Respiratory Disorders: Pleural & Thoracic Injury

by Charlotte Cooper RN, MSN, CNSmodified by Kelle Howard RN, MSN

Thoracic Cavity

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Normal Anatomy

• Thoracic cavity• Chest wall• Pleural space• Fluid

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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

• 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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Categories for Traumatic Injuries

• Blunt trauma

• Penetrating trauma

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

What needs to be done?

• Client comes to ED following a MVA• Assessment

• Respiratory• Cardiovascular• Surface findings

• Interventions • Monitoring • Diagnostic Test

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Respiratory Disorders: Pleural and Thoracic Injury

• Pleural Effusion• A collection of excess fluid in the pleural space

• Classification• Transudative aka: hydorthoraces• Exudative

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• Pathophysiology of Pleural Effusionhydrostatic pressure

oroncotic pressure

Formation of excess fluid=Transudate

capillary permeability

Formation of fluid & cells=Exudate

Empyema

• What is it?

• What causes it?

• How do we treat it?

What are some causes of:

• Transudative

• Exudative

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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How do we diagnosis pleural effusions?

Pleural Effusion -- Diagnositcs

• ____________• ____________• ____________• ____________

How do we know what type of

pleural effusion it is?

Interventions: Pleural Effusion

• Thoracentesis Diagnostic vs. Therapeutic

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Interventions: Pleural Effusion

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Interventions: Pleural Effusion

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Interventions: Pleural Effusion

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Interventions: Pleural Effusion

Treat underlying condition – CHF/Renal failurePneumoniaLiver DiseaseLupus/RAMalignancy

Pleurodesis Chest tube insertionAllow to resolve

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Complications of Pleural Effusion

• Trapped Lung

• Recurrent effusions

• Pneumothorax

PNEUMOTHORAX

• 3 types– Closed

– Open

– Iatrogenic

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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, fractured ribs that penetrate the pleura.

Occurs in stabbings, gunshot wounds, impalement injury.

Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation

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Clinical Manifestations: Pneumothorax

• Respiratory

• Cardiac

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Tension Pneumothorax

• Air/blood/fluid rapidly entering the pleural space

• Lung collapses

• Emergency situation

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Pathophysiology: Tension Pneumo

• Increase in intrapleural pressure

• Compression of lung

• Compresses against trachea, heart, aorta, esophagus

• 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

Other Types

• Hemothorax

• Chylothorax

Intervention: Pneumothorax

• High Fowlers position• Oxygen as ordered• Rest to decrease oxygen demand• ***Chest tube insertion• Pleurodesis• Surgery

?

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Trauma of the Chest/Lung

• What is involved• Chest wall• Lungs• Heart and great vessels• Esophagus

• Airway obstruction• Pneumothorax • Flail chest

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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

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Pathophysiology: Pulmonary Contusion

Abrupt chest compression then rapid decompression

Intra-alveolar hemorrhage

Interstitial/bronchial edema

Decrease 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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