Thoracic Trauma
1
Chest Trauma
Second leading cause of trauma deaths
after head injury
About 20% of all trauma deaths
2
Chest Trauma
Initial exam directed toward:
Open pneumothorax
Flail chest
Tension pneumothorax
Massive hemothorax
Cardiac tamponade
3
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
4
Rib Fracture
Most commonly 5th to 9th ribs
Poor protection
5
Rib Fracture
Fractures of 1st, 2nd ribs require high force
Frequently have injury to aorta or bronchi
30% will die
6
Rib Fracture
Fractures of 8th to 12th ribs can damage
underlying abdominal solid organs:
Liver
Spleen
Kidneys
7
Rib Fracture
Signs and Symptoms
Localized pain, tenderness
Increases when patient:
Coughs
Moves
Breathes deeply
Chest wall instability
Deformity, discoloration
Associated pneumo or hemothorax
8
Rib Fracture
Management
High concentration O2
Splint using pillow, swathes
Encourage patient to breath deeply
9
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
10
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
11
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
12
Flail Chest
Consequences
Pain, leading to decreased ventilation
Increased work of breathing
Contusion of lung
13
Flail Chest
Management
Establish airway
Suspect spinal injuries
Assist ventilation with BVM and oxygen
Stabilize chest wall
14
Simple Pneumothorax
Air in pleural space
Partial or complete lung collapse
occurs
15
Simple Pneumothorax
Causes
Chest wall penetration
Fractured rib lacerating lung
Paper bag effect
May occur spontaneously following:
Exertion
Coughing
Air Travel
16
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
17
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
18
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”
19
Open Pneumothorax
Management
Close hole with occlusive dressing
High concentration O2
Assist ventilations
Consider transport on injured side
Monitor for tension pneumothorax
20
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
21
Tension Pneumothorax
Trapped air pushes heart, lungs away
from injured side
Vena cavae become kinked
Blood cannot return to heart
Cardiac output falls
22
Tension Pneumothorax
Signs and Symptoms
Extreme dyspnea
Restlessness, anxiety, agitation
Decreased breath sounds
Hyperresonance to percussion
Cyanosis
Subcutaneous emphysema
23
Tension Pneumothorax
Signs and Symptoms
Rapid, weak pulse
Decreased BP
Tracheal shift away from injured side
Jugular vein distension
Early dyspnea/hypoxia - Late shock
24
Tension Pneumothorax
Management
Secure airway
High concentration O2 with NRB
If available, request ALS intercept for pleural
decompression
25
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
26
Hemothorax
Signs and Symptoms
Rapid, weak pulse
Cool, clammy skin
Restlessness, anxiety
Thirst
Chills
Hypotension
Collapsed neck veins
27
Hemothorax
Signs and Symptoms
Decreased breath sounds
Dullness to percussion
Dyspnea
Ventilatory failure
Shock precedes ventilatory failure
28
Hemothorax
Management
Secure airway
Assist breathing with high concentration O2
Rapid transport
29
Traumatic Asphyxia
Blunt force to chest causes
Increased intrathoracic pressure
Backward flow of blood out of heart into
vessels of upper chest, neck, head
30
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
31
Traumatic Asphyxia
Name given because patients
looked like they had been
strangled or hanged
32
Traumatic Asphyxia
Management
Airway with C-spine control
Assist ventilations with high concentration O2
Spinal stabilization
Rapid transport
33
Cardiovascular Trauma
Any patient with significant
blunt or penetrating trauma to
chest has heart/great vessel
injury until proven otherwise
34
Myocardial Contusion
Bruise of heart muscle
Most common blunt cardiac injury
Usually due to steering wheel impact
35
Myocardial Contusion
Behaves like acute MI
May produce arrhythmias
May cause cardiogenic shock, hypotension
36
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
37
Myocardial Contusion
Management
High concentration O2
Transport
Consider ALS intercept
38
Cardiac Tamponade
Rapid accumulation of blood in space
between heart, pericardium
Heart compressed
Blood entering heart decreases
Cardiac output falls
39
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
40
Cardiac Tamponade
Signs and Symptoms
Narrowing pulse pressure
Pulsus paradoxicus
Radial pulse becomes weak or disappears when
patient inhales
41
Cardiac Tamponade
Management
Secure airway
High concentration O2
Rapid transport
Definitive treatment is pericardiocentesis
followed by surgery
42
Traumatic Aortic Aneurysm
Caused by sudden decelerations, massive
blunt force:
Vehicle collisions
Falls from heights
Crushing chest trauma
Blunt chest trauma
Animal kicks
43
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
44
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
45
Traumatic Aortic Aneurysm
Management
High concentration oxygen
Assist ventilation
Suspect spinal injury
Rapid transport
46
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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