Respiratory Disorders: Pleural & Thoracic Injury
by Charlotte Cooper RN, MSN, CNS
modified by Kelle Howard, RN, MSN
Thoracic Cavity
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Terminolgy
• Pleura– the thin serous membrane around the lungs and inner walls of the
chest (2 layers)• Pleural space
– thin space between the 2 layers of pleura• Pleural cavity
– body cavity that surrounds the lungs• Parietal Pleura
– Pleura that lines the inner chest walls and covers the diaphragm• Viceral Pleura
– Pleura that lines the lung itself
• Pleural Fluid– pleura that lines the inner chest wall and covers the diaphragm
Pleural Fluid
• pH 7.6 – 7.64• 1-2g/dL protein• Less than 1000 WBC per cubic millimeter• Glucose level similar to plasma• LDH less than 50% that of plasma• Na, K+, & Ca levels similar to that of interstitial
fluid
• Viceral pleura –– Covers surface of the lung– Cannot be disected away from the lung
• Parietal pleura-– Lines the wall of the chest and covers the diaphragm
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Chest Trauma & Thoracic Injury
• 20-25% of trauma victims with chest trauma die
• 45% of trauma victims have some type of chest trauma
• BEWARE: External injury may appear minor
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Traumatic Chest InjuriesMechanism of Injury Common Related Injury
Blunt TraumaBlunt steering wheel injury to chest Rib fractures, flail chest, pneumothorax,
hemopneumothorax, myocardial contusion, pulmonary contusion, cardiac tamponade, great vessel tears
Shoulder harness seat belt injury Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, pericardial contusion, cardiac tamponade
Crush injury (heavy equipment, crushing the thorax)
Pneumothorax and hemopneumothorax, flail chest, great vessel tears and rupture, decreased blood return to heart with decreased cardiac output
Penetrating traumaGunshot, stab wound to chest Open pneumothorax, tension pneumothorax,
hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears 9
Respiratory Disorders: Pleural and Thoracic Injury
• Pleural Effusion• A collection of excess fluid in the pleural space
• Classification• Transudative aka: hydorthoraces ----- systemic causes
– Usually not caused by inflammatory processes– Most common type
• Exudative ----- localized cause– Usually caused by an inflammatory process– Often recurrent, difficult to treat
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Etiology: Pleural Effusion Identify the Class of Effusion
Disease Process Classification of Effusion
Heart Failure
TB
Lupus/RA
Renal Disease
Lung Cancer
Trauma
Pneumonia
Liver Failure
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Clinical Manifestations: Pleural Effusion
• Dyspnea• Pleurisy• Decreased breath sounds• Decreased chest wall movement • Dullness on percussion
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Thoracentesis
• What are your nursing responsibilities pre & post thoracentesis?– ______________– ______________– ______________– ______________– ______________– ______________
Interventions: Pleural Effusion
Treat underlying condition CHF/Renal failurePneumoniaLiver DiseaseLupus/RAMalignancyPleurodesis
Chest tube insertionAllow to resolve
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Closed Pneumothorax
No opening from external chest.
Open Pneumothorax
Opening from external chest wall into pleura.
Iatrogenic Pneumothorax
Puncture or laceration of visceral pleura during medical tx
Occurs in crashes, falls, MVAs, CPR, COPD, fractured ribs that penetrate the pleura.
Occurs in stabbings, gunshot wounds, impalement injury.
Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation, central line placement 26
ww
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Tension Pneumothorax
• Air/blood/fluid rapidly entering the pleural space
• Lung collapses
• Emergency situation
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Pathophysiology: Tension PneumoIncrease in intrapleural pressure
Compression of lung
Compresses against trachea, heart, aorta, esophagusWhat is this called?
Ventilation and cardiac output greatly compromised
__________________________
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Clinical Manifestations: Tension Pneumo
• Severe dyspnea• Tracheal deviation• Decreased cardiac output• Distended neck veins• Increased respiratory rate• Increased heart rate• Decreased blood pressure• Shock
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Treatment Tension Pneumo
• Emergency --- quick intervention– Needle decompression– Chest tube placement
Intervention: Pneumothorax
• High Fowlers position• Oxygen as ordered• Rest to decrease oxygen demand• ***Chest tube insertion• Pleurodesis• Surgery
?
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Clinical Manifestations: Rib Fractures
• Ribs 5-10 most commonly fractured• Pain• Splinting & rapid, shallow respirations• Decreased breath sounds• Crepitus • Signs/symptoms of pneumothorax
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Treatment: Rib Fractures
• Reduce or minimize pain• Do we wrap or bind the chest?• Do we use opiods?• Goal?
Pathophysiology: Flail Chest• 2 or more ribs fractured
• 2 or more separate places
• Unstable / free floating chest
• Usually involves anterior or lateral fx
• Paradoxical respirations
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Clinical Manifestations: Flail Chest• Dyspnea with rapid, shallow inspiration
• Pain
• Palpable crepitus
• Decreased breath sounds
• Unequal chest expansion
• Tachycardia
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Interventions: Flail Chest
• Oxygen as ordered• Elevate HOB• Analgesia • Suction• Splint affected side?• *Intubation• *Mechanical ventilation
• What do you think the major goals are?
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Pathophysiology: Pulmonary Contusion
Abrupt chest compression then rapid decompression
Intra-alveolar hemorrhage
Interstitial/bronchial edema
Decreased surfactant production
Increase pulmonary vascular resistance
Decrease blood flow
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Clinical Manifestation: Pulmonary Contusion
• Increased SOB• Restlessness• Anxiety• Chest pain• Copious sputum• Increased respiratory• Increased heart rate• Dyspnea• Cyanosis
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Intervention: Pulmonary Contusion
• Intubation• Mechanical ventilation• Bronchoscopy • Fluids • Volume expanders• Pulmonary artery pressure monitoring
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