Thoracic Trauma
Temple College EMS Professions
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Chest Trauma
Second leading cause of trauma deaths after head injury About 20% of all trauma deaths
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Chest Trauma
Initial exam directed toward:
Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade
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Rib Fracture
Most common chest injury More common in adults than children Especially common in elderly Ribs form rings
Consider possibility of break in two places
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Rib Fracture
Most commonly 5th to 9th ribs Poor protection
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Rib Fracture
Fractures of 1st, 2nd ribs require high force Frequently have injury to aorta or bronchi 30% will die
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Rib Fracture
Fractures of 8th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen Kidneys
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Rib Fracture
Signs and Symptoms
Localized pain, tenderness Increases when patient: Coughs Moves Breathes deeply Chest wall instability Deformity, discoloration Associated pneumo or hemothorax
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Rib Fracture
Management
High concentration O2 Splint using pillow, swathes Encourage patient to breath deeply
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Rib Fracture
Management
Monitor elderly and COPD patients carefully Broken ribs can cause decompensation Patients will fail to breath deeply and cough, resulting in poor clearance of secretions
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Flail Chest
Two or more adjacent ribs broken in two or more places Produces free-floating chest wall segment Usually secondary to blunt trauma More common in older patients
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Flail Chest
Signs and Symptoms
Paradoxical movement May NOT be present initially due to intercostal muscle spasms Be suspicious in any patient with chest wall: • Tenderness • Crepitus
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Flail Chest
Consequences
Pain, leading to decreased ventilation Increased work of breathing Contusion of lung
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Flail Chest
Management
Establish airway Suspect spinal injuries Assist ventilation with BVM and oxygen Stabilize chest wall
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Simple Pneumothorax
Air in pleural space Partial or complete lung collapse occurs
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Simple Pneumothorax
Causes
Chest wall penetration Fractured rib lacerating lung Paper bag effect May occur spontaneously following: Exertion Coughing Air Travel
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Simple Pneumothorax
Signs and Symptoms
Pain on inhalation Difficulty breathing Tachypnea Decreased or absent breath sounds
Severity of symptoms depends on size of pneumothorax, speed of lung collapse, and patient’s health status
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Simple Pneumothorax
Management
Establish airway Suspect spinal injury based on mechanism High concentration O2 with NRB Assist decreased or rapid respirations with BVM Monitor for tension pneumothorax
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Open Pneumothorax
Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance air will enter there than through trachea
“Sucking Chest Wound”
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Open Pneumothorax
Management
Close hole with occlusive dressing High concentration O2 Assist ventilations Consider transport on injured side Monitor for tension pneumothorax
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Tension Pneumothorax
One-way valve forms in lung or chest wall Air enters pleural space; cannot leave Air is trapped in pleural space Pressure rises Pressure collapses lung
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Tension Pneumothorax
Trapped air pushes heart, lungs away from injured side Vena cavae become kinked Blood cannot return to heart Cardiac output falls
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Tension Pneumothorax
Signs and Symptoms
Extreme dyspnea Restlessness, anxiety, agitation Decreased breath sounds Hyperresonance to percussion Cyanosis Subcutaneous emphysema
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Tension Pneumothorax
Signs and Symptoms
Rapid, weak pulse Decreased BP Tracheal shift away from injured side Jugular vein distension
Early dyspnea/hypoxia - Late shock
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Tension Pneumothorax
Management
Secure airway High concentration O2 with NRB If available, request ALS intercept for pleural decompression
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Hemothorax
Blood in pleura space Most common result of major chest wall trauma Present in 70 to 80% of penetrating, major non-penetrating chest trauma
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Hemothorax
Signs and Symptoms
Rapid, weak pulse Cool, clammy skin Restlessness, anxiety Thirst Chills Hypotension Collapsed neck veins
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Hemothorax
Signs and Symptoms
Decreased breath sounds Dullness to percussion Dyspnea Ventilatory failure
Shock precedes ventilatory failure
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Hemothorax
Management
Secure airway Assist breathing with high concentration O2 Rapid transport
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Traumatic Asphyxia
Blunt force to chest causes
Increased intrathoracic pressure Backward flow of blood out of heart into vessels of upper chest, neck, head
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Traumatic Asphyxia
Signs and Symptoms
Possible sternal fracture or central flail chest Shock Purplish-red discoloration of: Head Neck Shoulders Blood shot, protruding eyes Swollen, cyanotic lips
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Traumatic Asphyxia
Name given because patients looked like they had been strangled or hanged
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Traumatic Asphyxia
Management
Airway with C-spine control Assist ventilations with high concentration O2 Spinal stabilization Rapid transport
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Cardiovascular Trauma
Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise
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Myocardial Contusion
Bruise of heart muscle Most common blunt cardiac injury Usually due to steering wheel impact
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Myocardial Contusion
Behaves like acute MI
May produce arrhythmias May cause cardiogenic shock, hypotension
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Myocardial Contusion
Signs and Symptoms
Cardiac arrhythmias after blunt chest trauma Angina-like pain unresponsive to nitroglycerin Chest pain independent of respiratory movement
Suspect in all blunt chest trauma
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Myocardial Contusion
Management
High concentration O2 Transport Consider ALS intercept
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Cardiac Tamponade
Rapid accumulation of blood in space between heart, pericardium Heart compressed Blood entering heart decreases Cardiac output falls
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Cardiac Tamponade
Signs and Symptoms
Hypotension unresponsive to treatment Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP) Small quiet heart (decreased heart sounds)
Beck’s Triad
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Cardiac Tamponade
Signs and Symptoms
Narrowing pulse pressure Pulsus paradoxicus
Radial pulse becomes weak or disappears when patient inhales
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Cardiac Tamponade
Management
Secure airway High concentration O2 Rapid transport Definitive treatment is pericardiocentesis followed by surgery
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Traumatic Aortic Aneurysm
Caused by sudden decelerations, massive blunt force:
Vehicle collisions Falls from heights Crushing chest trauma Blunt chest trauma Animal kicks
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Traumatic Aortic Aneurysm
Rupture usually occurs just beyond left subclavian artery Attachment of aorta to pulmonary artery at this point produces shearing force on aortic arch
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Traumatic Aortic Aneurysm
Signs and Symptoms
Increased BP in arms in absence of head injury Decreased femoral pulses with full arm pulses Respiratory distress Ache in chest, shoulders, lower back, abdomen. (Only 25% of patients)
Detection requires high index of suspicion
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Traumatic Aortic Aneurysm
Management
High concentration oxygen Assist ventilation Suspect spinal injury Rapid transport
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Associated Abdominal Trauma
Diaphragm forms dome that extends up into rib cage Trauma to chest below 4th rib = Abdominal injury until proven otherwise
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