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Copyright © 2004, Mosby Inc. All rights reserved. Chapter 27 Chest and Abdominal Trauma Slide 1 Copyright © 2004, Mosby Inc. All rights reserved. Anatomy and Physiology of the Chest Slide 2 Copyright © 2004, Mosby Inc. All rights reserved. Anatomy and Physiology of the Chest Slide 3 Copyright © 2004, Mosby Inc. All rights reserved. Thoracic Cavity • Subdivided into two smaller spaces Mediastinum – in center » Contains heart, great vessels, esophagus, trachea, nerves Pleural spaces – on either side of mediastinum Slide 4 Copyright © 2004, Mosby Inc. All rights reserved. Chest Trauma – Mechanisms of injury • Blunt • Sudden deceleration of chest wall against a fixed object • Penetration Slide 5 Copyright © 2004, Mosby Inc. All rights reserved. Rib Fractures • Most often the result of blunt trauma • Isolated rib fracture usually not a serious emergency • Can puncture lung or blood vessel Pneumothorax, hemothorax, flail chest • Lower rib fractures may injure abdominal organs Liver, spleen, kidneys Slide 6 Copyright © 2004, Mosby Inc. All rights reserved. Case History You respond to an MVC to find a 65-yearold female victim of a front end collision. She is complaining of severe chest pain and dyspnea. She is pale, cyanotic, and diaphoretic. You notice that the steering wheel is deformed. Slide 7 Copyright © 2004, Mosby Inc. All rights reserved. Flail Chest • Two or more ribs fractured in two or more places Paradoxical chest movement • Look for signs of underlying injury (e.g., pneumothorax) Slide 8 Copyright © 2004, Mosby Inc. All rights reserved. Flail Chest – Management • Splint chest wall Blanket, towel, sheet Rigid splint • Positive-pressure ventilation When hypoventilation is present and patient can tolerate Restores adequate ventilation Otherwise nonrebreather device Slide 9 Copyright © 2004, Mosby Inc. All rights reserved. Traumatic Asphyxia • Severe compression of thorax High-velocity or steering wheel injuries, heavy weight dropped on chest • Heart compressed; blood driven to thorax and neck Ecchymosis and edema Life-threatening injury • • Look for associated injuries to lungs and chest wall Management: high-concentration oxygen, possible PPV Slide 10 Copyright © 2004, Mosby Inc. All rights reserved. Traumatic Asphyxia Slide 11 Copyright © 2004, Mosby Inc. All rights reserved. Case History You respond to a call for “difficulty breathing” to find a 19-year-old male complaining of dyspnea and chest pain. He states that it started suddenly while he was running. His breathing difficulty has gotten worse over the last hour. Slide 12 Copyright © 2004, Mosby Inc. All rights reserved. Pneumothorax • Occurs when air enters visceral and parietal pleura Collapses lung • Less alveolar surface for diffusion of oxygen • Results in hypoxia • Two mechanisms Trauma Spontaneous rupture Slide 13 Copyright © 2004, Mosby Inc. All rights reserved. Traumatic • Penetrating Missile Sharp object Broken rib • Blunt Person takes deep breath just before auto collision » “Paper bag effect” Slide 14 Copyright © 2004, Mosby Inc. All rights reserved. Spontaneous • Ruptured bleb in lung tissue • Young, muscular males • COPD patients Slide 15 Copyright © 2004, Mosby Inc. All rights reserved. Open Pneumothorax Slide 16 Copyright © 2004, Mosby Inc. All rights reserved. Open Pneumothorax – Assessment and Recognition • Sucking wound • Dyspnea • Pleuritic chest pain Slide 17 Copyright © 2004, Mosby Inc. All rights reserved. Open Pneumothorax – Assessment and Recognition • Absent or diminished breath sounds on affected side • Signs of respiratory distress • Subcutaneous emphysema • Historical profile Slide 18 Copyright © 2004, Mosby Inc. All rights reserved. Open Pneumothorax – Management • • Check ABCs. • Administer oxygen; positive-pressure ventilation, if needed (carefully). Seal wound with airtight dressing on three sides. • Place patient in position of comfort. • Transport to definitive care. Slide 19 Copyright © 2004, Mosby Inc. All rights reserved. Closed Pneumothorax • Also called simple pneumothorax • Management High-concentration oxygen; possible PPV Transport without delay. » Watch for signs of a developing tension pneumothorax. Slide 20 Copyright © 2004, Mosby Inc. All rights reserved. Case History You respond to an MVC and find a 32year-old female involved in victim of a front end collision complaining of severe chest pain and dyspnea. She is pale, cyanotic, and diaphoretic. The police on scene says she was fine when they arrived but she suddenly started to become “very sick.” Slide 21 Copyright © 2004, Mosby Inc. All rights reserved. Tension Pneumothorax Slide 22 Copyright © 2004, Mosby Inc. All rights reserved. Tension Pneumothorax • Air trapped within pleural space Acts as a one-way valve Increased intrathoracic pressure Can collapse superior and inferior vena cavae » Reduces blood return to heart o Causes profound shock Slide 23 Copyright © 2004, Mosby Inc. All rights reserved. Tension Pneumothorax – Assessment and Recognition • Increasing respiratory distress and cyanosis Breath sounds absent on affected side • Distended neck veins • Tracheal shift • Signs of shock Slide 24 Copyright © 2004, Mosby Inc. All rights reserved. Tension Pneumothorax – Management • If airtight dressing was applied, remove dressing Reapply dressing after air escapes. Watch for further tension. • Transport immediately. • Consider ALS intercept (for needle decompression). Slide 25 Copyright © 2004, Mosby Inc. All rights reserved. Hemothorax • Blood within the pleural space Thorax has the capacity for massive blood loss. • Physiologic effects Primary effect – hypovolemic shock May exist with or without an associated pneumothorax May occur due to penetrating injuries or to rib fractures Slide 26 Copyright © 2004, Mosby Inc. All rights reserved. Hemothorax – Assessment and Recognition • Signs of hypovolemic shock Delayed or absent capillary refill (children) Pale, cool, sweaty skin Tachycardia Rapid and shallow breathing Slide 27 Copyright © 2004, Mosby Inc. All rights reserved. Hemothorax – Assessment and Recognition • Breath sounds absent on the affected side • Hemoptysis (coughing blood) • Hypotension (late sign) • Altered mental state (late sign) • Cardiovascular collapse (cardiac arrest) Slide 28 Copyright © 2004, Mosby Inc. All rights reserved. Hemothorax – Management • Establish a patent airway. • Suction available to manage hemoptysis • High-concentration oxygen; possible PPV • Transport immediately. Slide 29 Copyright © 2004, Mosby Inc. All rights reserved. Pulmonary Contusion • From severe blows to chest wall • Can result in swelling and fluid buildup Decreases diffusion of oxygen into capillaries • Management High-concentration oxygen Slide 30 Copyright © 2004, Mosby Inc. All rights reserved. Cardiac Tamponade • Fluid accumulation in the pericardial sac caused by bleeding or fluid loss • May result from blunt or penetrating trauma Slide 31 Copyright © 2004, Mosby Inc. All rights reserved. Cardiac Tamponade — Physiologic Effects • Bleeding places pressure on atria, ventricles, and vena cava. • Venous return is obstructed. Interferes with the normal dynamics of contraction. • Cardiac output is decreased. Slide 32 Copyright © 2004, Mosby Inc. All rights reserved. Cardiac Tamponade — Assessment and Recognition • Penetrating wound or precordial contusion may be present. • Signs of shock • Decreased pulse pressure • Muffled heart sounds • Distended neck veins Slide 33 Copyright © 2004, Mosby Inc. All rights reserved. Cardiac Tamponade — Management • Early recognition and rapid hospital intervention – most essential Slide 34 Copyright © 2004, Mosby Inc. All rights reserved. Case History You respond to a “man down” to find a 20-yearold construction worker who fell 30 feet from a rooftop. He is complaining of pain in his chest and back. He is pale and diaphoretic. His pulse is 130 and thready. He is responsive to painful but not verbal stimuli. Slide 35 Copyright © 2004, Mosby Inc. All rights reserved. Aortic Tear • Complete tear results in exsanguination and death. • Partial tear causes leak and hemorrhage. • Hypovolemic shock is main problem. • Mortality is very high from massive hemorrhage. 80% die within first hour Slide 36 Copyright © 2004, Mosby Inc. All rights reserved. Abdominal Trauma Slide 37 Copyright © 2004, Mosby Inc. All rights reserved. Anatomy and Physiology of the Abdomen Slide 38 Copyright © 2004, Mosby Inc. All rights reserved. Anatomy and Physiology of the Abdomen Slide 39 Copyright © 2004, Mosby Inc. All rights reserved. Anatomy and Physiology of the Abdomen Slide 40 Copyright © 2004, Mosby Inc. All rights reserved. Abdominal Injuries • Large vessels and highly vascular organs within abdomen Rapid blood loss and death Maintain high level of suspicion • May be from blunt or penetrating trauma • Primary goal Recognize life-threatening injuries. Administer essential life support. Transport without delay (requires surgical intervention). Slide 41 Copyright © 2004, Mosby Inc. All rights reserved. Mechanism of Injury • Blunt trauma Compression injuries Deceleration injuries Seat belt injuries • Penetrating trauma Slide 42 Copyright © 2004, Mosby Inc. All rights reserved. Assessment • Scene size-up Obtain MOI • Initial assessment Look for signs of hypovolemia Slide 43 Copyright © 2004, Mosby Inc. All rights reserved. Assessment • Focused history and physical examination Look for bruises, tire marks, seat belt marks. Is abdomen distended? DCAP-BTLS Palpate abdomen for tenderness and guarding. » Save painful area for last. Palpate iliac crest. » If pelvic bones move, stop examination. Slide 44 Copyright © 2004, Mosby Inc. All rights reserved. Assessment • Focused history and physical examination (continued) Associated head or spinal injuries may present with loss of pain perception. SAMPLE history Elderly? History of medications that slow heart rate? Signs of alcohol or drugs Slide 45 Copyright © 2004, Mosby Inc. All rights reserved. Management • Management occurs in hospital. • Treat for shock. • Transport without delay. Slide 46 Copyright © 2004, Mosby Inc. All rights reserved. Special Considerations • Evisceration Do not attempt to put organs back in abdomen. » Cover with moist, sterile dressing or airtight dressing. Transport in supine position with hips and legs flexed with pillow under knees. Slide 47 Copyright © 2004, Mosby Inc. All rights reserved. Evisceration Slide 48 Copyright © 2004, Mosby Inc. All rights reserved. Special Considerations • Urinary tract injuries Look for bruises over flank. Injuries to pelvis can cause bladder or urethral tears. • Injuries to male genitalia May result in lacerations, bruising, avulsion, or amputation • Injuries to female genitalia May occur from direct trauma or straddle injuries Slide 49 Copyright © 2004, Mosby Inc. All rights reserved. Acute Abdomen • Recent onset of abdominal pain • Requires early diagnosis and surgical intervention Slide 50 Copyright © 2004, Mosby Inc. All rights reserved. Acute Abdomen – Assessment • Identify life threats and transport immediately. • Initial assessment If shock present, rapid transport. Establish and maintain patent airway. Administer high-concentration oxygen. Place patient in position of comfort, if not contraindicated. Slide 51 Copyright © 2004, Mosby Inc. All rights reserved. Acute Abdomen – Assessment • Focused history Gather SAMPLE history with O-P-Q-R-S-T approach. Slide 52 Copyright © 2004, Mosby Inc. All rights reserved. SAMPLE History for Patients with Abdominal Complaints Slide 53 Copyright © 2004, Mosby Inc. All rights reserved. SAMPLE History for Patients with Abdominal Complaints Slide 54 Copyright © 2004, Mosby Inc. All rights reserved. SAMPLE History for Patients with Abdominal Complaints Slide 55 Copyright © 2004, Mosby Inc. All rights reserved. Acute Abdomen – Assessment • Focused physical examination Look for findings associated with abdominal complaints. » Jaundice in sclera or skin? » Signs of dehydration? Ask patient to point to area of pain. » Palpate that quadrant last. Slide 56 Copyright © 2004, Mosby Inc. All rights reserved.