Page 661 - ACCCN's Critical Care Nursing

638 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

determinant of maintaining adequate spontaneous intrapleural pressure. Insertion of an intercostal catheter
breathing. Avoiding mechanical ventilation is a major drains the air and/or blood from between the pleura,
goal in the less-severe group of chest trauma patients, so resulting in reinstatement of the negative intrapleural
effective deep-breathing and coughing must be pro- pressure and reinflation of the underlying lung.
moted. Pain relief will normally include IV opioids, but A central principle in the treatment of chest trauma is the
may also include intercostal or epidural analgesia and use of the intercostal catheter (ICC) for chest drainage
non-steroidal anti-inflammatory agents in selected purposes. The principles of chest drainage include:
patients (see Chapter 7). Non-pharmacological means
such as the use of supplemental oxygen, use of cold l The lungs are encased in a potential space. The visceral
packs early and heat packs late in the treatment course, pleura attaches to the parietal pleura via surface
massage, relaxation and diversion techniques should also tension, creating a negative intrapleural pressure and
be considered. Providing and maintaining a comfortable attaching the lung to the chest wall. During inspira-
posture for the patient that includes the elevation and tion the rib cage moves out and the diaphragm con-
support of injured limbs has remarkable analgesic prop- tracts and moves down, increasing the size of the
erties. A confident, competent and efficient nurse that intrathoracic space. Air moves from an area of higher
engenders trust from both the patient and family is very pressure in the environment to an area of lower pres-
comforting. sure within the lungs along a pressure gradient.
l An intercostal catheter is inserted into the pleural
Collaborative practice space, passing between the ribs. The ICC is designed
to drain both air and fluid as required.
Caring for the patient with chest trauma requires a team
effort with input from nursing, medical and allied health l The drainage system and seal provides an ongoing
professionals. While the medical management is largely means of removing air and/or fluid from the pleural
directed towards attempting to correct the damage done space, while preventing air from the atmosphere enter-
by the trauma, the allied health interventions are largely ing via the ICC. The seal is provided by placing the
directed at minimising such complications as atelectasis distal end of the ICC under water (usually 2 cm). The
and ongoing problems with mobility. Nursing interven- catheter should not be placed under excessive levels
tions are essential to ensure patient comfort, minimise of water, as this creates resistance and will limit air
complications and promote healing of wounds through and fluid escaping from the pleural space.
such interventions as chest drainage and wound care. l Suction is often added to the drainage system to
promote drainage of fluid.
Collaborative practice: surgical Care of the chest trauma patient with intercostal drainage
management of injury is directed towards ensuring sterility and patency of the
system, assessing the amount and type of drainage, as
Surgical intervention in the chest trauma patient is gener- well as the impact on the patient (see Table 23.7). Addi-
ally limited to repair of tears and lacerations, for example tional considerations include the following:
repair of vessel injuries including aortic rupture, lung
lacerations, heart injuries including lacerations and val- l ICC may be positional, or alternatively haemo/
vular injury. A ruptured diaphragm or oesophageal per- pneumothoraces may be loculated. Repositioning of
foration will also be repaired surgically. either the patient or the catheter may be necessary.
l Side-lying or lifting the patient, especially with a
The emergency thoracotomy has proven beneficial in a
select group of patients with penetrating trauma and less frame, may kink or disconnect the ICC.
than 15 minutes of cardiopulmonary resuscitation; l Surgical emphysema around the site of the ICC may
however, it is generally recognised as not providing dislodge the tip of the catheter out of the pleural cavity
benefit in patients with blunt chest trauma. While dif- as the emphysema swells. Ongoing assessment, includ-
61
ferent techniques are used in different settings, the main ing a chest X-ray, will be required to confirm the posi-
access to the thoracic cavity is via a left thoracotomy, a tion of the ICC.
midline sternotomy or a ‘clam shell’ incision. Initial l Movement of the patient, including sitting upright,
assessment of the patient is used to determine the need will assist with fluid drainage; the volume of drainage
for a thoracotomy in either the emergency department or should be assessed after moving the patient.
the operating room. Nurses working in a trauma recep- l Monitoring of respiratory function should continue
tion facility that has the capacity for emergency thora- after removal of the ICC to detect recollection of air
cotomy should be familiar with the equipment and or fluid.
process for this procedure. Postoperative nursing care of
these patients should follow the same principles as those
for patients who have undergone routine cardiothoracic
surgery. Practice tip
Fresh, brightly-coloured blood drained from the ICC indicates
Collaborative practice: chest drainage continued active bleeding, while dark blood usually indicates
When injury to the pleura occurs, air or blood collects older blood that has been resting in the pleural space for some
between the two layers of the pleura, causing collapse of time.
the underlying area of lung and loss of the negative