oxygen therapy careful administration of IV solutions pain control positive pressure ventilation (CPAP, BiPAP) intubation ventilation surgery

tx. of flail chest

heal on its own thoracentesis chest tube with water seal drainage pleurodesis partial pleurectomy stapling

tx. of pneumothorax:

NO strapping or binding chest (predisposes the individual to atelectasis) NSAIDs, opioids, nerve blocks Deep breathing and coughing Incentive spirometry Appropriate use of anaglesics

tx. of rib fractures:

A, B, D, F

A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition:* A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia F. Tachypnea

Beck's triad of cardiac tamponade

1. Hypotension 2. muffled heart sounds 3. elevated neck veins (JVD) The 3 D's - Distant heart sounds, Distended jugular veins and Decreased arterial pressure

D

A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side, and there is a large crack in the system. What is your next PRIORITY?* A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

lower

A chest tube will be placed __ in the lung with the presence of a *hemothorax* (approximately 5th intercostal space) *blood sinks*

Flail Chest

A condition in which two or more ribs are fractured in two or more places or in association with a fracture of the sternum so that a segment of the chest wall is effectively detached from the rest of the thoracic cage causing paradoxic movement of the chest. Crepitus, subcutaneous emphysema, and asymmetrical chest wall expansion are common findings

B

A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention?* A. The water seal chamber has intermittent bubbling. B. The patient has slight tracheal deviation to the right side. C. The water seal chamber fluctuates while the patient inhales and exhales. D. The patient complains of tenderness at the chest tube insertion site.

B

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as?* A. Closed pneumothorax B. Open pneumothorax C. Tension pneumothorax D. Spontaneous pneumothorax

D

A patient is diagnosed with a primary spontaneous pneumothorax. Which of the following is NOT a correct statement about this type of pneumothorax?* A. It can be caused by the rupture of a pulmonary bleb. B. It can occur in patients who are young, tall and thin without a history of lung disease. C. Smoking increases the chances of a patient developing a spontaneous pneumothorax. D. It is most likely to occur in patients with COPD, asthma, and cystic fibrosis.

hypoxemia (PaO2 < 80)

ABGs in pneumothorax/hemothorax

Smoking Tall and thin Male gender Family history, Previous spontaneous pneumothorax

Bleb Formation Risk Factors: (spontaneous pneumothorax)

Closed Pneumothorax

Caused by air leaking into the pleural space from an opening within the lung.

C

In regards to the patient in the question above, (A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as?) which of the following options below is a nursing intervention you would provide to this patient?* A. Place the patient in supine position B. Place a non-occlusive dressing over the chest wound C. Place a sterile occlusive dressing over the chest wound and tape it on three sides D. Prepare the patient for a thoracentesis

pleurodesis

Infusion of a sterile, irritating substance into the pleural space, causing the pleural linings to fuse to one another by developing scar tissue

open thoracotomy

Initial output of hemothorax drainage greater than 1500 mL is considered an indication for

Pulmonary contusion

Injury or bruising of lung tissue that results in hemorrhage. S/S include chest pain or SOB Management is largely pulmonary support, avoidance of fluid overload, and use of noninvasive ventilation with positive airway pressure.

Pain Splinting Shallow respirations

rib fracture s/s:

Atelectasis Pneumonia

rib fractures can lead to:

Hemothorax

The accumulation of blood between the membranes lining the lungs (the pleura).

Cardiac Contusion

The heart muscle is bruised, with varying amounts of injury to the myocardial cells. Usually results in sinus tachycardia or VT or VF.

Rapid, thready pulse Decreased BP with narrowed pulse pressure and/or asymmetric readings Distended neck veins Muffled heart sounds Chest pain Dysrhythmias

cardiac distress s/s

Pulsus paradoxus

drop in blood pressure >10 mmHg with inspiration is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration

chest x-ray thoracentesis (hemothorax only)

hemo/pneumothorax diagnostic:

Dyspnea diminished or absent breath sounds dullness to percussion decreased Hgb shock depending on blood volume lostten

hemothorax s/s:

Variable Mild tachycardia and dyspnea → severe respiratory distress Shallow, rapid respirations Dyspnea Air hunger Oxygen desaturation Chest pain Cough Absent breath sounds over affected area X-ray shows the presence of air or fluid in the pleural space and reduction in lung volume

pneumothorax s/s

Ensure patent airway. Administer O2 to keep SpO2 >90%. Establish IV access with two large-bore catheters. Begin fluid resuscitation as appropriate. Remove clothing to assess injury. Cover sucking chest wound with nonporous dressing taped on three sides. Stabilize impaled objects. Assess for other significant injuries and treat appropriately. Stabilize flail rib segment. Place patient in a semi-Fowler's position or position of comfort. Prepare for emergency needle decompression. Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status, and urinary output. Anticipate intubation for respiratory distress. Release dressing if tension pneumothorax develops after sucking chest wound is covered. HOB @ 90 degrees

respiratory distress nursing interventions:

Dyspnea Cough with or without hemoptysis Cyanosis Tracheal deviation Decreased breath sounds Decreased O2 saturation Frothy secretions

respiratory distress s/s