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Published byElijah Anthony Modified over 9 years ago
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Respiratory Disorders: Pleural & Thoracic Injury
by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard, RN, MSN
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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 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
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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
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Viceral pleura – Parietal 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 Parietal ---- of or related to the formation of bone, organ or cavity.
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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
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Traumatic Chest Injuries
Mechanism of Injury Common Related Injury Blunt Trauma Blunt 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 trauma Gunshot, stab wound to chest Open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears
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Respiratory Disorders: Pleural and Thoracic Injury
Pleural Effusion A collection of excess fluid in the pleural space Is it normal to have fluid in this space? Would you consider a pleural effusion a disease? 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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Empyema What is it? What causes it? How do we treat it?
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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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How do we diagnosis pleural effusions?
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Pleural Effusion -- Diagnositcs
____________
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How do we know what type of pleural effusion it is?
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Interventions: Pleural Effusion
Thoracentesis Diagnostic vs. Therapeutic
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Interventions: Pleural Effusion
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Interventions: Pleural Effusion Chest tube placement/ PleurX catheter
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Interventions: Pleural Effusion
Treat underlying condition – CHF/Renal failure Pneumonia Liver Disease Lupus/RA Malignancy Pleurodesis Chest tube insertion Allow to resolve
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Complications of Pleural Effusion
Trapped Lung Recurrent effusions Pneumothorax
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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, 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
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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
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Other Types Hemothorax Chylothorax
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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?
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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 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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Chest Surgeries Lewis 593 Table 28-22; NCP 28-2
Exploratory thoracotomy Incision into thorax to look for injured or bleeding tissue Thoracotomy not involving lung VATS Video-assisted thoracic surgery to do lung biopsy, lobectomy, ect
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