Chapter 35
Chest Trauma
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35-1
Objectives
35-2
Anatomy of the Chest Cavity
35-3
Deadly and Potentially Deadly Chest Injuries
Deadly
• Tension pneumothorax
Potentially Deadly
• Pulmonary contusion
•
Open pneumothorax
• Myocardial contusion
•
Massive hemothorax
•
Cardiac tamponade
•
Flail chest
35-4
Categories of Chest Injuries
• Closed injuries
– No break occurs in the skin over the
chest wall
– Usually the result of blunt trauma
• Open chest injuries
– Break in the skin over the chest wall
– Injuries result from penetrating trauma
35-5
Closed Chest Injuries
35-6
Rib Fractures
• Common injury due to
blunt chest trauma
– May be associated
underlying lung or
heart injury
• Seat belts occasionally
cause injury
35-7
Rib Fractures
• Ribs 1-3
– Protected by shoulder
girdle
– Fractures associated with
significant trauma
• Ribs 4-9
– Most commonly fractured
35-8
Rib Fractures
Signs and Symptoms
• Localized pain at the • Chest wall deformity
fracture site
• Crepitus
• Self-splinting of the
• Swelling and/or
injury
bruising at fracture
• Pain on inspiration
site
• Shallow breathing
• Tenderness on
palpation
• Possible
subcutaneous
emphysema
35-9
Rib Fractures
Emergency Care
• Spinal stabilization if spinal injury suspected
• Establish and maintain an open airway
• Give oxygen
• Encourage patient to breathe deeply
• Do not apply tape or straps to the ribs or
chest wall
• Allow patient to self-splint
• Perform ongoing assessments
35-10
Flail Chest
• Occurs when two or
more adjacent ribs are
fractured in two or more
places or when the
sternum is detached
• “Flail segment”
35-11
Flail Chest
• Paradoxical movement
35-12
Flail Chest
• Life-threatening injury
• Respiratory failure may occur due to:
– Bruising of underlying lung and
hemorrhage of the alveoli
– Chest wall instability and pain
– Interference with normal "bellows" action
of the chest
35-13
Flail Chest
Signs and Symptoms
•
•
•
•
•
•
•
•
Crepitus
Breathing difficulty
Bruising of the chest wall
Increased heart rate (tachycardia)
Pain and self-splinting of the affected side
Increased respiratory rate (tachypnea)
Pain in the chest associated with breathing
Paradoxical chest wall movement
35-14
Flail Chest
Emergency Care
• Keep on scene time to a minimum
• Request Advanced Life Support (ALS)
personnel early
• Suspect associated spinal injuries
• Establish and maintain an open airway
• Give oxygen
• Treat for shock if indicated
• Transport
35-15
Simple Pneumothorax
35-16
Simple Pneumothorax
Signs and Symptoms
• Sudden onset of
sharp pain in the
chest associated
with breathing
• Shortness of breath
• Increased
respiratory rate
(tachypnea)
• Increased heart rate
(tachycardia)
• Difficulty breathing
• Subcutaneous
emphysema (may
• Decreased or absent
not be present)
breath sounds on
the affected side
35-17
Spontaneous Pneumothorax
• Does not involve trauma to the lung
• Two types
– Primary spontaneous pneumothorax
– Secondary spontaneous pneumothorax
35-18
Spontaneous Pneumothorax
• Typically occurs while at rest or during sleep
• Usually caused by the rupture of a bleb
– Small air- or fluid-filled sac in the lung
• Common signs and symptoms
– Sudden onset of chest pain on affected
side
– Shortness of breath
– Increased respiratory rate
– Cough
35-19
Pneumothorax
Emergency Care
• Spinal stabilization if suspected spinal injury
• Establish and maintain an open airway
• Give oxygen
• Transport
• Reassess often for signs of a tension
pneumothorax
35-20
Tension Pneumothorax
35-21
Tension Pneumothorax
Signs and Symptoms
•
•
•
•
•
Cool, clammy skin
Increased pulse rate
Cyanosis (late sign)
JVD
Decreased blood
pressure
• Severe respiratory
distress
• Agitation, restlessness,
anxiety
• Bulging of intercostal
muscles on the affected
side
• Decreased or absent
breath sounds on the
affected side
• Tracheal deviation
toward the unaffected
side (late sign)
• Possible subcutaneous
emphysema
35-22
Tension Pneumothorax
Emergency Care
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
If an open chest wound was bandaged with an
occlusive dressing, release the dressing
• Treat for shock if indicated
• Transport
• Reassess often
35-23
Hemothorax
35-24
Hemothorax
Signs and Symptoms
• Cool, clammy skin
• Weak, thready pulse
• Flat neck veins (caused
by hypovolemia)
• Restlessness, agitation,
anxiety
• Decreasing blood
pressure (hypotension)
• Coughing up blood
(hemoptysis) (may not
occur)
• Decreased or absent
breath sounds on the
affected side
• Rapid, shallow
breathing (tachypnea)
35-25
Hemothorax
Emergency Care
•
•
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
35-26
Cardiac Tamponade
35-27
Cardiac Tamponade
Signs and Symptoms
• Cool, clammy skin
• Normal breath sounds
• Narrowing pulse
pressure
• Trachea in the midline
position
• Increased heart rate
(tachycardia)
• Cyanosis of the head,
neck, and upper
extremities
• Muffled heart sounds
(often difficult to assess
in the field)
• Distended neck veins
(may not be present in
hypovolemia)
35-28
Cardiac Tamponade
Emergency Care
•
•
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
35-29
Traumatic Asphyxia
35-30
Traumatic Asphyxia
Signs and Symptoms
• JVD
• Swelling of the tongue and lips
• Eyes that appear bloodshot and bulging
• Deep red, purple, or blue discoloration of the head
and neck (“hooding”)
• Low blood pressure when compression is released
• Normal-looking skin below the level of the crush
injury (unless other injuries are present)
35-31
Traumatic Asphyxia
Emergency Care
•
•
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
35-32
Pulmonary Contusion
35-33
Pulmonary Contusion
Signs and Symptoms
• Signs of blunt chest
trauma
• Coughing up blood
(hemoptysis)
• Restlessness,
anxiety
• Chest pain
• Increased
respiratory rate
• Difficulty breathing
• Cyanosis
• Increased heart rate
• Cough
35-34
Pulmonary Contusion
Emergency Care
•
•
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
35-35
Myocardial Contusion
35-36
Myocardial Contusion
Signs and Symptoms
• Chest pain or discomfort
• Increased or slowed heart rate
• (Possibly) irregular heart rhythm
35-37
Myocardial Contusion
Emergency Care
•
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
35-38
Commotio Cordis
• Sudden cardiac death due to a blunt force
injury to the chest
– The blow to the chest causes ventricular
fibrillation
– The force of the blow typically ranges from
30-50 mph
35-39
Commotio Cordis
Causes
•
•
•
•
•
•
•
•
•
•
Baseball
Hockey
Softball
Lacrosse
Karate
Basketball
Cricket
Martial arts
Boxing
Motor vehicle crash
• Playful shadow boxing
• Parent to child
discipline
• Gang rituals
• Snowball
• Pet dog (collie) head
• Plastic (hollow) toy bat
• Hiccups remedy
• Fall on monkey bars
35-40
Commotio Cordis
• Patient typically found unresponsive, apneic,
and pulseless.
– Many patients are cyanotic.
– Seizures have been observed in some
individuals.
– Bruising of the chest wall present in about
one-third of patients.
• Survival is most dependent on early
resuscitation (within 1 to 3 minutes of the
event), including CPR and defibrillation.
35-41
Open Chest Injuries
35-42
Open Pneumothorax
35-43
Open Pneumothorax
Possible Causes
• Blast injuries
• Knife wounds
• Impaled objects
• Gunshot wounds
• MVCs
35-44
Open Pneumothorax
Signs and Symptoms
•
•
•
•
•
•
•
•
Shortness of breath
Increased heart rate
Pain at the site of injury
Increased respiratory rate
Subcutaneous emphysema
Sucking sound on inhalation
Open wound in the chest wall
Decreased breath sounds on the affected
side
35-45
Open Pneumothorax
Emergency Care
•
•
•
•
•
•
•
•
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Seal the open wound – tape on 3 sides
Give oxygen
Treat for shock if indicated
Transport
35-46
Questions?
24-47