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181 Cards in this Set

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What is chest trauma with skin intact and damage inside
blunt
Two types of chest trauma
blunt
penetrating
What is chest trauma with something sticking into lungs
penetrating
How do you open airway if patient has collar on or C spine injury?
jaw thrust or emergency trach
What would you do for a trauma patient?
2 large bore IV to get fluids in right away
EKG
Labs
Chest Xray
How long do you leave collar on patient with C spine?
until cleared
Why is chest trauma life threatening?
hypoxemia, hypovolemia, cardiac failure
Why do you want to know WHEN chest trauma occurred?
golden hour to know how close to death and chances of survival
What do you assess in chest trauma patient
How? When? ABC? responsive and breathing? auscultate breath and heart sounds, Get IV in
Where is best place to put in an IV during chest trauma or emergency
antecubital or jugular because you need a large vein
Diagnostics you can run for chest trauma?
CXR, CBC, EKG, ABG, clotting studies, type and cross, electrolytes, CT, Foley, Kidney, Liver, Tox screen, Vitals, pulse ox, BP, LOC, JVD
Why do you check tox screen if chest trauma
may have been etiology for accident
Why do you check blood sugar with chest trauma?
could cause accident
Why do you do chest xray for chest trauma
fractures, pneumo/hemothorax, cardiac silhouette, foreign debris, trach deviation, cardiac tamponade
Why do you assess EKG with chest trauma
for myocardial damage, STE, rate, rhythm, tachy? PVC?
what do you look for in ABG of chest trauma
hypoxia, respiratory acidosis, CO2
What clotting studies are done in chest trauma
PT, PTT, INR
Why do you do type and cross with chest trauma?
anticipate transfusion
When might you not do type and cross
Jehovah Witness
What should you do before type and cross
check if Jehovah Witness or if they don't receive blood products
What electrolytes are important to monitor if chest trauma
potassium or sodium
Potassium could explain PVC or Output
Sodium in case had seizure
Why do you check CPK, Troponin in chest trauma?
for cardiac damage
Why do you put in Foley with chest trauma
to measure output and to check for blood that may show abdominal injury
Why do you measure BUN and Cr with chest trauma
kidney damage
Why do you do liver studies with trauma
liver damage
What do you need if you give blood without patient consent?
physician order
Why do fractures to upper ribs have such high mortality?
because large vessels like aortic arch and SVC are in this area
Why do you check LOC and JVD in chest trauma
decrease blood or decrease oxygen
What does belly stick check for
blood in abdomen
How often monitor BP with chest trauma?
every 5 minutes
what are complications of rib fractures
pneumothorax
lacerate SVC or aortic arch
puncture liver/spleen
How is fracture treated?
conservatively: control pain because it hurts to breathe!
What can pain lead to with rib fracture?
pneumonia and atelectasis
If you have multiple rib fractures and comorbidities, you have....?
increased mortality
What does mortality of flail chest depend on
comorbidities and age
What is flail chest
multiple rib fractures cause free floating section and unstable chest wall
Breathing in flail chest?
paradoxical
in on inspiration
out on expiration
S/S flail chest
paradoxical movement, increase RR, increase HR, low BP, respiratory acidosis
Treatment for flail chest
depends on severity
What do you do with severe flail chest?
intubate and add PEEP
What is the goal with pneumo/hemo thorax?
get rid of blood/air from pleural space
What are symptoms for pneumo/hemo thorax?
depend on severity: dyspnea to shock
How can we cause pneumo/hemo thorax?
triple lumen line placement, surgery
How do you diagnose pneumo/hemo thorax?
chest xray
Treatment for pneumo/hemo thorax?
chest rube
When do you USUALLY insert chest tube?
over 20% of lung affected
What do you do after triple lumen
chest xray
What does chest tube placement depend on?
patient
age, COPD, percent of lung involved
When might the chest tube be placed in lower?
hemothorax; blood sinks
When can you clamp chest tube?
ONLY when insert and remove!
Why can't you clamp chest tube
can cause tension pneumothorax
What is a big sign of tension pneumothorax?
tracheal deviation
What occurs in tension pneumothorax?
air goes in on inspiration and stays in on expiration, causing increased pressure that pushes the lung, heart, and trachea to the opposite side

MEDICAL EMERGENCY
What is treatment for tension pneumothorax?
large bore needle 2nd intercostal space midclavicular line then chest tube later
What is the sound when you insert needled into tension pneumothorax?
pop as pressure released; sounds like opening a can of soda
What must happen before removing chest tube
lung must be healed
How do you know when to remove tube?
no fluid or little fluid in chest
good chest xray
lung inflated
fully stable patient
What is open pneumothorax?
sucking chest wound
inspiration air goes in and expiration air goes out (through hole)
What must you do with open pneumothorax?
evaluate quickly
treatment for open pneumothorax?
cover hole! until surgery
what happens to heart and vessels with open pneumothorax?
move back and forth
What is goal with gunshot wounds and stab wounds?
restore and maintain cardiac/pulmonary function
What is treatment for gunshot wounds and stab wounds?
depends on injury
What should you NEVER do with gunshot wounds and stab wounds?
pull it out!
What do you do with gunshot wounds and stab wounds?
support it
What do you look for with gunshot wounds and stab wounds?
check entrance and exit
If there is no exit with gunshot wounds and stab wounds, what does that mean?
it's still inside
What may have happened with a GSW if only a small hole
may have entered body and ricocheted around
If there is one GSW, there is...
probably more
what is a pulmonary contusion?
bruise and swelling of lung tissue
What is treatment for pulmonary contusion?
monitoring to full ventilatory support
depends on severity/size
How long should you watch pulmonary contusion
12 hours
What is cardiac tamponade?
compression of the heart from fluid in the pericardial sac
What are s/s of cardiac tamponade?
depends on how quickly it comes

Low BP, distant heart sounds (listen through blood), SOB, tachypnea, anxiety, pulsus paradoxus (uneven pulses)
What is treatment for cardiac tamponade?
pericardiocentesis
thoracotomy
Why are heart sounds distant with cardiac tamponade?
listening through blood
What is cardiac tamponade?
medical emergency!
What does cardiac tamponade cause?
decrease in SV and CO
Will increasing preload help cardiac tamponade?
NO! it's a mechanical malfunction
no matter the preload or afterload, it won't help!
Why do you run CXR with cardiac tamponade?
to look at cardiac silhouette
What is subcutaneous emphysema?
air passage under the skin that sounds like rice crispies under the skin
Where do you check for subcutaneous emphysema?
around chest tubes and trachs
What do you do if you noticed subcutaneous emphysema?
mark site and outline with pen and let someone know
you can monitor if grows or decreases
How do you find subcutaneous emphysema?
ONLY feeling with fingertips
When should you NOT put a patient in high fowlers
if BP too low
What is the problem with aspiration?
serious and can cause death
What are some causes of aspiration?
vomit, food, drowning
When does aspiration usually occur
when reflexes are lack
How often do you check and document residual with peg tube?
every 4 hours!!
How can we cause aspiration
tube feeds if we don't check tube placement
Why is aspiration common with chest trauma
NOT NPO for 12 hours before surgery and often eat during accidents
When should you hold feed?
if over 2-3 hours worth of feed in stomach
How can you check NG tube placement?
auscultation for air LUQ and bubbles
aspirate contents
chest Xray
What is gold standard to check NG placement
CXR
You should document that you checked NG placement how many times
at least 2
What should you do with PEG tube before feed?
check placement!
especially if obese!!
What should you watch for with chest trauma
hypoxemia, hypovolemia, cardiac failure
Hypovolemic shock
due to volume loss of blood: decrease preload, decrease SV, decrease afterload, increase HR
Cardiogenic shock
due to impairment of heart's ability to pump blood; decrease SV
Some causes of cardiogenic shock
MI, chest trauma, myo problems
What type of shock do patients with trauma usually experience?
cardiogenic AND hypovolemic
What can we give if had MI and systolic BP 68
increase fluid and give catecholamines (to increase contractility)
What is PE
obstruction of one or more branches of pulmonary artery
only venous artery in body
pulmonary arteries
What do PE's arise?
venous system
Where do most thrombus originate?
deep veins of legs but can't be anywhere
why is PE a problem?
ventilation without perfusion

can breathe but can't perfuse
What are s/s of PE?
same as MI
severe sudden dyspnea
extreme anxiety, restlessness
sharp pain in chest
fever
coughing with hemoptysis (not always)
dullness over area upon auscultation
Diagnostics for PE
CXR, EKG, ABG, pulmonary angiography, spiral CT
What is the gold standard to diagnose PE
spiral CT; goes in slices by the pulmonary artery to SEE obstruction
What may person with PE seem like
increase pulse, increase BP at first, decrease PaO2
Can you treat PE with O2
no, because it won't get through
What is order of care for PE
High Fowlers, Oxygen, Start IV, relieve pain/anxiety, dissolve clot/prevent others from forming
What is thrombolytic therapy for PE
urokinase/streptokinase
high risk for bleed
dissolves clot
CANNOT do with surgical patients!
Some anticoag thearpy for PE
coumadin
Other therapies for PE
pulmonary embolectomy
vena cava filter
What is pulmonary embolectomy
go to cath lab, go up to P.A. and remove clot; not common
What is vena cava filter
for patients with multiple PE or if can't handle anti coag; it catches the clots and has fibronolysis to break down clot
What are risk factors for PE
venous stasis, hypercoagulation (surgery, disorders), venous disease (Diabetes, large legs), disease states (hypertension, CAD, PVD)
What is best for PE
PREVENTION!
TED hose, compression stockings, LMWH/Lovenox
what do you do with those on bedrest?
anticipate PE and DVT; do Dopplers!
Why don't you follow PTT if on heparin or Lovenox twice daily?
dose won't be steady in blood; have peak and trough
Why do you monitor platelets if on heparin therapy
can get heparin induced platelet allergy which will cause platelets to drop!
How do you flush hep lock and why
with normal saline to prevent Heparin induced platelet allergy
Pleural space
potential space, usually parietal and viceral pleurae stick together with surfactant
When do you do chest tube
usually if pneumothorax is 20% or greater
Single bottle chest drainage system
water seal
cup with a straw in it;
inhale and water moves up and exhale water moves down;
air can't go into lung through tube
What should you always have in room with chest tube
bottle of sterile water or 0.9% N/S
Two bottle chest tube system
water seal PLUS suction usually at 20 cm H20 continuously to promote drainage
Can you take suction off chest tube?
yes, as long as you still have waterseal
3 bottle chest tube drainage system
water seal PLUS suction PLUS separate drainage container to measure what's coming out
How often do you measure chest tube drainage
depends on policy
What position do you place a person with chest tube
usually Fowlers
but any position is fine EXCEPT laying on tubing
Can patients ambulate with chest tube
YES! THEY SHOULD! you carry chest tube system while patient walks
What is dressing for chest tube
vaseline gauze or split 4x4 covered with tape

change prn or hospital policy
What are flucuations with chest tubes?
water rises with inspiration adn falls with expiration
When do you see no fluctuations in chest tubes system
if tubing is occluded or if lung is totally re-expanded
What does it mean if bubbles are seen in the "left arm" of the water seal chamber
there is an air leak!!!
What do you do if there is an air leak in the chest tubes system
check connections, container, and site! if still leak, CALL PHYSICIAN!!!
What should you do with chest tubes drainage system at end of shift?
mark the site to figure out I and O
What will color of chest tube drainage be like?
depends on placement
early after surgery- lots of output and blood
When should you call the physician in terms of chest tubes drainage?
if over 100 cc/hr!!!

could be actively bleeding!
What should you NOT do to chest tube
clamp or milk or strip

may cause damage
What do you do with clot in chest tubing?
tap on tubing or gently kneed to work out
What do you do if patient with chest tubes has difficult breathing
assess patient and tube, look at whole picture (may be caused by pain), could be tension pneumo, PE, or hemorrhage
What does TCDB do?
promote reexpansion of lung, drainage, prevent atelectasis, medicate frequently for pain
How do you pull out chest tube
check policy
have patient valsava, clamp and pull out, cover with vaseline gauze and 4x4
What does a high ventilatory alarm mean?
obstruction
kink or goo
probably secretions
anticipate suction
What does a low ventilatory alarm mean?
leak
disconnection
extubate
What do you do if ventilatory alarm sounds and you're in doubt of what to do
ambu
What emergency equipment should be at bedside with ventilator
ambu, suction, o2
Who puts in chest tube
NP or MD
what does it mean if bobber in chest tube is moving up and down?
suction is on
How do you tell if coumadin or heparin therapy has been effective
optimum PT, PTT, INR
no new DVT or PE
What is normal PTT on heparin therapy
2-2.5 times normal
What is normal PTT
20-30
What are heparin protocols based on?
weight
When do you monitor PTT when on heparin
4 hours, then Q 6 hours after
What is normal hep therapy?
bolus then continuous (5,000 units)
What is point of heparin therapy
prevent clots
How is protamine sulfate given
IV ONLY!
What is protamine sulfate given for
too much heparin
What is the antidote for heparin
protamine sulfate
How should you give protamine sulfate
IV SLOWLY!
Why can't you give protamine sulfate IV quickly?
drop BP
What is antidote for Coumadin/Warfarin?
Vitamin K
Why do you give Coumadin WHILE on heparin?
to try to ease off Heparin
What do you monitor while on Coumadin
PT and INR
What is normal INR
1
What is INR on coumadin
2-3
What are bleeding precautions
no hard toothbrush
fall risk
don't cut nails
no sticks
watch while shaving
What is cause of code with PE
hypoxia
When do you stop Heparin therapy
if PTT OVER 100!!
Why do you stop heparin if PTT over 100
greater risk of bleeding than you have of getting another PE
What would an INR of 7 mean to the nurse
SAFETY! HIGH RISK FOR BLEED!

GIVE VITAMIN K IV OR SUBQ!
When should you hold heparin
based on protocol or over 100 PTT
Why is Coumadin given at night?
because we check labs in the morning and it will reflect a steady state
What do you do if theres a stick ordered and the INR is too high
call physician and document
What happens in blood in stool but no signs of bleeding?
contact MD or if worried, call 911
What happens if the patient turns off their heparin drip?
restart and call teh MD
what diet precautions should a patient be given when on coumadin
do not increase or decrease anything in your diet!