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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

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chest trauma chest tubes underwater seal drainage

Chest Trauma, Chest Tubes & Underwater Seal Drainage

By: Victoria Murray

& Mary Beth Chauder

  • 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
The Respiratory System

(Day et al., 2010)

ventilation mechanisms
Ventilation Mechanisms

(Day et al., 2010)

what is chest trauma
What is Chest Trauma?

Classified as either:

Blunt or Penetrating Trauma

blunt 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
Penetrating Trauma

Most Common Causes:

  • Gunshot
  • Stab Wound

Classified By:

Velocity: Stab Wound Low

Gunshot High

initial assessment of suspected chest trauma
Initial Assessment of Suspected Chest Trauma


Temperature, Pulse, RR, BP, SPO2 & PAIN


Respirations Effort & Depth; Chest Wall Symmetry. Paradoxical Chest Wall Motion; Bruising ; Penetrating Wounds


Trachea for deviation; Adequate and Equal Chest Wall Movement; Chest wall tenderness; Rib 'crunching' indicating rib fractures


Percuss Both Sides of the Chest Looking for Dullness or Resonance


Normal & Equal Breath Sounds

(Brown et al., 2009)

secondary assessment of chest trauma
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
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
Pneumothorax defined & types individually discuss
  • Three Types:
  • Simple
  • Traumatic
    • Open
    • Hemothorax
  • Tension

(Day et al., 2010)

tension pneumothorax
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)


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


  • Sudden onset of pain
  • ↓ Tactile Fremitis
  • Absent breath sounds
  • Hyperresonant Percussion
  • Minimal respiratory



  • 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
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
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
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
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
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 fractures1
Sternal & Rib Fractures


  • Chest Pain
  • Ecchymosis
  • Crepitus
  • Swelling
  • Chest Wall Deformities


  • Pain Control
  • Deep Breathing and Coughing
  • Surgery is Rarely Necessary

Patient Must Be Closely Monitored for Underlying Cardiac Injuries!!

flail chest
Caused by Blunt traumaFlail Chest

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

Pulmonary Contusion

(Day et al., 2010)

pulmonary contusion1
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
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
  • 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 embolism1
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.

Nurses need to watch for it!

misdiagnosed why
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.

Misdiagnosed for

who is at risk
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
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
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
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


PC: Bleeding

Risk for infection


Chest Tubes

Chest Tube

what are chest tubes
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
Indications for Use

(Briggs, 2010)


Tension Pneumothorax

Bilateral Pneumothoraces


Post-Operatively (Cardiac Surgery)

Pleural Effusion



Esophageal Rupture with Gastric Contents in Pleural Space

equipment required
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
Chest Tubes Continued

There are two types of Chest tubes:



pleural chest tube
Pleural Chest Tube

Durai, et al., 2010; Perry & Potter, 2010

mediastinal chest tubes
Mediastinal Chest Tubes

Perry & Potter, 2010

pre insertion of chest tubes
Pre-Insertion of Chest Tubes

* MD responsible for admin of analgesic

(Durai, 2010)

  • 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
methods for insertion
Methods for Insertion

Durai, 2010

Two Methods for Tube Insertion

Trocar based (i.e. the Seldinger technique)

Allows for easier insertion

Greater Risk

Less Painful

Blunt dissection

More painful for the patient

Safest Method

chest drainage systems
Chest Drainage Systems

(Day et al., 2010).

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
traditional water seal drainage system
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
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
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).

management of chest tube
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
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
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.

patient assessment
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
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
Complications of CT drainage systems

(Durai et al., 2010; Sullivan2008).

  • 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.
what if the tubing becomes dislodged
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
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
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
Post Removal Nursing Interventions

Respiratory Assessment

Assess Vital Signs

Chest X-Ray

Assess Pain

Assess Wound & Dressing

pain management related to
Pain ManagementRelated 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
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?


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 MedicalSurgical 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