1. Chest Injuries

2. Statistics
According to the Centers for Disease Control (CDC), chest trauma causes:
700,000 ER visits per year in the US
18,000 Death per year in the US
Nearly 1/3 of people killed instantly in MVCs die from a traumatic rupture of the aorta AAOS 11th Ed Page 1035
Any injury that interferes with normal breathing must be treated immediately
AAOS 11th Ed Page 1031

3. Causes of Chest Injuries
Chest injuries are caused by:
Blunt trauma
MVCs
Falls
Penetrating trauma
Shootings
Stabbings
Industrial Accidents
AAOS 11th Ed Page 1031

4. Anatomy of the Chest The chest, or thoracic cavity, contains the:
Heart
Lungs
Esophagus
Trachea
Major blood vessels
AAOS 11th Ed Page 1032 and 1033

5. Anatomy of the Chest

6. Pleura and Pleural Space
Pleura: The serous membranes covering the lungs (visceral pleural) and lining the thorax (parietal pleural)
Pleural Space: The potential space between the lung and the thorax. No space exists here except from injury.
AAOS 11th Ed Page 1532

7. Source:

8. General Categories of Chest Injuries
Open
The skin is broken
Generally caused by penetrating trauma
Impaled object
Example: a knife sticking out of a chest
Stabilize in place. Do Not Remove
AAOS 11th Ed Page 1034 and 1035

9. General Categories of Chest Injuries
Closed
The skin is not broken
Generally caused by blunt force trauma
Broken ribs may lacerate organs in the chest
Vital organs my be torn
Internal bleeding may not be visible
Internal bleeding can be life-threatening
AAOS 11th Ed Page 1034

10. Closed Chest Injuries
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.

11. General Categories of Chest Injuries
Open Chest Injury

12. Signs & Symptoms of Chest Injury
Pain at the site
Pain increased with breathing
Bruising to the chest
Crepitus (bone ends grinding together)
Penetrating injury
Dyspnea (difficulty breathing)

13. Signs & Symptoms of Chest Injury
Tachypnea (rapid breathing)
Hemoptysis (coughing up blood)
Failure of chest to expand normally
Pules: rapid, weak
BP: low
Cyanosis around lips & fingernails
AAOS 11th Ed. Page 1035 and 1036

14. Signs & Symptoms of Chest Injury
Any change in normal breathing is a very important sign
Healthy, uninjured adults breath 12 to 20 breaths per minute
Respirations of less than 12 or more than 20 may indicate inadequate breathing

15. Scene Size-Up PPE Scene Safe? Mechanism of injury
Determine the number of patients
Additional resources
Determine level of consciousness
Determine patient priority

16. Primary Assessment Quickly identify & treat potential life treats
Treat life-threatening hemorrhage FIRST then
ABC
Airway (Open with C-spine precaution)
Breathing
Circulation
Perform a rapid physical exam
AAOS 11th Ed Page 1037

17. Complications Pneumothorax Tension pneumothorax Hemothorax
Open pneumothorax / sucking chest wound
Simple pneumothorax
Tension pneumothorax
Hemothorax
Hemopneumothorax

18. Complications
Cardiac Tamponade
Rib Fracture
Flail Chest

19. Pneumothorax
AAOS 11th Ed Page 1041

20. Pneumothorax
Pneumothorax is an accumulation of air in the thorax, outside the lung.
As the pneumothorax expands, the lung collapses and cannot be ventilated.

21. Pneumothorax
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.

22. Pneumothorax Signs and symptoms include:
Chest pain that worsens with deep inspiration
Dyspnea
Tachypnea
Accessory muscle us
Decreased or absent breath sounds on the affected side
Decreased oxygen saturation on the pulse ox
Subcutaneous emphysema (air under the skin)
AAOS 11th Ed Page 1043

23. Spontaneous Pneumothorax
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.

24. Treatment for Pneumothorax / Spontaneous Pneumothorax
ABCs
Pulse Ox
Oxygen
Vital Signs including Respirations
Listen to Lung Sounds
Rapid transport

25. Open Pneumothorax

26. Open Pneumothorax
An open pneumothorax is a result of an open wound to the chest created by a penetrating object.
You may hear air 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.”
AAOS 11th Ed. Page 1041

27. Open Pneumothorax
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.
You must immediately occlude an open wound to the chest.
Initially seal it with your gloved hand and then with an occlusive dressing.

28. Treatment for Open Pneumothorax
Use a gloved hand to cover the wound
ABCs
Pulse Ox
Oxygen
Vital Signs including Respirations
Listen to Lung Sounds
Apply an occlusive dressing

29. Occlusive Dressings Carried by Charlotte Fire
Vaseline Gauze
FoxSeal

30. FoxSeal Directions

31. Tension Pneumothorax

32. Tension Pneumothorax
Tension pneumothorax occurs when air from an injured lung continues to enter the thorax, completely collapsing the affected lung.
This pushes the mediastinum away from the injured side, compressing the heart, major vessels and opposite lung.
A tension pneumothorax is an immediately life- threatening condition resulting from a pneumothorax.
AAOS 11th Ed. Page 1043

33. Tension Pneumothorax
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.

34. Tension Pneumothorax Signs and symptoms include: Rapid deterioration
Severe respiratory distress
Signs of shock
Absent breath sounds on one side of the chest
Diminished breath sounds on the side opposite to the injury
AAOS 11th Ed. Page 1043

35. Tension Pneumothorax Signs & Symptoms that may be seen:
Cyanosis
Distended neck veins (JVD)
Deviation of the trachea to the uninjured side
If ventilating your patient, it may become increasingly difficult to ventilate due to the increasing thoracic pressure
AAOS 11th Ed. Page 1043

36. Tension Pneumothorax
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.

37. Hemothorax

38. Hemothorax
A significant hemothorax represents a large volume of blood loss and presents as shock.
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.

39. Hemothorax
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 caused by penetrating objects or fractured ribs.

40. Hemothorax
Suspect a hemothorax if signs & symptoms of shock without external bleeding or a reason for shock
Bleeding in and around the lungs commonly produces a pink or red frothy sputum when the patient coughs.
Emergency medical care is the same as for pneumothorax and shock.

41. Pericardial Tamponade

42. Pericardial Tamponade
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.
The most common cause of a pericardial tamponade is a penetrating wound to the heart

43. Pericardial Tamponade
It is a life-threatening condition that requires prompt recognition and transport.
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.

44. Pericardial Tamponade
Signs & Symptoms include:
Beck’s Triad:
JVC
Narrowing Pulse Pressure
Muffled Heart Sounds

45. Pericardial Tamponade
Signs & Symptoms con’t:
Decrease in mental status
Signs of shock
Tachycardia
Decreased blood pressure
Weak pulses, with radial pulses disappearing or diminishing during inhalation.

46. Rib Fracture
Rib fractures may be accompanied by laceration of intercostal blood vessels
While a fractured rib is not life-threatening, it can cause life-threatening damage to other structures and organs.

47. Rib Fracture The most common signs & symptoms of rib injury include:
Pain with movement and breathing
Crepitus (bones grinding together)
Tenderness
Deformity of the chest wall
Inability to breathe deeply
Tachypnea that may be shallow

48. Rib Fracture
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.

49. Rib Fracture
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.

50. Flail Chest
Flail Segment

51. Flail Segment
A flail segment occurs when three 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.

52. Flail Segment
The effects of pressure during inhalation and exhalation explain why paradoxical movement happens.
The flail segment requires immediate recognition and management, but the underlying pulmonary contusion to the lung is a more serious injury.

53. Flail Segment Treatment: Maintain the Airway Oxygen
Listen to Lung Sounds
Splinting with Bulky Dressings No Longer Recommended
Positive Pressure Ventilation is Preferred
AAOS 11th Ed. Page 1046

54. Other Chest Injuries Pulmonary Contusions Sternal Fracture
Clavicle Fracture
Traumatic Asphyxia
Blunt Myocardial Injury
Commotio Cordis
Laceration of the greater vessels

55. Pulmonary Contusion Pulmonary contusion interferes with
gas exchange in
the lungs.

56. Pulmonary Contusion
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.

57. Pulmonary Contusion
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.

58. Pulmonary Contusion
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.

59. Traumatic Asphyxia

60. Traumatic Asphyxia
Traumatic asphyxia is due to a sudden, forceful compression of the chest, forcing blood backward out of the heart and into the upper body.

61. Traumatic Asphyxia
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.

62. Traumatic Asphyxia
The signs and symptoms of traumatic asphyxia include:
Bluish or purple discoloration of the face, head, neck, and shoulders
JVD
Bloodshot eyes that are protruding from the socket
Cyanotic and swollen tongue and lips
Bleeding of the conjunctiva.
AAOS 11th Ed. Page 1047

63. Traumatic Asphyxia Treatment: Ventilation support Oxygen
Rapid transport

64. Cardiac Contusion
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.

65. Cardiac Contusion
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.

66. Emergency Medical Care—Open Chest Wound
Manage open chest wounds and flail segments as soon as they are recognized.
Seal an occlusive dressing over an open chest wound on only three sides to prevent tension pneumothorax.

67. Emergency Medical Care—Open Chest Wound
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.

68. Emergency Care— Flail Segment
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.

69. Chest injuries