Thoracic Injury Management Jan 08

8/10/2019 Thoracic Injury Management Jan 08

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THORACIC INJURY

MANAGEMENT

A GUIDE FOR

EDUCATION & COMPETENCY

Compiled by: Pat Standen,

Grampians Regional Trauma, Emergency and Critical Care Coordinator.


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ACKNOWLEDGEMENTS

Thank you to:Wendy Porteous, Clinical Educator, Emergency Department, Ballarat Health Services,

and Dr Andrew Dean, Director of Emergency Medicine, St John of God Health Care forreviewing the document and providing their expert advice.

Ballarat Health Services and Rural Ambulance Victoria for so generously allowing their

clinical practice guidelines to be used as a guide.

For information regarding this Guide contact:Pat StandenDepartment of Human ServicesPO Box 712Ballarat 3353Email: [email protected]: 03 5333 6026http://www.dhs.vic.gov.au/regional/grampians/

Version Date Major Changes Page No1.0 January 2008

Front page image sourced from -http://images.google.com.au/imgres?imgurl=http://www.24dr.com/reference/pictures/6.jpg&imgrefurl=http://www.24dr.com/reference/pictures/lungs_ribs.htm&h=226&w=271&sz=25&tbnid=cbuw7fG0VOhnCM:&tbnh=90&tbnw=108&hl=en&start=16&prev=/images%3Fq%3Dribs%2Blungs%26svnum%3D10%26hl%3Den%26lr%3D

DISCLAIMER:

Care has been taken to confirm the accuracy of the information presented in this guide, however, the authors,editors and publisher are not responsible for errors or omissions or for any consequences from application of

the information in the guide and make no warranty, express or implied, with respect to the contents of the

publication.

Every effort has been made to ensure the clinical information provided is in accordance with current

recommendations and practice. However, in view of ongoing research, changes in government regulationsand the flow of other information, the information is provided on the basis that all persons undertake

responsibility for assessing the relevance and accuracy of its content.

Thoracic Injury Management - January 2008 Page 2 of 39


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TABLE OF CONTENTS

Page

INTRODUCTION 4

SECTION 11.0 Overview Anatomy and Physiology 5

1.1 Bones 51.2 Muscles of respiration 61.3 Internal organs 61.4 The mechanics of breathing 9

SECTION 22.0 Assessment 11

2.1 Preparation for arrival 112.2 Mechanism of injury 11

2.3 Danger 122.4 Response 122.5 Primary survey (breathing) 122.6 Secondary survey (thorax) 12

Primary Survey Chart 13Secondary Survey Chart 14

SECTION 33.0 Thoracic Injuries 15

3.1 Mechanism of injury 153.2 Chest wall injuries 17

3.3 Pulmonary injuries 18

3.4 Mediastinal injuries 23

SECTION 44.0 Procedures 25

4.1 Needle thoracentesis 254.2 Thoracostomy 26

4.2.1 Indications 264.2.2 Sizes 264.2.3 Equipment 264.2.4 Technique 27

4.2.5 Complications 304.2.6 Post Insertion 30

4.2.7 Documentation 304.2.8 Chest Drainage System 304.2.9 Heimlich Valve 31

SECTION 55.0 Pain Management 33

5.1 Thoracic Injury Pain Management 335.2 Pain Assessment 34

5.3 Pain Severity 345.4 Treatment Choices 34

REFERENCES 38SUGGESTED FURTHER READING 39



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INTRODUCTION

The purpose of this guide is to assist educators in the Grampians Region to design theirown Health Service specific package for Registered Nurses Division 1 & 2 required to

manage patients in an emergency situation. The aim of this guide is to provide genericinformation based on principles of care.

It is the responsibility of each individual practitioner and Health Service to ensureappropriate education for all equipment and that competency in the use of theequipment is maintained.

The majority of this guide refers to adults. For information regarding paediatric trauma

management it is suggested you refer to the Paediatric Trauma Manual and CDprovided to all trauma services in the Grampians Region.

Bevan, C. and Officer, C. (Editors) 2004 Paediatric Trauma Manual, Practical TraumaProcedures pp291-311, Royal Childrens Hospital, Melbournewww.rch.org.au/paedtrauma

http://www.rch.org.au/paedtraumahttp://www.rch.org.au/paedtrauma


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SECTION 1

1.0 OVERVIEW OF ANATOMY AND PHYSIOLOGY

1.1 Bones: protector of thoracic contents

1.1.1 Ribs

The first seven (7) ribs are called true ribs. These are attached posteriorly to thevertebrae and anteriorly, through cartilage, to the sternum

The next three (3) ribs are called false ribs. They are attached posteriorly to thevertebrae and anteriorly they are attached to the costal cartilage of the ribsabove

The last two (2) ribs are called floating ribs. The posterior end is attached to thevertebrae and anteriorly they are unattached

1.1.2 Sternum

Sits anterior midline with the thoracic cavity

Manubrium - superior portiono Articulates with clavicles laterally and first two pairs of ribs

Mesosternum (body) - mid portion

o Bulk of sternumo Articulates with third to seventh ribs

Xiphoid process - inferior end

o Articulates with body

o Anchors diaphragm and some abdominal muscles1.1.3 Scapula

Two triangular flat bones located on the dorsal thorax between ribs two to seven

Each has three borderso Superior shortest bordero Medial parallels with vertebral columno

Lateral abuts the armpit and has small shallow fossa called the glenoidcavity which articulates with the humerus to form the shoulder joint

1.1.4 Clavicles

Extend horizontally across the upper thorax

The rounded medial sternal end attaches to the sternum manubrium

The flattened lateral acromial end articulates with the scapula

Source of images:http://images.google.com.au/imgres?imgurl=http://www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_images/15_t.gif&imgrefurl=http://www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_car1_crs_lec02.htm&h=144&w=200&sz=11&tbnid=q-

irhPrfGZ_gLM:&tbnh=71&tbnw=99&hl=en&start=56&prev=/images%3Fq%3Dmediastinum%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN



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1.2 Muscles of respiration:

1.2.1 Intercostal:The main muscles of the chest wall are the internal and external intercostal muscles.Each one extends from one rib to the rib below. They run obliquely and at right anglesto each other

External intercostals Eleven pairs lie between the ribs

Function is to drawer the ribs together and elevate the rib cage and enlarge thethoracic cavity horizontally

Internal intercostals

Eleven pairs lie between the ribs

Function is to decrease the dimensions of the thoracic cavity through passiverelaxation

1.2.2 Diaphragm:The main muscle of respiration. It stretches across the base of the thorax, separatingthe thoracic cavity from the abdominal cavity. The diaphragm contracts downwardsduring inspiration enlarging the thoracic cavity vertically.

1.3 Internal organs:

1.3.1 Trachea

Half housed in the neck and half in the thorax

Moves up/down 5 cm.

Extends from cricoid cartilage to the level of the carina at the level of the fifththoracic vertebrae

1.3.2 Bronchi

The trachea bifurcates into right and left main stem bronchus at the sternal

angle (where the second rib is attached) within the mediastinum

The bronchi leave the mediastinum and enter the lungs at the hilum along with

the great vessels



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1.3.3 Bronchioles

Conduct air down into the alveoli, where gas exchange takes place

1.3.4 Great vessels

Aorta, inferior and superior vena cava

Pulmonary vessels

1.3.5 Oesophagus

Muscular tube

Approx 25cms long

Collapses when no food propulsion

Thoracic divisions there are three subdivisions of the space within the thoracic cavity.The two lateral subdivisions hold the lungs; between the lungs is the mediastinum.

1.3.6 Mediastinum contents

The thymus gland

The thoracic duct

Small lymph nodes The heart

A branch of the phrenic nerve

Parts of the trachea

Parts of the oesophagus

Great vessels includingo Aortic Arch

o Roots of subclavian arteries

o Roots of brachio-cephalic artery

o Roots of left common carotid arteries

o Superior vena cava

o Pulmonary trunk

o

Brachio-cephalic veinsMost of these structures communicate with other parts of the body:

The blood vessels bring blood from the rest of the body and carry it away fromthe heart

The phrenic nerve and oesophagus pass through the mediastinum inferiorly andterminate in the diaphragm and stomach respectfully.

Source of image:http://images.google.com.au/imgres?imgurl=http://www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_images/15_t.gif&imgrefurl=http://www.med.uottawa.ca/medweb/demo_site/undergrad/webct/lectures/curriculum_cardio/e_car1_crs_lec02.htm&h=144&w=200&sz=11&tbnid=q-irhPrfGZ_gLM:&tbnh=71&tbnw=99&hl=en&start=56&prev=/images%3Fq%3Dmediastinum%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN



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1.3.7 The heart

Size of a persons fist

Weighs 250-350 grams

Sits in mediastinum in thoracic cavity

Extends from second rib to fifth intercostal space

Lies anterior to vertebral column and posterior to sternum Approx 2/3 extends to left side

Covered byo Parietal pericardium

Fibrous layer

Serous layer

o Visceral pericardium

o Epicardium

Cardiac muscle

o epicardium

o myocardium

o endocardium

Source of image:http://images.google.com.au/imgres?imgurl=http://media.wiley.com/assets/8/01/0-7645-5422-0_0901.jpg&imgrefurl=http://www.dummies.com/WileyCDA/DummiesArticle/id-1211,subcat-MATH.html&h=367&w=525&sz=40&tbnid=kAIGlawwwoD7JM:&tbnh=90&tbnw=129&hl=en&start=4&prev=/images%3Fq%3Dcardiac%2Banatomy%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DX

1.3.8 LungsThe lungs straddle the heart with the right lung shorter and broader than the left. Eachlungs concave base rests on the diaphragm, and the apex extends slightly above thefirst rib. The hilum provides an opening through which the pulmonary and bronchialblood vessels, lymphatics and nerves pass. The lungs are anchored at the level of thehilum.The lungs should never completely collapse as there is always a small amount of air leftin them. This is called the residual volume, air that cannot be exhaled even after

maximal effort.

The pleurae - thin layers that wrap structures in the chestParietalpleura

Lines thoracic wall and mediastinum

Folds around the heart, between lungs

Extends as visceralpleura to cover external lung surface

Divides thoracic cavity into three chambers

Produces pleural fluid which

o Allows lungs and thoracic cavity organs to move and slide easily

o Reduces friction

o Holds visceral and parietal pleurae together

Pleural cavityo Space between the two membranes

Pleural space potential (negative pressure)

Essential for normal lung function



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1.4 The Mechanics of Breathing

Respiration is a cycle of active inspiration and passive expiration whereby air moves inand out of the lungs due to changes in pressure. The lung itself expands because of themovement of the diaphragm and chest wall.

Pressure relationships in the thoracic cavity:The intrapulmonary pressure, the pressure within the alveoli of the lungs, rises and falls

with the phases of breathing but will always equalise to the atmospheric pressureoutside the body.

The intrapleural pressure, the pressure within the intrapleural space, also fluctuateswith breathing. However this pressure is always about 4mm Hg less than in the alveoliand is said to be negative. This negative pressure results from two factors, (a) factorsacting to hold the lungs to the thoracic wall and are opposed to (b) the factors acting topull the lungs away from the thorax wall.Three main factors holding the lungs to the thoracic wall:

1. The adhesive force created by pleural fluid in the pleural space2.

Absorption of gases in the pleural space into the capillary blood creating a partialvacuum

3.

The positive pressure in the lungsTwo factors acting to pull the lungs away from the thoracic wall:

1. The natural recoil tendency of the lungs2. The surface tension of the fluid film in the alveoli that constantly acts to collapse

the alveoli.

The importance of the negative pressure in the intrapleural space and the tight couplingof the lungs to the thoracic wall cannot be overemphasised. Any changes to this cancause the lung to collapse.

InspirationOn inspiration the diaphragm is stimulated by the phrenic nerve, causing the diaphragm

to contract and move inferiorly and flatten thus increasing the vertical diameter of thethoracic cavity. Contraction of the external intercostal muscles causing elevation of therib cage and thrusting forward of the sternum. This causes an increase in thoraciccavity volume and hence decreases pressure in the lungs. This volume change makesthe intrapulmonary pressure lower than atmospheric pressure, thus drawing air into thelungs. Normal inspiration ceases when the atmospheric and intrapulmonic pressureequalises.



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ExpirationWhen the nerve impulses to the diaphragm cease, the diaphragm returns to its relaxed,elevated state, the intercostal muscles relax and the chest wall moves back in, thelungs return to their resting size and position. This passive reduction in the lung sizeand thoracic cavity volume causes intrapulmonic pressure to rise above atmospheric

pressure so air leaves the lungs.

Source of inspiration and expiration images:http://images.google.com.au/imgres?imgurl=http://owensboro.kctcs.edu/gcaplan/anat2/notes/Image250.gif&imgrefurl=http://owensboro.kctcs.edu/gcaplan/anat2/notes/Notes4%2520Function%2520of%2520the%2520Respiartory%2520System.htm&h=400&w=699&sz=37&tbnid=XXo-MWmbwHbJhM:&tbnh=78&tbnw=138&hl=en&start=3&prev=/images%3Fq%3Dexpiration%2Batmospheric%2Bpressure%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DG

Why the lungs dont collapse The negative pressure between the two pleurae maintains partial lung expansion bykeeping the lung pulled up against the chest wall. Under normal conditions there isalways negative pressure in the pleural cavity. The degree of negativity changes duringrespiration. Under normal conditions the mechanical attachment of the pleurae, plus the

residual volume, keep the lungs from collapsing



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SECTION 2

2.0 Assessment

Hypoxia and hypoventilation are the primary killers of trauma patients. Within the

primary survey, breathing is the step that will identify most chest conditions.Thoracic injuries can cause damage to:

Chest wall: causing fractured ribs, fractured sternum, flail chest or open chestwounds

Blood vessels: causing ruptured great vessels, haemothorax and contusions tomajor organs

Lungs: causing contusion, pneumothorax, tension pneumothorax or surgicalemphysema

The principle aim of the primary survey is to identify and treat life threatening injuries.In thoracic trauma these include:

Tension pneumothorax

Massive haemothorax

Open pneumothorax Cardiac tamponade

Flail chest

Patients may present with:

Multiple trauma with involvement of the thorax

Isolated chest injury secondary to blunt or penetrating trauma

Pain

Tachycardia, respiratory distress

Hypotension

Remember:

Use your eyes to look/see

Use your ears to listen/hear

Use your hands to feel/touch

Use your mind to problem solve

Use your experience/intuition to guide you

Use your common sense to know what is right and wrong

2.1 Preparation for arrival

Ensure the Doctor has been notified and his/her expected time of arrival isknown

Call for assistance RNs from other wards or back up staff if required

Delegate and prioritise tasks (person in charge, airway, scribe, procedures etc)

Ensure emergency area clear and accessible

Turn on monitors and set up/check all equipment Attempt to obtain brief history of events leading to presentation

Commence documentation

Initiate transfer if necessary

2.2 Mechanism of InjuryConsider:

Car occupants involved in high speed MCA; e.g. impact speed >60kphwith major damage to vehicle

Pedestrians hit by vehicles travelling at >30kph

Patients ejected from vehicles following MCA

Patients in car, which has rolled over following MCA



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Patients in car where the death of another occupant in that car hasoccurred

Patients falling from a height greater than 5-6 metres

Patient hit by an object, which has fallen greater, than 5-6 metres

Motorcyclists, cyclists

Explosions

The injured patient who is trapped, and has remained so for >30 minutes.

2.3 Danger

Ensure your own safety first

Make sure your work area is safe

Assess risks and, if needed, control hazards, seek assistance.

2.4 Response

Can you hear me?

Open your eyes

Whats your name?

Squeeze my hand

2.5 Primary survey (Breathing)Assessment:

Expose the chest - note rate, rhythm and depth of respiration

Look for chest wall symmetry, equal chest wall movement, paradoxical chestwall motion

Look for bruising, contusions, penetrating wounds

Feel for tracheal deviation and signs of tension pneumothorax

Feel for tenderness over chest wall and subcutaneous emphysema

Listen for breath sounds equal on both sides. Can patient talk? (words,sentences)

Percuss both sides of chest for dullness or resonance. Hypo resonance (fluid),hyperresonance (air)

Management: Administer oxygen high flow 6-15 l/min

Breathing ineffective bag valve device with high flow oxygen, intubate

Tension pneumothorax needle thoracotomy & chest tube

Sucking chest wound 3 sided non porous dressing

Flail chest consider assisted ventilation

Haemothorax insert chest tube

2.6 Secondary survey (thorax)Examine the entire chest (front, back and two sides) for injury:

Palpate the clavicle and ribs;

Apply gentle sternal compression to detect sternal fractures or flail segments;

Auscultate breath and heart sounds, Do ECG.

Think abdominal injuries if lower ribs injured.

Consider cardiac/pulmonary contusion, cardiac arrhythmias, ruptured aorta,ruptured diaphragm, and perforated oesophagus.

Monitor oxygen saturation if not already started in primary survey

Pay attention to end tidal carbon dioxide if patient intubated

Investigations: (depending on availability)

Chest X-ray

CT scan

Arterial blood gas analysis

Pathology



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Enquiries to: Pat Standen 5333 6026 [email protected] Jan 2008

mailto:[email protected]:[email protected]:[email protected]


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Enquiries to:Pat Standen 5333 6026 or [email protected] Jan 2008

Adult Retrieval Victoria: 1300 36 86 61
mailto:[email protected]:[email protected]


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SECTION 3

3.0 THORACIC INJURIES

Mechanical energy is the most common energy source associated with chest injury.

Motor vehicle accidents (MVA) cause 80% of chest trauma MVA are the contributing factor in 50% of deaths

Death rate in isolated chest injury is approximately four to eight percent

Early deaths are due to

o Airway obstruction

o Flail chest

o Open pneumothorax

o Massive haemothorax

o Tension pneumothorax

o Cardiac tamponade

Later deaths are due too Respiratory failure

o

Sepsis

3.1 Mechanism Of Injury

Action of forces and energy on the bodyTissues are injured when exposed to excessive amounts of mechanical, electrical,thermal or chemical energy and/or deprived of heat and oxygen.

Kinetic Energy (energy in motion):The wounding potential of an event is affected by the amount of kinetic energy that is

transferred to the patient. Kinetic energy (KE) is determined by the mass of the objectin motion and its velocity (speed) or amount of acceleration. KE = mass X velocity2 .

Speed is more important than mass. Doubling the mass doubles the energy whereasdoubling the speed generates four times the energy

Newtons Laws of Motion:When a body is set in motion it will remain in motion until acted on by another force(causes deceleration). Deceleration forces cause deformation of tissue referred to asstrains:

Tensile or stretching

Shear opposing forces across an object

Compressive or crushingWhen the deforming force exceeds the tissues ability to regain its original shape

(elasticity) or its ability to resist a change in shape during motion (viscosity) tissueinjury will occur. For example, when a vehicle travelling at a set speed is suddenly

stopped (crashes), the occupant continues to travel at that speed until an outside forceor object causes the occupant to stop (seat belt, steering wheel, air bag, vehicleinterior). There are some internal organs that are not anatomically fixed that willcontinue in motion until stopped by a hard structure or the strain on flexible points ofattachment. The first impact is car to tree, the second impact is occupant to steering

wheel and third impact is heart to sternum.

Acceleration and deceleration forces can cause injuries to the thoracic contents. Thefirst and second ribs and the sternum resist energy forces better than most other

bones. If these bones are fractured you can suspect significant injury to underlyingstructures. Mechanical energy applied to the chest can cause fractures along with bluntcardiac injury and pulmonary contusions. The relative fixation of the descending aorta



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makes it susceptible to injury through deceleration forces. Penetrating injury to theheart usually injures the right ventricle.

Deceleration forces cause heart, aorta and bronchus distal to the carina to tearfrom points of attachment.

Compressive forces that cause fractures of relatively strong skeletal structures

can also cause underlying organ damage:o Ribs pulmonary contusion, injury to pulmonary artery, lacerated liver,

spleen or ruptured diaphragmo Scapula pulmonary contusion, brachial plexus disruption

o Sternum cardiac contusion, lacerated liver

Ecchymosis or abrasions in areas consistent with the seat belt should alert youto the potential for pulmonary and/or cardiac contusion or rib fractures with orwithout a flail segment.

Blunt injuries:Blunt forces involve compression, deformation or sudden change in atmosphericpressure. They result in contusions, lacerations, fractures or ruptures and could involvea number of structures.

Penetrating injuriesPenetrating forces involve direct contact with an instrument that cuts the skin. Lessforce is required to injure and usually result in less structures being involved.



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3.2 Chest wall injuriesChest wall injuries are very common following blunt trauma.

3.2.1 Rib fracturesThe most common type of blunt chest injury in adults. Lower rib fractures may beassociated with diaphragmatic tears. Left lower rib fractures may be associated with

splenic injury. Right lower rib fractures may be associated with hepatic injury. Due tothe amount of force required to fracture the first rib close assessment looking for other

injuries should be undertaken.Symptoms:

Pain on inspiration

Localised tenderness over fracture site

DyspnoeaDiagnosis:

Usually clinical diagnosis

X-rays may miss a large number of fracturesManagement:

Oxygen and airway management

Analgesia

Strapping should be avoided as it can lead to interference with ventilation andlead to atelectasis

Consider admission to hospital foro Fractures of 3 or more ribso Flail chest

o Those with respiratory co-morbidityo Those with complications of fracture (pneumothorax etc)

o Uncontrollable pain

o Inability to cope at home

3.2.2 Sternal fracturesSternal fractures are most commonly associated with steering wheel impact. The most

common fracture site is the manubrium and the body of the sternum (angle of Louis)that is adjacent to the second intercostal space.Symptoms:

Localised tenderness and haematomaDiagnosis:

Chest X-ray, to exclude other injuries

ECG, to exclude myocardial infarction or cardiac arrhythmias

CK/troponin, may be of limited valueManagement:

Oxygen and airway management Analgesia

Chest physiotherapy

Consider admission to hospital foro Presence of obvious cardiovascular sequelae during presentationo Those with respiratory co-morbidityo Those with complications of fracture (pneumothorax etc)o Uncontrollable paino Inability to cope at home

3.2.3 Flail chestFlail chest occurs when a portion of the chest wall becomes isolated by multiplefractures, or disruption of the cartilaginous costo condral junctions. Usually by multiple

anterior rib fractures of at least two fractures per rib, in at least two ribs (causing a freesegment) or when rib fractures cause a free floating sternum.



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The flail segment moves paradoxically or opposite from the rest of the chest wall duringinspiration and expiration. Associated lung contusion is common with a flail segment.Symptoms:

Bruising, grazes on visible inspection

Localised pain especially on inspiration

Dyspnoea

May be crepitus associated with fractured ribs Paradoxical chest wall movement

Diagnosis:

Radiology may assist

Paradoxical chest wall movementManagement:


Analgesia

Ventilatory assistance intubation may be required

Consideration of prophylactic ICC insertion

3.3 Pulmonary injuries

3.3.1 HaemothoraxAn accumulation of blood in the pleural space, may be caused by blunt or penetratingtrauma

Minimal less than 350mls

Moderate 350 to 1500mls

Massive greater than 1500mlsSigns & Symptoms:

Signs of significant trauma, bruising, lacerations and/or penetrating object

Decreased breath sounds on injured side Dullness to percussion in dependant areas

Decreased chest expansion

Dyspnoea, tachypnoea

Chest pain

Signs of shockManagement:


Thoracostomy (Insertion of a tube into the pleural space through a smallincision).(Refer Section 4 Procedures)

Thoracotomy (Incision into the chest wall)

Thoracoscopy (Endoscopic examination of the chest cavity)



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3.3.2 PneumothoraxAn accumulation of air in the pleural space. This may result in pulmonary andcardiovascular compromise.

Spontaneous

o Tall thin young males

o Marfans syndrome

Secondaryo Trauma

o Asthmao Iatrogenic

o TBo Pneumocystis pneumoniao Carcinoma

o Sniffingo IV drug users due to attempts at central vein injection

o Associated with Valsalva, prolonged inspiration in marijuana smokers

Loculated

o In patients with pleural adhesions due to previous pleural inflammatoryconditions or previous intercostal catheter (ICC) insertion

Signs and Symptoms:

Chest pain (in 90%)

Dyspnoea (in 80%)

Decreased chest motion

Cough

On the side of the pneumothorax

o Decreased breath sounds

o Decreased vocal fremitus

o Increased percussion noteManagement:


Chest X-ray not always reliable, better in erect films CT more sensitive than X-ray

Conservativeo In a pneumothorax involving less than 20% of the hemithorax, with no

respiratory compromiseo Repeat CXR in 24 hours and again at 3 5 days

Catheter aspirationo Approximately 70% success rate

o Use 16G IV cannula or purpose built catheter

o Insert (anterior approach) into 2ndintercostal space in the mid clavicularline or (axillary approach) 5th intercostal space, mid axillary line just

above the upper edge of the rib below on the affected side

o

Infiltrate with local anaesthesia above the rib belowo Using an extension tubing, 60ml syringe and a three way tap aspirate up

to three litreso Re X-ray

Thoracostomy (Refer Section 4 Procedures)

3.3.3 Tension pneumothoraxA life threatening injury usually due to a lung laceration. Air enters the pleural space oninspiration, but the air cannot escape on expiration. Rising intrathoracic pressurecollapses the lung on the side of the injury causing a mediastinal shift, to the other side

of the chest, that compresses the heart, great vessels, trachea and ultimately theuninjured lung. Venous return is impeded, cardiac output falls and hypotension results.



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Tension pneumothorax may develop insidiously especially in patients with positivepressure ventilation which may exacerbate the one way valve effect. The presence of achest tube does not mean a tension pneumothorax cannot develop.

Signs and symptoms:

Severe respiratory distress

Tachycardic

Tachypnoea

Breath sounds and percussion may be difficult to assess and misleading

Hypotension

Distended neck veins, head and upper extremity veins

Hyper expanded chest

Tracheal deviation away from the side with the tension (late)

Cyanosis (late)

Management: Oxygen and airway management

Tension pneumothorax is a clinical diagnosis and immediate decompression should beperformed.

Needle thoracentesis (Refer Section 4 Procedures)

This intervention will convert a tension pneumothorax into a simplepneumothorax

Follow up with insertion of ICC

3.3.4 Open pneumothorax (sucking chest wound)A pneumothorax associated with a chest wall defect allowing the pneumothorax to

communicate with the exterior of the body. It results from a wound through the chest

wall which allows air to move in and out of the pleural cavity resulting in impairment toventilatory function.

During inspiration when a negative intra-thoracic pressure is generated, air is entrainedinto the chest cavity not through the trachea but through the wound in the chest wall.This is due to the chest wall defect being much shorter than the trachea and providingless resistance. Once the size of the hole is more than 0.75 times the size of thetrachea, air preferentially enters through the chest cavity. A tension may result if a flap

develops that allows air to move into the chest but not out.

Signs and symptoms:

A wound in the chest wall that appears to be sucking

Reduced breath sounds



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Increased percussion note

Reduced expansion of the hemithorax

Management:


Immediate treatment with an occlusive dressingo Cover the wound with thin flexible paper, defibrillator pads or soft plastic

wrap (glad wrap)o Seal three sides well, leave one edge free

o Create a valve effect so that air can escape out of the chest on expirationbut not enter on inspiration

With each exhale, air in the chest is pushed out from underneath the occlusive patch.With each inhale, the patch sticks to the skin, keeping air from coming back into the

chestSource:http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/Treat

aSuckingChestWound.htm

Analgesia

Insertion of ICC

NB - Never remove any object that is sticking into the chest pack aroundthe object with gauze pads soaked in normal saline.

http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/TreataSuckingChestWound.htmhttp://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/TreataSuckingChestWound.htmhttp://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/TreataSuckingChestWound.htmhttp://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/TreataSuckingChestWound.htm


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3.3.5 PneumomediastinumSigns and symptoms:

Subcutaneous emphysema may be present

Hammans sign

o Pericardial or mediastinal crunch sound

o Sounds like the crushing of a foil packet

o

Accentuated by heart beat and respiration Tension pneumomediastinum rare

Management:


Usually conservative

3.3.6 Tracheobronchial injuries

Rare

Usually (65%) related to penetrating trauma

80% of blunt trauma usually occur within 2.5cm of the carinaSigns and symptoms:

Pneumomediastinum

Subcutaneous emphysema

Persistent leak from ICC Segmental lung collapse

Haemoptysis

Dyspnoea, tachypnoea

Decreased or absent breath soundsManagement:


Primary closure of tear

3.3.7 Air embolismAir embolism happens when a communication occurs between the pulmonary veins andlung airways. When airway pressures exceed venous pressures, gas is forced into the

pulmonary venous system. It is then embolised into the systemic arterial tree. It occursmost commonly following penetrating trauma rather than blunt trauma.Signs and symptoms:

Focal neurological abnormalities in the absence of head trauma

Air bubbles in the retinal vessels may be visible on fundoscopic examination

Cardiovascular collapse shortly after institution of IPPV in the absence of tensionpneumothorax

Gas or froth in the arterial blood gases if present death is almost certainManagement:

100% oxygen and airway management IV fluid challenge

3.3.8 Pulmonary contusionAn injury to lung parenchyma, leading to oedema and blood collecting in the alveolarspaces resulting in loss of normal lung function and structure. Developing over 24hours, pulmonary contusion leads to poor gas exchange, increased pulmonary vascularresistance and decreased lung compliance. A large number of patients develop AcuteRespiratory Distress Syndrome (ARDS).

Diagnosis:

Dyspnoea, ineffective cough, haemoptysis and/or hypoxia

Tachycardia

Chest wall contusion or abrasions

Rarely diagnosed on clinical examination.

Suggested by mechanism of injury



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Plain X-ray 24 to 48 hours post injury

CT

Management:


Analgesia

Close monitoring May need ventilatory support

3.3.9 Ruptured Diaphragm

A ruptured diaphragm can be a life threatening injury if the initial diagnosis is missed.The diagnosis can be difficult without a laparotomy.

In blunt trauma 90% of diaphragmatic injuries are due to motor vehicle accident.Approximately 50% have pelvic fractures and there is a 33% mortality rate due toblood loss from associated injuries and delayed diagnosis. In penetrating trauma 85%are due to knife wounds. If penetration below the level of the nipples occurs,

consideration should be given to diaphragmatic injury.

Injuries to the diaphragm usually affect the left side as the liver cushions the right side.The majority of diaphragmatic defects will enlarge over time with the organs most likely

to herniate being the:

Omentum

Transverse colon

Stomach

Small bowel and

SpleenHerniation of abdominal contents into the thoracic cavity may cause respiratorycompromise due to displacement of the lungs and/or mediastinum.

Diagnosis:

Dyspnoea Abdominal pain

Sharp epigastric pain radiating to left shoulder

Bowel sounds in the lower to middle chest

Management:Laparotomy and repair of tear

3.4 Mediastinal injuries

3.4.1 Aortic injury:

This is usually caused by high-speed frontal impact motor vehicle accidents and is

frequently fatal pre hospital. The rupture occurs at the junction of the descending aortaand left brachial artery.

Diagnosis:

Chest pain

Hypotension

Deceased level of consciousness

Deceased quality of femoral pulses compared to upper extremity pulses

Widened upper mediastinum on chest X-ray

CT is approximately 90% sensitive for aortic rupture

A haemothorax which drains bright red blood in ongoing significant amounts

Angiography



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Management:

Primary repair

Close observation and management of blood pressure

3.4.2 Myocardial contusion: (rare for patients with myocardial rupture to survive tohospital)

This is usually caused by high-speed frontal impact motor vehicle accidents from thesteering wheel.

Diagnosis:

Pleural rub

New cardiac murmurs

Signs of low cardiac output

ECG findings may includeo Presence of ST elevation

o Arrhythmia

o Conduction abnormality

o T wave inversion

Transoesophageal Echo (TOE) diagnostic tool of choice

CKMB not reliable Troponin I

o Only required if ECG abnormal

Coronary angiography if ST elevation on ECG

Management:

Cardiac monitoring may be required

3.4.3 Oesophageal perforationOccurs infrequently and usually associated with other mediastinal injuries.

Diagnosis:

Dysphagia Regurgitation of blood

Subcutaneous emphysema

Features of pneumomediastinum

Food/fluid draining from ICC

Chest X-ray

o Mediastinal gas or wideningo Pleural effusion

Management: Nasogastric tube placed under direct vision by a surgeon

Antibiotics

Acid suppression therapy Surgical closure

Large bore pleural drainage



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SECTION 4

4.0 Procedures

4.1 Needle thoracentesis

o

14g needle inserted (anterior approach) into 2nd

intercostal space in themid clavicular line or (axillary approach) 5thintercostal space, mid axillaryline just above the upper edge of the rib below on the affected side

o attach a 10ml syringe to the needle (may help to hold the needle)

o advance the needle until air can be aspirated ( use a 4.5cm minimumlength needle to ensure you can reach the pleural cavity)

o air will escape with a rush from the pleural space under pressure with aneasing of the respiratory distress (in the presence of a tensionpneumothorax)

o if using a cannula, after placement, remove the metal stylet and leaveplastic sleeve in place

o cut a finger from a disposable glove, put a hole in the tip of the finger

and attach base of finger to the cannula to act as a flutter valve.

Source: Clinical Procedures in Emergency Medicine (P136)

This intervention will convert a tension pneumothorax into a simplepneumothorax

Follow up with insertion of ICC

After the ICC has been inserted, the needle/cannula may be removed

Considerations:

If no rush of air is heard on insertion it may not be possible to determine if therewas a tension present or whether the needle reached the pleural cavity

There is the possibility that the lung may be lacerated during the insertion of theneedle, an air embolism through the laceration is of concern

In the absence of haemodynamic compromise, further assessment and/orinvestigation may be warranted prior to needle thoracentesis



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Source of images:http://images.google.com.au/imgres?imgurl=http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/Images/NeedleThoracentesis.jpg&imgrefurl=http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/NeedleaTensionPneumothorax.htm&h=204&w=252&sz=11&tbnid=DDCdQl_KL-

niUM:&tbnh=85&tbnw=106&hl=en&start=1&prev=/images%3Fq%3Dneedle%2Bthoracentesis%2Btension%2Bpneumothorax%26svnum%3D10%26hl%3Den%26lr%3D

4.2 Thoracostomy (Insertion of chest drain)

When air and/or blood enters or becomes trapped in the chest causing a pleural space,the lungs cannot fully expand resulting in respiratory distress.

For information on an audit tool for insertion and removal of a chest drain go towww.thoracic.org.au/audittools.html4.2.1 Indications:

Pneumothorax (tension, open or simple)

Haemothorax

Traumatic arrest (bilateral)

Intermittent positive pressure required post trauma

Failed aspiration

4.2.2 Sizes:

Newborn 8 to 12 FG

Infant 12 to 16 FG

Child 16 to 24 FG

Adults:

o Usually 20 FG for air

o 28 to 36 FG for blood, 28 to 32 FG post popular size

4.2.3 Equipment:

Marking pen

Sterile dressing pack

Sterile gloves +/- sterile gown

http://www.thoracic.org.au/audittools.htmlhttp://www.thoracic.org.au/audittools.html


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Gauze

Skin cleaning solution

Local anaesthetic (lignocaine 1%)

10ml syringe, 21g and 25g needles

23 g sterile scalpel blade and handle

Sterile long artery forceps

Sterile suture set Sterile intercostal catheter

Sterile Heimlich valve or chest drainage device

Suture material (3.0 silk/prolene)

Sterile drainage bag (urinary)

2 large clear dressings eg opsite/tegaderm

Tape

4.2.4 Technique:

Ensure patient has:

o Patent intravenous access

o Oxygen via mask > 8 litres per minute

o Adequate analgesia

o

Cardiac and oxygen saturation monitoring Identify site:

o Injured sideo mid or anterior axillary line behind the pectoralis majoro on inspiration the diaphragm can rise to the level of the fifth rib or nipple

line. Chest drains should be placed above this lineo rib spaces are counted down from the second rib at the sub manubrial

joint

o use the highest rib space that can be felt in the axilla, usually the fourthor fifth. (the fourth intercostal space is about three fingers below thearmpit)

o mark the site

Source of image:http://images.google.com.au/imgres?imgurl=http://www.hcmc.org/manualHCMC/Procedure_Lab/thoracostomy_tube_files/image004.jpg&imgrefurl=http://www.hcmc.org/manualHCMC/Procedure_Lab/thoracostomy_tube.htm&h=279&w=312&sz=12&tbnid=qpan2WSbJBFOxM:&tbnh=101&tbnw=113&hl=en&start=11&prev=/images%3Fq%3Dthoracostomy%26svnum%3D10%26hl%3Den%26lr%3D

set up your equipment (remove the metal trocar from the ICC and discard)

clean the site

infiltrate with local anaesthetico put approximately 2ml under the skin

o push the needle down to the level of the inner rib putting in 1 ml at atime as you go, checking for veins/arteries

o if when you pull back on the syringe you get air you have gone too farand are in the pleural cavity. Pull back the needle about 2mm and inject1ml into the pleura

o wait about five minutes for the local to take effect (if patient stable)



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Source of image: Clinical Procedures in Emergency Medicine (p157)

insertion of drain

o use scalpel to make 2.5cm superficial skin incision parallel to rib alongthe upper border of the rib below the intercostal space to be used toavoid the vessels lying below each rib

o use the artery forceps to blunt dissect down to the pleura (3 to 4 cm)

o push the forceps in a few millimetres at a time and open them to

separate the muscle, continue until the pleura is reached you will feel apop as it goes through

Source: Clinical Procedures in Emergency Medicine (p158)

o open the forceps fully in three or more directions to make space for yourfinger

o

insert your finger and sweep around gently to clear any tissue (lung,diaphragm and/or heart may be felt)

o remove your finger and attach forceps to the chest tube

o use the forceps to guide the tube towards the top of the chest (apex ofthe lung) through the hole



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Blunt dissection occurs by forcing the

closed points of the forceps forward and

then spreading the tips and pulling backwith the points spread.

A rush of air or fluid signifies penetration

into the pleural space.

The chest tube is grasped with the curved

forceps, with the tip protruding from the

jaws.

Using the finger as a guide to ensure entryinto the pleural cavity, the tip of the chest

tube is placed into the pleural cavity.

It can be easy to advance a chest tubesubcutaneously, entirely missing the

pleural space.

Source: Clinical Procedures in Emergency Medicine (p159)

o continue to advance the tube until all the drainage holes along the tube

are inserted. (10 to 12cm) You should not need any force; the tubeshould slide in easily. If it is difficult, remove the tube check the hole withyour finger and the cavity and try again

connect the tube to the Heimlich valve (if patient is not being transferred, and itis appropriate, connect to the underwater seal drainage system that is availableto you)

o connect valve end to the drain and watch the valve flap as air comes out

o connect the drainage bag to the Heimlich valve to collect any blood thatmay drain out

o

ensure to leave the drainage bag opento allow the air to escape

Source of image:

Council of Rural Area Nurses of Australia (CRANA) 2001 Clinical Procedures Manual for remote and rural

practice



30/39

secure the draino use a purse string suture to secure the drain or put a suture on each side

of the tube to close the wound then put a suture in the skin above thetube and tie the long ends around the tube to hold it in place

cover with a clear dressing and tape securely to the chest wall

Consider antibiotic prophylaxis

4.2.5 Complications

malposition

empyema

organ damage

haemorrhage

pulmonary oedema

subcutaneous emphysema

pain (tube in too far)

failure to re expand

o improper connections

o

improper position of ICCo occlusion of bronchi with secretions or foreign body

o tear in larger airwayo large tear of lung parenchyma

4.2.6 Post insertion

immediate observation of air and/or fluid drainage

assess haemodynamic status of patient

assess and manage pain

on a regular, ongoing basis assess

o general patient comfort and anxiety level

o respiratory rate and depth

o

work of breathingo oxygen saturationo skin colour and peripheral perfusiono neurological stateo haemodynamic stateo dressing and insertion site

o

Chest X-ray

o Check position of ICC

o Assess lung re expansion

o Detect complications

4.2.7 Documentation Record:

o Time of insertiono Patient respiratory and haemodynamic statuso Site/location of ICCo Size of ICC

o Nature and volume of chest drainage

4.2.8 Chest Drainage System:The purpose of the chest drainage system is to assist with the re establishment ofnormal pressures by removing air and fluid in a closed one-way system. The simple

one-way action of the water seal allows air to escape within a closed system.



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Check system:

Observe insertion site for inflammation or infection

Ensure there are no drainage holes in the tube exposed

All connections are secure

There are no dependant loops, kinks or obstructions that may inhibit drainage

Ensure the drainage system is kept below the level of the patients chest

Assess drainage for:

Volume

Colour

Consistence

Air leak

The presence of swinging

Dislodgement of chest tube:

Dislodgement from the patient

o have patient cough or exhale forcibly

o apply a dry sterile dressing taped in three sides

o obtain assistance

o

observe patient for respiratory distresso set up for re insertion of tube

Dislodgement from the drainage systemo Clamp the chest tube (ideally for less than one minute) or place the end

of the drainage tubing (approx 2.5cm) into a container of sterile watero set up new system

o Do not leave the patient unattended

o Assess for respiratory distress

Observe and document:

o Respiratory assessment

o

Site of chest tube placement and size of tubeo Suction applied and amounto Drainage volumeo Drainage colour and consistenceo Presence or absence of air leak and/or subcutaneous emphysemao Presence or absence of swinging

o Patient comfort/anxiety levelo Analgesia

o Any procedures, changes in patients condition, interventions and resultsof interventions

Transporting with a drainage system

o

Ensure the system is below the level of the patients chest at all timeso Do not clamp the tubeo Never leave the patient unattended

4.2.9 Heimlich Valve:http://www.bd.com/surgical/pdfs/bd_bardparker_heimlich_chest_drain_valve_brochure.pdf

The Heimlich Chest Drain Valve is a specially-designed flutter valve used to replaceunderwater bottles in chest drainage. Constructed of rubber tubing, the valve is compressed at one end to form leaflets thatcontrol unidirectional flow. The valve is encased in a transparent plastic chamber with tapered ends.

http://www.bd.com/surgical/pdfs/bd_bardparker_heimlich_chest_drain_valve_brochure.pdfhttp://www.bd.com/surgical/pdfs/bd_bardparker_heimlich_chest_drain_valve_brochure.pdf


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The proximal end of the casing can be attached to most chest catheters and the distalend to tubing that empties into a plastic bag. If desired, the distal end can be connected to regulated suction. The Heimlich Chest Drain Valve is sterile and a single use device.

Because reflux is prevented by its flutter mechanism, the Heimlich Chest Drain Valvefunctions even in the event of a disrupted connection beyond the point at which thevalve is attached to the chest catheter. This feature makes it a safe alternative forpatient transfer When connected to a chest catheter, the Heimlich Chest Drain Valve allows fluid, clotsand air to flow out of the chest without reflux into the pleural cavity. Unlike underwater

drainage bottles, the Heimlich Chest Drain Valve is uncomplicated, and easy to use. The Heimlich Chest Drain Valve functions in any position, is not restricted to use at alevel below the patients chest, as are underwater drainage bottles. With the valve,there is no need to clamp the chest catheter during transport of the patient, andcomplications arising from interrupted drainage are avoided.



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SECTION 5

5.0 ACUTE PAIN MANAGEMENT

Pain is best treated early and effectively because once established it is more difficult totreat. Multimodal analgesia is an integral part of managing pain. This can include theuse of analgesic drugs, local anaesthetic techniques (eg. nerve blocks) and non-drugtechniques paying attention to psychosocial issues, such as massage, heat and

transcutaneous electrical nerve stimulation. The response to the treatment can beequally important in pain management especially in the ongoing treatment choices.

Acute pain is described as being of recent onset, usually of short duration and the causeis generally identifiable. Acute pain has a defined pattern of onset, site, character andduration. The main reasons for treating acute pain effectively and quickly is to preventsuffering, reduce negative physiological and psychological effects, assist in rehabilitationand reduce the ability of acute pain progressing to chronic pain.

5.1 Thoric Injury Pain ManagementSource: http://www.adhb.govt.nz/trauma/injury04talks/davis/davis.htm

Treat life threatening Injuries

Assess and decide treatment options early

Pharmacologyo Simple analgesics

o Opiates oral or iv

Invasive techniques

o Intercostal nerve blocks

o Thoracic epidural

o Paravertebral nerve block

Morbidity

Chest trauma causes pulmonary contusionso Ventilation Perfusion mismatcho Decreased lung complianceo Hypoxaemia

Pain Causeso Decreased coughing

o Shallow hyperventilation

o Reduced FRC

o Sputum retention

The elderly (over 65)

o

Mortality 22% vs 10%o Pneumonia 31% vs 17%o LOS 15.4 vs 10.7

o Ventilator days 4.3 vs 3.1o Intensive care days 6.1 vs 4.0o Each additional # rib increased mortality by 19% and pneumonia by

27%

Effective pain management

o Enables deep breathing and coughing

o Less than 3 #s

oral analgesics, NSAIDs paracetamol, weak opiates intercostal nerve blocks (ICNB)

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o More extensive intravenous opiates, IV protocol or PCA Sedation can cause respiratory depression and cough

suppression Regional techniques shown to be better

Choice of analgesic technique

o

Pain relief needs to be individualisedo Less than 3 # ribs oral analgesia +/- ICNB

o Patients requiring immediate surgery are best managed with IVopiates

o Regional techniques can be added in latero Head injury and spinal trauma are contraindication for epidural

analgesia

5.2 Pain assessment:

Identify the pain mechanism

Measure the pain severity

Identify any drug and/or alcohol history

Develop a pain management plan including regular reassessment and review at

specific intervals

5.3 Pain severity:

Pain is subjective and cannot be measured directly

Patient self reporting is the best way to assess pain

When using a measure of pain be consistent in its use. Examples include:o Numerical rating scale, rates pain on a scale from 0 (no pain) to 10

(worst pain imaginable)

o Verbal rating scale, use words to describe the pain eg. None, mild,moderate, severe, worst possible

o Visual analogue scale, eg. 10cm line with no pain at one end and worstpain imaginable at the other

o

Wong-Baker FACES pain rating scale For acute pain using a scale provides a way of monitoring intensity andtreatment response.

5.4 Treatment choices:Treatment should be commenced as soon as possible following identification and whenpain may be predictable, eg prior to invasive procedures. Opioids are the drugs ofchoice for severe acute pain. The intra venous route is the most effective and allows fortitration of the dose. Oral analgesics can be used alone or in combination with opioids

depending on the patients condition and cause of pain.


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5.4.1 Non-opioid analgesics

Practice points:

Paracetamol is an effective analgesic for acute pain (Level I evidence).

NSAIDs and COX-2 inhibitors are effective analgesics with similar efficacy for acute pain (Level I

NSAIDs given in addition to paracetamol improve analgesia (Level I evidence). COX-2 inhibitors and NSAIDs have similar adverse effects on renal function (Level I evidence).

Paracetamol, NSAIDs and COX-2 inhibitors are valuable components of multimodal analgesia (Le

COX-2 inhibitors do not impair platelet function (Level II evidence).

Gastric ulceration rates with short-term use of COX-2 inhibitors are similar to those for placebo

Adverse effects of NSAIDs are significant and may limit their use (clinical practice point).

The risk of adverse renal effects of NSAIDs and COX-2 inhibitors is increased in the presence of impairment, hypovolaemia, hypotension, use of other nephrotoxic agents and angiotensin-convepractice point).

Accessed at - http://www.mja.com.au/public/issues/184_03_060206/mac10793_fm.html

Drug Name Mode of Action Indications Acetylsalicylic Acid (Aspirin) Analgesic, antipyretic, anti-inflammatory and anti plateletactions. A non selective NSAID,preventing synthesis of

prostaglandins bynoncompetitively inhibiting both

forms of cyclo-oxygenase(COX), COX-1 and COX-2

Mild to moderate pain, can beused in combination withcodeine.Fever.

Paracetamol Analgesic and antipyretic.

May be due to inhibition ofprostaglandin synthesis

centrally, and to a lesser extentperipherally, where othermechanisms, which block painimpulses, may be involved.

Mild to moderate pain, can be

used in combination withcodeine.Fever

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5.4.2 Opioid analgesics:

Mode of Action:Opioid analgesics mimic endogenous opioids by activating opioid receptors in the central and periphanalgesia, respiratory depression, sedation and constipation. They prevent transmission of pain imp

synaptically in the spinal cord, and by modulating the descending inhibitory pathways from the braimedullary centre of the brain. (Australian Medicines Handbook 2006 (AMH) p48)

Clinical practice points:

Morphine is the predominantly used opioid analgesic because of familiarity, availability and cost.

The key advantage of using opioids in pain management is the variety of dosages and routes, theffective and have low risk to benefit ratios.

Naloxone is used to reverse opioid sedation and respiratory depression.

Dextropropoxyphene has low analgesic efficacy (Level I evidence).

In the management of acute pain, one opioid is not superior over others but some opioids are beevidence).

Tramadol has a lower risk of respiratory depression and impairs gastrointestinal motor function

analgesic doses (Level II evidence). Pethidine is not superior to morphine for treating pain of renal or biliary colic (Level II evidence)

In adults, age is a better predictor of opioid requirements than weight, although there is a large evidence).

Assessing sedation level is a more reliable way of detecting early opioid-induced respiratory deprespiratory rate (clinical practice point).

The use of pethidine should be discouraged in favour of other opioids (clinical practice point).Accessed at - http://www.mja.com.au/public/issues/184_03_060206/mac10793_fm.html

Drug Name Dose suggestions Approximateduration of action(hours)

Suggested doseequivalent to10mg IM/SCmorphine

Comm

Codeine AdultOral.SC/IM 30 60mg every 4 hoursto a maximum240mg in 24 hours

3 to 4 130mg IM200mg oral

Mild toexceedCan beaspirin

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Drug Name Dose suggestions Approximateduration of action(hours)

Suggested doseequivalent to10mg IM/SCmorphine

Comm

Fentanyl Dosage varies with

age and clinicalcondition of patient

0.1 to 1 50-100 microgram

IV100 150microgram SC

Moder

in renaDuratiuseful

Morphine Titrate to patientsneeds; in acute painthere is nomaximum dose.Adverse effects limit

the dose.

2 to 3 or 12 to 24(controlled release)

30mg oral Morphopioidrelatioconcenrelief.

Pain reshorte

injecti

individOxychodone Initial dose 5

15mg every 4 to 6hours. Titrate dosedepending onresponse.

3 to 4 or 12 to 24

(controlled release)

15 20mg oral Moder

Pethidine Initial IV dose 5 20mg repeatedevery 3 to 5minutes. Titratedose according toresponse and

adverse effects.

2 to 3 75 100mg IM For uspain

Tramadol IV/IM 50 100mgevery 4 to 6 hours

up to total dailydose of 600mg

3 to 6 100 120mg IM/IV150mg oral

Moder


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REFERENCES

Bowers, A.C. and Thompson, J.M. 1988 Clinical Manual of Health Assessment Third

EditionSt Louis: CV Mosby Company

Council of Rural Area Nurses of Australia (CRANA) 2001 Clinical Procedures Manual forremote and rural practice www.crana.org.auDavis, K. 2007 Pain Management for Patients with Chest Trauma, Acute Pain Service,

Aukland City Hospital http://www.adhb.govt.nz/trauma/injury04talks/davis/davis.htmDriscoll, P., Skinner, D. and Earlam, R. (Editors) 2000ABC of Major Trauma ThirdEdition London: BMJ Publishing Group

Dunn, R., Dilley, S., Leach, D., Brookes, J., Maclean, A. and Roger, I 2003 The

Emergency Medicine Manual Third Edition Volume 2. Tennyson: Venom Publishing

OH, T.E. (Editor) 1998 Intensive Care Manual Fourth Edition Bath: Butterworth

Heinemann

Proel, J. (Editor) 2004 Emergency Nursing Procedures Third Edition St Louis: Saunders

Roberts, J.R. & Hedges, J.R., 1985, Clinical Procedures in Emergency Medicine ThirdEdition, Philadelphia: W.B.Saunders Company

Rural Ambulance Victoria, Clinical Guidelines, www.rav.vic.gov.au

Sheey, S.B., Blansfield, J.S., Danis, D.M. and Gervasoni, A.A. 1999 Manual of ClinicalTrauma Care, The First Hour Third Edition St Louis: CV Mosby Company

The Royal Australian College of General Practitioners, Australian Society of Clinical and

Experimental Pharmacologists and Toxicologists and Pharmaceutical Society of AustraliaAustralian Medicines Handbook 2006 www.amh.net.au

Tortora, G.T and Grabowski, S.R. 1996 Principles of Anatomy and Physiology Eighth

Edition. Sydney: Harper Collins.

Trauma.Org: Thoracic Trauma (accessed 7 June 2007) www.trauma.orgVictorian Clinical Nursing Consortium, 2003, Trauma Nursing Program: Emergency Care(Initial Resuscitation) Module Melbourne

http://www.crana.org.au/http://www.adhb.govt.nz/trauma/injury04talks/davis/davis.htmhttp://www.rav.vic.gov.au/http://www.amh.net.au/http://www.trauma.org/http://www.trauma.org/http://www.amh.net.au/http://www.rav.vic.gov.au/http://www.adhb.govt.nz/trauma/injury04talks/davis/davis.htmhttp://www.crana.org.au/


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SUGGESTED FURTHER READING:

Allibone, L. 2003 Nursing management of chest drains Nursing Standard Vol. 17, Iss,22; pg 45, 12 pgshttp://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=

4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280Australian and New Zealand College of Anaesthetists and Faculty of Pain MedicineAcutePain Management: Scientific Evidence Second Edition 2005http://www.anzca.edu.au/publications/acutepain.htm(accessed June 2007)

Bevan, C. and Officer, C. (Editors) 2004 Paediatric Trauma Manual, Practical TraumaProceduresRoyal Childrens Hospital, Melbourne www.rch.org.au/paedtraumaGrey, E. 2000 Pain Management for patients with chest drains Nursing Standard. 14,23,40-44

http://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6

Salerno, M Sept 2006John Hunter Hospital Intensive Care Unit: Nursing Managementof a Patient with an Intercostal Catheter, Self Directed Learning Package

http://intensivecare.hsnet.nsw.gov.au/five/doc/education%20packages/jhh_uwsd_sdlp.pdf
http://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280http://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280http://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280http://www.anzca.edu.au/publications/acutepain.htmhttp://www.rch.org.au/paedtraumahttp://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6http://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6http://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6http://intensivecare.hsnet.nsw.gov.au/five/doc/education%20packages/jhh_uwsd_sdlp.pdfhttp://intensivecare.hsnet.nsw.gov.au/five/doc/education%20packages/jhh_uwsd_sdlp.pdfhttp://intensivecare.hsnet.nsw.gov.au/five/doc/education%20packages/jhh_uwsd_sdlp.pdfhttp://intensivecare.hsnet.nsw.gov.au/five/doc/education%20packages/jhh_uwsd_sdlp.pdfhttp://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6http://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6http://72.14.235.104/search?q=cache:BQa_4btdmV8J:www.nursing-standard.co.uk/archives/ns/vol14-23/pdfs/p40-44.pdf+Nursing+management+of+chest+drains&hl=en&gl=au&ct=clnk&cd=6http://www.rch.org.au/paedtraumahttp://www.anzca.edu.au/publications/acutepain.htmhttp://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280http://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280http://proquest.umi.com/pqdweb?index=0&did=310340781&SrchMode=1&sid=1&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1153888201&clientId=65280

Thoracic Injury Management Jan 08

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