1. Chapter 23
Thoracic Trauma

2. Objectives
23.1 List the major anatomical structures of the thoracic cavity.
23.2 Describe the basic physiology of thoracic structures.
continued

3. Objectives
23.3 Describe the pathology of the following thoracic injuries:
flail chest
pneumothorax
hemothorax
tension pneumothorax
sucking chest wound
pericardial tamponade
continued

4. Objectives
23.4 List the signs and symptoms of various thoracic injuries.
23.5 Describe and demonstrate how to assess the chest for trauma, using the L.A.P. method.
23.6 Describe and demonstrate the emergency management of a sucking chest wound.

5. Topics Anatomy and Physiology of the Chest Chest Injuries Assessment
Management
Chapter Summary

6. Case Presentation
A snowboarder enters the half pipe and slams into the rail on the top deck and slides down the wall. When you arrive the patient is sitting up, complaining of difficulty breathing, but resisting attempts to maintain manual spinal stabilization.
Discussion Points:
Often patients will try to minimize their injuries, and may resist attention they think is unnecessary.
Discuss why spinal stabilization is considered in this case knowing the injury is to the ribs with breathing concerns.
Discuss what MOIs might lead to similar injuries in which spinal issues may not be of concern.

7. Anatomy and Physiology of the Chest
Thorax: Protected by bony structures
Two major organs:
Lungs (trachea, and esophagus)
Aveoli, capillary nets
Pleuras: visceral and parietal
Heart and great vessels
Pericardium
Discussion Points:
Often students think of the lungs as large balloons, rather than a sponge, which is how they actually appear.
If models of the thoracic organs are available to you, they are excellent teaching tools for this class.
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8. Anatomy and Physiology of the Chest
The anatomy of the chest cavity.
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9. Anatomy and Physiology of the Chest
Diaphragm is the primary muscle of respiration
Controlled by two phrenic nerves located at C3, C4, and C5
Assisted by intercostals
Breathing process
Lungs fill and empty due to pressure changes within the chest as muscles contract and relax
Gas exchanges in aveoli
Discussion Points:
Remind students that the lungs are passive participants in the breathing process and that the function of the muscles is to change the volume of the thoracic cavity, with pressure differentials doing the real work of breathing.
Much of the injury information relates to disturbances of those pressure differentials.

10. Chest Injuries Closed Open Indirect Inertia Blunt trauma
Fall or collision
Open
Penetration of chest
Compression
Indirect
Inertia
Deceleration
Discussion Points:
Open and closed injuries are a review.
Pay special attention to Indirect and Inertia as these are ‘hidden’ injuries that the OEC tech will have to treat based on signs and symptoms with little or no apparent external trauma. Similar injuries were discussed in Chapter 21 regarding brain and spinal cord injuries that might also present with no apparent injury.

11. Types of Chest Injuries
Contusions
Fractures and dislocations
Flail chest
Pnuemothorax/ Hemothorax
Pericardial tamponade
Aortic tear or rupture
Commotio cordis
Traumatic asphyxia
Discussion Point:
Each injury is discussed in more detail on the slides that follow.

12. Contusions External from minor blunt trauma
Pulmonary = lung tissue bruise
Fluid/blood in alveoli compromise gas exchange, leads to hypoxia
Occurs often with rib fractures
Myocardial = heart bruise
Less effective contractions
Arrhythmia
Cardiogenic shock
Discussion Point:
Note that the extent of injury is directly related to the force causing the contusion and can be minor to life threatening.

13. Contusions
A pulmonary contusion is a bruise on the lung tissue that causes the alveoli to fill with fluid and blood.

14. Fractures and Dislocations
Suspect internal damage
Painful – self splinted often
Rib
May lacerate lung tissues
Flail chest
Two or more ribs/fractures
Paradoxical motion
Hypoxia
Discussion Points:
See if someone in the class has or wants to share a rib fracture story. If no one in the class has one, point out that this type injury is very painful.
Inform students that patients may not want any help if they have found a comfortable position.
Note that the most serious injuries that result from the fractures or dislocations are to internal organs.
continued

15. Fractures and Dislocations
A flail chest is when each of two or more adjacent ribs are fractured in two or more places.
continued

16. Fractures and Dislocations
Scapula
Severe trauma
Serious internal injury
Sternum
Severe underlying organ damage
Severe trauma – entire flail segment
Sternoclavicular joint
Posterior dislocation puts pressure on the great vessels to the heart
Discussion Points:
The injuries listed above are ones that are difficult to incur, and are therefore serious.
The text notes that the sternum may separate from the ribs during CPR and as a result of injury.
The chapter in the text emphasizes the importance of the upper area of the thorax—it is represented by the ‘scv’ joint.

17. Pneumothorax Air in the pleural space Trauma (blunt or penetrating)
Spontaneous
Compressive forces
Discussion Points:
This injury has many forms and levels of severity. The issue of air in the pleural space interrupts the negative pressure of the thorax, thus compromising the breathing process.
Include details from the text in your discussion.
continued

18. Pneumothorax Penetrating wounds create differential pressure
Sucking chest wound
Collapsed lung possible
Blow to chest may cause lung to burst
Discussion Points:
This injury has many forms and levels of severity. The issue of air in the pleural space interrupts the negative pressure of the thorax, thus compromising the breathing process.
Include details from the text in your discussion.

19. Tension Pneumothorax Pressurized air in pleural space
From burst or punctured lung
Organs are compressed, lungs may collapse
Vena cava may collapse
Life threatening
Rescue breathing (BVM) may cause or make worse
Discussion Points:
Tension pneumothorax may have no external signs, which may concern OEC techs.
Discuss rescue breathing. Normally we expect ventilation support to improve the patient’s condition, not make it worse, but this could be an important clue to the problem.
continued

20. Tension Pneumothorax May occur spontaneously – no trauma
Signs and Symptoms
Shortness of breath
Jugular vein distention (JVD)
Low BP
Cyanosis
Decreased lung sounds
Tracheal deviation (late sign)
Discussion Point:
The signs and symptoms on this slide are a comprehensive list that relate to tension pneumothorax as a broad category of injury.
continued

21. Tension Pneumothorax continued
Three complications of chest injuries. (a) Open pneumothorax. (b) Tension pneumothorax. (c) Hemothorax.
continued

22. Tension Pneumothorax Subcutaneous emphysema
Air under the skin – Rice Krispies® crackling
Discussion Point:
Consider including emphysema which is covered in the text.

23. Hemothorax Blood in pleural space
Blunt or penetrating injury
Arterial bleeding leads to hypovolemic shock
Hemopneumothorax = blood and air in pleural space
Multi-system trauma
Life threatening
Discussion Points:
Hemothorax often represents life-threatening issues.
Relate this to the serious blunt trauma injuries previously mentioned, as well inertia injuries (i.e., aortic rupture) later on in this presentation.

24. Hemothorax
Three complications of chest injuries. (a) Open pneumothorax. (b) Tension pneumothorax. (c) Hemothorax.

25. Pericardial Tamponade
Bleeding/fluid inside the pericardial sac
Blunt or penetrating trauma
Rupture of a cardiac vessel
Bacterial sepsis, viral infection
Pressure on heart impairs function
Discussion Points:
Main points of this injury are listed here.
Additional details from the text will cover this topic thoroughly.
continued

26. Pericardial Tamponade
Pain, shortness of breath, neck vein distention are early signs and symptoms
Muffled heart sounds, drop in pulse pressure come later
Discussion Points:
Main points of this injury are listed here.
Additional details from the text will cover this topic thoroughly.

27. Pericardial Tamponade
The physical findings of pericardial tamponade.

28. Aortic Rupture and Dissection
Often lethal
Deceleration/inertia injury
Massive bleeding/hypovolemic shock and death
Partial thickness tear may lead to aneurysm, later rupture
Signs and symptoms are acute chest or back pain, signs of profound shock
Discussion Points:
OEC techs encounter many deceleration injuries. The chapter notes that although uncommon, aortic rupture and dissection can be lethal.
Any injury with chest pain should be transported to definitive medical care.

29. Aortic Rupture and Dissection
(a) The progression of an aortic aneurysm to aortic rupture. (b) Aortic dissection.

30. Commotio Cordis
Sudden cardiac death due to blunt thoracic trauma that interrupts the electrical activity of the heart, usually following a direct blow to the chest
Discussion Points:
Purpose of this slide is to make students aware of commotio cordis.
Popular media may have addressed this when reporting on student athletes who have died as a result of being hit in the chest with a baseball; students may not have known what this injury was called.

31. Traumatic Asphyxia Pressure on chest wall prevents expansion
Compressive injury as from avalanche
Massive rib cage fractures where chest is unable to expand
Ruptured blood vessels in face, neck, and eyes causing discolorations
Discussion Point:
This could result from an avalanche burial, or as the text mentions, being under a car or other heavy object that has fallen on a person’s chest.

32. Traumatic Asphyxia
Traumatic asphyxia.

33. Environmental Factors
Altitude can complicate thoracic injuries
Descent in elevation is necessary
Helicopter evacuation may be contra-indicated with thoracic injuries

34. Case Update
You maintain cervical spine stabilization while you assess the patient. The airway is open, there is no external bleeding, circulation to all extremities is normal, and his mental status is normal He has moderate difficulty breathing and pain at the rib cage. He has shallow respirations at 28 per minute even after receiving oxygen. His pulse is 102 BPM.
Discussion Points:
How would you convince the snowboarder to allow cervical stabilization?
What do his vitals tell you?
What complications should you be looking for?
Students may ask about whether it is more important to deal with breathing issues or spinal immobilization, and they are mutually exclusive, and/or how you can do both. The guidelines will be covered in the management section.
Discuss complications as a review of issues presented so far.

35. Assessment Standard assessment procedures to start – ABCDs and vitals
Observe skin color and neck veins
Look for self-splinting
If breathing is a major concern, suspend secondary exam and transport
Discussion Point:
Important: If the chest injury impairs breathing or shows signs and symptoms of other major concerns, the secondary exam should be abridged in favor of immediate transport.
continued

36. Assessment Use L. A. P. method Monitor through ongoing assessment
Discussion Point:
Discuss the three parts of the L.A.P. method as explained in the text.
L—Look
A—Auscultate
P—Palpate

37. Management Sever symptoms - “Load and go” Do CPR, use AED
Open airway of avalanche victim ASAP
High flow oxygen, assist ventilations
Worsening condition here = tension pneumothorax
L —Look
A —Auscultate
P —Palpate
Discussion Points:
“Load and go” is the logical extension of the suspended secondary exam with severe symptoms.
See text for additional details on oxygen, ventilations, and occlusive dressing.
continued

38. Management Use occlusive dressing with sucking chest wound
Spinal involvement needs backboard
Control bleeding in usual manner
Splint flail segments
Consider patient comfort with O2, BVM
Leave impaled objects in place
Discussion Points:
This slide covers the management/treatment of injuries which may occur with thoracic injuries.
See text for situations in which you might remove an impaled object, as well as the comfort and breathing needs of patients in the toboggan and in the patrol room, especially if the patient is not on a backboard. Consider this for discussion with the class.
continued

39. Management
Taping an occlusive dressing on three sides of a sucking chest wound helps prevent a tension pneumothorax.
continued

40. Management Match transport position to patient’s breathing needs
Treat/position for shock

41. Case Disposition
You immobilize the patient’s spine on a long spine board, load him into a toboggan transport him to the first-aid room. His pulse has increased to 114, the blood pressure is 100/70, and the respiratory rate is 28 on high-flow oxygen. You show the paramedics a large bruise on the upper chest wall that extends beneath the patient’s armpit. The patient is transported by air.
Discussion Point:
What care was given?
How was this patient transported?
Why?
What do his changes in vital signs tell you?
This person was placed on a backboard because of the MOI. His vitals indicate that there is more to his injury than just the bruising on his chest such as pneumothorax. Rapid transport is advised.

42. Chapter Summary
Both blunt and penetrating chest injuries can be life threatening.
Maintain a high index of suspicion for chest injury based on the mechanism of injury.
Assess the entire chest, including the upper back and armpits. Provide oxygen to any patient with a suspected chest injury.
Discussion Points:
Discuss with students the major points of the chapter.
continued

43. Chapter Summary Treat sucking chest wounds with an occlusive dressing.
If the condition of a hypoxic patient with chest trauma worsens, consider a tension pneumothorax.
Discussion Points:
Discuss with students the major points of the chapter.