Download Chapter 1 EMS Systems, Roles, and Responsibilities

Chapter 23 Thoracic Injuries
Introduction
• Thoracic trauma accounts for a significant amount
of injuries and fatalities annually
– Approximately 700,000 emergency department visits
– Over 18,000 deaths
• You are dispatched to a call involving a gunshot
victim. You are told he was trying to rob the liquor
store and the clerk shot him with a .32-caliber
handgun.
• When you arrive, things are very quiet and still
around the store. You see no obvious dangers, and
the scene seems safe. However, police are still on
the scene, two inside the store and two walking
around the parking lot and front of the store.
– Since you were dispatched to that scene, should
you assume that it is safe to enter?
Anatomy (1 of 2)
• Thorax: a bony cage consisting of the following
structures:
– 12 pairs of ribs
– Scapula
– Clavicle
– Sternum
– Thoracic vertebrae
Anatomy (2 of 2)
Sternum
• Sternum: composed of three sections called
the manubrium, body, and xyphoid process
• Suprasternal notch: just superior to the manubrium
• Angle of Louis: junction of the manubrium
and sternal body
Rib Anatomy
• Each of the 12 ribs attach posteriorly to the
12 vertebrae
• Intercostal space: area located between the ribs
• Neurovascular bundle: artery, vein, and nerve
located in the intercostal space
Mediastinum
• Located within the central region of the thorax
• Contains heart, great vessels, esophagus, trachea,
mainstem bronchi, and vagus and phrenic nerves
Pericardium
• The heart is located within the pericardial sac.
• The pericardial sac consists of two layers: visceral
and parietal.
• There is a potential for blood or fluid to become
trapped between these layers.
Aorta
• The largest artery in the human body
• It exits the left ventricle, and attaches at three points:
anulus, ligamentum arteriosum, and aortic hiatus.
• These points represent sites of potential injury.
Lungs
• Occupy most of the space in the thoracic cavity
• Lined with two pleural membranes
• Small amount of fluid found between parietal
and visceral membranes
Respirations (1 of 2)
• The diaphragm is the principle muscle of respiration.
• Intercostal muscles work in conjunction with the
diaphragm.
• The thoracic cavity increases in size when the
muscles contract.
Respirations (2 of 2)
Physiology
• The process of breathing includes delivery
of oxygen and removal of carbon dioxide.
• Gas exchange occurs at alveoli.
Respiratory Stimulus
• Stimulation to breathe occurs via chemoreceptors
located in the carotid sinus and aortic arch.
• When CO2 level increases, the brain is stimulated
to increase respiratory rate and depth and “blow
off” CO2.
Inspiration
• The diaphragm contracts and moves downward
while the intercostals contract and move outward.
• Intrathoracic pressure decreases resulting in air
entering the thoracic cavity.
Expiration
• The diaphragm relaxes and moves upward while the
chest wall relaxes.
• Intrathoracic pressure increases above atmospheric
pressure.
• Air leaves the body.
Oxygenation and Ventilation
• Oxygenation is the delivery of oxygen from the air
to the blood.
• Oxygen binds with hemoglobin.
• Ventilation is the removal of carbon dioxide from the
body to the atmosphere.
Cardiac Output
• Proper cardiac output is required to ensure adequate
tissue perfusion.
• Cardiac output is the volume of blood delivered
in one minute.
• Cardiac output is equal to heart rate times stroke
volume.
(continued)
• When the scene is declared safe, you go in to find a man
lying on the floor. He is bleeding heavily. Upon closer
inspection, you can see that he has been shot twice—
once in the upper chest, about an inch below his right
clavicle, and once in the abdomen, slightly up and to the
left of his belly button.
• You note that the patient is pale; has cool, clammy skin;
and is breathing rapidly but shallowly. The majority of the
bleeding is coming from the wound in his abdomen. The
one in his chest is bleeding only slightly. He tries to be
combative and uncooperative, but he is weak and seems
to be very confused.
– When assessing the patient’s injuries, what possible
(or probable) life-threatening problems are you facing?
– How would you quickly and efficiently find out if any
life-threatening conditions do exist for this patient?
Thoracic Injuries
• Thoracic injuries risk serious airway, respiratory,
and circulatory compromise for your patient.
• Aggressive identification and management
of injuries is required.
Flail Chest (1 of 2)
• Major chest wall injury from blunt force trauma
• Two or more adjacent ribs fractured in two or more
places
• Creates a “free-floating” segment that impairs chest
wall motion
Flail Chest (2 of 2)
Rib Fractures
• Most common thoracic injury
• Patient often “self-splints,” leading to inadequate
ventilation and atelectasis
• Consider underlying injuries
Sternal Fractures
• 1 out of 4 patients with this injury will die.
• Patient will complain of anterior chest pain.
• Look for deformity, flail sternum, and ECG changes.
Simple Pneumothorax (1 of 2)
• Presentation depends upon size of pneumothorax.
• Small pneumothorax may cause only mild dyspnea
and pleuritic chest pain.
• Breath sounds may be diminished.
Simple Pneumothorax (2 of 2)
• Large pneumothorax will produce increased
respiratory compromise:
– Absent breath sounds
– Hypoxia
– AMS
– Tachycardia
– Cyanosis
Open Pneumothorax (1 of 2)
• Occurs when a defect in the chest wall allows air
to enter the thoracic space
• Results from penetrating chest trauma
• Air is drawn into the pleural space.
• Collapse of lung results in mismatch between
ventilation and perfusion.
Open Pneumothorax (2 of 2)
Tension Pneumothorax (1 of 3)
• Life-threatening condition that results from
continued air accumulation within the intrapleural
space
• May occur from open thoracic injury, blunt trauma,
barotrauma, or shearing forces
Tension Pneumothorax (2 of 3)
• Injury to the lung
can cause a one-way
valve to develop.
• Air enters pleural
space.
• Air exerts increasing
pressure.
Tension Pneumothorax (3 of 3)
• Classic signs include:
– Increased dyspnea
– Absent breath sounds on affected side
– Tachycardia
– JVD (late sign)
– Tracheal deviation (late sign)
Massive Hemothorax (1 of 2)
• Occurs when blood begins to fill the potential space
between the parietal and visceral pleura
• Occurs in approximately 25% of chest trauma
patients
• Each lung can hold up to 3,000 mL of blood.
Massive Hemothorax (2 of 2)
• Condition will result in both ventilatory compromise
and circulatory collapse.
• There are several physical findings that help
differentiate between tension pneumothorax
and hemothorax.
Pulmonary Contusion (1 of 2)
• Caused by compression of lung tissue against
chest wall
• Alveolar and capillary damage results
• Results in reduced delivery of oxygen across
the alveolar-capillary membrane
Pulmonary Contusion (2 of 2)
• Patient may have
hemoptysis.
• Look for signs of
overlying injury,
such as crepitus,
tenderness, or
contusions.
Pericardial Tamponade (1 of 3)
• Excessive fluid in the pericardial sac causing
compression of the heart
• May be caused by blunt or penetrating injury
Pericardial Tamponade (2 of 3)
• In medical conditions, inflammation leads to fluid
collection.
• As the pericardium fills, the atria and vena cavae
become compressed.
• Preload is therefore reduced, which reduces stroke
volume.
Pericardial Tamponade (3 of 3)
• Beck’s triad is a classic combination:
– Muffled heart tones
– Hypotension
– JVD
• Patient appears in shock with signs and symptoms
similar to tension pneumothorax.
Myocardial Contusion (1 of 2)
• Blunt cardiac injury caused by the heart colliding
with the sternum
• Leads to local tissue contusion, hemorrhage, edema,
and cellular damage
• May lead to dysrhythmias
Myocardial Contusion (2 of 2)
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•
•
•
Patient complains of sharp, retrosternal chest pain.
Soft-tissue injury may be present.
Lung sounds may reveal crackles.
ECG changes may occur.
Myocardial Rupture
• Acute perforation of the ventricles, atria, septum,
chordae, muscles, or valves
• Caused by severe blunt force compression
• Life-threatening condition that accounts for 15%
of fatal chest injuries
Commotio Cordis
• Immediate cardiac arrest caused by blunt trauma
during the heart’s repolarization period
• Patient appears in ventricular fibrillation, which
responds well to defibrillation if performed quickly.
Vascular Injuries (1 of 2)
• Injury to the thoracic aorta accounts for one in every
five blunt trauma deaths.
• Caused by transection or dissection
• Aorta is sheared at its fixed points.
• Most patients die before EMS arrives.
Vascular Injuries (2 of 2)
• Patient may complain of pain behind sternum.
• Patient may also show signs and symptoms
of hypoperfusion.
Diaphragmatic Injuries (1 of 2)
• May be due to blunt or penetrating trauma
• The most serious injury is diaphragmatic herniation.
• Abdominal organs enter the thoracic cavity, causing
a tension gastrothorax.
Diaphragmatic Injuries (2 of 2)
• May be identified by bowel sounds in the
chest cavity
• Absence of breath sounds on affected side
Esophageal Injuries
• Rapidly fatal injury
• Associated with other significant injuries especially
tracheal injuries
• Patient may have subcutaneous emphysema.
• There is no prehospital treatment.
Tracheobronchial Injuries
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Rare injuries normally caused by penetrating trauma
Have a high mortality rate
May lead to a tension pneumothorax
Be prepared to decompress the patient as needed.
Traumatic Asphyxia (1 of 2)
• Caused by the sudden and forceful compression
of the thoracic cavity
• Causes pressure to be translated into the veins
of the head, neck, and kidneys
• Pressure in capillary beds results in their rupture.
Traumatic Asphyxia (2 of 2)
• Dramatic findings on patient
– Cyanosis of head and upper extremities
– Subconjunctival hematoma
– Exophthalmos
– Tongue and lips may be swollen
(continued)
• You do not find exit wounds from either bullet upon examination.
The patient’s blood pressure is 104/62. Heart rate is 24 bpm and
irregular. O2 saturation is 87% on room air. He has diminished
breath sounds on the upper right section of his lungs, where a
bullet penetrated. Radial pulses are palpable, but not strong.
• You and your partner work quickly to address the lifethreatening injuries that are most likely in this case. You take
vitals a second time before going out to the ambulance: there is
no radial pulse, his heart rate is very irregular and fast
(tachycardia), and he is taking short, shallow breaths at a rate of
28 breaths per minute. His blood pressure is now 78/46. Instead
of being confused, the patient is close to losing consciousness.
– Given the second set of vitals and the injury sustained, what
is most likely happening inside your patient’s body?
– What should you be prepared to do quickly if your findings
suggest a life-threatening condition such as tension
pneumothorax?
Scene Size-up
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Is the scene safe to enter?
Do you have the proper BSI?
How many patients are there?
Has triage been performed?
Do you need additional resources?
Initial Assessment
• Mental status: Assess the patient’s LOC while
maintaining C-spine.
• Airway: Consider the MOI when determining the
possibility of airway compromise.
• Airway obstruction may be due to the tongue, blood,
or broken teeth.
Signs of Airway Compromise
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Stridor
Hoarseness
Gurgling
Snoring
Signs of hypoxia
AMS
Tachypnea
Coughing
Hemoptysis
Accessory muscle usage
Retractions
Airway Management
• If a patient has signs of airway compromise, it must
be controlled immediately.
• Use jaw-thrust in all trauma patients.
• Suction, use airway adjuncts, or use advanced
airway management skills as necessary.
Breathing (1 of 2)
• Identify and manage any impairment of the patient’s
oxygenation and ventilation.
• Expose the thoracic cavity.
• Palpate, percuss, inspect, and auscultate.
• Note the rate and quality of respirations.
Breathing (2 of 2)
Circulation (1 of 2)
• AMS is the first sign of hypoperfusion.
• Assess pulses to determine rate, quality,
and rhythm.
• Tachycardia may be caused by shock or other
causes.
• The absence of tachycardia does not exclude
hypovolemia.
Circulation (2 of 2)
• “Weak and thready” suggests hypovolemia.
• Irregular pulse suggests hypoxia of the myocardium.
• Blood pressure is only a clinical guide in managing
a shock patient.
Jugular Venous Distension
• Must be measured
at a 45º angle
• Cannot be
determined when
the patient is
immobilized
• Lack suggests
hypovolemia
Heart Auscultation
• Listening for heart sounds is difficult, but crucial.
• Muffled heart sounds may indicate tension
pneumothorax or pericardial tamponade.
Focused History and Physical Exam
• Due to patient’s condition, this may need to be done
en route to the hospital.
• Obtain a complete set of vital signs.
• Obtain a SAMPLE history.
• Question the events surrounding the incident
and the MOI.
Detailed Physical Exam
• Complete a head to toe exam on your patient.
• Identify any missed injuries and reassess injuries
already noted.
• Pay particular attention to injuries affecting the
ABCs.
Ongoing Assessment
• Any patient with suspected chest trauma should
be considered unstable and reassessed every
five minutes.
• Check vital signs, ABCs, oxygenation, and
lung sounds.
• Maintain a high degree of suspicion for the
“deadly dozen.”
General Management
• Focus on the maintaining an airway, ensuring
oxygenation and ventilation, providing circulatory
support, and rapid transport.
• Use jaw thrust to maintain airway.
Airway Management
• If you suspect a possible tracheal injury, reconsider
intubation unless absolutely necessary.
• Intubation may worsen the injury and lead to a
completely unmanageable airway.
Ventilation
• When ventilating patients with possible lung trauma,
ventilate gently.
• Watch closely for patient’s chest rise.
• If too much force is used, a simple pneumothorax
may be converted into a tension pneumothorax.
Circulatory Support
• If a patient is showing signs of circulatory
compromise, provide supportive care.
• Establish IV access and administer fluids as needed.
Golden Hour
• Remember that surgery is the definitive care
required for a patient who has suffered a
thoracic injury.
• Scene times should be kept to 10 minutes.
• Rapidly transport patient to a trauma center.
(continued)
• Your patient is confused, weak, and worsening rather
quickly.
– When you try to get a patient history in this
particular case, is it important to doggedly push to
find out what medications he is on, what he may
be allergic to, when he ate last, and other
questions normally asked during the SAMPLE
history?
– If time does not permit given the severity of the
patient’s injuries, what other way might you be
able to get important information regarding your
patient? What must you be careful to do if the
information comes from a source other than the
patient himself?
Flail Chest Management (1 of 2)
• Signs and symptoms
– Paradoxical motion
– Dyspnea
– Chest pain
• Underlying pulmonary contusion common
with flail segment
Flail Chest Management (2 of 2)
• Life-threatening emergency
• Stabilize immediately with bulky dressing during
exhalation.
• Control airway and assist ventilations as needed.
Rib Fracture Management
• Assessment is key.
• Signs and symptoms
– Hypoxia, hypercarbia, and pain
• Threat to breathing
• External stabilization is no longer recommended.
• Supportive care
Sternal Fracture Management
• Pain in anterior chest
• Risk of myocardial contusion
• Supportive treatment only
Simple Pneumothorax
• Treatment begins with ABCs.
• Deliver high-concentration oxygen.
• The most critical intervention is repeat assessments
to ensure tension pneumothorax is not developing.
Open Pneumothorax
Management (1 of 2)
• Determine if a
“sucking chest
wound” exists.
• Sucking chest
wounds must be
treated immediately.
Open Pneumothorax
Management (2 of 2)
• Cover open pneumothorax with occlusive dressing
secured on three sides.
• Place patient on high-flow oxygen.
• Intubation may be required if ventilation is
inadequate.
Tension Pneumothorax
• Patient complains of pleuritic chest pain
and dyspnea.
• High-flow supplemental oxygen
Skill Drill 23-1 Needle
Decompression (1 of 2)
Step 1
Step 2
Step 3
Step 4
Skill Drill 23-1 Needle
Decompression (2 of 2)
Step 5
Step 6
Step 7
Step 8
Massive Hemothorax
Management (1 of 2)
• Significant findings
– Lack of JVD
– Lack of tracheal deviation
– Hemoptysis
– Dull to percussion
Massive Hemothorax
Management (2 of 2)
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Management is supportive care of ABCs
High-flow oxygen
Two large-bore IVs
Treat for shock.
Pulmonary Contusion Management
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Hemoptysis
Airway management
Edema may exacerbate the injury.
Supportive care
Pericardial Tamponade Management
• Beck’s triad
• Treatment consists of
– Ensuring adequate oxygenation
– Giving IV fluids
– Transporting rapidly to trauma center
• Surgery is definitive care.
Myocardial Contusion Management
• Abnormal ECG
• Coronary artery injury
• Care consists of ABCs and frequent reassessment
of vital signs.
• Monitor cardiac rhythm and establish IV.
• Consult with medical direction.
Myocardial Rupture Management
• Patient may present with acute pulmonary edema
or signs of cardiac tamponade.
• Give patient supportive care.
• Rapid transport to a trauma center
Vascular Injury Management
• Maintain a high index of suspicion based
upon the mechanism of injury.
• Provide supportive care.
• Establish two large-bore IVs.
• Do not use PASG.
• Transport to trauma center.
Diaphragmatic Injury Management
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Diagnosis improbable in the field
Acute phase
Obstructive phase
Maintain adequate oxygenation
Rapid transport
Esophageal Injury Management
• Pleuritic chest pain may be present.
• Subcutaneous emphysema
• No prehospital therapy
Tracheobronchial Injuries
Management
• Physical findings may include
– Respiratory distress
– Hoarseness
– Hemoptysis
• Do not intubate unless it is absolutely necessary.
• Be sure to bag gently and slowly.
Traumatic Asphyxia Management
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Implies a fatal outcome
Maintain C-spine on all patients.
Intubate as necessary.
Provide high-flow oxygen.
Two large-bore IVs
Transport to a trauma center.
Summary
• Once the life threats to your patient have been
addressed and treated, you should concentrate on
packaging the patient and getting him to a trauma
center as quickly as possible. When you arrive at the
emergency department, having radioed in the
condition of the patient before arrival, they are ready
to begin immediate work on your patient.
• A chest tube is put in almost immediately. Emergency
surgery is performed to fix the internal injuries to his
lung, liver, and small intestine. After 4 days in ICU, he
is moved to a room to recover from his injuries. Your
quick thinking and efficient response saved his life.
Criminal charges will be pressed by officials when he
is recovered enough.
Summary
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Anatomy and physiology
Pathophysiology
General assessment and management
Managing specific injuries