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Chest Trauma

Chest Trauma

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Chest Trauma

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  1. Chest Trauma Chapter 34

  2. Objectives • Review the Anatomy of the Chest • Discuss General Categories of Chest Injuries • Discuss Specific Chest Injuries • Assessment-based Approach: Chest Trauma

  3. Anatomy of the Chest Thoracic cavity and pleural lining • Visceral pleura • Parietal pleura • Ribs • Diaphragm • Mediastinum • Trachea • Venae cavea • Aorta • Esophagus • Heart

  4. Open Chest Injuries • Causes – Gunshot, Knife, Any hard, sharp object • Effects; • Bullet wound – tiny entrance, extensive damage from ricochet, Exit wound, if bullet doesn’t lodge itself • Injuries to the heart • Injuries to major vessels • Injuries to respiratory system – Lungs unable to inflate, Pneumothorax, Sucking chest wound

  5. Closed Chest Injuries Blunt trauma with no open wound • Injury to lungs, heart, great vessels, respiratory tract, diaphragm, esophagus • Flail segment

  6. Flail Segment • Two or more adjacent ribs broken in two or more places • Produces a freely moving section of chest wall • Display paradoxical movement during breathing

  7. Paradoxical Breathing • Movement in the opposite direction from the rest of the chest wall • Created by pressure of inhalation and exhalation • Underlying contusion to the lungs is more serious than the broken ribs because it reduces patient’s air intake and leads to hypoxia • To stabilize, splint and treat with PPV

  8. Pulmonary Contusion • Patient suffers from bleeding within the lung tissue • Bleeding occurs in and around the alveoli and into the interstitial space between the alveoli and capillaries • Leads to severe hypoxia and can lead to death • Often seen with flail segment injury • Other signs/symptoms include shortness of breath, cyanosis, and sign of blunt trauma to the chest • Oxygenate by NRB at 15 lpm or PPV with supplemental oxygen

  9. Pneumothorax • Air accumulates in the pleural cavity, causing lung collapse on the injured side of the chest • Usually due to either blunt or penetrating trauma • Spontaneous pneumothorax • Occurs with no trauma or other external cause • Usually the result of bleb • Bleb ruptures and allows air into thoracic cavity • Common among smokers and emphysema patients • Signs/Symptoms • Dyspnea, Respiratory distress, Sharp chest pain, Absent breath sounds on one side

  10. Open Pneumothorax • Open – Sucking chest wound • Result of a blow from a penetrating object • Air may be heard escaping or entering through the wound • Has same signs/symptoms as a closed one, plus the presence of an open chest wound • Treat by immediately occluding, first with your gloved hand, then with an occlusive dressing

  11. Tension Pneumothorax • Immediately life-threatening condition • Continues to trap air and collapses the injured lung • Mediastinum begins to shift to uninjured side • Uninjured lung, heart and large veins are compressed • Results in poor cardiac output, ineffective ventilation, inadequate oxygenation, and severe hypoxia • Signs/symptoms include rapid deterioration, severe respiratory distress, shock and absent breath sounds on injured side • If symptoms develop, after treating for an open pneumothorax, lift the occlusive dressing to allow air to escape and transport immediately

  12. Hemothorax • Thoracic cavity is filled with blood • Lung collapses as the blood continues to collect • Blunt or penetrating trauma may be the cause • Injury may be open or closed • Severe blood loss often results in severe shock, with signs of respiratory distress developing later • Patient will often produce pink or red frothy sputum when coughing • Treatment is same for pneumothorax and shock

  13. Traumatic Asphyxia • Severe and sudden compression of the thorax causes a rapid increase in pressure in the chest • Sternum and ribs severely compress the heart and lungs • Causes a backflow of blood from the right ventricle into the head, shoulder and chest • Signs/Symptoms: Bluish/purple discoloration of face, head, neck and shoulders, JVD, bloodshot eyes protruding from eye sockets, cyanotic and swollen tongue and lips, bleeding of the conjunctivae

  14. Cardiac Contusion • Occurs when heart is violently compressed between the sternum and spinal column • Actual bruise may occur to the heart wall • Heart wall may be ruptured • Electrical conduction system of the heart may be disturbed • Right ventricle is the most likely injured • Signs/Symptoms: Chest pain/discomfort, evidence of blunt trauma, tachycardia, irregular pulse • Transport promptly

  15. Pericardial Tamponade • Blunt/penetrating trauma may cause bleeding into the pericardial sac • Since sac cannot expand much, the heart is compressed • Cardiac output drops significantly, and blood backs up into veins • Life-threatening • Signs/Symptoms: JVD, hypoperfusion, tachycardia (can be extreme), decreased BP, narrow pulse pressure (< 30mmHg), weak pulses (radial will diminish or disappear)

  16. Rib Injury • Not life-threatening, can cause life-threatening damage to other organs • Ribs most commonly fractured are the 3rd – 8th; most common site is lateral aspect of the chest • Fracture may lacerate the intercostal artery or vein and cause internal bleeding • Less common in children because their cartilage is more resilient than an adult’s

  17. Signs/Symptoms • Severe pain with movement and breathing • Crepitation • Tenderness upon palpitation • Deformity of the chest wall • Inability to breathe deeply • Coughing • Tachypnea

  18. Treatment • Place arm over the injury site and apply a sling and swathe to hold in place • Give patient a pillow to hold over the injury to splint manually • Do not completely wrap the chest or apply swathe snugly

  19. Assessment-based Approach Scene Size-up • Do not enter scene of a shooting or stabbing until police tell you it is safe • Take BSI • Wear gloves and eye protection • Ask bystanders what happened • Scan scene for details that will show MOI • Sports accident? Fighting? Shooting? MVC? • Crushed between two objects? • Is patient guarding? • Explosion?

  20. Primary Assessment • Form general impression • Cyanotic? Respiratory distress? Breathing shallow or rapid? Guarding? Extreme pain? • Expose/examine chest • Open chest wound, occlude with gloved hand • Paradoxical movement • Mental status? • Airway obstruction? Blood? • Jaw-thrust • Listen to speech pattern • Oxygen • PPV if breathing inadequate • High priority for transport • Log roll patient to assess posterior for a exit/entrance wound if shooting is suspected

  21. Secondary Assessment • Inspect/palpate for other injuries • Breathing status • Assess neck for subcutaneous emphysema, JVD, tracheal deviation • Spine injury suspected, C-collar • Expose chest, cut clothes off • Look for flail chest signs • Palpate the chest, check for equal movement on both sides, paradoxical movement, swelling and deformities

  22. Secondary Assessment • Determine breath sounds are clear and equal or decreased or absent on one or both sides • Inspect abdomen for excessive muscle movement during breathing • Assess baseline vital signs • Obtain history from responsive patient; bystanders if unresponsive

  23. Signs/Symptoms • Cyanosis: fingernails, fingertips, lips, face • Dyspnea or Tachypnea • Contusions, lacerations, punctures, swelling, or other obvious signs of trauma • Hemoptysis (coughing up blood/bloody sputum • Signs of shock • Tracheal deviation • Paradoxical movement • Open wound that may/may not produce sucking sound • Subcutaneous emphysema • JVD • Absent or decreased breathing sounds upon auscultation • Pain at injury site • Failure of chest to expand normally during inhalation • Peripheral pulses that become extremely weak or absent during inhalation • Drop of 10 mmHg or more in systolic BP during inhalation

  24. Emergency Care – Open Chest Wound • Seal with gloved hand • Occlusive dressing • Constantly assess respiratory status • Signs/Symptoms of complications: difficulty breathing, tachypnea, decreased/absent breath sounds, cyanosis, tachycardia, decreasing BP or narrowing pulse pressure, JVD, Unequal movement in chest wall, extreme anxiety and apprehension, increased resistance to PPV • If you observe complications, burp the occlusive dressing

  25. Emergency Care – Open Chest Wound

  26. Emergency Care – Flail Segment • Place hand over flail segment to splint it in a inward position • Patient breathing inadequately, initiate PPV • Place bulky dressings, a pillow, or a towel over the unstable segment, or secure the patient’s arm to body, to stabilize the injury • Reassessment: Evaluate effectiveness of treatment, assess for further deterioration • If there is deterioration, (increasing breathing difficulties, worsening cyanosis) repeat secondary assessment, look for injuries you may have missed • Reassess vital signs

  27. Emergency Care – Flail Segment

  28. Questions ????