Chest trauma

Definition
• Any form of physical injury to the chest including the ribs, heart, lungs
great vessels, trachea and esophagus.
Anatomy review
• thoracic cage include
• 12 thoracic vertebrae,
• 12 ribs (with their associated costal cartilages)
• Clavicle and sternum.
• The superior 7 ribs ("true ribs") are attached by cartilage to the
sternum.
• The inferior 5 ribs ("false ribs") articulate with the vertebrae, but do
not attach directly to the sternum
Boundaries

Posteriorly: thoracic vertebrae and the ribs

Inferiorly: diaphragm
Anteriorly and laterally: sternum & the ribs
Superiorly: the clavicle & soft tissues of the neck
Inferiorly: diaphragm
Muscle tissues:
• Trapezius
• Latissimus dorsi
• Rhomboids
• Pectoralis
• SCM
Physiologic functions
• Maintain oxygenation and ventilation
• Maintain circulation
Definition
• Any form of physical injury to the chest and tissues/organs
underneath
• Potentially life threatening due to disturbance of cardiorespiratory
physiology and hemorrhage, infection, damaged lung and thoracic
cage.
Pathophysiology
• Penetrating injury: a knife, a bullet, or a piece of metal
• blunt trauma: a blow to the chest may fracture the ribs, the sternum,
or whole areas of the chest wall
• Although skin and chest wall are not penetrated in a closed injury, broken ribs
may lacerate the intrathoracic organs.
Impairment in ventilatory efficiency

• Chest excursion compromise

• Pain
• Air in the plural space
• Asymmetrical movement
• Bleeding in pleural space
• Ineffective diaphragm contraction
Impairment in gas exchange
• Atelectasis
• Pulmonary contusion
• Respiratory tract disruption
Mechanism of injury
Blunt trauma
• MVC
• Explosion
• Fall
• Assault with blunt object
• Crush injury
• Although skin and chest wall are not penetrated in a closed injury, broken ribs
may lacerate the intrathoracic organs.
• Penetrating trauma
• Stab injury
• Bullet injury
Signs and symptoms

• Pain at the site of injury

• Localized pain aggravated or increased with breathing
• Bruising to the chest wall
• Crepitus with palpation of the chest
• Dyspnea
• Hemoptysis
• Failure of one or both sides of the chest to expand normally with inspiration
• Rapid, weak pulse
• Low blood pressure
• Cyanosis around the lips or fingernails
Patient Assessment
• Scene size-up
• Primary assessment
• History taking
• Secondary assessment
• Reassessment
Scene size-up
• Scene safety (traffic, smoke, electricity, hazmat, hostile person,
weapons, drug)
• BSI (gloves, goggles,mask and gown)
• Identify number of patients
• Request additional resources needed (extrication, traffic ctrl, utilities)
• Determine the MOI
Primary survey
• Aims to identify and treat immediately life threatening conditions.
• Massive hemothorax
• Tension pneumothorax
• Open pneumothotax
• Flail chest
• Pericardial tamponade
Primary survey
• Form a general impression of the patient’s condition
• AVPU
• If in cardiac arrest proceed with CAB
• Assess for:
• Obvious injuries
• Blood
• difficulty breathing
• Cyanosis
• irregular breathing, asymmetric chest rise and accessory muscle use
Primary survey
Airway and breathing

• Assess for patency while providing manual in-line stabilization of the c-spine
• Jaw-thrust maneuver
• Avoid nasal airways if there is signs of facial injury, perform intubation.
• If pt has a possible tracheal injury, endotracheal intubation should be
reconsidered.
• Expose the thoracic cavity.
• Is there JVD, tracheal deviation?
• Is breathing present and symmetrical?
• Check for paradoxical motion
• Inspect for STI (DCAP-BTLS)
Primary survey
• Address for life threats
• Apply occlusive dressing to all penetrating injuries.
• Support ventilations.
• oxygen with a nonrebreathing mask at 15 L/min
• PPV if breathing inadequate based on LOC & RR
• Ventilation is a more delicate issue in light of the potential
complications that can arise from underlying thoracic injuries; could
potentially hasten the expansion of a pneumothorax, convert a
pneumothorax into a tension pneumothorax, or increase the dissection
of air through a tracheobronchial injury.
• Reassess the effectiveness of ventilatory support.
• Signs of circulation to the skin
• SpO2.
• Signs of an impending tension pneumothorax
• Palpate, percussion, auscultation of the chest
• point tenderness
• Crepitus
• Subcutaneous emphysema or edema
• Hyperresonance/dullness
• Assessment for lung sounds
Primary survey
• Circulation
• Pulse rate and quality (hemodynamic stability, cardiac tamponade)
• Skin color and temperature
• Address life-threatening bleeding immediately, using direct pressure and a
bulky dressing.
• JVD suggests increased CVP possibly from tension PTX, tamponade
• Muffled heart tones indicates presence of either a tension pneumothorax or a
cardiac tamponade.
• Transport decision:
• Prioritize those with impaired ABCs
• When in doubt, transport rapidly
• Perform the remainder of the assessment en route to the ED
• Relevant patient history
• SAMPLE hx
• Insert table
Secondary assessment
• Complete head-to-toe assessment
• identify any physical injuries
• reassess injuries identified in the primary survey
• For an isolated injury, focus on:
• Patient’s complaint
• Body region affected
• Location and extent of injury
• Anterior and posterior aspects of the chest wall
• Changes in respirations
Secondary assessment
• For significant trauma
• Use DCAP-BTLS to determine the nature and extent of the thoracic injury.
• Quickly assess the entire patient from head to toe.
• Vitals
• Q 5min or less
• Continuous monitoring
Reassessment
• Repeat primary assessment
• Vitals
• Injuries
• Interventions
• Do not delay transport to complete non lifesaving treatments.
• Communication and documentation
• Communicate all relevant information to the staff at the receiving hospital.
• Describe all injuries and the treatment given.
Flail Chest
• Two or more adjacent ribs that are fractured in two or more places.
• may result from a variety of blunt force mechanisms such as falls,
MVC, and assaults
• Creates “free floating” segment of chest
• High mortality rate
• Location and the size of the segment can affect the degree to which
the flail segment impairs air movement.
• Paradoxical movement a late sign
• Proper assessment of this area includes palpating for fractures &
crepitus
• Auscultation will reveal decreased or even absent breath sounds
depending on the degree of underlying injury, splinting, and
pneumothorax.
• Pain, tenderness, splinting, shallow breathing, agitation (hypoxia) or
lethargy (hypercapnia), tachycardia, and cyanosis.
• Tape a bulky dressing or pad against that segment of the chest.
• Have the patient hold a pillow against the chest wall.
• Management involves the use of positive pressure ventilation as well
as PEEP when you are assisting ventilations for the patient.
• Bag-mask ventilation and supplemental oxygen.
• Continuous positive airway pressure up to endotracheal intubation
may be needed for patients experiencing a reduced Spo2.
• Analgesics
Open Pneumothorax
• Results from penetrating chest trauma.
• A “sucking chest wound” & subcutaneous emphysema.
• tachycardia, tachypnea, and restlessness (non specific, maybe pain)
• Decreased breath sounds & hyper-resonanace on affected side.
• Three way dressing
• High-flow supplemental oxygen via a nonrebreathing mask.
• If oxygenation or ventilation remains inadequate, endotracheal
intubation may be required.
Tension Pneumothorax
• Injury to the lung can cause a one-way valve to develop, allowing air
to move into the pleural space but not to exit from it.
• May result from an open or closed injury.
• Open thoracic injury, an injury to the lung parenchyma due to blunt
trauma (the most common cause of tension pneumothorax),
barotrauma due to PPV.
• The pressure increase causes the lung collapse on the affected and
mediastinal shift on contralateral sides.
• Right-to-left intrapulmonary shunting and hypoxia.
• A reduction in CO due to compression of the heart and vena cava.
• Absence of breath sounds on the affected side, unequal chest rise,
pulsus paradoxus, tachycardia and dysrhythmias, JVD, narrow pulse
pressure, and tracheal deviation.
• High-flow supplemental oxygen (12 to 15 L/min) via a NRB mask.
• Needle thoracentesis
Hemothorax
• Rib fractures and injuries to the lung parenchyma most common cause.
• Massive hemothorax if more than 1,500 mL of blood within the pleural
space.
• May reveal signs of both ventilatory insufficiency (hypoxia, agitation,
anxiety, tachypnea, dyspnea) and hypovolemic shock (tachycardia,
hypotension, pale and clammy skin).
• Supportive mx with rapid transport.
• High-flow supplemental oxygen via a NRM
• Two 18-gauge peripheral IV lines, with fluid resuscitation
Cardiac Tamponade
• Excessive fluid in the pericardial sac, causing compression of the heart
and decreased CO.
• Beck’s triad
• Electrical alternans
• Narrowing pulse pressure
• Weak or absent peripheral pulses, diaphoresis, dyspnea, cyanosis,
altered mental status, tachycardia, tachypnea, and agitation.
• Ensure adequate oxygen delivery, and rapid fluid bolus to maintain
cardiac output.
• Transported rapidly and pericardiocentesis