1. Chest Trauma
Chapter 34

2. Objectives Review the Anatomy of the Chest
Discuss General Categories of Chest Injuries
Discuss Specific Chest Injuries
Assessment-based Approach: Chest Trauma

3. Anatomy of the Chest Thoracic cavity and pleural lining
Visceral pleura
Parietal pleura
Ribs
Diaphragm
Mediastinum
Trachea
Venae cavea
Aorta
Esophagus
Heart

4. Open Chest Injuries Causes – Gunshot, Knife, Any hard, sharp object
Effects;
Bullet wound – tiny entrance, extensive damage from ricochet, Exit wound, if bullet doesn’t lodge itself
Injuries to the heart
Injuries to major vessels
Injuries to respiratory system – Lungs unable to inflate, Pneumothorax, Sucking chest wound

5. Closed Chest Injuries Blunt trauma with no open wound
Injury to lungs, heart, great vessels, respiratory tract, diaphragm, esophagus
Flail segment

6. Flail Segment Two or more adjacent ribs broken in two or more places
Produces a freely moving section of chest wall
Display paradoxical movement during breathing

7. Paradoxical Breathing
Movement in the opposite direction from the rest of the chest wall
Created by pressure of inhalation and exhalation
Underlying contusion to the lungs is more serious than the broken ribs because it reduces patient’s air intake and leads to hypoxia
To stabilize, splint and treat with PPV

8. Pulmonary Contusion
Patient suffers from bleeding within the lung tissue
Bleeding occurs in and around the alveoli and into the interstitial space between the alveoli and capillaries
Leads to severe hypoxia and can lead to death
Often seen with flail segment injury
Other signs/symptoms include shortness of breath, cyanosis, and sign of blunt trauma to the chest
Oxygenate by NRB at 15 lpm or PPV with supplemental oxygen

9. Pneumothorax
Air accumulates in the pleural cavity, causing lung collapse on the injured side of the chest
Usually due to either blunt or penetrating trauma
Spontaneous pneumothorax
Occurs with no trauma or other external cause
Usually the result of bleb
Bleb ruptures and allows air into thoracic cavity
Common among smokers and emphysema patients
Signs/Symptoms
Dyspnea, Respiratory distress, Sharp chest pain, Absent breath sounds on one side

10. Open Pneumothorax Open – Sucking chest wound
Result of a blow from a penetrating object
Air may be heard escaping or entering through the wound
Has same signs/symptoms as a closed one, plus the presence of an open chest wound
Treat by immediately occluding, first with your gloved hand, then with an occlusive dressing

11. Tension Pneumothorax Immediately life-threatening condition
Continues to trap air and collapses the injured lung
Mediastinum begins to shift to uninjured side
Uninjured lung, heart and large veins are compressed
Results in poor cardiac output, ineffective ventilation, inadequate oxygenation, and severe hypoxia
Signs/symptoms include rapid deterioration, severe respiratory distress, shock and absent breath sounds on injured side
If symptoms develop, after treating for an open pneumothorax, lift the occlusive dressing to allow air to escape and transport immediately

12. Hemothorax Thoracic cavity is filled with blood
Lung collapses as the blood continues to collect
Blunt or penetrating trauma may be the cause
Injury may be open or closed
Severe blood loss often results in severe shock, with signs of respiratory distress developing later
Patient will often produce pink or red frothy sputum when coughing
Treatment is same for pneumothorax and shock

13. Traumatic Asphyxia
Severe and sudden compression of the thorax causes a rapid increase in pressure in the chest
Sternum and ribs severely compress the heart and lungs
Causes a backflow of blood from the right ventricle into the head, shoulder and chest
Signs/Symptoms: Bluish/purple discoloration of face, head, neck and shoulders, JVD, bloodshot eyes protruding from eye sockets, cyanotic and swollen tongue and lips, bleeding of the conjunctivae

14. Cardiac Contusion
Occurs when heart is violently compressed between the sternum and spinal column
Actual bruise may occur to the heart wall
Heart wall may be ruptured
Electrical conduction system of the heart may be disturbed
Right ventricle is the most likely injured
Signs/Symptoms: Chest pain/discomfort, evidence of blunt trauma, tachycardia, irregular pulse
Transport promptly

15. Pericardial Tamponade
Blunt/penetrating trauma may cause bleeding into the pericardial sac
Since sac cannot expand much, the heart is compressed
Cardiac output drops significantly, and blood backs up into veins
Life-threatening
Signs/Symptoms: JVD, hypoperfusion, tachycardia (can be extreme), decreased BP, narrow pulse pressure (< 30mmHg), weak pulses (radial will diminish or disappear)

17. Rib Injury
Not life-threatening, can cause life-threatening damage to other organs
Ribs most commonly fractured are the 3rd – 8th; most common site is lateral aspect of the chest
Fracture may lacerate the intercostal artery or vein and cause internal bleeding
Less common in children because their cartilage is more resilient than an adult’s

18. Signs/Symptoms Severe pain with movement and breathing Crepitation
Tenderness upon palpitation
Deformity of the chest wall
Inability to breathe deeply
Coughing
Tachypnea

19. Treatment
Place arm over the injury site and apply a sling and swathe to hold in place
Give patient a pillow to hold over the injury to splint manually
Do not completely wrap the chest or apply swathe snugly

20. Assessment-based Approach
Scene Size-up
Do not enter scene of a shooting or stabbing until police tell you it is safe
Take BSI
Wear gloves and eye protection
Ask bystanders what happened
Scan scene for details that will show MOI
Sports accident? Fighting? Shooting? MVC?
Crushed between two objects?
Is patient guarding?
Explosion?

21. Primary Assessment Form general impression
Cyanotic? Respiratory distress? Breathing shallow or rapid? Guarding? Extreme pain?
Expose/examine chest
Open chest wound, occlude with gloved hand
Paradoxical movement
Mental status?
Airway obstruction? Blood?
Jaw-thrust
Listen to speech pattern
Oxygen
PPV if breathing inadequate
High priority for transport
Log roll patient to assess posterior for a exit/entrance wound if shooting is suspected

22. Secondary Assessment Inspect/palpate for other injuries
Breathing status
Assess neck for subcutaneous emphysema, JVD, tracheal deviation
Spine injury suspected, C-collar
Expose chest, cut clothes off
Look for flail chest signs
Palpate the chest, check for equal movement on both sides, paradoxical movement, swelling and deformities

23. Secondary Assessment
Determine breath sounds are clear and equal or decreased or absent on one or both sides
Inspect abdomen for excessive muscle movement during breathing
Assess baseline vital signs
Obtain history from responsive patient; bystanders if unresponsive

24. Signs/Symptoms Cyanosis: fingernails, fingertips, lips, face
Dyspnea or Tachypnea
Contusions, lacerations, punctures, swelling, or other obvious signs of trauma
Hemoptysis (coughing up blood/bloody sputum
Signs of shock
Tracheal deviation
Paradoxical movement
Open wound that may/may not produce sucking sound
Subcutaneous emphysema
JVD
Absent or decreased breathing sounds upon auscultation
Pain at injury site
Failure of chest to expand normally during inhalation
Peripheral pulses that become extremely weak or absent during inhalation
Drop of 10 mmHg or more in systolic BP during inhalation

25. Emergency Care – Open Chest Wound
Seal with gloved hand
Occlusive dressing
Constantly assess respiratory status
Signs/Symptoms of complications: difficulty breathing, tachypnea, decreased/absent breath sounds, cyanosis, tachycardia, decreasing BP or narrowing pulse pressure, JVD, Unequal movement in chest wall, extreme anxiety and apprehension, increased resistance to PPV
If you observe complications, burp the occlusive dressing

26. Emergency Care – Open Chest Wound

27. Emergency Care – Flail Segment
Place hand over flail segment to splint it in a inward position
Patient breathing inadequately, initiate PPV
Place bulky dressings, a pillow, or a towel over the unstable segment, or secure the patient’s arm to body, to stabilize the injury
Reassessment: Evaluate effectiveness of treatment, assess for further deterioration
If there is deterioration, (increasing breathing difficulties, worsening cyanosis) repeat secondary assessment, look for injuries you may have missed
Reassess vital signs

28. Emergency Care – Flail Segment

30. Questions ????