Chest Trauma Chapter 34

Objectives Review the Anatomy of the Chest Discuss General Categories of Chest Injuries Discuss Specific Chest Injuries Assessment-based Approach: Chest Trauma

Anatomy of the Chest Thoracic cavity and pleural lining Visceral pleura Parietal pleura Ribs Diaphragm Mediastinum Trachea Venae cavea Aorta Esophagus Heart

Open Chest Injuries Causes – Gunshot, Knife, Any hard, sharp object Effects; Bullet wound – tiny entrance, extensive damage from ricochet, Exit wound, if bullet doesn’t lodge itself Injuries to the heart Injuries to major vessels Injuries to respiratory system – Lungs unable to inflate, Pneumothorax, Sucking chest wound

Closed Chest Injuries Blunt trauma with no open wound Injury to lungs, heart, great vessels, respiratory tract, diaphragm, esophagus Flail segment

Flail Segment Two or more adjacent ribs broken in two or more places Produces a freely moving section of chest wall Display paradoxical movement during breathing

Paradoxical Breathing Movement in the opposite direction from the rest of the chest wall Created by pressure of inhalation and exhalation Underlying contusion to the lungs is more serious than the broken ribs because it reduces patient’s air intake and leads to hypoxia To stabilize, splint and treat with PPV

Pulmonary Contusion Patient suffers from bleeding within the lung tissue Bleeding occurs in and around the alveoli and into the interstitial space between the alveoli and capillaries Leads to severe hypoxia and can lead to death Often seen with flail segment injury Other signs/symptoms include shortness of breath, cyanosis, and sign of blunt trauma to the chest Oxygenate by NRB at 15 lpm or PPV with supplemental oxygen

Pneumothorax Air accumulates in the pleural cavity, causing lung collapse on the injured side of the chest Usually due to either blunt or penetrating trauma Spontaneous pneumothorax Occurs with no trauma or other external cause Usually the result of bleb Bleb ruptures and allows air into thoracic cavity Common among smokers and emphysema patients Signs/Symptoms Dyspnea, Respiratory distress, Sharp chest pain, Absent breath sounds on one side

Open Pneumothorax Open – Sucking chest wound Result of a blow from a penetrating object Air may be heard escaping or entering through the wound Has same signs/symptoms as a closed one, plus the presence of an open chest wound Treat by immediately occluding, first with your gloved hand, then with an occlusive dressing

Tension Pneumothorax Immediately life-threatening condition Continues to trap air and collapses the injured lung Mediastinum begins to shift to uninjured side Uninjured lung, heart and large veins are compressed Results in poor cardiac output, ineffective ventilation, inadequate oxygenation, and severe hypoxia Signs/symptoms include rapid deterioration, severe respiratory distress, shock and absent breath sounds on injured side If symptoms develop, after treating for an open pneumothorax, lift the occlusive dressing to allow air to escape and transport immediately

Hemothorax Thoracic cavity is filled with blood Lung collapses as the blood continues to collect Blunt or penetrating trauma may be the cause Injury may be open or closed Severe blood loss often results in severe shock, with signs of respiratory distress developing later Patient will often produce pink or red frothy sputum when coughing Treatment is same for pneumothorax and shock

Traumatic Asphyxia Severe and sudden compression of the thorax causes a rapid increase in pressure in the chest Sternum and ribs severely compress the heart and lungs Causes a backflow of blood from the right ventricle into the head, shoulder and chest Signs/Symptoms: Bluish/purple discoloration of face, head, neck and shoulders, JVD, bloodshot eyes protruding from eye sockets, cyanotic and swollen tongue and lips, bleeding of the conjunctivae

Cardiac Contusion Occurs when heart is violently compressed between the sternum and spinal column Actual bruise may occur to the heart wall Heart wall may be ruptured Electrical conduction system of the heart may be disturbed Right ventricle is the most likely injured Signs/Symptoms: Chest pain/discomfort, evidence of blunt trauma, tachycardia, irregular pulse Transport promptly

Pericardial Tamponade Blunt/penetrating trauma may cause bleeding into the pericardial sac Since sac cannot expand much, the heart is compressed Cardiac output drops significantly, and blood backs up into veins Life-threatening Signs/Symptoms: JVD, hypoperfusion, tachycardia (can be extreme), decreased BP, narrow pulse pressure (< 30mmHg), weak pulses (radial will diminish or disappear)

Rib Injury Not life-threatening, can cause life-threatening damage to other organs Ribs most commonly fractured are the 3rd – 8th; most common site is lateral aspect of the chest Fracture may lacerate the intercostal artery or vein and cause internal bleeding Less common in children because their cartilage is more resilient than an adult’s

Signs/Symptoms Severe pain with movement and breathing Crepitation Tenderness upon palpitation Deformity of the chest wall Inability to breathe deeply Coughing Tachypnea

Treatment Place arm over the injury site and apply a sling and swathe to hold in place Give patient a pillow to hold over the injury to splint manually Do not completely wrap the chest or apply swathe snugly

Assessment-based Approach Scene Size-up Do not enter scene of a shooting or stabbing until police tell you it is safe Take BSI Wear gloves and eye protection Ask bystanders what happened Scan scene for details that will show MOI Sports accident? Fighting? Shooting? MVC? Crushed between two objects? Is patient guarding? Explosion?

Primary Assessment Form general impression Cyanotic? Respiratory distress? Breathing shallow or rapid? Guarding? Extreme pain? Expose/examine chest Open chest wound, occlude with gloved hand Paradoxical movement Mental status? Airway obstruction? Blood? Jaw-thrust Listen to speech pattern Oxygen PPV if breathing inadequate High priority for transport Log roll patient to assess posterior for a exit/entrance wound if shooting is suspected

Secondary Assessment Inspect/palpate for other injuries Breathing status Assess neck for subcutaneous emphysema, JVD, tracheal deviation Spine injury suspected, C-collar Expose chest, cut clothes off Look for flail chest signs Palpate the chest, check for equal movement on both sides, paradoxical movement, swelling and deformities

Secondary Assessment Determine breath sounds are clear and equal or decreased or absent on one or both sides Inspect abdomen for excessive muscle movement during breathing Assess baseline vital signs Obtain history from responsive patient; bystanders if unresponsive

Signs/Symptoms Cyanosis: fingernails, fingertips, lips, face Dyspnea or Tachypnea Contusions, lacerations, punctures, swelling, or other obvious signs of trauma Hemoptysis (coughing up blood/bloody sputum Signs of shock Tracheal deviation Paradoxical movement Open wound that may/may not produce sucking sound Subcutaneous emphysema JVD Absent or decreased breathing sounds upon auscultation Pain at injury site Failure of chest to expand normally during inhalation Peripheral pulses that become extremely weak or absent during inhalation Drop of 10 mmHg or more in systolic BP during inhalation

Emergency Care – Open Chest Wound Seal with gloved hand Occlusive dressing Constantly assess respiratory status Signs/Symptoms of complications: difficulty breathing, tachypnea, decreased/absent breath sounds, cyanosis, tachycardia, decreasing BP or narrowing pulse pressure, JVD, Unequal movement in chest wall, extreme anxiety and apprehension, increased resistance to PPV If you observe complications, burp the occlusive dressing

Emergency Care – Open Chest Wound

Emergency Care – Flail Segment Place hand over flail segment to splint it in a inward position Patient breathing inadequately, initiate PPV Place bulky dressings, a pillow, or a towel over the unstable segment, or secure the patient’s arm to body, to stabilize the injury Reassessment: Evaluate effectiveness of treatment, assess for further deterioration If there is deterioration, (increasing breathing difficulties, worsening cyanosis) repeat secondary assessment, look for injuries you may have missed Reassess vital signs

Emergency Care – Flail Segment

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