Chest Trauma, Chest Tubes & Underwater

Seal Drainage

By: Victoria Murray

& Mary Beth Chauder

To review the anatomy and physiology of the respiratory system.

To identify the various types of trauma associated with the chest, and the nursing management associated with them

To discuss the mechanics of chest tubes, their uses, and the nursing management associated with them

To discuss pain management, nursing interventions and nursing diagnosis associated with chest trauma

To evaluate the understanding of the class with the use of a case study.

Objectives

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

Most Common Causes:• Gunshot• Stab Wound

Classified By:Velocity: Stab Wound Low

Gunshot High

Penetrating Trauma

VITALS & LOCTemperature, Pulse, RR, BP, SPO2 & PAIN

InspectRespirations Effort & Depth; Chest Wall Symmetry. Paradoxical Chest

Wall Motion; Bruising ; Penetrating Wounds

PalpateTrachea for deviation; Adequate and Equal Chest Wall Movement; Chest wall tenderness; Rib 'crunching' indicating rib fractures

PercussPercuss Both Sides of the Chest Looking for Dullness or Resonance

AuscultateNormal & Equal Breath Sounds

Initial Assessment of Suspected Chest Trauma

(Brown et al., 2009)

Initial Assessment of Suspected Chest Trauma

Trachea Chest Expansion

Breath Sounds

Percussion

Tension Pneumothorax

Away from Affected side

Decreased (Hyperexpansion)

Diminished Hyper-resonate

Simple Pneumothorax

Midline Decreased May be Diminished

May be Hyper-resonate

Hemothorax Midline Decreased Diminished (lg) or Normal (sm)

Dull

Pulmonary Contusion

Midline Normal Normal , Crackles

Normal

Lung Collapse

Towards Affected Side

Decreased Diminished Normal (Trauma. Org, 2004)

Secondary Assessment of Chest Trauma

Gather history of event from family, client, and EHS.

Chief complaintIn depth medical historyAllergiesPain 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)

Hemothorax40% 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 1500cc 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 mL 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

Rib Fractures are the most common type of Chest Trauma (60%)

Fractures to the 5th-9th Rib are most common site of fracture

Sternal Fractures are most common in MVCs

(Day et al., 2010)

Sternal & Rib Fractures

Manifestations Chest Pain Ecchymosis Crepitus Swelling Chest Wall

Deformities

Interventions: Pain Control Deep Breathing and

Coughing Surgery is Rarely

Necessary

Patient Must Be Closely Monitored for Underlying Cardiac Injuries!!

Flail Chest Caused by Blunt trauma

http://www.youtube.com/watch?v=uJHfX1RFkF0

Flail chest trauma

Pulmonary ContusionDamage to the lung

tissues resulting in hemorrhage and localized edema.

The client is unable to clear secretions effectively, and the work of breathing is significantly increased

Primary defect is the abnormal accumulation of fluid (Day et al., 2010)

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

Pulmonary Contusion

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.

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

Nursing Diagnosis for Chest Traumas

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)

Pneumothorax Tension Pneumothorax Bilateral Pneumothoraces Hemothorax Post-Operatively (Cardiac Surgery) Pleural Effusion Empyema Chylothorax Esophageal Rupture with Gastric Contents in

Pleural Space

Indications for Use

(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)

There are two types of Chest tubes:Pleural Mediastinal

Chest Tubes Continued

Pleural Chest Tube

Durai, et al., 2010; Perry & Potter, 2010

Mediastinal Chest Tubes

Perry & Potter, 2010

Nurse prepares sterile tablescalpel, 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

Pre-Insertion of Chest Tubes

(Durai, 2010) * MD responsible for admin of analgesic

Two Methods for Tube Insertion

1)Trocar based (i.e. the Seldinger technique) Allows for easier insertion Greater Risk Less Painful 2)Blunt dissection More painful for the patient Safest Method

Methods for Insertion

Durai, 2010

Chest Tube Insertion

Site of Insertion

Site of Insertion

Digital Exploration

Drain Insertion

Drain Sutured in Place

Underwater Seal Drainage System

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 Water Seal• Dry Suction with a One way Valve

Chest Drainage Systems

(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=WVHelcIIee8

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).

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

Drainage System Assessment

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 the Water-Seal Chamber

Monitoring ContinuedDrainage collection Chamber

Underwater Seal Chamber

Assessment & Management of

Air LeakTIDALING BUBBLING

Yes Yes indicates patient air leak (pneumothorax)

No Noindicates lung re-

expansion or obstruction by kinks

or clots

No Yesindicates possible

connection or system air leak

Yes Noobserved with

pneumonectomy or decreased lung

compliance

Assess client for:• Comfort level• Auscultate lung sounds, and assess for rate, rhythm,

and depth.• Monitor HR, BP, Temp, RR, O2 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.

Patient Assessment

• Mediastinal Chest Tube• Less than 50-200 mL/hr immediately after surgery• Approximately 500 mL in the first 24 hours

• Pleural Chest Tube• Between 100-300 mL may drain 3 hours post insertion• The 24 hour rate is 500-1000mL • 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.

Drainage Assessment

(Perry & Potter, 2010).

• 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.

Complications of CT drainage systems

(Durai et al., 2010; Sullivan2008).

• 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 Tubing Becomes Dislodged?

• 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!

What if the chest tube becomes disconnected from

the drainage system?

Removal of Chest Tube

• Explain Procedure

• Administer Analgesics

• Remove Drain

• Cleanse Wound

• Apply Sterile Dressing

(Durai, 2010; Sullivan, 2008; Perry & Potter, 2010)

Respiratory Assessment Assess Vital Signs Chest X-Ray Assess Pain Assess Wound & Dressing

Post Removal Nursing Interventions

• 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.

Pain ManagementRelated to:

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 85/50mmHg, HR 120, RR 30, Temp is 37.o, and Sp02 is 90%.

What type of chest trauma is suspected? What initial assessments would you want to

perform?

Case Study

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 2nd or 3rd intercostal space, what do you do?

What are some complications of chest tube drainage systems?

Questions & Comments ?

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 (7th 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

References