1. Combat Trauma TreatmentChest Injury1 Thoracic Trauma

2. Combat Trauma TreatmentChest Injury2 Chest injuries may result from: –Vehicle accidents –Falls –Gunshot wounds –Crush injuries –Stab wounds Introduction

3. Combat Trauma TreatmentChest Injury3 Skeletal System

4. Combat Trauma TreatmentChest Injury4 Heart Myocardium Epicardium Endocardium

5. Combat Trauma TreatmentChest Injury5 Anatomy of the Thorax Trachea Lungs Bronchi Mediastinum

6. Combat Trauma TreatmentChest Injury6 Anatomy

7. Combat Trauma TreatmentChest Injury7 Muscles of the Thorax

8. Combat Trauma TreatmentChest Injury8 Diaphragm

9. Combat Trauma TreatmentChest Injury9 Mechanism of injury –Penetrating trauma Gunshot or stab wounds Bullet trajectory is unpredictable –Blunt trauma Viceral injuries occur from: –Deceleration –Compression –Sheering forces –Bursting Determine MOI

10. Combat Trauma TreatmentChest Injury10 Assess the casualty Identify signs and symptoms –AVPU –Airway –Breathing –Circulation –Rapid trauma survey / focused exam

11. Combat Trauma TreatmentChest Injury11 Signs indicative of chest injury Shock Cyanosis Hemoptysis Chest wall contusion Flail chest Open wounds Distended neck veins Tracheal deviation Subcutaneous emphysema

12. Combat Trauma TreatmentChest Injury12 Assess Vital Signs Pulse Blood pressure –Hypotension –Hypertension

13. Combat Trauma TreatmentChest Injury13 Assess Vital Signs Respiratory rate and effort –Tachypenia –Bradypenia –Labored –Retractions

14. Combat Trauma TreatmentChest Injury14 Assess the Skin Diaphoresis-sweating Pallor-pale Cyanosis Open wound Ecchymosis-bruising

15. Combat Trauma TreatmentChest Injury15 Assess the Neck Position of trachea Subcutaneous emphysema Jugular venous distention Penetrating wounds

16. Combat Trauma TreatmentChest Injury16 Assess the Chest Contusions Tenderness Asymmetry Open wounds or impaled objects Crepitation Paradoxical movement

17. Combat Trauma TreatmentChest Injury17 Assess the Chest Lung sounds –Absent or decreased –Unilateral –Bilateral –Location –Bowel sounds in chest

18. Combat Trauma TreatmentChest Injury18 Assess the Chest Lung sounds Percussion –Hyperresonance –(pneumothorax-tension pneumothorax) –Hyporesonance (hemothorax)

19. Combat Trauma TreatmentChest Injury19 Assessing The Chest Compare both sides of the chest at the same time when assessing for asymmetry.

20. Combat Trauma TreatmentChest Injury20 Assessing The Chest Feel carefully and listen closely for subcutaneous emphysema.

21. Combat Trauma TreatmentChest Injury21 Assess the Chest Heart sounds Muffled (cardiac tamponade) Distant

22. Combat Trauma TreatmentChest Injury22 Cardiac Auscultation Sites Listen between the rib spaces, paying particular attention to changes in tone from previous assessment.

23. Combat Trauma TreatmentChest Injury23 Pneumothorax (closed) May be caused by blunt trauma or may be spontaneous Overpressurization ( eg. blast, diving) What it is : accumulation of air within space between visceral and parietal pleura

24. Combat Trauma TreatmentChest Injury24 Pneumothorax (closed) Signs and symptoms Pleuritic chest pain Dyspnea Decreased breath sounds Hypertympany to percussion

25. Combat Trauma TreatmentChest Injury25 Pneumothorax (closed) Management –Administer oxygen – Establish large bore IV –Initiate cardiac monitoring –Transport to nearest medical facility –Chest tube by PA/MD

26. Combat Trauma TreatmentChest Injury26 Pneumothorax (closed)

27. Combat Trauma TreatmentChest Injury27 Penetrating thoracic injury May present as a sucking chest wound Management –Ensure open airway –Administer oxygen 15 lpm if available –Close chest wall defect, occlusive dressing (Asherman Chest Seal) –Initiate large-bore IV Initiate cardiac monitoring –Transport to nearest medical facility Open Pneumothorax

28. Combat Trauma TreatmentChest Injury28 Open Pneumothorax

29. Combat Trauma TreatmentChest Injury29 Open Pneumothorax

30. Combat Trauma TreatmentChest Injury30 Open Pneumothorax Petroleum Gauze can also be used to seal a sucking chest wound.

31. Combat Trauma TreatmentChest Injury31 Open Pneumothorax

32. Combat Trauma TreatmentChest Injury32 Open Pneumothorax If, after sealing the open pneumothorax, the patient develops increased difficulty breathing, the dressing may not be allowing air to escape. In that case, raise a corner of the dressing to allow the air to escape or remove it completely and re-apply it. Consider needle chest decompression if authorized.

33. Combat Trauma TreatmentChest Injury33 One-way valve created from either penetrating or blunt trauma Air enters thoracic space but cannot escape, pressure builds and further collapses the lung and forces mediastinum and heart away from effected lung. May also compromise good lung. Tension Pneumothorax

34. Combat Trauma TreatmentChest Injury34 Tension Pneumothorax Clinical Signs Anxiety, agitation, apprehension Diminished or absent breath sounds Increasing dyspnea with cyanosis Tachypnea Hyperresonance to percussion on effected side

35. Combat Trauma TreatmentChest Injury35 Tension Pneumothorax Clinical Signs Distended neck veins Hypotension - loss of radial pulse Cool clammy skin, patient deteriorates rapidly Decreased lung compliance while bagging

36. Combat Trauma TreatmentChest Injury36 Tension Pneumothorax Clinical signs Tracheal deviation is a late sign and its absence does not rule out a tension pneumothorax Decreased level of consciousness All the above signs may be difficult to detect in a combat situation, you must be alert to this problem with penetrating chest trauma.

37. Combat Trauma TreatmentChest Injury37 Tension Pneumothorax Management –Ensure open airway –Administer oxygen 15 lpm –Decompress affected side of chest (shown later) –Insert large-bore IV –Transport to nearest medical facility

38. Combat Trauma TreatmentChest Injury38 Loss of 1500 cc blood or 200 cc per hour from the chest tube Signs and symptoms Hypotension from blood loss or compression of great vessels Dullness to percussion Decreased breath sounds Anxiety or confusion secondary to hypovolemia or hypoxia Massive Hemothorax

39. Combat Trauma TreatmentChest Injury39 Massive Hemothorax Management –Ensure open airway –Administer oxygen 15 lpm if available –Initiate IV to carefully replace fluids and maintain BP @ 80-90mmHg (radial pulse) –Observe for development of tension pneumothorax –Rapid transport to nearest medical facility

40. Combat Trauma TreatmentChest Injury40 Two or more adjacent ribs are fractured in at least two places or separation of sternum from ribs Flail Chest

41. Combat Trauma TreatmentChest Injury41 Flail Chest Signs and symptoms Flail segment moves with paradoxical motion Force also causes pulmonary contusion Observe for hemo or pneumothorax Pain from injury causes increased hypoxia Chest wall palpation may reveal crepitus

42. Combat Trauma TreatmentChest Injury42 Treatment for Flail Chest Ensure open airway Administer oxygen 15 lpm Assist ventilation Analgesia for pain (IV Morphine) Initiate IV - may need to limit fluids Monitor heart for myocardial trauma Initiate manual pressure to stabilize flail segment, then apply bulky dressing Rapid transport

43. Combat Trauma TreatmentChest Injury43 Treatment for Flail Chest

44. Combat Trauma TreatmentChest Injury44 Pulmonary Contusion Common injury produced by blunt trauma, which may be potentially lethal Bruising of lung can produce marked hypoxemia Management –Oxygen administration 15 lpm –Insert large bore IV - may need to limit fluids –Transport to nearest medical facility

45. Combat Trauma TreatmentChest Injury45 Myocardial Contusion Potentially lethal lesion resulting from blunt chest injury S/S- chest pain, dysrhythmias, cardiogenic shock May mimic a myocardial infarction Management –Administer oxygen –Initiate large bore IV – may need to limit fluids –EKG monitoring, pulse oximetry (if available) –Transport to nearest medical facility

46. Combat Trauma TreatmentChest Injury46 Myocardial Contusion

47. Combat Trauma TreatmentChest Injury47 Cardiac Tamponade

48. Combat Trauma TreatmentChest Injury48 Cardiac Tamponade Usually secondary to penetrating trauma Blood rapidly collects between heart and pericardium, this pressure compresses the ventricles and prevents the ventricles from filling, which decreases cardiac output. Small amounts of fluids <100ml can cause this

49. Combat Trauma TreatmentChest Injury49 Cardiac Tamponade Signs and symptoms Hypotension (narrow pulse pressure) Muffled heart sounds Distended neck veins Becks Triad consists of all of the above

50. Combat Trauma TreatmentChest Injury50 Cardiac Tamponade Management –Ensure airway and administer oxygen 15 lpm –Initiate IV - a bolus of electrolyte solution (500-1000 ml) may increase filling of the heart and increase cardiac output –Rapidly fatal and not easily treated in field –Initiate cardiac monitoring –Transport to nearest medical facility

51. Combat Trauma TreatmentChest Injury51 Cardiac Tamponade

52. Combat Trauma TreatmentChest Injury52 Fractures Fractures of the Scapula or the first or second rib requires a significant force This should alert you to the possibility of major thoracic vascular injury 20-30% of patients with fractures of the 1 st or 2 nd ribs die of associated injuries, 5% die of a ruptured aorta

53. Combat Trauma TreatmentChest Injury53 Fractures Management –Ensure airway –Oxygen 15 lpm if available –Initiate large bore IV and treat for shock –Transport to nearest medical facility

54. Combat Trauma TreatmentChest Injury54 Simple Rib Fracture Most frequent injury to the chest Pain may prohibit casualty from breathing adequately Area of rib fracture may be unstable and tender Management –Administer oxygen 15 lpm –Monitor for pneumothorax or hemothorax –Pain Management Encourage deep breathing –Transport if complications arise

55. Combat Trauma TreatmentChest Injury55 Diaphragmatic Tears Signs and symptoms Can result from a severe blow to abdomen Abdomen can appear scaphoid Usually occurs on the left side May have marked respiratory distress with diminished breath sounds May hear bowel sounds in the chest cavity

56. Combat Trauma TreatmentChest Injury56 Diaphragmatic Tears Management –Ensure airway –Administer oxygen 15 lpm if available –Insert large bore IV and treat for shock –Transport to nearest medical facility

57. Combat Trauma TreatmentChest Injury57 Traumatic Asphyxia Severe compression injury to the chest Compression of heart and mediastinum Signs and symptoms Cyanosis and swelling of the head and neck Lips and tongue may be swollen Conjunctival hemorrhage may be evident Body below the injury remains pink

58. Combat Trauma TreatmentChest Injury58 Traumatic Asphyxia Management –Ensure airway –Oxygen 15 lpm if available –Initiate large bore IV and treat for shock –Treat other injuries –Transport to nearest medical facility

59. Combat Trauma TreatmentChest Injury59 Traumatic Asphyxia

60. Combat Trauma TreatmentChest Injury60 Impalement Injuries Caused by penetrating object (s) DO NOT remove object Management –Ensure airway and oxygen 15 lpm –Stabilize object –Initiate large bore IV and treat for shock –Transport to nearest medical facility

61. Combat Trauma TreatmentChest Injury61 Impaled Object

62. Combat Trauma TreatmentChest Injury62 Traumatic Aortic Rupture Viewed from behind

63. Combat Trauma TreatmentChest Injury63 Traumatic Aortic Rupture Most common cause of deaths in high speed MVA and falls from heights, 90% die immediately Diagnosis is difficult in the field High index of suspicion in above types of accidents Occasionally patients will have upper extremity hypertension and diminished lower extremity pulses

64. Combat Trauma TreatmentChest Injury64 Traumatic Aortic Rupture Management –Ensure airway –Administer oxygen 15 lpm if available –Initiate large bore IV and treat for shock –Transport to nearest medical facility

65. Combat Trauma TreatmentChest Injury65 Tracheobronchial Tree Injury Results from blunt or penetrating trauma Blunt injury may present with subtle findings Penetrating injuries frequently have associated major vascular injuries Presenting signs include: –Dyspnea –Hemoptysis –Subcutaneous emphysema of chest, neck, or face –Associated pneumothorax or hemothorax

66. Combat Trauma TreatmentChest Injury66 Tracheobronchial Tree Injury Management Establishing an airway may be difficult Administer oxygen 15 lpm Initiate large bore IV and treat for shock Observe for pneumothorax/hemothorax Transport to nearest medical facility

67. Combat Trauma TreatmentChest Injury67 Needle Chest Decompression Indications –Tension Pneumothorax with any two: Respiratory Distress & Cyanosis Decreasing Level of Consciousness Loss of Radial Pulse (hypovolemia) Required Materials –12 to 14 gauge I.V. needle w/catheter 5 cm long –Betadine or Alcohol Prep Pads –Surgical Gloves (2 pair) –1/2” Tape –Condom or finger from glove

68. Combat Trauma TreatmentChest Injury68 Needle Chest Decompression Review anatomy of the chest and identify the following anatomical landmarks on the side of the tension pneumothorax –Mid-clavicular line –Second intercostal space - superior edge of the 3rd rib

69. Combat Trauma TreatmentChest Injury69 Needle Chest Decompression Steps for performing the procedure –Position of Casualty: this procedure is not dependant on any single position that the casualty may be in or able to be moved to. Casualty may be lying flat, sitting etc.

70. Combat Trauma TreatmentChest Injury70 Needle Chest Decompression Site preparation: accomplished using either alcohol and or betadine prep pads to disinfect the skin –Using your index finger trace the mid- clavicular line, then identify the second intercostal space (between the second and third ribs) on the side of the tension pneumothorax

71. Combat Trauma TreatmentChest Injury71 Needle Chest Decompression

72. Combat Trauma TreatmentChest Injury72 Needle Chest Decompression Steps for performing the procedure –Insert the needle perpendicular to the chest wall, directly over the top of the third rib until a palpable pop is felt followed immediately by a hissing of air escaping from the chest cavity – A rush of air confirms the diagnosis and rapidly improves the patient's condition

73. Combat Trauma TreatmentChest Injury73

74. Combat Trauma TreatmentChest Injury74 Needle Chest Decompression

75. Combat Trauma TreatmentChest Injury75 Complications Laceration of the intercostal vessels or nerve may cause hemorrhage or nerve damage Creation of a pneumothorax may occur if not already present Infection is a possibility

76. Combat Trauma TreatmentChest Injury76 Questions

77. Combat Trauma TreatmentChest Injury77 Summary In multiple trauma patients chest injuries are common and may be life threatening. You as the soldier medic must have the ability to identify chest injuries and know the treatment modalities available to you. Your prompt action may be life-saving.