0. International Trauma Life Support, 7e
Thoracic Trauma 6
Key Lecture Points
Briefly review the anatomy of the chest, particularly the great vessels.
Emphasize load-and-go conditions in particular the deadly dozen and discuss why these conditions are so critical:
Massive hemothorax with shock: Explain that when massive hemothorax has occurred, as evidenced by dullness to percussion and diminished breath sounds in the base of the affected lung, massive hemorrhage has occurred into the chest with major blood vessel disruption and massive blood loss. If these patients are not rapidly taken to surgery, they usually die.
Tension pneumothorax: Explain how the increased pressure in the chest reduces blood return to the heart, causing reduction in cardiac output, and thus producing shock. Stress the signs and symptoms of the tension pneumothorax (review the Primary Survey) and how critical it is not to leave out steps in the Primary Survey, which would prevent the identification of this problem.
Penetrating chest trauma with shock: Explain that the penetrating chest injury with resulting evidence of shock is a load-and-go situation because of the many serious and potentially lethal conditions that may result.
Discuss the mechanics of airflow during inspiration and expiration. Discuss how the presence of an open wound into the pleural space decreases air movement through the tracheobronchial tree.
Discuss the pathophysiology of the flail chest and the management of this problem: Assisted ventilation and prevention of movement of the flail segment if it is decreasing air movement through the tracheobronchial tree. Stress that hand stabilization is usually adequate until the patient is moved into the ambulance. Point out that nasotracheal intubation (patient usually has a gag reflex) is the most effective method to stabilize the flail and oxygenate the patient.
A review of the mechanism of injury in chest trauma is appropriate. Stress the importance of anticipating serious chest trauma or the potential for life-threatening injury even before deterioration has occurred. This is particularly important in those patients with evidence of major chest trauma.

1. Thoracic Trauma
© Pearson

2. Overview Major signs and symptoms Pathophysiology and management
Immediate life-threatening injuries
Pathophysiology and management
Open pneumothorax
Tension pneumothorax
Massive hemothorax
Flail chest
Cardiac tamponade

3. Overview
Cardiac involvement with blunt injury
Other thoracic injuries

4. Thoracic Trauma Thoracic injury is common
50% of multiple trauma
25% of trauma deaths
Potentially fatal thoracic injuries saved by rapid recognition and intervention
Many require surgical intervention

5. Chest Anatomy Many vital organs are crowded into this area.
Trauma to this area is often life-threatening.
Bony cavity is formed by 12 pairs of ribs, which join posteriorly with the thoracic spine and anteriorly with the sternum.
Intercostal neurovascular bundle runs along inferior surface of each rib.
Inner side of cavity and lung itself are lined with thin layer of tissue, pleura. The space between pleural layers is normally only a potential space.
One lung occupies each thoracic cavity.
Between the two cavities is mediastinum, which contains heart, aorta, superior and inferior vena cava, trachea, major bronchi, and esophagus. (High potential for life-threatening injury because of vital cardiovascular and tracheobronchial structures within this area.)
Spinal cord is protected by vertebral column.
Diaphragm separates thoracic organs from abdominal cavity. Upper abdominal organs, including spleen, liver, kidneys, pancreas, and stomach, are protected by lower rib cage.

6. Mechanism of Injury Blunt Penetrating Direct compression
Fracture of solid organs
Blowout of hollow organs
Deceleration forces
Tearing of organs and blood vessels
Penetrating
Direct trauma to organ and vasculature
Energy transmitted from mass and velocity
In the trimodal distribution of trauma deaths (immediate, hours, weeks), injuries to the chest are responsible for most deaths at the scene (immediate deaths) and those within a few hours (early deaths).

7. Tissue Hypoxia Inadequate oxygen delivery Hypovolemia
Ventilation/perfusion mismatch
Pleural pressure changes
Pump failure
Inadequate oxygen delivery to tissues secondary to airway obstruction
Hypovolemia from blood loss
Ventilation/perfusion mismatch from lung parenchymal injury
Changes in pleural pressures from tension pneumothorax
Pump failure from severe myocardial injury

8. Thoracic Trauma Signs and symptoms Shortness of breath
Chest pain
Hemoptysis
Cyanosis
Neck veins distended
Tracheal deviation
Asymmetrical movement
Chest wall contusion
Open wounds
Subcutaneous emphysema
Shock
Tenderness, instability, crepitation (TIC)
Breath sounds abnormal
Major symptoms are shortness of breath and chest pain.
Mechanism of injury is also a sign of chest injury or gives us a strong index of suspicion for the potential of major injury .

9. ITLS Primary Survey “Deadly Dozen” Airway obstruction Flail chest
Open pneumothorax
Massive hemothorax
Tension pneumothorax
Cardiac tamponade

10. ITLS Secondary Survey “Deadly Dozen” Myocardial contusion
Traumatic aortic rupture
Tracheal or bronchial tree injury
Diaphragmatic tears
Pulmonary contusion
Blast injuries

11. Primary “Deadly Dozen”
Airway obstruction
Secondary hypoxia
Common cause of preventable death
Foreign body, tongue, aspiration
Always assume cervical spine injury
NOTE: Management of airway has been discussed in Chapter 4, so nothing further will be added here other than to stress its importance.

12. Primary “Deadly Dozen”
Flail chest
IMAGE: Figure 6-5 Flail chest anatomy.
IMAGE: Figure 6-6 Flail chest physiology.
NOTE: See also Figure 6-13.
Flail chest: Three or more adjacent ribs are fractured in at least two places, resulting in a segment of the chest wall that is not in continuity with thorax.
A lateral flail chest or anterior flail chest (sternal separation) may result.
With posterior rib fractures, heavy musculature usually prevents the occurrence of a flail segment.
If patient is breathing spontaneously, flail segment moves with paradoxical motion relative to rest of chest wall.
Multiple rib fractures with or without flail chest can cause hypoxia from mechanical ventilatory problems as well as pulmonary contusion. Patient, especially if older, must be closely monitored for hypoxia and respiratory failure.
Monitoring with pulse oximetry and capnography is very helpful.

13. Primary “Deadly Dozen”
Flail chest
Assist ventilation
Possible intubation
Load-and-go
Stabilize flail segment
Monitor for:
Pulmonary contusion
Hemothorax
Pneumothorax
Intubation and positive pressure ventilation are best stabilization. This is usually not possible, as patient is usually awake with an intact gag reflex.
Flail may contribute to development of pulmonary contusion, hemothorax, pneumothorax.
Consider intubation early in order to provide positive end-expiratory pressure.
Continuous positive airway pressure (CPAP) could be used in non-intubated patient.
(Courtesy of Stanley Cooper, EMT-P )

14. Primary “Deadly Dozen”
Open pneumothorax
“Sucking chest wound”
Air enters pleural space
Ventilation impaired
Hypoxia results
Signs and symptoms
Proportional to size of defect
NOTE: See also Figure 6-10.
Normal ventilation involves negative pressure being generated inside chest by diaphragmatic contraction.
As air is drawn through upper airway, lungs expand.
With a large open chest wound (larger than trachea or about size of patient's little finger), the path of least resistance for airflow is through the chest wall defect.
Air going in and out of this opening makes a sucking sound, and bubbles on expiration.
This air will enter only pleural dead space. It will not enter the lung and therefore will not contribute to oxygenation of blood. Ventilation is impaired, and hypoxia results.

15. Primary “Deadly Dozen”
Open pneumothorax
Close chest wall defect
Load-and-go
Above photo courtesy of Teleflex Incorporated, all
rights reserved. No other use shall made of the image without the prior
written consent of Teleflex Incorporated.
Use impervious material taped on three sides.
Consider the collection of drainage when deciding which sides to tape.
The Asherman chest seal can be used to seal a sucking chest wound or can be placed over a decompressing needle.

16. Primary “Deadly Dozen”
Massive hemothorax
Anxiety and confusion
Neck veins
Flat: hypovolemia
Distended: mediastinal compression
Breath sounds decreased
Dull if percussed
Shock
IMAGE: Figure 6-14 Massive hemothorax.
NOTE: See also Table 6-1.
Discuss pathophysiology and diagnosis.
Blood in pleural space is a hemothorax.
A massive hemothorax occurs as a result of at least a 1,500 cc blood loss into thoracic cavity. Each thoracic cavity may contain up to 3,000 cc of blood.
As blood accumulates within the pleural space, the lung on the affected side is compressed. If enough blood accumulates (rare), the mediastinum will be shifted away from the hemothorax. The inferior and superior vena cava and contralateral lung are compressed. Thus, ongoing blood loss is complicated by hypoxemia.

17. Primary “Deadly Dozen”
Massive hemothorax
Load-and-go
Treat for shock
Fluid administration
Titrate to peripheral pulse (80-90 mmHg)
Monitor for:
Tension hemopneumothorax
Fluid administration to increase blood pressure,may increase bleeding.
Titration of fluid resuscitation is important.
If tension hemopneumothorax develops acute chest decompression is required.

18. Primary “Deadly Dozen”
Tension pneumothorax
Dyspnea
Anxiety
Tachypnea
Distended neck veins
Tracheal deviation (rare)
Breath sounds diminished
Hypertympany if percussed
Shock with hypotension
IMAGE: Figure 6-15 Tension pneumothorax.
NOTE: See also Figure 6-19.
Tension pneumothorax is a circulatory (obstructive) emergency.
Occurs when a one-way valve is created from either blunt or penetrating trauma. Air can enter but not leave pleural space.
This causes an increase in intrathoracic pressure, which will collapse the affected lung and will then exert pressure on the mediastinum.
This pressure will eventually collapse the superior and inferior vena cava, resulting in a loss of venous return to the heart.
A shift of the trachea and mediastinum away from the side of the tension pneumothorax will also compromise ventilation of other the lung, although this is a late phenomenon and usually cannot be detected except by x-ray.

19. Primary “Deadly Dozen”
Tension pneumothorax
Decompress affected side
Respiratory distress and cyanosis
Loss of radial pulse
Decreasing level of consciousness
Load-and-go
NOTE: Decompression is discussed in skill station.
Stress that loss of breath sounds on one side does not make a diagnosis of tension pneumothorax.
A needle decompression is a temporary, but life-saving, measure.
(Courtesy of Louis B. Mallory, MBA, REMT-P)

20. Primary “Deadly Dozen”
Cardiac tamponade
Beck's triad
Hypotension
Neck veins distended
Heart sounds muffled
Paradoxical pulse
Breath sounds equal
IMAGE: Figure 6-17 Cardiac tamponade.
Discuss pathophysiology and diagnosis.
The pericardial sac is an inelastic membrane that surrounds the heart. If blood collects rapidly between heart and pericardium from a cardiac injury, ventricles of the heart will be compressed. A small amount of pericardial blood may compromise cardiac filling. As compression of ventricles increases, the heart is less able to refill, and cardiac output falls.

21. Primary “Deadly Dozen”
Cardiac tamponade
Load-and-go
Treat for shock
Fluid administration
Titrate to peripheral pulse (80–90 mmHg)
Monitor and treat dysrhythmias
Monitor for:
Hemothorax
Pneumothorax
Fluid administration may increase bleeding.
If available perform a 12-lead ECG (including V4R).

22. Secondary “Deadly Dozen”
Myocardial contusion
Most common cardiac injury
Blunt anterior chest injury
Same as myocardial infarction
Chest pain
Dysrhythmias
Cardiogenic shock (rare)
Treat as cardiac tamponade
IMAGE: Figure 6-20 Myocardial contusion.
Myocardial contusion is a potentially lethal lesion resulting from blunt chest injury.
The chest pain may be difficult to differentiate from associated musculoskeletal discomfort that patient also suffers as a result of injury.
If available a 12-lead ECG should be performed.

23. Secondary “Deadly Dozen”
Traumatic aortic rupture
Most common cause of immediate death
Motor-vehicle collisions or falls from heights
80% die immediately
Scene Size-up and history extremely important
No obvious sign of chest trauma
Hypertension in upper extremities and hypotension in lower extremities (rare)
Traumatic thoracic aortic tears usually are due to deceleration injury with heart and aortic arch moving suddenly anteriorly (third collision), transecting the aorta where it is fixed at ligamentum arteriosum.
In 20% of patients who do not exsanguinate (promptly) suggest immediately, the aortic tear will be contained temporarily by surrounding tissues and adventitia. However, this will usually rupture within hours unless surgically repaired.
NOTE: Hypertension in upper extremities and hypotension in lower extremities (as assessed by pulse strength) are rare.

24. Secondary “Deadly Dozen”
Tracheal or bronchial tree injury
Subcutaneous emphysema
Chest, face, neck
Ensure adequate airway
Cuffed ET tube past site of injury
Monitor for:
Pneumothorax
Hemothorax
NOTE: This may be one occasion when a main stem intubation would be beneficial.

25. Secondary “Deadly Dozen”
Diaphragmatic tear
Severe blow to abdomen
Herniation of abdominal organs
More common on left
Breath sounds diminished
Bowel sounds auscultated in chest (rare)
Abdomen appears scaphoid
NOTE: Scaphoid: “sucked in,” comma shaped.
Tears in diaphragm may result from a severe blow to abdomen.
A sudden increase in intra-abdominal pressure, such as a seat-belt injury or kick to abdomen, may tear diaphragm and allow herniation of abdominal organs into the thoracic cavity.
Occurs more commonly on left than right, as the liver protects right hemidiaphragm.
Blunt trauma produces large radial tears in diaphragm.
Penetrating trauma may also produce holes in diaphragm, but these tend to be small.

26. Secondary “Deadly Dozen”
Pulmonary contusion
Common from blunt trauma
Hours to develop
Marked hypoxemia
A very common chest injury resulting from blunt trauma, a pulmonary contusion takes hours to develop and rarely develops during prehospital care, unless very long transport times or delayed discovery of victim occurs.
Contusion of lung may produce marked hypoxemia.
Management consists of intubation and/or assisted ventilation if indicated, oxygen administration, transport, and IV insertion.

27. Secondary “Deadly Dozen”
Blast injury
Penetrating trauma
Difficult to assess in field
If unrecognized, may be lethal
With the increase in terrorism, understanding blast injury is important. The magnitude of the blast wave depends on the size of the explosion and the environment in which it occurs. Closed spaces, such as buses, produce highly lethal blast injury.
The mechanism of injury by explosions is due to three and potentially five factors (see Chapter 1).

28. Other Chest Injuries Impaled objects Do not remove
Stabilize the object
Monitor for:
Tension pneumothorax
Hemothorax
Cardiac tamponade

29. Other Chest Injuries Traumatic asphyxia Severe compression
Ruptures capillaries
Cyanosis above crush
Swelling of head, neck
Swollen tongue, lips
Conjunctival hemorrhage
IMAGE: Traumatic asphyxia.
Courtesy of John Campbell

30. Other Chest Injuries Simple pneumothorax Fractured ribs
Pleuritic chest pain
Dyspnea
Decreased breath sounds
Hypertympany if percussed
Monitor for:
Tension pneumothorax

31. Other Chest Injuries Sternal fracture Simple rib fracture
Significant blunt trauma to anterior chest
Signs of fracture on palpation
Myocardial contusion presumed
Simple rib fracture
Most frequent chest injury
Monitor for:
Pneumothorax
Hemothorax
Pneumothorax is caused by accumulation of air within the potential space between visceral and parietal pleura.
Lung may be totally or partially collapsed as air continues to accrue in thoracic cavity.
In a healthy patient, this should not acutely compromise ventilation, if there is not a large pneumothorax or a tension pneumothorax does not evolve.
Patients with less respiratory reserve may not tolerate even a simple pneumothorax.

32. Summary Chest injuries common Often life-threatening
Require prompt recognition
Require prompt intervention
Frequently require load-and-go
Airway and oxygenation always priority
Frequent Ongoing Exams