1. Chapter 34 Chest Trauma Advance Preparation
Review local protocols on the management and transportation of patients with chest injuries.
Bring anatomical models of the thorax, lungs, and heart to class. (See slide 9.)
Bring to class occlusive dressings and materials for stabilizing a flail segment.
Set up equipment for lab practice in managing chest injuries, including airway management, ventilation, and oxygenation equipment; stethoscopes; and dressing and bandaging materials.
Prehospital Emergency Care, Ninth Edition
Joseph J. Mistovich • Keith J. Karren
Copyright ©2010 by Pearson Education, Inc.
All rights reserved.

2. Talking Points
The chest cavity is also known as the thoracic cavity. It is surrounded by the ribs and bordered inferiorly by the diaphragm.
The mediastinum houses the trachea, the vena cavae, the aorta, the esophagus, and the heart.
The pleural lining of the thorax plays a major role in some types of chest injuries. The pleura consists of the visceral pleura and the parietal pleura. Between the two pleural layers is a potential space that contains serous fluid.
Air in the chest cavity is called a pneumothorax.

3. Anatomy of Chest
Pneumothorax
Video

4. Open Chest Injury Causes Sucking chest wound Tension pneumothorax
Talking Points
An open chest injury is the result of a penetrating chest wound caused by a knife, gunshot, or a wide variety of other objects such as ice picks, screwdrivers, letter openers, broken glass, nails, or car keys.
The ability of the lungs to inflate will be seriously impeded.
An open chest wound can pull air into the thoracic cavity. This is referred to as a sucking chest wound.
Two problems in managing an open or sucking chest wound are preventing additional air from being sucked into the chest cavity and avoiding trapping the air that is already in the chest cavity.
Cover a sucking chest wound with your gloved hand upon first identifying it; then apply a nonporous dressing and tape it on three sides. This will prevent both pulling in additional air and trapping air already in the cavity.
A tension pneumothorax, caused by air leaking into the chest cavity from a damaged lung with no opening through the outer chest wall, cannot be managed by EMTs in the prehospital setting.
Causes
Sucking chest wound
Tension pneumothorax

5. Sucking Chest Wound Video Remember first priority
Cover with gloved hand immediately
Put 3 sided occlusive dressing to cover

6. A pellet fired from an air gun creates an extremely small entrance wound. Although a pellet wound may be very small, a pellet can penetrate the thoracic cavity, ricochet around, and potentially cause lethal injuries. When you suspect trauma, you must expose and closely inspect the chest to avoid missing potentially lethal injuries. (

7. Closed Chest Injury Cause Injury Flail segment Talking Points
A closed chest injury occurs when blunt trauma is applied to the chest but no open wound results.
Injury to the lung, heart, great vessels, respiratory tract, diaphragm, and esophagus can result from blunt trauma.
A common life-threatening closed chest injury occurs when two or more adjacent ribs are broken in two or more places. This creates a segment of the chest that is unattached to the rest of the rib cage, an injury known as a flail segment.
– A flail segment may also result from more than one rib being fractured and separated from the cartilage along the edge of the rib cage.
– A large, unstable flail segment is life-threatening because it interferes with proper expansion of the chest cavity, causing intrathoracic pressure changes and severe respiratory distress or inadequate respiration and rapid patient deterioration.
Cause
Injury
Flail segment

8. Flail Segment Definition Paradoxical movement Effect on respiration
Talking Points
A flail segment occurs when two or more consecutive ribs are fractured in two or more places, producing a freely moving section of chest wall.
During inhalation and exhalation, the flail segment displays paradoxical movement; that is, the flail segment moves in a direction opposite to the movement of the rest of the chest wall.
The effects of pressure during inhalation and exhalation explain why paradoxical movement happens.
The flail segment requires immediate recognition and management, but the underlying contusion to the lung is a more serious injury.
Stabilization of the segment reduces the paradoxical movement and improves ventilation. Stabilize the fail segment by splinting it.
Because lung contusion and lung collapse are associated with a flail segment, positive pressure ventilation with supplemental oxygen is the ideal treatment.
Definition
Paradoxical movement
Effect on respiration
Emergency medical care

9. Pulmonary Contusion Causes Signs and symptoms Emergency medical care
Talking Points
A pulmonary contusion is often a serious consequence of a flail segment. Bleeding occurs in and around the alveoli and into the interstitial space that separates the alveoli and capillaries. This greatly reduces the exchange of oxygen and carbon dioxide, leading to severe hypoxia.
Suspect a patient who has suffered a direct blow or any other blunt trauma to the chest of having a pulmonary contusion.
The amount of respiratory distress depends on the amount of damaged lung tissue.
To provide emergency medical care, maximize oxygenation by a nonrebreather mask at 15 lpm for the patient who is breathing adequately or by positive pressure ventilation with supplemental oxygen for the patient breathing inadequately.
Pulmonary Contusion

10. Pneumothorax Causes Signs and symptoms Talking Points
A pneumothorax is the accumulation of air in the pleural cavity, causing collapse of a portion of the lung.
It is usually caused by either blunt or penetrating trauma.
The accumulation of air in the thoracic cavity causes the lung on the injured side to collapse, either partially or fully. This results in a decrease in gas available within the alveoli, causing a reduction of oxygen delivered to the cells of the body.
Signs and symptoms include chest pain that worsens with deep inspiration, dyspnea, tachypnea, and decreased or absent breath sounds on the affected side.
A patient may suffer a pneumothorax in the absence of blunt or penetrating trauma to the chest. This condition is called a spontaneous pneumothorax. It usually results from a congenitally weak area on the surface of the lung that ruptures and allows air to enter the thoracic cavity.
Causes
Signs and symptoms

11. Open Pneumothorax Cause Signs and symptoms Emergency medical care
Talking Points
An open pneumothorax is a result of an open wound to the chest created by a penetrating object.
You may hear air may escaping or entering through the chest wound, creating a bubbling or sucking sound. For this reason, an open pneumothorax is referred to as a “sucking chest wound.”
The signs and symptoms of an open pneumothorax are the same as for a closed pneumothorax, with the exception of the presence of an open wound the chest.
You must immediately occlude an open wound to the chest. Initially seal it with your gloved hand and then with an occlusive dressing.

12. Tension Pneumothorax Cause Effect on body Severity Signs and symptoms
Emergency medical care
Tension Pneumothorax
Talking Points
A tension pneumothorax is an immediately life-threatening condition resulting from a pneumothorax. With each breath, a massive volume of air accumulates in the thoracic cavity on the injured side. This completely collapses the injured lung and begins to compress and shift the mediastinum over to the uninjured side. The uninjured lung, heart, and large veins are compressed, leading to poor cardiac output, ineffective ventilation, inadequate oxygenation, and severe hypoxia. Death can occur rapidly.
Signs and symptoms include rapid deterioration, severe respiratory distress, signs of shock, absent breath sounds on one side of the chest, cyanosis, unequal movement of the chest, distended neck veins, diminished breath sounds on the side opposite to the injury, and deviation of the trachea to the uninjured side.
This condition may develop following the application of an occlusive dressing to an open chest wound. Alleviate the pressure by lifting the dressing and allowing air to escape during expiration, even if it is taped on only three sides.
If you suspect a tension pneumothorax, rapid transport is critical.

13. Hemothorax Definition Cause Signs and symptoms Emergency medical care
Talking Points
With a hemothorax, the thoracic cavity is filled with blood rather than air. As the blood continues to collect, the lung is compressed.
A hemopneumothorax is the collection of both blood and air in the thoracic cavity.
A hemothorax may be the result of blunt or penetrating trauma to the chest and may be associated with open or closed injuries. The bleeding usually originates from lacerated blood vessels in the chest wall or chest cavity caused by penetrating objects or fractured ribs. The patient can lose a significant amount of blood in the chest, resulting in severe shock.
Early signs and symptoms of hemothorax are usually the same as for shock. Signs and symptoms of respiratory distress develop late. In addition, bleeding in and around the lung commonly produces a pink or red frothy sputum when the patient coughs.
Emergency medical care is the same as for pneumothorax and shock.

14. Traumatic Asphyxia Cause Signs and symptoms Emergency medical care
Talking Points
Traumatic asphyxia is caused when a severe and sudden compression of the thorax rapidly increases the pressure in the chest. The heart and lungs are usually severely compressed by the sternum and ribs, causing a backflow of blood out of the right ventricle and into the veins of the head, shoulders, and upper chest. The patient often looks as if he has been strangled.
The signs and symptoms of traumatic asphyxia include bluish or purple discoloration of the face, head, neck, and shoulders; jugular vein distention; bloodshot eyes that are protruding from the socket; cyanotic and swollen tongue and lips; and bleeding of the conjunctiva.
Provide emergency medical care for any wounds to the chest and for shock.

15. Cardiac Contusion Cause Signs and symptoms Emergency medical care
Talking Points
Cardiac contusion is a common cardiac injury following severe blunt trauma to the chest. It occurs as the heart is violently compressed between the sternum and the spinal column.
An actual bruise may occur to the heart wall. Also, the heart wall may be ruptured or a disturbance in its electrical conduction system may occur. The right ventricle, directly beneath the sternum, is the most likely area of the heart to be injured.
Signs and symptoms of cardiac contusion are chest pain or chest discomfort; signs of blunt trauma to the chest, including bruises, swelling, crepitation, and deformity; tachycardia; and an irregular pulse.
Prompt transport is required.
Cause
Signs and symptoms
Emergency medical care

16. Pericardial Tamponade
Definition
Causes
Signs and symptoms
Talking Points
Blunt or penetrating trauma may cause bleeding into the pericardial sac. Since this sac cannot expand outward very much with the filling blood, the result is inward compression of the heart, causing cardiac output to drop significantly and blood to back up in the venous system. This condition is known as pericardial tamponade.
It is a life-threatening condition that requires prompt recognition and transport.
The most common cause of a pericardial tamponade is a penetrating wound to the heart from a knife or similar object. Bullets may also cause pericardial tamponade.
The signs and symptoms of pericardial tamponade are very similar to those of tension pneumothorax, except that breath sounds remain normal in pericardial tamponade because only the heart is involved and not the lungs.
Signs and symptoms include jugular vein distention; signs of shock; tachycardia; decreased blood pressure; narrow pulse pressure (less than 30 mmHg); and weak pulses, with radial pulses disappearing or diminishing during inhalation.

17. Rib Injury Effect Signs and symptoms Emergency medical care
Talking Points
While a fractured rib is not life-threatening, it can cause life-threatening damage to other structures and organs.
The most common signs and symptoms of rib injury include pain with movement and breathing; crepitation; tenderness; deformity of the chest wall; inability to breathe deeply; coughing; and tachypnea that may be shallow.
You may suspect a simple rib fracture if the patient presents in the guarded position, holding his arm over the injured site.
You can use the arm to splint the injury by placing it over the injury site and applying a sling and swathe to hold it in place. You can also give the patient a pillow to hold firmly over the injury in order to manually splint it.
Do not completely wrap the chest or apply the swathe snugly. This will impede normal ventilation.
Suspect a potential chest injury based on the mechanism of injury and a high index of suspicion; adequately assess the patient; and provide the necessary emergency medical care.

18. Scene Size-Up Scene safety Mechanism of injury Talking Points
When you arrive on the scene, assess for threats to your safety.
Do not enter the scene of a shooting or stabbing until the police secure it and tell you it is safe to enter.
Take the necessary Standard Precautions.
While the scene is being cleared of safety hazards, concentrate on the mechanism of injury.
Ask bystanders to tell you what happened.
Scan the scene.
Blunt trauma commonly occurs in sports accidents, falls, blows to the chest during fights, and, most commonly, automobile crashes.
Penetrating trauma most often is associated with violence.
Scene safety
Mechanism of injury

19. Primary Assessment In-line spine stabilization General impression
Expose chest
ABCs
Mental status
Treat life threats
Talking Points
After ensuring that the scene is safe, proceed with the primary assessment.
If you suspect trauma to the chest based on a significant mechanism of injury and a high index of suspicion, establish and maintain in-line spine stabilization.
Form a general impression of the patient.
Expose the chest and examine it. If you note an open wound to the anterior, lateral, or posterior chest, immediately seal it with a gloved hand. If you note paradoxical movement, immediately place a gloved hand over the flail segment to splint it in an inward position. The ideal treatment for a flail segment is positive pressure ventilation.
Assess the mental status. Open and maintain a patent airway.
Assess the breathing status. Provide oxygen and ventilate as needed.
Assess the circulation. Treat any life threats.
This patient is a high priority and requires immediate transport.
If you suspect that the patient has been shot or stabbed, assess the posterior body for another potentially life-threatening open wound.

20. Secondary Assessment Head-to-toe assessment Lung sounds
Accessory muscle use
History
Signs and symptoms
Talking Points
Perform a rapid secondary assessment.
Assess the breathing status. Be sure that the patient is on high-flow, high- concentration oxygen or ventilated adequately.
Assess the neck for subcutaneous emphysema, jugular vein distention, and tracheal deviation. Apply a cervical spine immobilization collar.
If found, immediately seal an open chest wound. If you note paradoxical movement, immediately stabilize the segment.
Auscultate the breath sounds bilaterally. Inspect the abdomen for excessive muscle movement during breathing.
Assess the baseline vital signs and obtain a history.
Signs and symptoms of chest trauma include cyanosis; dyspnea; obvious signs of trauma to the chest; hemoptysis; signs of shock; tracheal deviation; paradoxical movement of a segment of the chest wall; subcutaneous emphysema; JVD; absent or decreased breath sounds; pain at the injury site; and a systolic blood pressure drop by ten mmHg or more during inhalation.

21. General Emergency Care– Chest Trauma
Maintain open airway
Continue O2 therapy
Reevaluate breathing status
Stabilize impaled objects
Immobilize patient on long backboard, if needed
Treat for shock
Talking Points
Chest injuries can be life threatening. Therefore, prompt recognition and emergency medical care are essential to the patient’s survival.
An open chest wound, a flail segment that produces paradoxical movement, and inadequate breathing are all conditions that you must manage immediately upon identification.
Maintain an open airway. Take in-line stabilization and open the airway using a jaw-thrust maneuver if you suspect spine injury. Suction if necessary.
Continue oxygen therapy. Continuously administer high-flow, high- concentration of oxygen to all patients with suspected chest injury via a nonrebreather mask at 15 lpm or with positive pressure ventilation.
Reevaluate breathing status. Stabilize an impaled object in place.
Completely immobilize the patient if you suspect spine injury.
Treat the patient for shock if signs and symptoms are present.

24. Emergency Care– Open Chest Wound
Seal open wound with gloved hand immediately
Apply occlusive dressing to seal wound
Continuously assess patient’s respiratory status
Talking Points
Emergency medical care includes the general care plus the following:
Immediately seal the open wound with your gloved hand.
Apply an occlusive dressing to seal the wound.
Continuously assess the patient’s respiratory status. If the patient’s condition begins to deteriorate and you notice more severe signs and symptoms of respiratory distress along with signs of shock, the patient may be developing a tension pneumothorax.
If the signs and symptoms of a tension pneumothorax develop after you have applied the occlusive dressing, lift a corner of the dressing for a few seconds to allow the air to escape during expiration. Repeat this procedure several times if necessary.

25. Inspiration
Expiration

27. Emergency Care— Flail Segment
Place hand over flail segment
Initiate positive pressure ventilation, if needed
Stabilize with bulky dressings
Talking Points
Initially splint paradoxical movement of a flail segment in an inward position by placing your hand over the unstable flail segment.
If the patient is breathing inadequately, initiate positive pressure ventilation during the primary assessment.
You can also stabilize paradoxical movement by placing bulky dressings, a pillow, or towels over the unstable segment or by securing the patient’s arm to his body.

28. Stabilizing Flail Segment

29. Reassessment Evaluate interventions
Watch for worsening signs and symptoms
Monitor for tension pneumothorax
Reassess vital signs
Talking Points
During the reassessment evaluate the effectiveness of your treatment and assess for further deterioration of the patient’s condition.
Reevaluate your treatment and repeat the rapid secondary assessment if you note any of the following signs and symptoms: increasing breathing difficulty; decreasing mental status; decreasing breath sounds; worsening cyanosis; and shock. Look for signs of injury that you might have missed initially. Reconsider the need to provide positive pressure ventilation if it has not already been initiated.
Look for signs of a developing tension pneumothorax. If an occlusive dressing is in place, lift it to relieve any pressure that has potentially built up.
Reassess and record the baseline vital signs.
Knowledge Application
Given a variety of chest injury scenarios, students should be able to identify patients’ injuries and provide both general supportive and injury-specific management.