Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 4 Trauma Emergencies

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 10 Thoracic Trauma

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Introduction to Thoracic Injury Anatomy and Physiology of the Thorax Pathophysiology of Thoracic Trauma Assessment of the Chest Injury Patient Management of Chest Injury Patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Thoracic Injury

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Thoracic Injury The thoracic cavity contains many vital structures 25% of all motor vehicle deaths are due to thoracic trauma –Traumatic chest injury can cause significant co- morbidity Thoracic trauma may result from penetrating and blunt injuries

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax The thoracic cage is the chamber that moves air in and out Consists of the thoracic skeleton, diaphragm, and associated musculature Dynamics of the chest are controlled by a series of centers in the brain and blood vessels

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax Thoracic Skeleton –Defined by 12 pairs of C-shaped ribs –The sternum –Divisions Midclavicular line Anterior axillary line Midaxillary line Posterior axillary

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax Diaphragm –Muscular, domelike structure –Major muscle of respiration Associated musculature –Chest wall musculature –Shoulder musculature –Clavicles, scapula, and humerus

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax Trachea, Bronchi, and Lungs –Trachea Hollow and cartilage-supported –Bronchi Trachea divides into the right and left mainstem bronchi at the carina Bronchi enter their respective lungs at the pulmonary hilum Pulmonary arteries and veins enter Sole point of lung attachment in thoracic cavity

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax Bronchioles –Alveoli are terminal ends of bronchioles –Ventilation results in air exchange External respiration Lungs –Lobes Right lung has 3 lobes Left lung has 2 lobes –Pleura Visceral Parietal

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Anatomy Click here to view an animation on respiration.here

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Lung Volumes Tidal volume Residual volume Expiratory reserve Inspiratory reserve Functional residual capacity Inspiratory capacity Total lung capacity Vital capacity Minute volume Dead space –Anatomical –Alveolar –Physiological

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Control Respiratory centers within the brainstem control respiration –Medulla oblongata Central chemoreceptors –Respond to increased CO 2 levels Peripheral chemoreceptors –Aorta –Carotid –Hypoxemia (PaO 2 < 60 mmHg) stimulates the peripheral chemoreceptors

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Control Respiratory Centers in the Pons –Apneustic Low in the pons Inhibits inspiration –Pnuemotaxic Upper pons Moderates the activity of the apneustic center Respiratory reflexes –Sigh reflex –Cough reflex

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Thorax Mediastinum –The central space within the thoracic cavity –Contains many vital structures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mediastinum Heart –The heart is a four- chambered pump, divided into right and left sides –Coronary arteries Fill in diastole Changes in afterload play a direct role in determining coronary perfusion pressure

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mediastinum Heart (cont.) –Tachycardia can limit coronary artery blood flow –Layers of the heart Epicardium Myocardium Endocardium

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mediastinum Great Vessels –Large arteries and veins that enter and leave the heart Aorta Attached to heart at the ligamentum arteriosum Superior and inferior vena cava Pulmonary arteries and veins Other structures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mediastinum Esophagus –Enters the thorax through the thoracic inlet with and just posterior to the trachea –Runs length of the mediastinum –Exits at the esophageal hiatus –Muscular tube Peristalsis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology of Thoracic Trauma

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology of Thoracic Trauma Two major categories –Blunt –Penetrating Examine these injury mechanisms and determine effects on the thorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blunt Trauma Injury resulting from kinetic energy forces transmitted through the tissues Blast, crush (compression), and deceleration injuries

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blunt Trauma Blast injury –Creates a pressure wave traveling outward from the epicenter of the explosion May be particularly damaging to hollow, air-filled structures –In the thorax, this action may tear blood vessels and disrupt the alveolar tissue –May include disruption of the tracheobronchial tree and traumatic rupture of the diaphragm

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blunt Trauma Crush Injuries –Occur when the body is compressed between an object and a hard surface Direct injury or disruption of the chest wall, diaphragm, heart, or tracheobronchial tree May also result in impaired perfusion of organs and soft tissues, resulting in ischemia of those organs and cellular acidosis Prolonged crushing may also result in rhabdomyolysis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blunt Trauma Deceleration Injuries –Occur when the body is in motion and impacts a fixed object Direct blunt trauma Organ collision Organ attachments Paper bag syndrome © Michael Grill

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blunt Trauma Age and physiology may alter the effects of the forces causing blunt trauma Pediatric –Flexible nature transmits forces without external signs Geriatric –Frequent fractures –Pre-existing disease –Decreased cardiac reserves

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Penetrating Trauma Penetrating thoracic injuries –An object enters the chest and causes either direct trauma or secondary injury Kinetic energy forces related to the cavitational wave of high-velocity projectiles –Subdivided into three categories Low energy, high energy, and shotgun wounds

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Penetrating Trauma Low Energy Wounds –Caused by arrows, knives, hand guns, and other relatively slow-moving objects Injury by direct contact or very limited creation of temporary cavities –Injury is related to the direct path that the missile or object takes

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Penetrating Trauma High Energy Wounds –Caused by military and hunting rifles Increased kinetic energy Cavitation –Other effects “Mushrooming” Tumbling

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Penetrating Trauma Shotgun Wounds –Distance between victim and weapon determines damage –Type I Distance > 7 meters Damage mostly skin and subcutaneous tissue –Type II Distance of 3 to 7 meters Pellets penetrate the deep fascia with internal organ injury possible

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Penetrating Trauma Shotgun Wounds (cont.) –Type III Distance of less than 3 meters Massive tissue destruction and life-threatening injury potential Penetrating thoracic trauma is often related to the structures involved

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries The most common injuries encountered in blunt chest trauma May cause disruption of ventilatory process Closed wounds include –Contusions, rib fractures, sternal fractures, dislocations, and flail chest Open wounds –Almost entirely due to penetrating trauma

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Chest wall contusion –Contusion of the chest wall may present with erythema initially, then ecchymosis –Symptom of chest wall contusion is pain Worsens with inspiratory effort May cause hypoventilation Elderly patient may be affected significantly

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Rib Fracture –Likely to occur at the point of impact or along the border of the object that impacts the chest –4 through 8 are the most commonly fractured ribs

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Rib Fracture (cont.) –The incidence and significance of rib fracture varies with age Pediatric has increased transmission of force Geriatric has comorbid factors –Multiple rib fractures in a young adult are probably associated with severe trauma

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Rib Fracture (cont.) –Associated problems Pain Hypoventilation Atelectasis Pulmonary trauma Resulting from sharp bone edges Pnuemonia Other organ damage

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Sternal Fracture or Dislocation –Associated with blunt anterior chest trauma Direct blow, a fall against a fixed object, or the blunt force of the sternum against the steering wheel –High mortality due to underlying cardiopulmonary involvement Cardiac rupture, pericardial tamponade, and pulmonary contusion

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Sternal Fracture or Dislocation (cont.) –Dislocation at the sternoclavicular joint is uncommon Requires severe forces –The clavicle may dislocate from the sternum Anterior Posterior May compress or lacerate underlying great vessels or compress or injure the trachea and esophagus

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Flail Chest –A segment of the chest that becomes free to move with the pressure changes of respiration Three or more adjacent ribs fracture in two or more places

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chest Wall Injuries Flail Chest (cont.) –One of the most serious chest wall injuries –The flail segment is no longer a controlled component of the chest wall and bellows system Paradoxical respiration Positive pressure ventilation is indicated Monitor hemodynamics

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Injuries to lung tissue Injuries that damage the system that holds the lung to the interior of the thoracic cavity Simple pneumothorax, open pneumothorax, tension pneumothorax, hemothorax, and pulmonary contusion

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Simple Pneumothorax –Occurs when lung tissue is disrupted and air leaks into the pleural space –As more and more air accumulates in the pleural space, the lung collapses

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Simple Pneumothorax (cont.) –Can occur with penetrating and blunt mechanisms Or a sudden increase in intrathoracic pressure “Paper-bag” effect –Reduces the efficiency of respiration and quickly leads to hypoxia May require oxygen and chest tube placement

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Open Pneumothorax –Occurs when a high- velocity bullet creates a significant wound in the chest wall Usually the exit wound A shotgun blast at close range

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Open Pneumothorax (cont.) –As the chest moves outward and the diaphragm moves downward during inspiration, air enters wound The opening must be at least two thirds the diameter of the trachea –Air passage through the wound and the wound’s associated hemorrhage may produce frothy blood around the opening

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Tension Pneumothorax –Injury generates and maintains a pressure greater than atmospheric pressure within the thorax Caused by a traumatic mechanism of injury or possibly by positive-pressure ventilation May also occur as an open pneumothorax accumulates air

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Tension Pneumothorax (cont.) –Increasing intrapleural pressure collapses the lung on the ipsilateral side of injury –Displaces the mediastinum Compresses vena cava decreasing preload Jugular venous distension Decreased cardiac output Narrows the pulse pressure Tracheal shifting

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Findings of Tension Pneumothorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Hemothorax –The accumulation of blood in the pleural space due to internal hemorrhage May be minor or severe –Frequently associated with rib fractures Blunt or penetrating trauma may induce bleeding –Often accompanies pneumothorax Hemopneumothorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Findings of Hemothorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Pulmonary Contusion –Soft-tissue contusions affecting the lung –Range in severity –Two specific mechanisms of injury Deceleration Organ collision with body Pressure Wave High velocity weapon Blast injury

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injuries Pulmonary Contusion (cont.) –Signs and symptoms of the pulmonary contusion take time to develop Increasing dyspnea Increasing respiratory effort Signs of hypoxia –Serious pulmonary contusion May cause hemoptysis Signs and symptoms of shock

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Subset of thoracic trauma that leads to the most fatalities Include –Blunt cardiac injury –Pericardial tamponade –Myocardial aneurysm or rupture –Aortic aneurysm or rupture –Other vascular injuries

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Blunt Cardiac Injury –Carries a high mortality rate –The heart impacts the inside of the anterior chest wall and then may be compressed Cardiac contusion

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Blunt Cardiac Injury (cont.) –Injury may reduce the strength of cardiac contraction –Electrical disturbances Ectopic beats and conduction system defects Bundle branch blocks and dysrhythmias –Extensive injury may lead to tissue necrosis (death), decreased ventricular compliance, congestive heart failure, cardiogenic shock, myocardial aneurysm, and acute or delayed myocardial rupture.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Blunt Cardiac Injury (cont.) –Signs and symptoms History of significant blunt chest trauma Chest or retrosternal pain Associated chest injuries Dysrhythmias Pericardial friction rub and murmur May take weeks to develop

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Blunt Cardiac Injury (cont.) –Commotio Cordis Rare event where ventricular fibrillation is induced by a direct blow to the chest Blow may seem minor Occurs with young athletes Treatment for commotio cordis is the same as for ventricular fibrillation and should include CPR and immediate defibrillation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Pericardial Tamponade –A restriction to cardiac filling caused by blood (or other fluid) within the pericardial sac Almost always related to penetrating injury –Begins with a tear in a superficial coronary artery or penetration of the myocardium Blood accumulates in the pericardial space –Pressure limits filling of ventricles Takes about 150 to 300 mL of blood to exert the pressure necessary to induce frank tamponade

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Findings of Pericardial Tamponade

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Myocardial Aneurysm or Rupture –Occurs almost exclusively in extreme blunt thoracic trauma –Condition can affect any of the heart’s chambers, the interatrial septum, the interventricular septum, or involve the valves –Mechanisms of injury Secondary to necrosis High-velocity gunshot wound

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Myocardial Aneurysm or Rupture –Signs and symptoms Rupture Serious blunt or penetrating trauma to the chest and may have severe rib or sternal fracture Pericardial tamponade Left heart failure Aneurysm If there is a myocardial aneurysm, rupture may be delayed –When rupture occurs, the patient will suddenly present with the absence of vital signs or the signs and symptoms of pericardial tamponade.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Traumatic Dissection or Rupture of the Aorta –Aortic dissection and rupture are extremely life- threatening injuries Most commonly results from blunt trauma Associated with high-speed automobile crashes Most commonly lateral impact High falls

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Traumatic Dissection or Rupture of the Aorta (cont.) –Large high-pressure vessel that provides outflow from the left ventricle –Areas of fixation Aortic annulus Aortic isthmus Ligamentum arteriosum Diaphragm –Shear forces secondary to severe deceleration of the chest cause injury at points of attachment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Traumatic Dissection or Rupture of the Aorta (cont.) –Traumatic aortic dissection occurs most commonly to the descending aorta Shear forces separate the layers of the artery Tunica intima from media –Aortic rupture presents with severe hypotension, loss of all vital signs, and death unless moved into surgery immediately.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Traumatic Dissection or Rupture of the Aorta (cont.) –Aortic dissection progresses more slowly History of a high fall or severe auto impact and deceleration Severe, tearing chest pain Pulse deficit Hypertension

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Injuries Other Vascular Injuries –Pulmonary arteries and venae cava Result in large amount of blood loss Most frequently result from penetrating trauma –Patient will present with signs and symptoms of shock

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Thoracic Injuries Traumatic Rupture or Perforation of the Diaphragm –The diaphragm may move superiorly to the level of the fourth intercostal space (nipple level) anteriorly and the sixth intercostal space posteriorly Penetrating trauma at this level may cause injury –Perforation and herniation occur most frequently on the left side

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Thoracic Injuries Traumatic Rupture or Perforation of the Diaphragm (cont.) –Abdominal organs may herniate through the defect into the thoracic cavity Causing strangulation or necrosis of the bowel, restriction of the ipsilateral lung, and displacement of the mediastinum –Signs and symptoms similar to tension pneumothorax Bowel sounds may be noted in one side of the thorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Thoracic Injuries Traumatic Esophageal Rupture –Rare complication of blunt thoracic trauma Injury usually coincides with other mediastinal injuries –The life threat is related to material entering the mediastinum as it passes down the esophagus or as emesis comes up –Deep, penetrating chest trauma may be present –Difficult or painful swallowing, pleuritic chest pain, and pain radiating to the midback

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Thoracic Injuries Tracheobronchial Injury (Disruption) –Relatively infrequent finding Carries a relatively high mortality similar to esophageal rupture –Most likely to occur within 2.5 cm of the carina –Signs and symptoms Respiratory distress with cyanosis, hemoptysis, and, in some cases, massive subcutaneous emphysema

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Thoracic Injuries Traumatic Asphyxia –Occurs when severe compressive force is applied to the thorax and leads to a reverse flow of blood from the right heart Blood forced into the vena cava and jugular veins –Back flow may damage cerebral circulation, resulting in numerous small strokes in geriatric patients

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Thoracic Injuries Traumatic Asphyxia (cont.) –If the thoracic compression continues, it restricts venous return and may prevent the victim from ventilating Rapid release may lead to hemorrhage –Signs and symptoms Face appears swollen, the eyes bulge, and there are numerous conjunctival hemorrhages Severe dyspnea Hypovolemia, hypotension, and shock

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment of the Chest Injury Patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment of the Chest Injury Patient Assessment of the patient with a severe chest injury mechanism is critical –Anticipate injury –Provide the correct interventions Special considerations occur during the scene size-up, initial assessment, and especially during the rapid trauma assessment.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Scene Size-Up Assure the scene is safe Examine the mechanism of injury carefully –Determine if the central chest might be in the pathway of penetrating trauma Gunshot injuries –Determine the type of weapon, caliber, distance between gun barrel and victim, and the probable pathway of the projectile Determine the direction of blunt trauma impact

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Initial Assessment Determine the patient’s mental status and the status of the airway, breathing, and circulation Watch for: –Dyspnea –Asymmetrical, paradoxical, or limited chest movement –Hyperinflation of the chest –An abdomen that appears hollow Waveform capnography may be useful to detect minute changes with ventilation and perfusion

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rapid Trauma Assessment Observe –Evidence of impact Erythema –Look carefully for penetrating trauma Presence of exit wounds –Intercostal and suprasternal retractions –JVD –Chest movement

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rapid Trauma Assessment Question –Any pain, pain on motion, pain with breathing effort (pleuritic pain), or dyspnea Palpate –Any swelling, deformity, crepitus, or subcutaneous emphysema © Maria A. K. Lyle

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rapid Trauma Assessment Auscultate –Auscultate all lung lobes, both anteriorly and posteriorly –Pay attention to inspiration and expiration –Note any crackles –Diminished breath sounds –Muffled heart sounds

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rapid Trauma Assessment Percuss –Percuss the chest and note the responses Resonance Hyperresonant Hyporesonant

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ongoing Assessment Takes on great importance for the patient with chest trauma Observe the respiratory depth, rate, and symmetry of effort Auscultate the lung fields for equality Monitor the distal pulses, oxygen saturation, skin color, and blood pressure

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Focuses on assuring good oxygenation and adequate respiratory volume and rate –Administer high-flow, high-concentration oxygen –Consider intubation if necessary –Bag-valve mask the conscious patient with severe dyspnea at a rate of 12 to 16 full breaths per minute

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Anticipate heart and great vessel compromise –Initiate at least one large-bore IV site –Be prepared to administer fluid boluses quickly if the patient’s systolic blood pressure is below 80 mmHg Fluid infusion for the patient with chest trauma should be conservative Auscultate all lung fields carefully when administering fluids

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Rib Fractures –Produce pain that significantly limits respiratory effort –Administer analgesics to grant greater patient comfort and improve chest excursion Diazepam, morphine sulfate, fentanyl or meperidine Use of nitrous oxide is contraindicated in chest trauma

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Sternoclavicular Dislocation –Supportive therapy with oxygen is usually all that is required Hemodynamic instability indicates associated injuries –If significant respiratory distress Place the patient in the supine position with a sandbag between the shoulder blades

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Flail Chest –Place the patient on the side of injury if spinal immobilization is not required –Secure a large and bulky dressing with bandaging –High-flow, high-concentration oxygen therapy, pulse oximetry, and ECG –Consider intubation and positive pressure ventilation –Rapid transport to the trauma center is indicated

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Open Pneumothorax –High-flow, high- concentration oxygen, monitor oxygen saturation and respiratory effort –Cover it with a sterile occlusive dressing

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Open Pneumothorax (cont.) –Provide positive pressure ventilations and intubate as indicated –Remove occlusive dressing if patient worsens Monitor and treat for tension pneumothorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Tension Pneumothorax –Successful treatment depends on rapid recognition of this condition and then pleural decompression –Apply high-flow, high-concentration oxygen and ventilate if necessary Intubate if the patient is unable to maintain an airway –Perform needle thoracentesis

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Needle Decompression of Tension Pneumothorax

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Tension Pneumothorax (cont.) –If the patient remains symptomatic, place a second or third catheter –Rapidly transport the patient to the trauma center for definitive treatment –If your patient remains hypotensive after chest decompression, consider the possibility of internal hemorrhage and the need for fluid resuscitation.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Hemothorax –Oxygen administration and ventilatory support –Be conservative in fluid administration Maintain a blood pressure of 80 mmHg Carefully listen to breath sounds during any infusion –Positive-end expiratory pressure (PEEP) may benefit the patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Blunt Cardiac Injury –Administer high-flow, high-concentration oxygen –Monitor ECG –Establish an IV line Fluid administration, if indicated Anti-dysrhythmics –Rapidly transport the patient to the trauma center

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Pericardial Tamponade –Administration of oxygen and IV fluids Maximize preload –Definitive care is to remove some of the fluid accumulating in the pericardial sac Rarely done in field Transport may be to nearest emergency room Patient may be transferred to trauma center later

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Aortic Dissection –Gentle but rapid transport to the trauma center Careful handling of patient at all times –Initiate IV therapy en route, but be very conservative in fluid administration –Rupture results in rapid exsanguination

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Tracheobronchial Injury –High-flow, high-concentration oxygen –Clear the airway of blood and secretions –If you are unable to maintain a patent airway Intubate Observe the patient carefully for the development of a tension pneumothorax –Provide rapid transport

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of the Chest Injury Patient Traumatic Asphyxia –Administer oxygen and support the airway and respirations –Establish two large-bore IV lines –Once the compressing force is removed, the direct effects of traumatic asphyxia spontaneously resolve Serious internal hemorrhage may begin –Consider the administration of sodium bicarbonate

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Introduction to Thoracic Injury Anatomy and Physiology of the Thorax Pathophysiology of Thoracic Trauma Assessment of the Chest Injury Patient Management of Chest Injury Patient