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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