 Hi, welcome to nursing school explaining this video on chest trauma, specifically pneumothorax and hemothorax. In terms of pathophysiology, pneumothorax occurs when air enters the pleurocavity and hemothorax occurs when blood enters the pleurocavity. Now risk factors include blunt trauma such as from a motor vehicle collision or a fall with significant injury to that chest wall, as well as penetrating trauma such as knife injuries or gunshot wounds. We can also have the occurrence of a spontaneous pneumothorax, which basically means that a small bleb, a small part of the alveoli ruptures and then air escapes into the pleurocavity. And tall, thin people are at risk for a spontaneous pneumothorax because of their physical makeup because of that tall and thin thoracic cavity that tends to happen, unfortunately. And also patients with underlying lung issues such as COPD, asthma, cystic fibrosis are at risk for bleb rupture and spontaneous pneumothorax. Now pneumothorax can also be caused by a procedure which is then called the iotrogenic pneumothorax. And this can happen when a central line is inserted or during a lung biopsy. So somehow during the procedure inadvertently a lung is punctured letting the air release into that pleurocavity. Over here in terms of the anatomy, so here we have the chest cavity and the lung on the right side has definitely been deflated. As you can see it's kind of shrunk up. The left lung here in the patient is still normal and then up here we have the trachea and the two minstem bronchi. So when air enters here it's called a pneumothorax and when blood is in this pleurocavity it's called a hemothorax. But the patient can also have a combination, a pneumohemothorax or hemolumothorax. Signs and symptoms of both hemothorax and pneumothorax when that lung is being deflated include significature as a breath as well as maybe cough or bloody sputum, cyanosis depending on the severity of that lung being deflated and then there might be a sucking chest wound and what that means is if there is a traumatic injury and now we have a whole human opening in the pleurocavity then because of the nature of the negative pressure that usually is in the lungs if there now is an opening air will enter through this sucking chest wound and that's usually what it sounds like it's kind of like suction in the air. On this affected side we will have diminished or absent breast sounds as well as see asymmetrical chest movement because the lung is now no longer fully expanded causing the full expansion of the chest and there might be subcutaneous emphysema which basically means that there is now air underneath the skin and that can be palpated and some people describe it as rice crispies so it feels like rice crispies and also almost sounds like rice crispies when you palpate it and there might be bruising or open chest wounds that we can see from this traumatic injury. Now in terms of vital science patient will be hypotensive if there's a significant hemothorax because now the blood is pulling in the thoracic cavity and not in the intravascular space anymore and the patient will start to look like they're developing hypovolemic shock. Heart rate will be increased partially also due because of the increase of the sympathetic nervous system activation respiratory rate will go up and our two-set will be decreased. A complication from a pneumo or hemothorax is called a tension pneumothorax and the patient here will be in severe distress and what that means is now that this air here is entering or the blood or the air is just pushing this lung out of the way so much that now it causes the entire structures of that affected side to move over to the left so it pushes the heart the trachea all these structures that are connected over to the unaffected side and this is also called a media stynum shift so across the media stynum is where that shift occurs and what this is a clear medical emergency patient will be very tactic heartache they will have tracheal deviation because of the shift the trachea will move and that will be visible to you the patient will also have JDD because these blood vessels are now being almost kind of occluded with that shift that occurs and the blood will be backing up into the jugular veins. Patient will be cyanotic as well as diapheretic in the shock state and again diminished or decreased or absent breast sounds here. Now the treatment for a tension pneumothorax is needle decompression and that is just an emergency measure to get this patient to buy the physician or the provider some time until a chest tube can be inserted which is more of a definite treatment but if we have a tension pneumothorax that means that this is an emergency that's happening right now chest tube insertion takes a little bit of time for setup and the actual insertion but a needle decompression can be done very quickly and what is done if we have the intra intercostal spaces here the provider will serve just a regular ID catheter a large four ID catheter such as 1816 or 14 French into the intercostal space and then leave that plastic piece of the catheter in place and that will basically release the air out of the chest cavity now it's basically kind of like a pressure cooker if the air here is so there's so much air in this plural cavity and we open it up on the top it has time to escape we're told to release the structures back over but again it's not a definitive treatment it's just to buy some time until the chest tube can be inserted and these patients will be so sick and because of the significant amount of trauma that they've gone through that they most likely will need mechanical ventilation to care for them. In terms of diagnostic tests a chest x-ray is usually indicated and there's a fairly quickly test that can be done fairly quickly and the CT and an ultrasound might be performed as well but it all depends on how significantly ill the patient is to see if we have enough time to take the patient to CT certainly you want to look at a CT and the lactate level as always indicated in anybody with traumatic injury as well as hemoglobin and immaculate to measure the amount of blood loss the patient might be suffering. Coagulation studies such as PT and INR and they cross match to get ready to transfuse the patient if there is no hyperbolemic shock associated with this traumatic injury. In terms of nursing care we always want to assure our ABCs first place the patient on high flow O2 and establish large four IVs times two that usually means at least an 18 gauge in one extremity to prepare for fluid resuscitation blood and administration and maybe any other medications that the patient might need. We want to elevate the head of the bed to facilitate better air movement and breathing however if there is a concern regarding a cervical spine injury if this was from a follow on a vehicle crash we want to be very careful on elevating the head of the bed and maybe not do that because we don't want to make any cervical spine injuries worse by elevating the head of the bed. Certainly the patient will need analgesia because this was a significant amount of trauma that's causing a lot of pain. If there is a second chest wound that we just discussed it needs to be covered with a non-porous dressing and taped to three sides which will basically create a one-way valve that lets the air escape but it won't allow the air to be sucked back into the chest cavity and then allow it to kind of passively deflate and this is just a temporary solution until the more definite treatment can be accomplished with the insertion of a chest tube. Chest drainage systems and chest tube management are very special procedures and it takes a little bit of skill and understanding to understand chest tubes so please watch my separate video about chest tube management here on Nursing School Explained. Thanks for watching.