Is trauma patient going to need a chest tube?
Your actions can avoid delays
Patients with a mechanism of injury relating to chest trauma, such as penetrating or blunt trauma, are more likely to require a chest tube, says Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center in Bangor, ME.
Gabriela McAdoo, RN, trauma nurse coordinator at Stanford (CA) Hospital & Clinics, says, "Delay in care may result in death. Tension pneumothorax is the most common adverse outcome."
To improve care of a trauma patient requiring a chest tube:
Assess for respiratory distress.
Assess for tachypnea, circumoral cyanosis, pallor, and signs of decreased oxygenation including pulse oximetry if available, says Sides.
Always consider the nature of injury.
"With any chest trauma or multi-trauma patient, you need to be suspicious of a pneumothorax or hemotoma, or both," says Sides. "Pay close attention to your patient. Be suspicious of any abnormal findings." She gives these tips:
Assess chest wall symmetry.
Inspect for soft tissue integrity.
When assessing breathing, look specifically for rate, rhythm, lung sounds, symmetry of chest, presence of spontaneous breathing, chest wall integrity, and skin color.
With circulation, look at the patient's skin temperature, color and moisture; central pulses; and any uncontrolled bleeding.
"A pneumothorax or hemotoma, especially a progressing pneumothorax or hemotoma, can present abnormal findings in either of those two steps in the assessment," says Sides.
Document the initial drainage output.
"Include description of fluid drainage," says McAdoo. "Is it bloody, straw-colored, or purulent? Documentation output every shift, and mark the chamber when transferring care."
Don't miss delayed injury.
Track and trend vital signs and intake/output to make sure your patient is improving and not deteriorating, advises McAdoo. "There may be times when trauma patients have delayed injury," she explains.
After any intervention, reassess your patient's condition, including airway, breathing, and circulation. "This is needed to make sure there are no life-threatening injuries that may have developed during your initial airway or fluid resuscitation," says McAdoo. (See story on equipment used for this procedure, below, and clinical tip on what to palpate for, right.)
Make sure equipment is working properly At the beginning of your shift, make sure that the equipment you will be using is working properly and is ready for an emergency at any given time. "This is an important practice," says Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center in Bangor, ME. At times, Sides has walked into a critical care emergency bay and not had suction available. "The tubing hasn't been replaced, the suction isn't hooked up, the wall-mounted suction isn't hooked up correctly, or Yankauer or French suction tips aren't available," says Sides. "This is dangerous and completely preventable." Do you work in an ED that doesn't use chest tubes frequently? Sides says to check with an educator to refresh your knowledge on the setup and proper monitoring of the equipment. "Many of the equipment manufacturers have tutorials on setup and maintenance on their web sites," says Sides. "Identify your resources, and be prepared before you need it." She recommends these steps:
"Be diligent in making sure your ED is adequately stocked with supplies," says Sides. "Chest drain systems all work under the same premise. Be familiar with the science and then your equipment." |
Palpate patient's skin for telltale symptom "A surgeon once told me, 'If you see someone come in with a 'pumpkin head,' you need to prep for bilateral chest tubes,'" says Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center in Bangor, ME. "Pumpkin head" refers to a large amount of subcutaneous emphysema within the soft tissue, explains Sides. "With chest and lung injuries, the patient can experience some severe subcutaneous air, causing the head to appear swollen," says Sides. "The feeling of 'Rice Krispies' under the skin as you palpate is the usual finding." |
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