Caring for Chest and Abdominal Emergencies 21 Caring for Chest and Abdominal Emergencies

Review the anatomy of the chest and abdomen from Chapter 4. Objectives Review the anatomy of the chest and abdomen from Chapter 4. Define the following terms: Closed chest injury Crepitus Diaphragm Distention Evisceration Flail chest Guarding Hemothorax (continued)

Define the following terms: Objectives Define the following terms: Mediastinum Occlusive dressing Open chest injury Paradoxical movement Penetrating injury Pleura Pleural space Pneumothorax Quadrant Retroperitoneal cavity (continued)

Define the following terms: Objectives Define the following terms: Spontaneous pneumothorax Sucking chest wound Tension pneumothorax Describe the major structures of the thoracic cavity. Explain the relationship between chest injury and perfusion. Differentiate between an open and closed chest injury. (continued)

Describe the signs and symptoms of a closed chest injury. Objectives Describe the signs and symptoms of a closed chest injury. Explain the appropriate assessment of a patient with a chest injury. Explain the appropriate care of a patient with a closed chest injury. Explain the appropriate care of a patient with an open chest injury. Describe the major structures of the abdominal and pelvic cavities. (continued)

Describe the signs and symptoms of internal bleeding. Objectives Describe the signs and symptoms of internal bleeding. Explain the appropriate assessment and care of a patient with abdominal pain. Explain the appropriate assessment and care of a patient with an open abdominal injury. Demonstrate the appropriate assessment and care of a patient with a chest injury. (continued)

Objectives Demonstrate the appropriate assessment and care of a patient with abdominal pain. Demonstrate the appropriate assessment and care of an open abdominal injury. Value the importance of proper body substance isolation (BSI) precautions when assisting with chest and abdominal injuries.

Media Slide 39 Digestive System Animation Slide 40 Human Anatomy Labeling Exercise

Topics Anatomy of the Chest Chest Injuries Abdominal Emergencies Abdominal Injuries

ANATOMY OF THE CHEST

Anatomy of the Chest Chest cavity (thoracic cavity) makes up approximately half of torso. Gets shape from 12 pairs of ribs. Major organs contained within chest are heart and lungs. Mediastinum houses trachea, esophagus, heart, vena cava, and aorta. Teaching Tip: Use anatomical models, x-rays, and multimedia graphics to better illustrate anatomy and physiology of the chest.

The chest contains the heart and lungs and is separated from the abdominal cavity by the diaphragm muscle.

Anatomy of the Chest Left and right sides of chest are occupied by the lungs. Pleura: thin saclike structure that surrounds each lung. Pleural space: potential space that exists between visceral and parietal pleura in chest. Critical Thinking: Where does the chest end and the abdomen begin?

Each lung is surrounded by a thin lining of tissue called the pleura. Class Activity: Divide class into groups. Provide one box of items to each group and direct students to create a lung model to demonstrate the mechanics of breathing. (A web search will produce a variety of sample plans to conduct this project.) Box of items: Scissors, 3 Large balloons, 2 Rubber bands, Electrical tape, Plastic 2 liter bottle, Flexible plastic tubing - 8 inches, Y-shaped hose connector. Each lung is surrounded by a thin lining of tissue called the pleura.

Think About It What might happen if a chest injury disrupts the parietal pleura? What might happen if a lung injury disrupts the visceral pleura? What if there is a problem with the fluid that provides lubrication between the pleural layers?

CHEST INJURIES

Chest Injuries Closed Chest Injuries Open Chest Injuries Result of blunt force trauma from falls, contact sports, vehicle collisions, blasts. Open Chest Injuries Result of penetrating injury from bullet, knife, or similar projectile. Discussion Topic: Compare and contrast closed and open chest injuries.

An open chest injury.

Chest Injuries Blunt trauma Penetrating objects Blow to chest can fracture ribs, sternum, and rib cartilages. Penetrating objects Bullets, knives, pieces of metal or glass, steel rods, pipes can penetrate chest wall, damaging internal organs and impairing respiration. Talking Point: Although penetrating trauma can be more dramatic, do not underestimate the damage that can be done by blunt trauma.

Chest Injuries Compression Results from severe blunt trauma in which chest is rapidly compressed (driver in motor-vehicle collision strikes chest on steering column). Discussion Question: How else might organs of the chest be injured by blunt trauma?

Chest Injuries Closed Chest Injuries: often caused by blunt force trauma to chest or back and are not associated with open wound. Damage to ribs. Pneumothorax: chest cavity filling with air from ruptured lung. Hemothorax: blood from damaged soft-tissues and vessels enter chest cavity. Discussion Question: How might rib fractures impair adequate breathing? (continued)

Injured ribs can be splinted by securing bulky dressings tightly over the injured area.

Chest Injuries Closed Chest Injuries Flail chest Crepitus Results when two or more ribs are broken in two or more places; can be life-threatening. Crepitus Grating sound when bones rub together. Discussion Topic: Describe flail chest and paradoxical movement. Describe crepitus and/or provide audio example.

A flail segment results when two or more ribs are fractured in two or more places.

Chest Injuries Closed Chest Injuries: Signs-Symptoms Pain on breathing Ecchymosis Increased difficulty breathing Accessory muscle use Uneven chest wall movement during breathing Signs and symptoms of shock Talking Point: Uneven chest wall movement during breathing is a critical sign!

Chest Injuries Chest Injury Assessment Perform primary assessment; ensure ABCs are intact. Provide positive pressure ventilations, if breathing is inadequate. Remove clothing over area where there is complaint of pain. Observe and palpate for signs of deformity. Discussion Topic: Discuss the treatment of a closed chest injury. (continued)

Chest Injuries Chest Injury Assessment Administer oxygen; follow local protocols. Splint chest using bulky dressings or towels. Place patient in a position of comfort, if no suspected spine injury. Care for shock. Transport patient.

Class Activity: Using manikins, direct students to work in pairs to take turns performing an assessment, palpating the chest for pain and deformity. Circulate around the room to provide guidance. Use both hands to carefully and thoroughly palpate the chest for pain and deformity.

Chest Injuries Open chest injuries Sucking chest wound Injury to chest that is associated with open wound. Sucking chest wound Open chest wound characterized by sucking sound each time patient inhales. Tension pneumothorax Air builds up inside chest cavity, causing excessive pressure on one side of chest. Discussion Question: How might a hole in the chest disrupt the mechanics of breathing? How does this relate to pneumothorax?

A B (A) Penetrating chest injuries can allow air and blood to enter the chest cavity. (B) A collapsed lung (spontaneous pneumothorax) can occur without outside trauma.

Chest Injuries Open Chest Wounds Immediately seal with something that prevents air from entering wound, like gloved hand. Take appropriate Standard Precautions. Occlusive dressing: sterile gauze saturated with petroleum jelly. Place occlusive dressing directly over wound and hold it in place. Provide high-flow oxygen; care for shock. Class Activity: Using a manikin, simulate an open chest wound. Direct students to demonstrate the proper application of an occlusive dressing.

Teaching Tip: Present examples of occlusive dressings Teaching Tip: Present examples of occlusive dressings. Place an occlusive dressing over an open chest wound and tape in either three or four sides. Follow local protocol.

Chest Injuries Impaled Chest Wounds Impaled objects must be stabilized and left in place. Take appropriate Standard Precautions. Perform primary assessment; ensure ABCs are intact. Assist ventilations as appropriate. Critical Thinking: Why is it important to never remove an impaled object? (continued)

Chest Injuries Impaled Chest Wounds Provide high-flow oxygen per local protocol. Provide care for shock. Initiate immediate transport.

Stabilize impaled objects using bulky dressings.

Think About It You respond to a residential home to find a 26-year-old female who was struck by a felled tree which impacted her chest. What are your concerns? How do you proceed?

ABDOMINAL EMERGENCIES

Abdominal Emergencies Anatomy of the Abdomen and Pelvis Diaphragm Primary muscle of respiration; divides chest cavity from abdominal cavity. Quadrant Area of abdomen; used to identify location of pain during palpation. Teaching Tip: Review the abdominal quadrants. Use landmarks to divide the abdomen and then discuss organ location within the quadrants. (continued)

Click here to view a three-dimensional animation of the digestive system. BACK TO DIRECTORY

Click here to participate in an interactive labeling exercise on human anatomy and body areas. BACK TO DIRECTORY

Abdominal Emergencies Anatomy of the Abdomen and Pelvis Retroperitoneal cavity Area behind abdominal cavity that contains kidneys and ureters.

Solid and Hollow Organs

For assessment purposes, the abdomen is divided into four quadrants.

Abdominal Emergencies Generalized Abdominal Pain Bleeding Infection Ulcers Indigestion Constipation Food poisoning Menstrual cramps Discussion Question: Some people have chronic issues that cause abdominal pain. Why is it important to ask “What is different today that made you call 911?” (continued)

Abdominal Emergencies Generalized Abdominal Pain Diabetic emergencies Kidney stones Gallstones Appendicitis Ectopic pregnancy Discussion Topic: Discuss the various medical causes for abdominal pain and how obtaining a thorough assessment in these cases is important. (continued)

Abdominal Emergencies Acute Abdominal Pain: Signs-Symptoms Pain that is either sharp or dull Pain on palpation Rigid or tight abdomen Bloating (distention) Nausea/vomiting Cramping Pain that radiates to other areas Guarding (protecting abdomen) Critical Thinking: What medical problems might cause internal bleeding which would lead to abdominal pain?

Abdominal Emergencies Acute Abdominal Pain: Assessment Rule out history of trauma. Injuries to abdomen can cause bleeding that is very slow. Signs and symptoms can be delayed for hours, sometimes days. Thorough medical history. Talking Point: Emphasize that although thorough assessment is important, the primary goal is finding the life threat.

Think About It You respond to the home of a 14-year-old female. Her mother reports that she dismissed her from school because of severe abdominal pain. She attempted to take the girl to the pediatrician, but the pain had intensified and she is unable to walk. (continued)

Think About It The patient has no other medical history, takes no medication, and has no allergies. She has a pulse of 100, blood pressure of 90/60, and respiratory rate of 24. You palpate the abdomen and find the patient guarding her RLQ, so you palpate that quadrant last (gently). She screams out in pain. (continued)

Think About It What are your suspicions? How will you proceed? What other questions should you be sure to include in your assessment of this patient? Teaching Tip: Discuss referred tenderness (palpation of the left lower quadrant may produce tenderness and rebound tenderness in the right lower quadrant in appendicitis).

ABDOMINAL INJURIES

Abdominal Injuries Abdominal injuries can produce life-threatening emergencies. Signs and Symptoms Deep cut or puncture wound to abdomen, pelvis, or lower back Blunt trauma to abdomen or pelvis Pain or cramps in abdominal or pelvic region (continued)

Abdominal Injuries Signs and Symptoms Guarding Lying still with legs drawn up Rapid, shallow breathing; rapid pulse Rigid, distended, and/or tender abdomen Critical Thinking: A patient with abdominal pain will often find that lying with knees bent and feet flat on stretcher or lying lateral recumbent with knees bent is more comfortable than lying with legs extended. Why might that be? Answer: It relieves abdominal musculature tension.

Abdominal Injuries Caring for Closed Abdominal Injury Perform thorough assessment of abdomen; palpate all quadrants. Expose abdomen to observe for signs of injury. Allow patient to maintain position of comfort. Discussion Question: What are the signs and symptoms of a closed abdominal injury? What are the potential life threats?

Abdominal Injuries Abdominal Evisceration: open wound of abdomen characterized by protrusion of intestines through abdominal wall. Never attempt to place spilled abdominal contents back into open wound. Discussion Question: How will you manage the treatment of an abdominal evisceration?

Cut away clothing to expose the entire injury.

Place a large sterile dressing moistened with sterile water or saline over the exposed abdominal contents.

Place a plastic sheet over the dressing and secure in place.

An abdominal evisceration. Class Activity: Using manikins or volunteers, simulate an evisceration with moulage. Read a realistic scenario and direct students to provide appropriate treatment. An abdominal evisceration.

Think About It You respond to a skateboard park where a 17-year-old boy has fallen onto concrete from a 20 foot height following a failed ramp jump attempt. He's complaining of persistent LUQ abdominal pain and nausea. His friends tell you he tried to get up but felt lightheaded. (continued)

Think About It Your patient is left lateral recumbent, guarding his abdomen, and moaning in pain. He has no other medical history, takes no medication, and is allergic to penicillin. His pulse is 100, blood pressure 100/70, and respirations are 28. (continued)

Think About It What are your suspicions? How will you proceed? What else could be going on?

SUMMARY

Summary Injuries to chest can affect ability of patient to breathe adequately and cause damage to internal organs. Injuries to chest classified as either open or closed. Types of closed injuries: broken ribs; collapse of a lung (pneumothorax); blood in chest cavity (hemothorax).

Summary Signs and Symptoms of Closed Chest Injuries Pain on breathing Difficulty breathing Discoloration Deformity Paradoxical movement

Summary Flail Chest: caused when two or more ribs are broken in two or more places. Compromises integrity of chest wall. Makes it very difficult for patient to breathe adequately.

Summary Be sure to expose all areas and palpate thoroughly with both hands. Consider high-flow oxygen when local protocols indicate.

Summary Open chest injuries result in sucking chest wound; must be covered immediately with occlusive dressing. Stabilize all impaled objects and secure object in place. Do not attempt to remove an impaled object.

Summary Abdomen and pelvis contain organs that are both hollow and solid. Injuries to organs can cause organ failure and severe internal bleeding.

Summary Signs and Symptoms of Abdominal Emergency Pain Rigidity Distention Blood in vomit, or feces

Summary Abdominal injuries classified as closed or open. Closed injuries result in organ damage and/or severe bleeding.

Summary Abdominal evisceration is open wound that has allowed abdominal contents to spill out. Cover with a sterile moist dressing and cover with plastic to minimize chances that exposed organs will dry out.

REVIEW QUESTIONS

What are the major structures of the thoracic cavity? Review Questions What are the major structures of the thoracic cavity? What is the relationship between chest injury and perfusion? What is the difference between an open and closed chest injury? What are the signs and symptoms of a closed chest injury? (continued)

What is the appropriate assessment of a patient with a chest injury? Review Questions What is the appropriate assessment of a patient with a chest injury? What is the appropriate care of a patient with a closed chest injury? What is the appropriate care of a patient with an open chest injury? What are the major structures of the abdominal and pelvic cavities? (continued)

What are the signs and symptoms of internal bleeding? Review Questions What are the signs and symptoms of internal bleeding? What is the appropriate assessment and care of a patient with abdominal pain? What is the appropriate assessment and care of a patient with an open abdominal injury?

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