Download Chapter 35 - Jones & Bartlett Learning

Chapter 35
Chest Trauma
National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan
for an acutely injured patient.
National EMS Education
Standard Competencies
Chest Trauma
• Recognition and management of
− Blunt vs penetrating mechanisms
− Open chest wound
− Impaled object
National EMS Education
Standard Competencies
• Pathophysiology, assessment, and
management of
− Blunt vs penetrating mechanisms
− Hemothorax
− Pneumothorax
• Open
• Simple
• Tension
National EMS Education
Standard Competencies
• Pathophysiology, assessment, and
management of (cont’d)
− Cardiac tamponade
− Rib fractures
−
−
−
−
Flail chest
Commotio cordis
Traumatic aortic disruption
Pulmonary contusion
National EMS Education
Standard Competencies
• Pathophysiology, assessment, and
management of (cont’d)
− Blunt cardiac injury
− Tracheobronchial disruption
− Diaphragmatic rupture
− Traumatic asphyxia
Introduction
• Annually, thoracic
trauma causes:
− 700,000 +
emergency
department visits
• One in four trauma
deaths are due to
thoracic injuries.
© PhotoStock-Israel /Alamy Images
− 18,000+ deaths
Anatomy
• Thorax—bony cage over chest organs
Anatomy
• Diaphragm inserts below 4th or 5th rib
− Size/dimension of thoracic cavity varies during
respiration
Anatomy
• Sternum
− Consists of:
• Superior manubrium
• Central sternal body
• Inferior xyphoid
process
• Clavicle
− Connects to the
manubrium and
overlies the first rib
• Scapula
− Overlies posterior
aspect of the upper
thoracic cage
Anatomy
• 12 pairs of ribs attach to 12 thoracic
vertebrae.
− First 7 pairs attach directly to sternum
− 8–10 attach indirectly to sternum
− 11 and 12 are “floating ribs”
Anatomy
• Intercostal space
houses:
− Intercostal muscles
− Neurovascular bundle
• Mediastinum
contains:
− Heart and great
vessels
− Esophagus
− Lymphatic channels
− Trachea
− Mainstem bronchi
− Vagus and phrenic
nerves
Anatomy
• Heart resides inside pericardium
− Anterior portion is the right ventricle
− Mostly protected anteriorly by the sternum
− Average cardiac output:
70 × 70 = 4,900 mL/min
Anatomy
• Aorta: largest artery in body
− Three points of attachment:
• Annulus
• Ligamentum arteriosum
• Aortic hiatus
Anatomy
• Lungs occupy most space in thoracic cavity
− Lined with pleura
− Pleura is separated by viscous fluid
• Keeps lungs from collapsing on exhalation
Anatomy
• Diaphragm: primary breathing muscle
− Breathing effort can be helped by accessory
muscles.
Physiology
• Primary functions of thorax:
− Maintain oxygenation and ventilation.
− Maintain circulation.
• Breathing process includes:
− Delivery of oxygen to body
− Elimination of carbon dioxide
Physiology
• Brain stimulates breathing via
chemoreceptors.
− If CO2 is too high, respiratory rate increases.
− Hypoxic drive: secondary mechanism
Physiology
• Intercostal and accessory muscles pull
chest wall away from the body as the
diaphragm contracts downward.
− Negative pressure draws air through mouth and
nose to alveolar spaces.
• Replaces air in the alveoli
Physiology
• Blood is delivered by pulmonary circulation
to capillaries adjacent to alveoli.
− Has low O2 and high CO2 concentrations
− Oxygenation process delivers O2 to blood
Physiology
• Ventilation: how CO2 leaves the body
− CO2 diffuses down its concentration gradient
and enters air within the alveoli.
− Positive pressure is created within the thorax
and air is exhaled.
Physiology
• Proper heart function is essential.
− Ability to pump blood depends on:
• A functional pump
• Adequate blood volume
• Lack of resistance to pumping mechanisms
− Factors determine cardiac output.
Pathophysiology
• Traumatic injury to chest may compromise:
− Ventilation
− Oxygenation
− Circulation
Pathophysiology
• Two mechanisms of
injury:
− Blunt
− Penetrating
• Two basic injury
patterns
− Closed
− Open
Pathophysiology
• Blunt trauma may lead to:
− Fracture of ribs, sternum, areas of chest wall
− Bruise of lungs and heart
− Damage to aorta
− Broken ribs lacerating intrathoracic organs
− Organs torn from attachment
Pathophysiology
• Blast injuries may be blunt or penetrating.
− Primary shock wave (blunt trauma)
− Secondary shock wave (penetrating trauma)
Pathophysiology
• Thoracic trauma may impair cardiac output.
− Blood loss
− Pressure change
− Vital organ damage
− Combination of these
Pathophysiology
• Ventilatory impairments can be rapidly fatal.
− Shallow breathing reduces minute volume.
− Air entering pleural space compresses lungs
and decreases tidal volume.
− Blood collection prevents full lung expansion.
Pathophysiology
• Other complications include:
− Atelectasis reduces area for gas exchange.
− Bruised lung tissue may cause hypoxemia.
− Tearing or rupture of respiratory structures
prevents O2 from reaching alveoli.
Scene Size-Up
• Be sure scene is safe to enter.
• Follow standard precautions.
• After identifying number of patients:
− Triage patients and request resources.
− Determine MOI if possible.
Primary Assessment
• Form a general impression.
− Assess level of consciousness.
− Perform a rapid scan.
− Observe the neck for:
• Accessory muscle use during breathing
• Extended or engorged external jugular veins
Primary Assessment
• Airway and breathing
− Assess while performing spinal immobilization.
− Airway compromise presentation depends on:
• Severity of impairment
• Duration
• Associated injuries
Primary Assessment
• Airway and breathing (cont’d)
− Signs of obstruction
may include:
− Abnormal findings
may include:
• Stridor
• Tachypnea
• Hoarseness
• Alterations in mental
status
• Hemoptysis
• Retractions
Primary Assessment
• Airway and breathing (cont’d)
− Immediate manage airway impairment:
• Manually immobilize patient.
• Use jaw-thrust maneuver.
− Identify and manage impairment of oxygenation
and ventilation.
Primary Assessment
• Airway and breathing (cont’d)
− Inspect chest wall.
− Underlying injury may be indicated by:
• Signs of soft-tissue injury
• Retractions
• Impaled objects
Primary Assessment
• Airway and breathing (cont’d)
− Address life-threats first.
− Apply occlusive dressing to penetrating injuries.
− Assess ventilation and oxygenation.
Primary Assessment
• Airway and breathing (cont’d)
− Apply O2 with nonrebreathing mask at 15 L/m.
• Evaluate skin circulation.
• Decreasing O2 saturation may indicate hypoxia.
• Watch for impending tension pneumothorax signs.
Primary Assessment
• Airway and breathing (cont’d)
− Palpate for:
• Point tenderness
• Bony instability
• Crepitus
• Subcutaneous emphysema
• Edema
• Tracheal position
Primary Assessment
• Airway and breathing (cont’d)
− Percuss for:
• Hyperresonance
• Dullness
− Auscultate for:
• Adventitious lung
sounds
• Confirmation of
lung sounds
Primary Assessment
• Circulation
− Begin by checking mental status for:
• Restlessness
• Agitation
• Confusion
• Irrationality
• Comatose
Primary Assessment
• Circulation (cont’d)
− Check pulses.
• Tachycardia is not always associated with
hypovolemia.
• Low heart rate does not rule out hypovolemia or
shock.
• Thready or weak pulse may suggest volume loss.
Primary Assessment
• Circulation (cont’d)
− Irregular pulse suggests:
• Hypoxia
• Hypoperfusion
• Serious underlying injuries or shock
Primary Assessment
• Circulation (cont’d)
− JVD suggests
increased
intravenous
pressure.
• Measured in a
45° semi-Fowler’s
position
Courtesy of Rhonda Beck
Primary Assessment
• Circulation (cont’d)
− Auscultate the heart.
• Note if heart sounds are easily heard or muffled.
− If shock suggested, may not be from thorax.
• Obtain history and complete physical.
Primary Assessment
• Transport decision
− Priorities: patients
with ABC problems
− If signs of poor
perfusion/
− inadequate
breathing:
• Transport quickly.
• Perform
assessment en
route.
History Taking
• May need to be done en route
• Obtain relevant patient history (SAMPLE).
• Questions about event should focus on
MOI.
Secondary Assessment
• Includes a head-to-toe assessment
− Check for injuries that may compromise ABCs.
• Obtain full set of vitals.
• Monitoring equipment can aid assessment
Secondary Assessment
• If chest injury is isolated with limited MOI,
focus on:
− Isolated injury
− Patient’s complaint
− Body region affected
Secondary Assessment
• If significant trauma, assess head-to-toe.
− Skin (ecchymosis, other trauma)
− Identify all wounds, control bleeding.
− Note location and extent of injury.
− Assess underlying systems.
Secondary Assessment
• If significant trauma affects multiple
systems:
− Perform full body scan using DCAP-BTLS.
− Inspect region for deformities.
− Palpate for tenderness.
− Check for lacerations and swelling.
Reassessment
• Obtain repeated assessments of:
− Vital signs
− Oxygenation
− Circulation
− Breath sounds
Reassessment
• If pneumothorax is suspected, patient
should be considered unstable.
− Reassess at least every 5 minutes.
• Maintain a high degree of suspicion during
on-scene treatment and transport.
Emergency Medical Care
• Management focuses on:
− Maintaining airway
− Ensuring oxygenation and ventilation
− Supporting circulatory status
− Expeditious transport
Emergency Medical Care
• Airway management same, except:
− Jaw-thrust maneuver instead of head tilt–chin
lift
• Avoid nasal airways if signs of facial injury
− Use ET intubation instead.
• Reconsider if possible partial tracheal tear.
Emergency Medical Care
• Ensure oxygenation and ventilation.
• Assess circulatory system’s ability to
provide oxygenation and ventilation.
− If compromised, provide supportive measures.
Emergency Medical Care
• Pharmacologic agents are limited.
− Medications for airway management
− Pain management, limited by:
• Local protocols
• Short transport times
• Clinical state of patient
Emergency Medical Care
• Nonpharmaceutical approaches:
− Splinting injury
− Cold pack application
− Careful handling
• Transport to appropriate facility.
Flail Chest
• May result from
blunt force
mechanisms
• Two or more
adjacent ribs
fractured in two or
more places
− Segment becomes
separated from
chest wall
Flail Chest
• Location and size affects degree that chest
wall and air movement are impaired.
− Flail sternum (most extreme)
• Underlying pressure causes paradoxical
movement of segment and rest of chest
wall.
Flail Chest
• May not be initially apparent
− Palpate for rib cage fractures and crepitus.
• Management may involve:
− Positive-pressure ventilation
− Positive end-expiratory pressure
Flail Chest
• Pulmonary
contusion can also
be caused by blunt
force trauma.
− Mechanisms:
• Implosion
• Inertial effects
• Spalding effects
Flail Chest
• Pneumothorax or hemothorax may occur if
bone fragments are driven into the body.
− Pain may prevent adequate tidal volume.
• Limits the ability to compensate for flail segment
Flail Chest
• Assessment and management
− Palpation may reveal:
• Crepitus
• Tenderness
• Dissection of air into tissue
− Auscultation may reveal:
• Decreased or absent breath sounds
Flail Chest
• Assessment and management (cont’d)
− Associated
findings include:
− Signs and
symptoms include:
• Tenderness
• Shallow breathing
• Hypoxia
• Hypercarbia
• Tachycardia
• Pain
Flail Chest
• Assessment and management (cont’d)
− Poses a threat to patient’s ability to breathe
• Intubation and positive-pressure ventilation may be
needed.
− Stabilization of flail segment is controversial.
Rib Fractures
• Most common thoracic injury
− Pain contributes to:
• Inadequate ventilation
• Self-splinting
• Atelectasis
• Pneumonia from inadequate respiration
Rib Fractures
• Palpate chest for subcutaneous
emphysema.
• Blunt trauma may result in fracture at:
• Point of impact
• Edge of object
• Posterior angle of rib
Rib Fractures
• May indicate associated injuries
− Ribs 4–9
• Aortic injury
• Tracheobronchial injury
• Pneumothorax
• Vascular injury
− Ribs 9–11
• Intra-abdominal injury
Rib Fractures
• Assessment and management
− Patients report:
• Pleuritic chest pain
• Mild dyspnea
− Exam shows:
• Chest wall
tenderness
• Soft-tissue injury
• Crepitus
• Subcutaneous
emphysema
Rib Fractures
• Assessment and management (cont’d)
− Management focuses on:
• ABCs and evaluating for other injuries
− Administer supplemental O2
− Gently splint chest wall.
− Consider intravenous analgesic.
Sternal Fractures
• One in 20 patients with blunt thoracic
trauma
− Associated with other injuries, including:
• Myocardial contusions
• Flail sternum
• Intra-abdominal injuries
Sternal Fractures
• Assessment and management
− Patient reports pain over anterior part of chest.
− Palpation may reveal:
• Tenderness
• Crepitus
• Possible flail segment
Sternal Fractures
• Assessment and management (cont’d)
− Perform an ECG rhythm analysis.
− Supportive treatment only
• ABCs
• Manage associated injuries.
• Analgesics
Clavicle Fractures
• One of the most common fractures
• Assessment and management
− Patient will:
• Report pain in the shoulder
• Usually hold arm across front of body
Clavicle Fractures
• Assessment and management (cont’d)
− Splint fracture with a sling and swathe.
• Apply gentle upward support to the olecranon
process of the ulna.
• Knot should be tied on the side of the neck.
Simple Pneumothorax
• Accumulation of
air/gas in pleural
cavity
− Air enters through
a hole in the chest
wall or lung.
• Causes lung
collapse on
affected side
Simple Pneumothorax
• The larger the hole, the faster the collapse.
• Delayed or improper treatment may lead to
a tension pneumothorax.
• Some low-velocity wounds may heal
themselves.
Simple Pneumothorax
• Assessment and management
− Small
pneumothorax
• Mild dyspnea and
pleuritic chest pain
• Diminished or
unequal breath
sounds
• Hyperresonance
− Larger
pneumothorax
• Increasing
dyspnea
• Signs of serious
respiratory
compromise and
hypoxia
Simple Pneumothorax
• Assessment and management (cont’d)
− Cover large open wounds immediately.
• Nonporous dressing secured on three sides
− Maintain ABCs, provide high-concentration O2.
• If tension develops, dressing may need to be
removed to release trapped air.
Open Pneumothorax
• Occurs when chest wall defect allows air
into thoracic space
− Results from penetrating chest trauma
− Negative pressure draws air into pleural space.
− As size increases, lung loses ability to expand.
Open Pneumothorax
• If hole is larger
than glottis
opening, air is
likely to enter chest
wall.
− Creates a “sucking
chest wound”
Open Pneumothorax
• If pulmonary vasculature on involved side
remains intact:
− Heart will continue to perfuse the collapsed
lung.
− Pneumothorax prevents ventilation.
Open Pneumothorax
• Assessment and management
− Physical assessment shows:
• Chest wall defect
• Impaled object
• Sucking chest wound
• Bubbling wound
• Subcutaneous emphysema
Open Pneumothorax
• Assessment and management (cont’d)
− Signs and symptoms may include:
• Tachycardia and tachypnea
• Restlessness
− As pneumothorax increases, breath sounds
decrease on affected side.
Open Pneumothorax
• Assessment and
management
(cont’d)
− Treat immediately.
• Convert wound to
a closed injury.
• Place on high-flow
supplemental O2
via nonrebreathing
mask.
Open Pneumothorax
• Assessment and management (cont’d)
− If progression to tension pneumothorax, remove
dressing or seal to allow a vent through
opening.
• If ineffective, treat for tension pneumothorax.
Tension Pneumothorax
• Life-threatening
condition from air
accumulation
within interpleural
space
− Results from open
or closed injury
Tension Pneumothorax
• As air accumulates, pressure builds against
surrounding tissue.
− Compresses the lung, which diminishes:
• Ability to oxygenate blood
• Ability to eliminate CO2
Tension Pneumothorax
• Pressure causes eventual lung collapse and
mediastinum to shift.
− May exceed pressure in major venous
structures
− If venous return decreases, the body will
increase heart rate.
Tension Pneumothorax
• Assessment and management
− Classic signs may include:
• Absence of breath sounds on affected side
• Pulsus paradoxus
• Tracheal deviation
Tension Pneumothorax
• Assessment and management (cont’d)
− Tachycardia is induced because blood cannot
return to heart.
• Accumulates in great vessels
• Pressure pushes blood into jugular vein.
Tension Pneumothorax
• Assessment and management (cont’d)
− During normal inspiration:
• Negative pressure decreases blood return.
• Preload and systolic blood pressure decrease.
− In tension pneumothorax, effect is magnified.
• Pulsus paradoxus
Tension Pneumothorax
• Assessment and management (cont’d)
− Jugular veins are distended when engorged 1 to
2 cm above the clavicle.
− May show trachea deviation from affected side
Tension Pneumothorax
• Assessment and management (cont’d)
− May have diminished breath sounds
− May have pleuritic chest pain and dyspnea
− Hypotension is a late finding.
Tension Pneumothorax
• Assessment and management (cont’d)
− Administer immediate high-flow supplemental
O₂.
− Inspect the chest.
− Cover open wounds with dressing.
− If elevated pressure is suggested:
• May need to perform a needle decompression
Hemothorax
• Occurs when blood
accumulates within
pleura
− Commonly caused
by lung
parenchyma
tearing
− Collection of blood
compresses and
displaces lung
Hemothorax
• Hemopneumothorax
− Blood and air in the
pleural space
• Massive hemothorax
− Accumulation of
more than 1,500 mL
of blood within pleura
Hemothorax
• Assessment and management
− Signs include:
• Ventilatory insufficiency
• Hypovolemic shock
Hemothorax
• Assessment and management (cont’d)
− Findings that differentiate from other injuries:
• Lack of tracheal deviation
• Possible hemoptysis
• Dullness on percussion
• Flat neck veins with hypovolemia
• Distended neck veins with increased pressure
Hemothorax
• Assessment and management (cont’d)
− Prehospital management:
• Supportive care
• Rapid transport
• High-flow supplemental O2
• Two large-bore peripheral IV
Pulmonary Contusion
• Alveolar and capillary damage results from
lung tissue compression against chest wall.
− Injury may lead to:
• Loss of fluid and blood into involved tissues
• White blood cell migration into area
• Local tissue edema
Pulmonary Contusion
• Local surfactant in alveoli is diluted.
− Causes atelectasis
• Delivery of O2 is reduced, causing hypoxia
• Attempt to shunt blood from injury further
worsens hypoxemia.
Pulmonary Contusion
• Assessment and management
− May not initially show presence or severity
− Hypoxia and CO2 retention may cause:
• Respiratory distress
• Tachycardia
• Agitation
Pulmonary Contusion
• Assessment and management (cont’d)
− Evidence of
overlying injury:
− Auscultation may
reveal:
• Contusions
• Tenderness
• Wheezes
• Rhonchi
• Crepitus
• Paradoxical
motion
• Rales
• Diminished lung
sounds
Pulmonary Contusion
• Assessment and management (cont’d)
− Treatment includes:
• Managing airway
• Using caution when administering IV fluids
• Administering small amounts of analgesics for pain
Cardiac Tamponade
• Excessive fluid in pericardial sac, causing
− Compression of the heart
− Decreased cardiac output
Cardiac Tamponade
• Hemodynamic effects determined by:
− Size of pericardium perforation
− Rate of hemorrhage
− Chamber of heart involved
Cardiac Tamponade
• Mortality varies.
• Can occur in both medical and trauma
− Medical—slow fluid collection
− Trauma—bleeding is rapid.
Cardiac Tamponade
• Continued bleeding increases pressure in
the pericardium.
− Atria and vena cavae compress.
− Preload delivery is drastically reduced.
− Heart increases rate to compensate.
Cardiac Tamponade
• Assessment and management
− 30% diagnosed will have Beck triad:
• Muffled heart tones
• Hypotension
• JVD
− Classic finding: electrical alternans in ECG strip
Cardiac Tamponade
• Assessment and management (cont’d)
− Findings typical of shock, including:
• Weak or absent peripheral pulses
• Cyanosis
• Tachycardia or tachypnea
Cardiac Tamponade
• Assessment and
management
(cont’d)
− Physical findings
similar to tension
pneumothorax
Cardiac Tamponade
• Assessment and management (cont’d)
− Treatment includes:
• Assess and manage ABCs.
• Ensure adequate O2 and establishing IV access.
• Provide a rapid fluid bolus.
• Rapidly transfer to trauma center.
Myocardial Contusion
• Sudden deceleration of chest wall may
cause collision of heart to sternum.
− Characterized by:
• Local tissue contusion and hemorrhage
• Edema
• Cellular damage within myocardium
Myocardial Contusion
• Damage to
myocardial tissues
may cause:
− Ectopic activity
− Reentry pathways
− Dysrhythmias
• Structural changes
may include:
− Ventricular septal
defect
− Myocardial rupture or
aneurysm
− Coronary artery
occlusion
Myocardial Contusion
• Assessment and management
− Signs and symptoms include:
• Sharp, retrosternal chest pain
• Soft-tissue or bony injury in area
• Crackles or rales on auscultation
− Often an abnormal ECG
Myocardial Contusion
• Assessment and management (cont’d)
− Treatment includes:
• Nonspecific supportive care
• Fluid resuscitation
• Consulting with medical control before administering
antidysrhythmic agents
Myocardial Rupture
• Acute perforation of:
− Ventricles
− Atria
− Intraventricular septum
−
−
−
−
Intra-atrial septum
Chordae
Papillary muscle
Valves
Myocardial Rupture
• Assessment and management
− Patients present with:
• Acute pulmonary edema
• Signs of cardiac tamponade
Commotio Cordis
• Cardiac arrest caused by a direct blow to
the thorax during the repolarization period
− Result of chest wall impact directly over heart
− Second most common cause of sudden cardiac
death in young male athletes
Commotio Cordis
• Assessment and management
− Signs and symptoms may include:
• Unresponsiveness
• Cyanotic
• Tonic-clonic seizures
Commotio Cordis
• Assessment and management
− Survival rates increased because of:
• Increased awareness
• CPR preparation
• Accessibility of AED at sporting events
Traumatic Aortic Disruption
• Dissection or rupture of the aorta
• Usually caused by crashes and falls
− Aorta is injured at fixed points by shearing
forces.
− Impact causes the aortic arch to swing forward.
− Tension and area rotation cause aorta to
rupture at point of attachment.
Traumatic Aortic Disruption
• If intima is
torn, blood
can dissect
along the
media.
• Severe
injuries may
allow blood to
leak from all
layers.
Traumatic Aortic Disruption
• Assessment and management
− Symptoms vary and may include:
• Tearing pain behind sternum or in the scapula
• Hypovolemic shock
• Dyspnea
• Altered mental state
Traumatic Aortic Disruption
• Assessment and management (cont’d)
− With hematoma, presentation may include:
• Dysphagia
• Stridor
• Hoarseness
• Difficulty swallowing
Traumatic Aortic Disruption
• Assessment and management (cont’d)
− Recognition often from suspicion based on MOI
• Assessment of extremity pulses is important
− Expect associated injuries, may include:
• Multiple rib fractures
• Pericardial tamponade
• Clavicle fracture
Traumatic Aortic Disruption
• Assessment and management (cont’d)
− Assess and manage ABCs.
− Gradual IV hydration to treat hypotension
− Do not use pressor agents.
− Expedite transport to trauma center.
Great Vessel Injury
• Great vessels protected by bony structures
and other tissues (except for aorta)
− Injuries more likely with penetrating trauma
− Injuries may result in occlusion or artery spasm.
Great Vessel Injury
• Presentation may include:
− Pain
− Pallor
− Paresthesias
− Pulselessness
− Paralysis
Great Vessel Injury
• Assessment and management
− If bleeding not prevented, presentation includes:
• Hypovolemic shock
• Hemothorax
• Cardiac tamponade
Great Vessel Injury
• Assessment and management (cont’d)
− Procedures for acute blood loss
• Establish IV for hydration during transport.
• Treat pericardial tamponade immediately.
• Do not use pneumatic antishock garment.
Diaphragmatic Injuries
• Occurs in a small percentage of trauma
• Most occur on left side
− Liver protects right side.
• Recovery is inhibited by pressure
differences between abdominal and
thoracic cavities.
Diaphragmatic Injuries
• Three phases:
− Acute—begins at injury; ends with recovery
from other injuries
− Latent—entrapment of abdominal contents
− Obstructive—abdominal contents herniate
through defect
Diaphragmatic Injuries
• Tension gastrothorax
− Herniation of abdominal contents into thoracic
cavity, causing pressure to:
• Compress lung on affected side.
• Compromise circulatory function.
Diaphragmatic Injuries
− Most likely to care
for in acute phase
© SIU Bio Med Comm./Custom Medical Stock Photo
• Assessment and
management
Diaphragmatic Injuries
• Assessment and management (cont’d)
− Acute phase:
• Hypotension
• Tachypnea
• Bowel sounds in
chest
• Chest pain
• Absent breath
sounds
− Obstructive phase:
• Nausea and
vomiting
• Abdominal pain
• Constipation
• Dyspnea
• Abdominal
distension
Diaphragmatic Injuries
• Assessment and management (cont’d)
− Management focus: maintaining oxygen and
providing rapid transport
• Elevate head of backboard.
• Positive-pressure ventilation
• NG tube placement (if allowed by protocol)
Esophageal Injuries
• Rapidly fatal injury in GI system
• Assessment and management
− Signs and symptoms include:
• Pleuritic chest pain
• Subcutaneous emphysema
• Associated tracheal injury
Esophageal Injuries
• Assessment and management (cont’d)
− No specific therapy in the prehospital setting
− Do not give anything orally.
Tracheobronchial Injuries
• Rare, typically caused by penetrating
injuries
− High mortality rate
− Allows for rapid movement of air into pleural
space, causing a pneumothorax
• May progress to tension pneumothorax
Tracheobronchial Injuries
• Assessment and management
− Presentation varies and may include:
• Hoarseness
• Dyspnea and tachycardia
• Respiratory distress
Tracheobronchial Injuries
• Assessment and management (cont’d)
− Focuses on ABCs
• Bag-bask ventilation instead of intubation
• Avoid high ventilatory pressure.
Traumatic Asphyxia
• Induced by traumatic injury that forcefully
compresses the thoracic cavity
− Causes pressure to major veins of the head,
neck, and kidneys
• Causes rupture of the capillary beds
Traumatic Asphyxia
• Assessment and
management
− Physical findings:
• Cyanosis of head,
upper extremities,
and torso
• Ocular
hemorrhage
• Swollen and
cyanotic facial
structures
© Chuck Stewart, MD.
Traumatic Asphyxia
• Assessment and management (cont’d)
− Provide high-flow supplemental O2.
− Take cervical spine precautions.
− Obtain IV access with two large-bore IV lines.
− Transport to nearest trauma center.
Summary
• Thorax contains ribs, thoracic vertebrae,
clavicle, scapula, sternum, heart, lungs,
diaphragm, great vessels, esophagus,
lymphatic channels, trachea, mainstem
bronchi, and nerves.
• Oxygenation, ventilation, and some aspects
of circulation take place in the thorax.
• Thoracic injuries can cause air or blood in
the lungs or prevent organs from moving
properly.
Summary
• A thoracic trauma assessment begins with
scene size-up and ABCs assessment.
• When assessing breathing, note any injury
to the thorax, which may indicate underlying
injuries.
• Consider ventilation and oxygenation
adequacy.
• Always consider spine stabilization.
Summary
• Managing chest injuries includes
maintaining airway, ensuring oxygenation
and ventilation, supporting circulation, and
transporting quickly.
• Chest wall injuries include flail chest, rib
fractures, sterna fractures, and clavicle
fractures.
• In flail chest, two or more ribs are broken in
two or more places, which can result in a
free-floating rib segment.
Summary
• Flail chest management includes airway
management and possible positivepressure ventilation.
• Rib fractures cause significant pain and
may prevent adequate ventilation.
• Rib fracture management should focus on
the ABCs and gentle splinting of the chest.
Summary
• Lung injuries include simple pneumothorax,
open pneumothorax, tension
pneumothorax, hemothorax, and pulmonary
contusion.
• In a pneumothorax, air leaks into the pleural
space from an opening in the chest or the
surface of the lung.
• Management of a pneumothorax starts with
the ABCs and high-concentration oxygen
administration.
Summary
• A tension pneumothorax results from air
collection in the pleural space, and is a lifethreatening condition.
• Patients with a tension pneumothorax
should be placed on high-flow supplemental
oxygen via a nonrebreathing mask. Cover
open wounds with a nonporous or occlusive
dressing.
Summary
• A hemothorax is the accumulation of blood
between the parietal and visceral pleura.
• If a patient with a hemothorax does not
require airway intervention, place the
patient on high-flow supplemental oxygen
via a nonrebreathing mask.
• A hemopneumothorax is the collection of
both blood and air in the pleural space.
Summary
• A pulmonary contusion occurs from
compression of the lung, resulting in alveolar
and capillary damage, edema, and hypoxia.
• If a patient has a pulmonary contusion or
cardiac tamponade, assess and manage the
ABCs and consider administering IV fluids.
• Myocardial injuries include cardiac tamponade,
myocardial contusion, myocardial rupture, and
commotio cordis.
Summary
• Cardiac tamponade occurs when excessive
fluid builds up in the pericardial sac around
the heart, which compresses the heart and
compromises stroke volume.
• Treating cardiac tamponade begins by
managing the ABCs, ensuring adequate
oxygen delivery, and establishing IV
access. Pericardiocentesis is the ultimate
treatment option.
Summary
• Myocardial contusion is blunt trauma to the
heart, and may cause hemorrhage, edema,
and cellular damage.
• Management for myocardial contusion is
supportive, but should also include cardiac
monitoring and establishing IV access.
• Myocardial rupture is perforation of one or
more elements of the anatomy of the heart,
occurring from blunt or penetrating trauma.
Summary
• Management for myocardial rupture should
include supportive care and rapid transport
to a trauma center for a thoracotomy.
• Commotio cordis occurs from a direct blow
to the chest during a critical portion of the
heart’s repolarization period.
• ALS treatment for commotio cordis must
follow standard ACLS guidelines for sudden
cardiac arrest.
Summary
• Vascular injuries include traumatic aortic
disruption and great vessel injury.
• Traumatic aortic disruption is the ripping of
the aorta.
• Management for traumatic aortic disruption
focuses on symptom control.
• Other injuries include diaphragmatic
injuries, esophageal injuries,
tracheobronchial injuries, and traumatic
asphyxia.
Credits
• Chapter opener: Courtesy of ED, Royal North Shore
Hospital/NSW Institute of Trauma & Injury
• Backgrounds: Blue–Jones & Bartlett Learning. Courtesy
of MIEMSS; Gold–Jones & Bartlett Learning. Courtesy of
MIEMSS; Green–Courtesy of Rhonda Beck; Red–© Margo
Harrison/ShutterStock, Inc.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by the
American Academy of Orthopaedic Surgeons.