Chapter 23 Chest and Abdominal Trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview  Anatomy Review  Chest Trauma  Chest Injuries  Abdominal Trauma  Abdominal Injuries

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 3 Anatomy Review  Thoracic cavity and abdominal cavity: two spaces in the trunk of the body  They contain some of the body’s most important organs

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 4 Chest Trauma  Chest injuries result in a significant number of deaths each year  The chest contains organs vital to life  Damage to vital organs threatens life  Most common consequence is hypoxia

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 5 Chest Trauma  Mechanism of injury (MOI): Blunt chest trauma –Most common cause of serious chest injuries –Motor vehicle collisions (MVCs), falls, direct blows, and crushing injuries –Many injuries are not immediately apparent in physical exam

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 6 Chest Trauma  Mechanism of injury (MOI): Blunt chest trauma –Injuries linked to size of object applying force and most important, to speed –Speed kills

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 7 Chest Trauma  MOI: Blunt chest trauma –Evaluating MOI at a motor vehicle collision Significant damage to vehicle’s exterior? Damage to interior of vehicle? Broken or bent steering wheel means significant force was applied to the driver’s chest The higher the forces, the higher the suspicion for serious injury to patient

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 8 Chest Trauma  MOI: Penetrating trauma –Increasingly common in today’s society –Immediate result can be severe bleeding or impaired breathing

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 9 Chest Trauma  MOI: Penetrating trauma –Any chest wound can involve underlying organ injury No matter how superficial it looks –Injuries to the heart, lungs, and great vessels can quickly lead to shock and cardiac arrest

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 10 Chest Trauma  Signs and symptoms –Most common symptoms: pain and difficulty breathing –Signs are obvious injury to the chest wall Use DCAP-BTLS, looking at both the front and back of the chest –Note any subcutaneous emphysema, or air present under the skin

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 11 Chest Trauma  Assessment –Follow all steps in the assessment of the trauma patient

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 12 Chest Trauma  Management –Ensure patient has adequate oxygenation and perfusion –Provide high-flow oxygen, ventilating when necessary –Halt any obvious bleeding

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 13 Chest Trauma  Management –Support circulation when needed –Rapidly transport patient to definitive care

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 14 Chest Trauma  Transport –Transport patient to a hospital with the capability to diagnose and treat serious traumatic injuries –Arrange for ALS intercept as guided by local protocols –Notify receiving hospital so staff can prepare

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 15 Chest Injuries  Open chest wounds –A sharp object penetrates the skin on the chest wall –Laceration of vessels such as the vena cava or aorta will likely cause bleeding between the lung and the chest wall The accumulation of blood in the pleural space is called a hemothorax

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 16 Chest Injuries  Open chest wounds –If penetrating object has pierced pleura, outside air can enter the thoracic cavity –As the volume of air in the thoracic cavity expands, the lung starts to collapse –Air within the pleural space is called a pneumothorax

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 17 Chest Injuries  When air enters between the lung and the chest wall, pneumothorax is created

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 18 Chest Injuries  Open chest wounds –As air passes in and out of an open wound, it can create a sucking-type sound –Sucking chest wound means possibility of pneumothorax –Signs of pneumothorax: difficulty breathing, cyanosis, diminished breath sounds on the affected side

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 19 Chest Injuries  Open chest wounds: Management –Cover open chest wounds with occlusive dressing –Gloved hand is an effective temporary occlusive dressing –Secure dressing on three sides

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 20 Chest Injuries  Open chest wounds: Management –High-flow oxygen –Transport with unaffected side slightly elevated –Arrange for ALS intercept

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 21 Open Chest Wound  Watch this animation illustrating management of an open chest wound.

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 22 Stop and Review  Name three signs of a simple pneumothorax.

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 23 Chest Injuries  Tension pneumothorax –Buildup of pressure in pleural space resulting in decrease in blood pressure –Potentially life-threatening condition that must be treated immediately –Can occur in blunt or penetrating chest trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 24 Chest Injuries  Increasing pressure in the lung pushes the heart and the great vessels to the opposite side of the chest.

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 25 Chest Injuries  Tension pneumothorax: Signs –Include all those of a pneumothorax –Jugular venous distension (JVD) –If ventilating becomes more difficult, significant lung compression is indicated

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 26 Chest Injuries  Tension pneumothorax: Signs –Tracheal deviation is a late sign –If patient is hypotensive, immediately lift a corner of the occlusive dressing Transport this patient rapidly Consider ALS intercept

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 27 Chest Injuries  Rib fractures –Local swelling and tenderness may be the only sign of a broken rib –Can be very painful –Patients often present with guarding and shallow breathing

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 28 Chest Injuries  Rib fractures: Management –Move the patient carefully to prevent the bone ends from puncturing a lung –Administer oxygen

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 29 Chest Injuries  Rib fractures: Management –Allow patient to self-splint by assuming the most comfortable position possible –Encourage patient to limit movement

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 30 Chest Injuries  Flail segment –When three or more ribs are broken in two or more places, a rib-cage segment may detach from the rest –Flail segment is free floating

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 31 Chest Injuries  Flail segment –Paradoxical movement: movement of flail segment in opposite direction of the rest of the chest wall –Paradoxical movement can significantly impair breathing and cause injury to the underlying lung

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 32

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 33 Flail Chest Segment  Watch this animation of a flail chest segment.

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 34 Chest Injuries  Flail segment: Management –Quickly stabilize flail segment by placing gloved hand over injured area –After manual stabilization, place folded universal dressing over segment and tape securely

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 35 Chest Injuries  Flail segment: Management –Consider assisting patient’s breathing if tachypnea increases –Transport on side with unaffected lung on top

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 36 Chest Injuries  Pulmonary contusion –Bleeding into the lung itself is a pulmonary contusion –Bleeding and edema can impair gas exchange, causing hypoxia –Soft crackles may be heard over injury site –Chest pain, point tenderness, and localized swelling over area of impact

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 37 Chest Injuries  Pulmonary contusion: Management –Support ventilation as needed –Supply high-flow supplemental oxygen –Transport to hospital

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 38 Chest Injuries  Cardiac contusion –Can impair heart’s ability to pump –Bleeding into heart tissue can cause heart to beat irregularly –Irregular pulse should alert EMT to possibility of a cardiac contusion

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 39 Chest Injuries  Cardiac contusion: Management –High-flow oxygen –Ventilation support as needed –Support of circulation if appropriate –Prompt transport –Request ALS backup

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 40 Chest Injuries  Pericardial tamponade –Bleeding around heart and into pericardial sac that encloses the heart can cause pericardial tamponade –Usually results from a penetrating chest trauma with laceration to the heart itself

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 41 Chest Injuries  Pericardial tamponade –Blood filling the pericardial sac compresses heart, causing blood to back up –JVD is a telltale sign of pericardial tamponade –Narrowed pulse pressures

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 42 Chest Injuries  Pericardial tamponade: Management –High-flow oxygen –Treat patient for shock –Transport rapidly to ED –Request ALS intercept –Notify hospital so staff can properly prepare

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 43 Chest Injuries  Aortic injury –In sudden decelerations such as high-speed head- on MVCs, body organs are thrown forcefully against the front of the body –Most significant tear: aorta –If tear is complete, patient will die in minutes Incomplete tears bleed severely

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 44 Chest Injuries  Aortic injury: Management –High-flow oxygen –Treat patient for shock –Transport rapidly to ED –Notify hospital so staff can properly prepare

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 45 Chest Injuries  Traumatic asphyxia –Rapid ejection of blood and air out of chest –Rapid compression of chest increases internal pressure dramatically Blood is immediately forced out of the chest and into the vessels in the neck, head, and face

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 46 Chest Injuries  Traumatic asphyxia –Neck veins immediately become distended –Cyanosis is apparent in face –Bleeding in the eyes’ sclera may occur

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 47 Chest Injuries  Traumatic asphyxia: Management –High-flow oxygen –Treat patient for shock –Transport rapidly to ED –Notify hospital so staff can properly prepare

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 48 Abdominal Trauma  MOI: Penetrating abdominal trauma –Stab or gunshot wound to abdomen, no matter how superficial, can seriously injure internal organs

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 49  MOI: Penetrating abdominal trauma –Inquire Kind of knife and length? Caliber of gun? How many shots were fired? Trajectory? Abdominal Trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 50 Abdominal Trauma  MOI: Blunt abdominal trauma –External signs of injury may not be readily apparent –Injury potential is as great as that of a penetrating trauma –Most vehicle air bags don’t protect against abdominal injury from lateral impacts in an MVC –Improper use of seat belts may cause abdominal injury in a collision

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 51 Abdominal Trauma  Signs and symptoms –Look for DCAP-BTLS –Look for signs of penetrating trauma –Pain –Guarding, rigidity, distension, masses –Rebound tenderness

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 52  Assessment –Follow all of the steps in patient assessment Abdominal Trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 53  Management –Ensure patient has adequate oxygenation and perfusion –Provide high-flow oxygen, ventilating when necessary Abdominal Trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 54  Management –Halt any obvious bleeding –Support circulation when needed –Rapidly transport patient to definitive care, usually a trauma center Abdominal Trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 55  Transport –Transport patient to a hospital with the capability to diagnose and treat serious traumatic injuries –EMT should arrange for ALS intercept as guided by local protocols –Notify hospital so staff can prepare Abdominal Trauma

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 56 Abdominal Injuries  Liver and spleen injury –Most commonly injured abdominal organs –Both are very vascular –Potential signs of liver or spleen injury: contusions and abrasions over the lower rib cage with upper abdominal tenderness

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 57 Abdominal Injuries  Liver and spleen injury: Management –High-flow oxygen –Ventilation support as needed –Support of circulation if appropriate –Prompt transport

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 58 Abdominal Injuries  Evisceration –Large abdominal wound may allow abdominal contents such as the small intestine to eviscerate through wound opening –The EMT can recognize evisceration easily but should not let it distract him from addressing other potentially life-threatening issues

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 59 Abdominal Injuries  Evisceration: Management –Do not replace abdominal contents into abdomen –Cover protruding contents with dry nonadherent sterile dressing –Cover dressings with a sheet of aluminum foil to retain heat and protect organs from further injury

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 60 Abdominal Injuries  Evisceration: Management –High-flow oxygen –Ventilation support as needed –Support of circulation if appropriate –Prompt transport

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 61 Abdominal Injuries  Pelvic fracture –Fractures of the bony pelvis can result in injury to the underlying organs and vessels –Internal bleeding can result in hemorrhagic shock

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 62 Abdominal Injuries  Pelvic fracture: Management –Consider use of MAST for stabilization –High-flow oxygen –Ventilation support as needed –Support of circulation if appropriate –Prompt transport

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 63 Stop and Review  What is the management for traumatic asphyxia?  Name two significant signs of pericardial tamponade.  What is a late sign of tension pneumothorax?