1. Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display. 35-1 Chapter 35 Chest Trauma

2. 35-2 Objectives

3. Anatomy of the Chest Cavity 35-3

4. Deadly and Potentially Deadly Chest Injuries Deadly Tension pneumothorax Open pneumothorax Massive hemothorax Cardiac tamponade Flail chest Potentially Deadly Pulmonary contusion Myocardial contusion 35-4

5. Categories of Chest Injuries Closed injuries –No break occurs in the skin over the chest wall –Usually the result of blunt trauma Open chest injuries –Break in the skin over the chest wall –Injuries result from penetrating trauma 35-5

6. Closed Chest Injuries 35-6

7. Rib Fractures Common injury due to blunt chest trauma –May be associated underlying lung or heart injury Seat belts occasionally cause injury 35-7

8. Rib Fractures Ribs 1-3 –Protected by shoulder girdle –Fractures associated with significant trauma Ribs 4-9 –Most commonly fractured 35-8

9. Rib Fractures Signs and Symptoms Localized pain at the fracture site Self-splinting of the injury Pain on inspiration Shallow breathing Tenderness on palpation Chest wall deformity Crepitus Swelling and/or bruising at fracture site Possible subcutaneous emphysema 35-9

10. Rib Fractures Emergency Care Spinal stabilization if spinal injury suspected Establish and maintain an open airway Give oxygen Encourage patient to breathe deeply Do not apply tape or straps to the ribs or chest wall Allow patient to self-splint Perform ongoing assessments 35-10

11. Flail Chest Occurs when two or more adjacent ribs are fractured in two or more places or when the sternum is detached “Flail segment” 35-11

12. Flail Chest Paradoxical movement 35-12

13. Flail Chest Life-threatening injury Respiratory failure may occur due to: –Bruising of underlying lung and hemorrhage of the alveoli –Chest wall instability and pain –Interference with normal "bellows" action of the chest 35-13

14. Flail Chest Signs and Symptoms Crepitus Breathing difficulty Bruising of the chest wall Increased heart rate (tachycardia) Pain and self-splinting of the affected side Increased respiratory rate (tachypnea) Pain in the chest associated with breathing Paradoxical chest wall movement 35-14

15. Flail Chest Emergency Care Keep on scene time to a minimum Request Advanced Life Support (ALS) personnel early Suspect associated spinal injuries Establish and maintain an open airway Give oxygen Treat for shock if indicated Transport 35-15

16. Simple Pneumothorax 35-16

17. Simple Pneumothorax Signs and Symptoms Sudden onset of sharp pain in the chest associated with breathing Shortness of breath Difficulty breathing Decreased or absent breath sounds on the affected side Increased respiratory rate (tachypnea) Increased heart rate (tachycardia) Subcutaneous emphysema (may not be present) 35-17

18. Spontaneous Pneumothorax Does not involve trauma to the lung Two types –Primary spontaneous pneumothorax –Secondary spontaneous pneumothorax 35-18

19. Spontaneous Pneumothorax Typically occurs while at rest or during sleep Usually caused by the rupture of a bleb –Small air- or fluid-filled sac in the lung Common signs and symptoms –Sudden onset of chest pain on affected side –Shortness of breath –Increased respiratory rate –Cough 35-19

20. Pneumothorax Emergency Care Spinal stabilization if suspected spinal injury Establish and maintain an open airway Give oxygen Transport Reassess often for signs of a tension pneumothorax 35-20

21. Tension Pneumothorax 35-21

22. Tension Pneumothorax Signs and Symptoms Cool, clammy skin Increased pulse rate Cyanosis (late sign) JVD Decreased blood pressure Severe respiratory distress Agitation, restlessness, anxiety Bulging of intercostal muscles on the affected side Decreased or absent breath sounds on the affected side Tracheal deviation toward the unaffected side (late sign) Possible subcutaneous emphysema 35-22

23. Tension Pneumothorax Emergency Care Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization if suspected spinal injury Establish and maintain an open airway Give oxygen If an open chest wound was bandaged with an occlusive dressing, release the dressing Treat for shock if indicated Transport Reassess often 35-23

24. Hemothorax 35-24

25. Hemothorax Signs and Symptoms Cool, clammy skin Weak, thready pulse Restlessness, agitation, anxiety Coughing up blood (hemoptysis) (may not occur) Rapid, shallow breathing (tachypnea) Flat neck veins (caused by hypovolemia) Decreasing blood pressure (hypotension) Decreased or absent breath sounds on the affected side 35-25

26. Hemothorax Emergency Care Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization if suspected spinal injury Establish and maintain an open airway Give oxygen Treat for shock if indicated Transport Reassess often 35-26

27. Cardiac Tamponade 35-27

28. Cardiac Tamponade Signs and Symptoms Cool, clammy skin Normal breath sounds Narrowing pulse pressure Trachea in the midline position Increased heart rate (tachycardia) Cyanosis of the head, neck, and upper extremities Muffled heart sounds (often difficult to assess in the field) Distended neck veins (may not be present in hypovolemia) 35-28

29. Cardiac Tamponade Emergency Care 35-29 Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization if suspected spinal injury Establish and maintain an open airway Give oxygen Treat for shock if indicated Transport Reassess often

30. Traumatic Asphyxia 35-30

31. Traumatic Asphyxia Signs and Symptoms JVD Swelling of the tongue and lips Eyes that appear bloodshot and bulging Deep red, purple, or blue discoloration of the head and neck (“hooding”) Low blood pressure when compression is released Normal-looking skin below the level of the crush injury (unless other injuries are present) 35-31

32. Traumatic Asphyxia Emergency Care 35-32 Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization Establish and maintain an open airway Give oxygen Treat for shock if indicated Transport Reassess often

33. Pulmonary Contusion 35-33

34. Pulmonary Contusion Signs and Symptoms Signs of blunt chest trauma Restlessness, anxiety Increased respiratory rate Increased heart rate Cough Coughing up blood (hemoptysis) Chest pain Difficulty breathing Cyanosis 35-34

35. Pulmonary Contusion Emergency Care 35-35 Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization Establish and maintain an open airway Give oxygen Treat for shock if indicated Transport Reassess often

36. Myocardial Contusion 35-36

37. Myocardial Contusion Signs and Symptoms Chest pain or discomfort Increased or slowed heart rate (Possibly) irregular heart rhythm 35-37

38. Myocardial Contusion Emergency Care 35-38 Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization Establish and maintain an open airway Give oxygen Treat for shock if indicated Transport

39. Commotio Cordis Sudden cardiac death due to a blunt force injury to the chest –The blow to the chest causes ventricular fibrillation –The force of the blow typically ranges from 30-50 mph 35-39

40. Commotio Cordis Causes Baseball Hockey Softball Lacrosse Karate Basketball Cricket Martial arts Boxing Motor vehicle crash Playful shadow boxing Parent to child discipline Gang rituals Snowball Pet dog (collie) head Plastic (hollow) toy bat Hiccups remedy Fall on monkey bars 35-40

41. Commotio Cordis Patient typically found unresponsive, apneic, and pulseless. –Many patients are cyanotic. –Seizures have been observed in some individuals. –Bruising of the chest wall present in about one-third of patients. Survival is most dependent on early resuscitation (within 1 to 3 minutes of the event), including CPR and defibrillation. 35-41

42. Open Chest Injuries 35-42

43. Open Pneumothorax 35-43

44. Open Pneumothorax Possible Causes Blast injuries Knife wounds Impaled objects Gunshot wounds MVCs 35-44

45. Open Pneumothorax Signs and Symptoms Shortness of breath Increased heart rate Pain at the site of injury Increased respiratory rate Subcutaneous emphysema Sucking sound on inhalation Open wound in the chest wall Decreased breath sounds on the affected side 35-45

46. Open Pneumothorax Emergency Care 35-46 Keep on scene time to a minimum Request an early response of ALS personnel Spinal stabilization Establish and maintain an open airway Seal the open wound – tape on 3 sides Give oxygen Treat for shock if indicated Transport

47. 24-47 Questions?