Chest Trauma and Pulmonary Emboli
Terms
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- Pulmonary contusion
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*bruise & swelling of the lung tissue
*"can't perfuse thru a bruise"
*Tx: depends on severity & size
*ranges from monitoring to full ventilatory support - Gun shot wound and stabs
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*check for entrance/exit wound
*goal: restore & maintain cardiac/pulmonary function
*must eval quickly
*tx: depends on injury - Chest trauma
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*responsible for up to 75% of trauma related deaths
*two types:
-blunt
-penetrating - Chest trauma is life threatening due to
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*hypoxemia (<breathing=<O2)
*hypovolemia (tachycardia, <LOC, SOB, <UO, cold/clammy)
*cardiac failure (<SV--><CO) - Quick assessment skills for chest trauma
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*is pt. responsive and breathing?
*auscultate breath(fl/air, shallow breath, neuro inj) & heart sounds (tachycardia)
*get a line in (IV) (NAVEL; NS, LR, Albumin)
*how did it happen
*when?
* - Diagnostics for chest trauma
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*CXR (pneumo/hemothorax, lung prob, cardiomegaly, cardiac tamponade, rib fx)
*CBC (how much bleeding? H&H)
*EKG (on 2 lead monitor; then 12 lead to look for cardiac injury)
*ABG's (acidosis = cell death, hypoxia, impending resp failure)
*clotting studies (can they stop bleeding)
*type & cross (if blood needed right away)
*electrolytes (<K=card. irrit.; <Na=seizures)
*CT (chest, head) - Rib fractures
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*fx to 1-3rd rib have 15-30% mortality
*complications include: pneumothorax, lacerate SVC, puncture liver/spleen, fx treated conservatively-control pain - Flail Chest
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*40% mortality
*multiple rib fx causing free floating rib section and unstable chest wall
*Paradoxical mvmt: in-inspir; out-expir
*s/s: ^HR, ^RR, <BP, resp acid(signs of shock)
*Tx depends on severity
*severe-intubate and add PEEP - Cardiac Tamponade
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*compression of the heart from fluid in the pericardial sac (Medical emergency)
*s/s: depend on how quickly it comes on (<BP, distant heart sounds, pulsus paradoxus, SOB, tachypnea, anxiety, restlessness, ^HR, <CO)
*surgical patients (open heart) at risk
*Tx: pericardiocentisis or thoracotomy - Risk factors for PE
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*venous stasis
*hypercoagulation
*venous disease
*disease states
*prevention is best - Subcutaneous Emphysema
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*"crepitus"
*air passage &/or lung injuries & air enters under skin
*check around chest tubes & trachs too
*usually harmless & self limiting (still document)
*mark site & check if size increases - Aspiration
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*serious! can cause death
*vomit/food/drowning
*usually happens when reflexes are lacking (unconscious, after prolonged intubation)
*we cause them (tube feeds) - Therapeutic Interventions
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*quick assessment skills
*Remember ABCs
*Tx and watch for hypoxemia, hypovolemia, and cardiac fail
*know chest tubes & ventilators
*explain what you are doing!
*offer support to family - Types of shock related to trauma
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*hypovolemic-d/t vol of blood loss
*cardiogenic-d/t impairment of hearts ability to pump bl.
*often in trauma, the person may experience both at once - ARDS (adult respiratory distress syndrome)
- diffuse interstitial edema all over lungs; looks like cotton candy (ventilate, PEEP)
- Pulmonary Embolus
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*obstr. of 1+ branches of pulm artery
*originate in venous system
*most thrombus orig. in deep veins of legs
*vent. without perfusion occurs - Clinical findings of PE
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*severe, sudden dyspnea
*extreme anxiety, restlessness
*sharp pain in chest
*fever
*coughing with hemoptysis
*on ausc: dullness over area of infarction - Diagnostic evaluation of PE
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*CXR
*EKG (r/o MI)
*ABG's
*VQ scan (vent/persion)
*pulmonary angiography - Emergency Nursing Care of PE
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*high fowlers
*oxygen
*start IV
*relieve pain/anxiety
*dissolve clot/prevent others from forming - Thrombolytic Therapy
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*urokinase/streptokinase
*high risk for bleeding
*dissolves clot - Anticoagulation Therapy
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*Coumadin
*Heparin
*If believe pt had PE - bolus them with heparin (to prevent other clots from forming), then start coumadin
*PT levels affected by gr. leafy vegetables, antibiotics, and NPO status - Other therapies
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*pulmonary embolectomy
*vena cava filters (Greenfield filters) - Therapeutic Interventions of PE
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*Assess
*Nursing Diagnosis
*Plan of care
*Outcomes - Open pneumothorax
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*"sucking" chest wound
*inspiration air goes in
*expiration air goes out
*heart & vessels move back and forth
*Tx: cover hole - Tension Pneumothorax
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*air goes in with inspiration
*air stays in with expiration
*increased pressure (tension)
*pushes lung, heart, trachea to oppisite side
*Medical emergency!!
*Tx: large bore needle 2ICS MCL - Hemo/Pneumothorax
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*goal-get rid of blood/air from pleural space
*s/s depend on severity: dyspnea to shock
*Iatrogenic causes: line placement; surgery
*dx on CXR
*tx: chest tube