Chest Trauma, Chest Tubes &
Underwater Seal Drainage
By: Victoria Murray
& Mary Beth Chauder
Objectives
To review the anatomy and physiology of the
respiratory system.
To identify the various types of trauma associated
with the chest, and the nursing management
associated with them
To discuss the mechanics of chest tubes, their uses,
and the nursing management associated with them
To discuss pain management, nursing interventions
and nursing diagnosis associated with chest trauma
To evaluate the understanding of the class with the
use of a case study.
The Respiratory System
(Day et al., 2010)
Ventilation Mechanisms
(Day et al., 2010)
What is Chest Trauma?
Classified as either:
Blunt or Penetrating Trauma
Blunt Trauma
Most Common Causes:
• MVA (Seatbelt, wheel)
• Falls
• Bicycle Crashes
Generalized Symptoms:
• Hypoxemia
• Hypovolemia
• Cardiac Failure
Mechanisms of Blunt Chest Trauma:
• Acceleration – moving object impacts chest
• Deceleration – sudden decrease in speed/velocity
(MVA)
• Shearing – stretching forces to areas of chest
• Compression – direct blow to the chest
Penetrating Trauma
Most Common Causes:
• Gunshot
• Stab Wound
Classified By:
Velocity: Stab Wound Low
Gunshot High
Initial Assessment of Suspected
Chest Trauma
VITALS & LOC
Temperature, Pulse, RR, BP, SPO2 & PAIN
Inspect
Respirations Effort & Depth; Chest Wall Symmetry. Paradoxical Chest
Wall Motion; Bruising ; Penetrating Wounds
Palpate
Trachea for deviation; Adequate and Equal Chest Wall Movement;
Chest wall tenderness; Rib 'crunching' indicating rib fractures
Percuss
Percuss Both Sides of the Chest Looking for Dullness or Resonance
Auscultate
Normal & Equal Breath Sounds
(Brown et al., 2009)
Initial Assessment of Suspected Chest
Trauma
Trachea
Chest
Expansion
Breath Sounds
Percussion
Tension
Pneumothorax
Away from
Affected side
Decreased
(Hyperexpansi
on)
Diminished
Hyper-resonate
Simple
Pneumothorax
Midline
Decreased
May be
Diminished
May be Hyperresonate
Hemothorax
Midline
Decreased
Diminished (lg) Dull
or Normal (sm)
Pulmonary
Contusion
Midline
Normal
Normal ,
Crackles
Normal
Lung Collapse
Towards
Affected Side
Decreased
Diminished
Normal
(Trauma. Org, 2004)
Secondary Assessment of Chest Trauma
Gather history of event from family, client, and EHS.
Chief complaint
In depth medical history
Allergies
Pain assessment
Complications Of Chest Trauma
• Pneumothoraxes
• Simple
• Traumatic
• Open
• Hemothorax
• Tension Pneumothorax
•
•
•
•
•
•
Pleural Effusion
Sternal and Rib Fractures
Flail Chest
Pulmonary Contusion
Cardiac Tamponade
Pulmonary Embolism *
Pneumothorax defined & types
individually discuss
Three Types:
• Simple
• Traumatic
•
Open
•
Hemothorax
• Tension
(Day et al., 2010)
Tension Pneumothorax
• Air is drawn into the pleural space
from a laceration.
• Air that enters becomes trapped
• Increased positive pressure
• Lung collapses and causes a
mediastinal shift away from the
affected lung
(Day et al., 2010)
Hemothorax
40% of the circulating blood volume
can accumulate
A small amount of blood (<300) in the
pleural space may cause no clinical
manifestations and may require no
intervention (blood is reabsorbed
spontaneously).
Massive HTX results from a rapid
accumulation of more than 1500cc of
blood in the chest cavity. This may be
life threatening because of resultant
hypovolemia and tension
Rib fractures and pulmonary
parenchyma disruption are the most
common causes
Pneumothorax-Manifestations
Simple/Uncomplicated




Sudden onset of pain
↓ Tactile Fremitis
Absent breath sounds
Hyperresonant
Percussion
 Minimal respiratory
distress
Large/Tension
 Air hungry, anxious,
dyspnea, diaphoresis,
hypotension, tachycardia
 Central cyanosis may re
from severe hypoxemia
 Acute Respiratory
Distress—lung collapses
totally
Pleural Effusion
Pleural = Pleural Cavity
Effusion = abnormal, excessive
collection of this fluid
Pleural Effusion
 Abnormal buildup of fluid between linings of the
lung and chest wall
 result of a disease process or inflammation
 Normally 5 to 10 mL of serous fluid in the visceral and
parietal pleura.
 Any more can cause great changes in intrathoracic
pressure.
Signs and Symptoms
 Pleural effusion in itself does not cause symptoms.
 If effusion expands and presses on lung, patient may
develop
 sharp, localized pain that worsens with coughing, or
deep breathing.
 Dyspnea
 non-productive cough.
Signs and Symptoms cont...
 Early signs include decreased or bronchial breath
sounds on the affected side, dullness to percussion,
and decreased fremitus over area of fluid
accumulation
 Auscultation: EGOPHONY
 Hear “A” over fluid accumulation when patient speaks
“E”.
Complications of Pleural Effusion
 Respiratory compromise and distress from fluid
compressing lung.
 Infection in pleural space---Sepsis/Empyema
 Fistulas in bronchi or chest wall
 Inflammation/infection in pleural space leads to
increased potential for adhesions. Adhesions isolate
effusion to one lung and complicates treatment.
Sternal & Rib Fractures
Rib Fractures are the
most common type of
Chest Trauma (60%)
Sternal Fractures are
most common in
MVCs
Fractures to the 5th-9th
Rib are most common
site of fracture
(Day et al., 2010)
Sternal & Rib Fractures
Manifestations
 Chest Pain
 Ecchymosis
 Crepitus
 Swelling
 Chest Wall Deformities
Interventions:
 Pain Control
 Deep Breathing and
Coughing
 Surgery is Rarely
Necessary
Patient Must Be Closely Monitored for Underlying
Cardiac Injuries!!
Flail Chest
 Caused by Blunt trauma
http://www.youtube.com/watch?v=uJHfX1RFkF0
Flail chest trauma
Pulmonary Contusion
Damage to the lung tissues
resulting in hemorrhage and
localized edema.
The client is unable to clear
secretions effectively, and the
work of breathing is
significantly increased
Primary defect is the abnormal
accumulation of fluid
(Day et al., 2010)
Pulmonary Contusion
 Moderate Pulmonary Contusion:
Mucous, Serum and Frank Blood in the
Tracheobroncial Tree
Persistent Unproductive Cough
 Severe Pulmonary Contusion
Central Cyanosis, Agitation, Combativeness
Productive Cough with Frothy Bloody Secretions
 Treatment priorities are to maintain airway, provide
oxygenation and pain management
Day et al., 2010
Cardiac Tamponade
 Compression of the heart as a result of fluid within the
pericardial sac
 Usually due to chest trauma
 Manifestations
 Hypotension
 Jugular-venous distention
 Muffled heart sounds
 Periocardiocentesis to remove
fluid from pericardial sac
Pulmonary Embolism
 Pulmonary
embolism occurs
when a blood clot
becomes lodged in
a lung artery,
blocking blood flow
to lung tissue.
Blood clots often
originate in the
legs.
Pulmonary Embolism
 Blockage makes it more difficult for the heart to pump blood
through lungs. As a result, less oxygen is available to the rest
of the body. If the blockage is large enough, tissue death
(infarction) occurs in the lung area cut off
from
circulation. Pulmonary embolisms are commonly
misdiagnosed.
Misdiagnosed Why?
Easily attributed to other conditions and vary
with the size and number of clots.
 Such as a heart attack
 Pneumonia
 Hyperventilation
 Congestive heart failure
 Panic attacks.
Who is at risk?
 Immobilization — Being immobilized puts a
strain on the circulatory system. Although
the heart acts as the body’s main pump,
movement also assists in keeping blood
circulating properly.
 Long periods of inactivity may increase risk
of blood clots. Examples include lengthy
road trips or flights, or bed rest due to
illness or surgery.
 Blood abnormalities — Some people are
born with blood that’s more prone to
clotting & those dehydrated, septic, have
Ca, those giving birth.
Other Risk Factors for Pulmonary
Embolism
 Advanced age (especially over age 70)
 Significantly overweight
 Birth control pills, HRT drugs & the osteoporosis
drug raloxifene (Evista) are examples of drugs that
list a small risk of developing blood clots.
About 90 % of Pulmonary Emboli Result When a Clot
Travels from a Leg to a Lung - often no symptoms
 Blood tests, a chest X-ray, an electrocardiogram
— to help rule out other possible reasons for
symptoms.
 Sometimes a leg blood clot may cause redness,
swelling and pain in the calf muscle area. Refer to a
physician promptly.
 A pulmonary angiogram is a more definitive test,
although it involves some risk and is more
expensive.
 the CT scan (computed tomography scan) —
instead of lung scan or pulmonary angiogram. CT
scan is a less invasive test that provides fast and
accurate results.
Nursing Diagnosis for Chest Traumas










Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Patterns
Imbalanced Fluid Volume
Decreased Cardiac Output
Decreased tissue perfusion
Acute Pain
Anxiety
PC: Bleeding
Risk for infection
Chest Tubes
Chest Tube
What are Chest Tubes
 A chest tube is a large
catheter inserted
through the thorax to
remove air, blood, pus
or lymph
 Small Bore (12-20 Fr)
 Large Bore (24-32 Fr)
Perry & Potter, 2010)
Indications for Use









Pneumothorax
Tension Pneumothorax
Bilateral Pneumothoraces
Hemothorax
Post-Operatively (Cardiac Surgery)
Pleural Effusion
Empyema
Chylothorax
Esophageal Rupture with Gastric Contents in Pleural
Space
(Briggs, 2010)
Equipment Required
•
Chest tube of appropriate size
• Underwater seal drainage system
• Sterile gloves, gown and drapes
• Local anesthetic
• Skin Prep solution
• Chest Tube Tray
• Dressing Material
• Chest tube clamps
(Briggs, 2010)
Chest Tubes Continued
There are two types of Chest tubes:
Pleural
Mediastinal
Pleural Chest Tube
Durai, et al., 2010; Perry & Potter, 2010
Mediastinal Chest Tubes
Perry & Potter, 2010
Pre-Insertion of Chest Tubes
 Nurse prepares sterile table
scalpel, local anesthetic (such as lidocaine), thick silk or
polypropylene suture on a cutting needle, a chest tube
of appropriate size and the underwater seal with sterile
water filled to the mark
 Opens drain package and prepares drain as per
manufacturers instructions
 Nurse Positions Patient for Procedure
 Explain Procedure and assure patient
 Monitor Vital Signs and for Discomfort
* MD responsible for admin of analgesic
(Durai, 2010)
Methods for Insertion
Two Methods for Tube Insertion
1)Trocar based (i.e. the Seldinger technique)
Allows for easier insertion
Greater Risk
Less Painful
1)Blunt dissection
More painful for the patient
Safest Method
Durai, 2010
Chest Tube Insertion
Site of Insertion
Site of Insertion
Digital Exploration
Drain Insertion
Drain Sutured in Place
Underwater Seal Drainage System
Chest Drainage Systems
Consist of three parts:
• Suction Source
• Collection Chamber for pleural drainage
• Mechanism to prevent air reentry
• Three types of chest drainage systems:
• Traditional Water Seal
• Dry Suction Water Seal
• Dry Suction with a One way Valve
(Day et al., 2010).
Traditional Water Seal Drainage
System
Contains 3 Chambers:
• Collection chamber
• Water seal chamber
• Wet suction control
chamber
Additional suction source
can be added as needed.
Intermittent bubbling
indicates proper functioning
(Day et al., 2010).
Dry Suction Water Seal System
Contains 3 Chambers:
• Collection chamber
• Water seal chamber
• Wet suction control chamber
Suction pressure is set with
regulator.
Has an indicator to signify
suction pressure is adequate.
Quieter than traditional water
seal system.
(Day et al., 2010).
Dry Suction with One Way Valve System
Has a one-way mechanical valve that
allows air to leave the chest and
prevents air from moving back into
the chest.
Can be set up quickly in an emergency.
Works even if knocked over, ideal for
ambulatory patients.
(Day et al., 2010).
 http://www.youtube.com/
watch?v=WVHelcIIee8
Post Insertion & Maintenance of Chest
Tubes
Management of Chest Tube
• The nurse is responsible for managing the chest
tube and drainage system including:
• Caring for the tube and drainage system when
transporting patient
• Changing or emptying the drainage container
• Monitoring fluid drainage
• Monitoring chest tube position
• Milking and clamping contraindicated
(Durai, Hoque, & Davis, 2010).
Drainage System Assessment
Monitor drainage collection System for:
• Verify that all connection tubes are patent and connected
securely
• Assess that water seal is intact when using wet suction
system and assess regulator dial in dry suction system
• Fluctuations in the water seal chamber for wet suction
• Air bubbles in the water seal chamber
• Air leak indicator in dry suction systems
• Suction set at ordered rate
• Keep the system below patient’s chest level
• Maintain appropriate fluid in the water seal for wet suction
Monitoring the Water-Seal Chamber
 There will be an increase in the water level with
inspiration and a return to the baseline level with
exhalation. This is referred to as tidaling. If your
patient’s lung fully expands or the tubing becomes
obstructed, you may not see any fluctuations.
 Bubbling in the bottom of the water-seal chamber
indicates an air leak, caused by poor tubing
connections. You may notice a small amount of
bubbling right after chest tube insertion, or when the
patient coughs.
Monitoring Continued
Drainage
collection
Chamber
Underwater Seal
Chamber
TIDALING
BUBBLING
Yes
Yes
No
No
Yes
Assessment &
Management of
Air Leak
indicates patient air
leak (pneumothorax)
No
indicates lung reexpansion or
obstruction by kinks
or clots
Yes
indicates possible
connection or system
air leak
No
observed with
pneumonectomy or
decreased lung
compliance
Patient Assessment
Assess client for:
• Comfort level
• Auscultate lung sounds, and assess for rate, rhythm,
and depth.
• Monitor HR, BP, Temp, RR, O2 sats
• Drainage for amount, color and consistency
• Monitor dressing status and drainage from insertion
site
• Monitor chest wall at insertion site for subcutaneous
emphysema or air leaks
• Mark volume and drainage (time, date, initial)
every shift.
• Mark tube to ensure that it does not become
dislodged.
Drainage Assessment
• Mediastinal Chest Tube
• Less than 50-200 mL/hr immediately after surgery
• Approximately 500 mL in the first 24 hours
• Pleural Chest Tube
• Between 100-300 mL may drain 3 hours post insertion
• The 24 hour rate is 500-1000mL
• Drainage is grossly bloody during the first several hours
post-op and slowly changes to serous.
• Dark red drainage is expected only during the
immediate post-op period… Bright red drainage would
indicate active bleeding.
• Remember: a sudden gush of drainage may be retained
blood/fluid being released during position change.
(Perry & Potter, 2010).
Complications of CT drainage systems
• Nurse must be aware of the reason for chest tube
insertion and what type of drainage to expect.
• Tension pneumothorax may occur from incorrect
placement of tube.
• Tube may become disconnected from drainage system.
• Tube may accidentally be pulled out of pleural space.
• Occlusion of the chest tube.
• Drainage system may be knocked over disrupting seal.
• Risk for infection.
(Durai et al., 2010; Sullivan2008).
What if the Tubing Becomes Dislodged?
• Immediately cover the site with a dry, sterile
dressing and call the physician.
• If air is heard leaking from the site, tape the
dressing on only two or three sides to allow
air to escape and prevent tension
pneumothorax.
• Closely monitor the patient and prepare for
reinsertion.
What if the chest tube becomes
disconnected from the drainage system?
• If the chest tube and drainage system become
disconnected, air can enter the pleural space,
producing a pneumothorax. To prevent
pneumothorax if the chest tube is inadvertently
disconnected from the drainage system, a temporary
water seal can be established by immersing the chest
tube’s open end in a bottle of sterile water.
• Or if possible reconnect to the water seal drainage
system!
Removal of
Chest Tube
• Explain Procedure
• Administer Analgesics
• Remove Drain
• Cleanse Wound
• Apply Sterile Dressing
(Durai, 2010; Sullivan, 2008; Perry & Potter, 2010)
Post Removal Nursing Interventions
 Respiratory Assessment
 Assess Vital Signs
 Chest X-Ray
 Assess Pain
 Assess Wound & Dressing
Pain Management
Related to:
•
Insertion – local anesthetic (lidocaine or prilocaine)
•
In situ – PCA pump (morphine)
•
Removal – EMLA cream (Eutectic mixture of Local
Anesthetics)
Overall goal is to provide pain management
but not to the extent that respirations are
depressed.
Case Study
 JB is a 25 year old male just arrived to the ER via EHS.
Only known hx is that JB was involved in a head on
collision with a drunk driver. JB is transferred to
trauma stretcher and immediately you notice he is
anxious and in pain. He is having difficulty breathing
and his seatbelt has left him with bruising across the
chest. Vital signs are BP 85/50mmHg, HR 120, RR 30,
Temp is 37.o, and Sp02 is 90%.
 What type of chest trauma is suspected?
 What initial assessments would you want to perform?
 Following assessment it is determined JB has a
hemothorax and a chest tube is required. What
equipment would you gather for the physician?
 What size chest tube did you grab?
 You notice the physician is landmarking for the 2nd or
3rd intercostal space, what do you do?
 What are some complications of chest tube drainage
systems?
Questions & Comments ?
References
Briggs, D. (2010). Nursing care and management of patients with intrapleural drains. Nursing
Standard. 24(21), 47-55
Durai, R., Hoque, H., Davies, T.W. (2010). Managing a chest tube and drainage system.
Association of Perioperative Registered Nurses. (91) 2, 275-280
Day,R.A., Paul,P., Williams,B.,Smeltzer,S.C. & Bare,B.(2009). Textbook of Canadian Medical
Surgical Nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
Pearce, A.P. (2009). Chest drain insertion: Improving techniques and decreasing
complications. Emergency Medicine Australia. (21), 91-93
Perry & Potter . (2010). Clinical Nursing Skills & Techniques (7th ed.). St. Louis: Mosby,.
Sullivan, B. (2008). Nursing management of patients with a chest drain. British Journal of
Nursing. (17)6, 388- 393
Trauma. Org. (2004). Chest trauma: Initial Evaluation. Retrieved from
http://www.trauma.org/archive/thoracic/CHESTintro.html