Download Ready for Review - Paramedic EMS Zone

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The thorax contains the ribs, thoracic vertebrae, clavicle, scapula, sternum, heart,
lungs, diaphragm, great vessels (including the aorta), oesophagus, lymphatic
channels, trachea, mainstem bronchi, and nerves.
Oxygenation and ventilation (delivery of oxygen and removal of carbon dioxide)
take place within the thorax, as well as some aspects of circulation.
Injuries to the thorax can cause air or blood to enter the lungs, or may prevent the
organs from being able to move properly, inhibiting oxygenation and ventilation.
Chest wall injuries include flail chest, rib fractures, and sternal fractures.
In flail chest, two or more ribs are broken in two or more places. It can result in a
free-floating segment of rib that can move paradoxically in comparison to the rest
of the chest wall. The lung tissue beneath the flail segment is not adequately
ventilated as a result.
Rib fractures produce significant pain and can prevent adequate ventilation.
Sternal fractures are also problematic in that they are usually associated with other
serious injuries.
Lung injuries include simple pneumothorax, open pneumothorax, tension
pneumothorax, massive haemothorax, and pulmonary contusion.
A pneumothorax occurs when air leaks into the space between the pleural surfaces
from an opening in the chest or the surface of the lung. The lung collapses as air
fills the pleural space. The result is a mismatch between ventilation and perfusion.
A tension pneumothorax is life-threatening and results from collection of air in
the pleural space. The air exerts increasing pressure on surrounding tissues as it
accumulates, compromising ventilation, oxygenation, and circulation.
A haemothorax is the accumulation of blood between the parietal and visceral
pleura. It results in compression of structures around the collection of blood and
compromises ventilation, oxygenation, and circulation.
A haemopneumothorax is the collection of both blood and air in the pleural space.
Pulmonary contusion occurs from compression of the lung. It results in alveolar
and capillary damage, oedema, and hypoxia.
Myocardial injuries include cardiac tamponade, myocardial contusion, myocardial
rupture, and commotio cordis.
Cardiac tamponade occurs when excessive fluid builds up in the pericardial sac
around the heart. The heart becomes compressed and stroke volume is
compromised.
Myocardial contusion is essentially blunt trauma to the heart. Haemorrhage,
oedema, and cellular damage result. Arrhythmias may occur.
Myocardial rupture is perforation of one or more elements of the anatomy of the
heart, such as the ventricles, atria, or valves. It can occur from blunt or penetrating
trauma.
Commotio cordis occurs from a direct blow to the chest during a critical portion
of the heart’s repolarisation period, resulting in possible cardiac arrest.
Vascular injuries include thoracic aortic dissection/transaction and great vessel
injury. Thoracic aortic dissection/transaction is literally ripping of the aorta.
Injuries to other great vessels may cause similar problems of potentially fatal
bleeding.
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Other thoracic injuries include diaphragmatic injuries (abdominal contents may
herniate through the injury and cut off the blood supply); oesophageal injuries,
which can be rapidly fatal; tracheobronchial injuries (injury to the airways); and
traumatic asphyxia (sudden compression of the chest leading to pressure on the
head, neck, and kidneys, causing capillary beds to rupture).
Begin the assessment of a thoracic trauma patient as you would any other
patient—with a scene assessment and assessment of the ABCs.
In assessing breathing, note any signs of injury to the thorax, which could indicate
additional underlying injuries. Look for paradoxical motion, retractions,
subcutaneous emphysema, impaled objects, or penetrating injuries.
Consider adequacy of ventilation and oxygenation. Watch for signs of hypoxia, an
irregular pulse, changes in blood pressure, and JVD.
Because the mechanism of injury that caused the thoracic problem may have been
traumatic, always consider cervical spine stabilization in such cases.
Several chest injuries may have similar signs and symptoms, such as hypoxia,
pain, tachycardia, cyanosis, and shock. Managing the various chest injuries
involves several common steps: maintaining the airway, ensuring oxygenation
and ventilation, supporting circulatory status, and transporting quickly. Learning
the subtle differences between various chest injuries can help you manage them
more specifically.
The one exception to airway management in patients with thoracic trauma is the
decision to endotracheally intubate a patient with a possible tracheal injury. Such
a decision could further tear the trachea. These patients should be managed with
minimal invasion to the airway.
Management of flail chest includes airway management and possibly positivepressure ventilation, if the patient experiences respiratory failure. Intubation may
also be necessary.
Management of rib fractures should focus on the ABCs and gentle splinting of the
patient’s chest by having the patient hold a pillow or blanket against the area.
Management of a pneumothorax begins with the ABCs and highconcentration
oxygen. Cover a sucking chest wound with an occlusive dressing secured on three
sides.
Patients with a tension pneumothorax should be placed on highflow supplemental
oxygen by nonrebreathing mask, and a needle decompression should be
performed.
For patients with pulmonary contusions or cardiac tamponade, follow general
management (ABCs) and consider administering IV fluids.
Management of patients with myocardial contusion should be supportive, but also
includes cardiac monitoring and intravenous access.
Care for patients with thoracic aortic dissection focuses on symptom control.
Management of patients with great vessel injuries is no different from those with
acute blood loss.
Care for patients with tracheobronchial injuries entails assessment and
management of the ABCs.
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Don’t be distracted by the dramatic appearance of patients with traumatic
asphyxia. Care for the ABCs, obtain IV access, and transport.
Management of these chest injuries is supportive only: sternal fractures,
haemothorax, and myocardial rupture.