Respiratory Disorders: Pleural & Thoracic Injury by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard RN, MSN

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Normal Anatomy Thoracic cavity Chest wall Pleural space Fluid 3

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 – g/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

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 7

Categories for Traumatic Injuries Blunt trauma Penetrating trauma

Traumatic Chest Injuries Mechanism of InjuryCommon Related Injury Blunt Trauma Blunt steering wheel injury to chestRib fractures, flail chest, pneumothorax, hemopneumothorax, myocardial contusion, pulmonary contusion, cardiac tamponade, great vessel tears Shoulder harness seat belt injuryFractured 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 trauma Gunshot, stab wound to chestOpen 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 10

Respiratory Disorders: Pleural and Thoracic Injury Pleural Effusion A collection of excess fluid in the pleural space Classification Transudative aka: hydorthoraces Exudative 11

12 Pathophysiology of Pleural Effusion hydrostatic pressure or oncotic 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 ProcessClassification of Effusion Heart Failure TB Lupus/RA Renal Disease Lung Cancer Trauma Pneumonia Liver Failure 15

Clinical Manifestations: Pleural Effusion Dyspnea Pleurisy Decreased breath sounds Decreased chest wall movement Dullness on percussion 16

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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 23

Interventions: Pleural Effusion 24

Interventions: Pleural Effusion 25

Interventions: Pleural Effusion 26

Interventions: Pleural Effusion Treat underlying condition – CHF/Renal failure Pneumonia Liver Disease Lupus/RA Malignancy Pleurodesis Chest tube insertion Allow to resolve 27

Complications of Pleural Effusion Trapped Lung Recurrent effusions Pneumothorax

PNEUMOTHORAX 3 types – Closed – Open – Iatrogenic

30 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 32

Tension Pneumothorax Air/blood/fluid rapidly entering the pleural space Lung collapses Emergency situation 33

Pathophysiology: Tension Pneumo Increase in intrapleural pressure Compression of lung Compresses against trachea, heart, aorta, esophagus Ventilation and cardiac output greatly compromised 34

Clinical Manifestations: Tension Pneumo Severe dyspnea Tracheal deviation Decreased cardiac output Distended neck veins Increased respiratory rate Increased heart rate Decreased blood pressure Shock 35

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 ? 38

Trauma of the Chest/Lung What is involved Chest wall Lungs Heart and great vessels Esophagus Airway obstruction Pneumothorax Flail chest 39

Clinical Manifestations: Rib Fractures Ribs 5-10 most commonly fractured Pain Splinting & Rapid, shallow respirations Decreased breath sounds Crepitus Signs/symptoms of pneumothorax 40

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 42

Clinical Manifestations: Flail Chest Dyspnea with rapid, shallow inspiration Pain Palpable crepitus Decreased breath sounds Unequal chest expansion Tachycardia 43

Interventions: Flail Chest Oxygen as ordered Elevate HOB Analgesia Suction Splint affected side *Intubation *Mechanical ventilation 44

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 45

Clinical Manifestation: Pulmonary Contusion Increased SOB Restlessness Anxiety Chest pain Copious sputum Increased respiratory Increased heart rate Dyspnea Cyanosis 46

Intervention: Pulmonary Contusion Intubation Mechanical ventilation Bronchoscopy Fluids Volume expanders Pulmonary artery pressure monitoring 47