2 Chapter 15 Thoracic Trauma

3 Objectives There are no 1985 objectives for this chapter.

4 Thoracic Injuries Damage to heart, lungs, and great blood vessels Internal bleeding Pressure changes

5 Anatomy & Physiology: Review of the Thorax

6 Organs of the Chest

7 Anatomy of the Thorax Protection provided by the following: –Ribs –Intercostal muscles –Diaphragm –Sternocleidomastoid –Trapezius –Rhomboids –Lastissimus dorsi –Pectoralis major

8 Physiology Respiration C3,C4,C5 Chemical receptors Diffusion pH Buffer system

9 Injuries of the Chest Open Chest Injuries –Caused by penetrating trauma Closed Chest Injuries –Caused by blunt trauma

10 Pathophysiology of Thoracic Trauma Cardiac output Ventilatory efficiency Gas exchange

11 Assessment Findings (1 of 2) Failure of the chest to expand normally Rapid, weak pulse and low blood pressure Cyanosis around the lips or fingernail beds Pain at the site of injury Pain aggravated by or increased with breathing Dyspnea Hemoptysis

12 Assessment Findings (2 of 2) DCAP-BTLS Chest wall movement Paradoxical movement Hemoptysis Shock Cyanosis

13 Complications of Chest Injuries

14 Management ABCs C-spine control Occlude open wounds 2 large-bore IVs Fluid bolus Rapid transport

15 Chest Wall Injuries (1 of 8) Rib Fractures –They are very common in the elderly. –A fractured rib may lacerate the surface of the lung. –Patients will avoid taking deep breaths, and breathing will be rapid and shallow. The patient often holds the affected side to minimize discomfort. Administer oxygen.

16 Chest Wall Injuries (2 of 8) Assessment Findings of Rib Fractures –Localized tenderness –Pain on inspiration –Self splinting –Point tenderness –Crepitus

17 Chest Wall Injuries (3 of 8) Flail Chest –Three or more ribs fractured in two or more places, the sternum is fractured along with several ribs. –A segment of the chest wall may be detached from the rest of the thoracic cage. –Creates paradoxical movement.

18 Chest Wall Injuries (4 of 8)

19 Chest Wall Injuries (5 of 8) –Flail Chest (cont.) Breathing is extremely painful and patient rarely receives adequate oxygenation. Care includes the following: –Maintaining the airway –Providing respiratory support –Performing ongoing assessment –Immobilizing flail segment

20 Chest Wall Injuries (6 of 8) Assessment Findings for Flail Chest –Expose and examine the chest for DCAP-BTLS. –Check for accessory muscle use. –Paradoxical motion. –Tachycardia and tachypnea. –Immobilize the flail segment.

21 Chest Wall Injuries (7 of 8) Sternal Fracture –Deceleration injury –Myocardial contusion or rupture –Pulmonary contusion –Flail chest –Vascular disruption

22 Chest Wall Injuries (8 of 8) Assessment Findings of Sternal Fracture –Localized pain –Crepitus on palpation –Tachypnea –Cardiac compromise

23 Injury to the Lung (1 of 14) Simple Pneumothorax –Air accumulates in the pleural space. –Air enters through a hole in the chest wall. The lung may collapse in a few seconds or a few hours. –An open or penetrating wound to the chest is called a sucking chest wound.

24 Injury to the Lung (2 of 14)

25 Injury to the Lung (3 of 14) Spontaneous Pneumothorax –Some people are born with or develop weak areas on the surface of the lungs. –Occasionally, the area will rupture spontaneously, allowing air into the pleural space. –Patient experiences sudden chest pain and trouble breathing. –Consider a spontaneous pneumothorax for a patient with chest pain without cause.

26 Injury to the Lung (4 of 14) Assessment Findings of Pneumothorax –Tachypnea –Tachycardia –Decreased or absent breath sounds –Hyperresonance –Pleuritic chest pain

27 Injury to the Lung (5 of 14) Open Pneumothorax –Clear and manage the airway. –Provide oxygen. –Seal an open wound with an occlusive dressing. –Depending on local protocol, tape down all four sides or create a flutter valve.

28 Injury to the Lung (6 of 14) Assessment Findings of Open Pneumothorax –Penetration of chest wall –Sucking sound may be heard –Tachycardia –Tachypnea –Decreased or absent breath sounds –Subcutaneous emphysema

29 Injury to the Lung (7 of 14) Tension Pneumothorax –Can result from sealing all four sides of the dressing on a sucking chest wound. –Can also result from a fractured rib puncturing the lung or bronchus. –Can also result from a spontaneous pneumothorax.

30 Injury to the Lung (8 of 14) –Hypotension –Tracheal deviation –Tachycardia –Narrowed pulse pressure –Subcutaneous emphysema –Jugular venous distension –Hyperresonance Assessment Findings of Tension Pneumothorax –Absent breath sounds –Dyspnea –Tachypnea –Respiratory distress –Extreme anxiety –Cyanosis –Bulging of the intercostal muscles

31 Injury to the Lung (9 of 14) Care for Tension Pneumothorax –If a tension pneumothorax develops from sealing an open chest wound, partly remove the dressing to let the air escape. –If there is no open wound, follow local protocol.

32 Injury to the Lung (10 of 14) Hemothorax –Collection of blood in the pleural space. –Suspect Hemothorax if the following are seen: Signs and symptoms of shock Decreased breath sounds on affected side –If both air and blood are present in the pleural space, it is a hemopneumothorax.

33 Injury to the Lung (11 of 14)

34 Injury to the Lung (12 of 14) Assessment Findings for Hemothorax –Respiratory compromise –Sign and symptoms of shock –Decreased or absent breath sounds –Dullness on percussion

35 Injury to the Lung (13 of 14) Pulmonary Contusions –Bruising of the lung. –Develops over hours. –Alveoli fill with blood, and fluid accumulates in the lung, causing hypoxia. –Provide oxygen and ventilatory support.

36 Injury to the Lung (14 of 14) Assessment Findings for Pulmonary Contusions –Tachypnea –Tachycardia –Hemoptysis –Respiratory distress –Dyspnea –Cyanosis –Evidence of blunt chest trauma

37 Myocardial Injuries (1 of 3) Pericardial Tamponade –Blood or other fluids collect in the pericardium. –Signs and symptoms include the following: Very soft and faint heart tones Tachycardia with a weak pulse Low blood pressure Respiratory distress Decrease in difference between systolic and diastolic blood pressure Jugular vein distention (JVD) –Provide oxygen and transport quickly.

38 Myocardial Injuries (2 of 3)

39 Myocardial Injuries (3 of 3) Myocardial Contusion –Bruising of heart muscle. –Pulse is often irregular. –There is no prehospital treatment for this condition. –Check patient’s pulse and note irregularities. –Provide supplemental oxygen and transport immediately.

40 Vascular Injuries (1 of 2) Aortic Dissection and Rupture –Shearing of the aortic –Very high mortality rate –Retrosternal or interscapular pain –Dyspnea –Absent pulses

41 Vascular Injuries (2 of 2) Penetrating Wounds of the Great Vessels –The superior vena cava, the inferior vena cava, the pulmonary arteries and veins, and the aorta are contained in the chest. –Injury to these vessels can cause fatal hemorrhaging. –Treatment includes the following: CPR Ventilatory support Supplemental oxygen Transport immediately

42 Other Thoracic Injuries (1 of 4) Diaphragmatic Injury –Caused by high pressure compression –Bowel obstruction and strangulation –Tachypnea –Tachycardia –Respiratory distress –Dullness to percussion

43 Other Thoracic Injuries (2 of 4) Esophageal Injury –Most common with penetration trauma –Can occur with violent emesis, cancer, or anatomic distortions –Pain –Fever –Hoarseness –Subcutaneous emphysema

44 Other Thoracic Injuries (3 of 4) Tracheobronchial Injuries –Tear can occur anywhere along the tracheobronchial tree –Tension pneumothorax refractory to needle decompression –Tachypnea –Tachycardia –Subcutaneous emphysema –Hemoptysis

45 Other Thoracic Injuries (4 of 4) Traumatic Asphyxia –Sudden, severe compression of chest –Produces rapid increase in pressure within chest –Results in neck vein distention, cyanosis, and bleeding into the eyes –Provide supplemental oxygen and monitor vital signs –Transport immediately

46 Management of Thoracic Injuries Manage ABCs – Intubate as needed. Supplemental oxygen. 2 large-bore Ivs. Rapid transport to appropriate facility. Always follow local protocols.