27: Chest Injuries
Cognitive Objectives
(1 of 2)
1. Differentiate between a pneumothorax, a
hemothorax, a tension pneumothorax, and a
sucking chest wound.
2. Describe the emergency medical care of a patient
with a flail chest.
3. Describe the emergency medical care of a patient
with a sucking chest wound.
Cognitive Objectives
(2 of 2)
4. Describe the consequences of blunt injury to
the heart.
5. List the signs of pericardial tamponade.
6. Discuss complications that can accompany
chest injuries.
• There are no affective objectives for this
chapter.
Psychomotor Objectives
7. Demonstrate the steps in the emergency medical
care of a sucking chest wound.
Organs of the Chest
Structures of the Chest
Mechanics of Ventilation (1 of 2)
• Inspiration
– Intercostal muscles contract
and diaphragm flattens.
• Expiration
– Intercostal muscles and
diaphragm relax; tissues
move back to normal
position.
Mechanics of Ventilation (2 of 2)
• Phrenic nerves exit the spinal cord at C3, C4, and
C5.
• Spinal cord injury below C5
– Loss of ability to move intercostal muscles
– Diaphragm can still contract; patient can still
breathe.
• Spinal cord injury at C3 or higher
– No ability to breathe
Spinal Cord Injury Below C5
Injuries to the Chest
• Closed chest injuries
– Caused by blunt
trauma
• Open chest injuries
– Caused by
penetrating trauma
Signs and Symptoms
• Pain at site of injury
• Dyspnea
• Pain aggravated by
increased breathing
• Hemoptysis
• Bruising to chest wall
• Failure of chest to
expand normally
• Crepitus with palpation
of chest
• Rapid, weak pulse and
low blood pressure
• Penetrating injury to
chest
• Cyanosis around lips
or fingernails
• You and your EMT-B partner are dispatched to a
construction site where a worker fell on a piece of
metal and has an open chest wound.
• You arrive and see no scene hazard or need for
other resources.
You are the Provider
• What is the mechanism of injury?
• What precautions should you take?
You are the provider continued
Scene Size-up
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•
•
•
•
Observe for hazards.
Do not disturb potential evidence.
Put several pairs of gloves in your pocket.
Consider spinal immobilization.
Ensure that police are on scene if incident involved
violence.
• Your partner provides spinal immobilization.
• The patient is responsive with an open airway. He
says, “I can’t catch my breath. It hurts.”
• You find a penetrating injury on the right anterior
portion of the chest.
• You see a small amount of bleeding. The blood
bubbles as your patient breathes.
You are the provider
continued (1 of 2)
•
•
•
•
What are the steps of the initial assessment?
What life-saving treatments would you provide?
What treatment do you provide?
Describe the rest of your assessment process after
the initial assessment.
You are the provider
continued (2 of 2)
Initial
Assessment
• General impression
– Quickly evaluate ABCs.
– Difficulty speaking may indicate several
problems.
– Patients with significant chest injuries will look
sick.
• Airway and breathing
– Ensure that patient has a clear, patent airway.
– Protect the spine.
– Inspect for DCAP-BTLS.
Inspection
• Decreased breath sounds usually indicate
significant damage to a lung.
• If both sides of chest do not have equal rise and fall,
chest muscles have lost ability to work properly.
• If one section of chest moves in opposite direction
from the rest of the chest (paradoxical motion), this
is a life threat.
Immediate Interventions
• Apply an occlusive dressing to any penetrating chest
injury.
• Stabilize paradoxical motion with a large bulky
dressing and 2'' tape.
• Apply oxygen via nonrebreathing mask at 15 L/min.
• Provide positive pressure ventilations if breathing is
inadequate.
Circulation
• Assess patient’s pulse.
• Consider aggressive treatment for shock.
• Internal bleeding can quickly cause death.
Transport Decision
• Rapidly transport if patient has problems with ABCs.
• Pay attention to subtle clues.
– Skin signs
– Level of consciousness
– Sense of impending doom
• You ensure that his airway is open.
• Breathing is labored; you start oxygen via nonrebreathing
mask at 15 L/min.
• You quickly assess for DCAP-BTLS; seal sucking chest
wound with an occlusive dressing.
• You check distal pulse. Skin is clammy. Bleeding is noted and
controlled.
• High-priority transport
You are the provider
continued
Focused History and
Physical Exam
• Focused physical exam
– For a patient with isolated chest injury and
limited MOI
• Rapid physical exam
– For a patient with a significant MOI
– Use DCAP-BTLS.
– Do not focus just on the chest wound.
• Obtain baseline vital signs.
• Obtain SAMPLE history quickly.
Interventions
•
•
•
•
•
Provide complete spinal immobilization.
Maintain open airway; be prepared to suction.
Provide assisted ventilations if needed.
Control bleeding.
Place occlusive dressing over penetrating chest
wound.
• Stabilize flail segment with a bulky dressing.
• Treat aggressively for shock.
• Do not delay transport.
Detailed Physical Exam
• Perform en route to the hospital if time allows.
Ongoing Assessment
• Assess effectiveness of interventions.
• Reassess vital signs.
• Communication and documentation
– Communicate with hospital early if patient has
significant MOI.
– Describe injuries and treatment given.
• Patient has a significant MOI; do a rapid physical
exam.
• Obtain baseline vital signs and SAMPLE history.
• Take c-spine precautions and transport continuing
oxygen therapy.
• Perform detailed physical exam and ongoing
assessment en route.
You are the provider continued
Complications of Chest Injuries
A pneumothorax occurs when air leaks into the space
between the pleural surfaces.
Pneumothorax
• Air accumulates in the
pleural space.
• Air enters through a
hole in the chest wall.
– The lung may
collapse in a few
seconds or a few
minutes.
• An open or
penetrating wound to
the chest is called a
sucking chest wound.
Care for Open Pneumothorax
• Clear and manage
the airway.
• Provide oxygen.
• Seal an open wound with
an occlusive dressing.
• Depending on local
protocol, tape down all
four sides or create a
flutter valve.
Spontaneous Pneumothorax
• Some people are born with or develop weak areas
on the surface of the lungs.
• Occasionally, the area will rupture spontaneously,
allowing air into the pleural space.
• Patient experiences sudden chest pain and trouble
breathing.
• Consider a spontaneous pneumothorax for a
patient with chest pain without cause.
Tension Pneumothorax (1 of 2)
• Can occur from sealing all four sides
of the dressing on a sucking chest
wound
• Can also occur from a fractured rib
puncturing the lung or bronchus
• Can also result from a spontaneous
pneumothorax
Tension Pneumothorax (2 of 2)
Signs and Symptoms of
Tension Pneumothorax
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•
•
•
•
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Respiratory distress
Distended neck veins
Tracheal deviation
Tachycardia
Low blood pressure
Cyanosis
Decreased lung sounds
Care for Tension Pneumothorax
• If a tension pneumothorax develops from
sealing an open chest wound, partly
remove the dressing to let the air escape.
• If there is no open wound, follow local
protocol.
Hemothorax (1 of 2)
• Collection of blood in the
pleural space
• Suspect if the following are
seen:
– Signs and symptoms of
shock
– Decreased breath sounds on
affected side
• If both air and blood are present
in the pleural space, it is a
hemopneumothorax.
Hemothorax (2 of 2)
Rib Fractures
• They are very common in the older people.
• A fractured rib may lacerate the surface of the lung.
• Patients will avoid taking deep breaths and
breathing will be rapid and shallow.
• The patient often holds the affected side to minimize
discomfort.
• Administer oxygen.
Flail Chest (1 of 2)
• Segment of chest wall detached from rest of
thoracic cage
• Occurs when:
– Three or more ribs are fractured in two or
more places.
– Sternum is fractured along with several ribs.
• Creates paradoxical motion
Flail Chest (2 of 2)
Care for Flail Chest
• Maintain airway.
• Provide respiratory
support with BVM if
needed.
• Perform ongoing
assessments for
pneumothorax and
other respiratory
complications.
• Immobilize flail
segment.
Pulmonary Contusions
• Bruising of the lung
• Develops over hours
• Alveoli fill with blood, and edema
accumulates in the lung, causing hypoxia.
• Provide oxygen and ventilatory support.
Traumatic Asphyxia
• Sudden, severe compression of chest
• Produces rapid increase in pressure within chest
• Results in neck vein distention, cyanosis, and
bleeding into the eyes
• Provide supplemental oxygen and monitor vital
signs.
• Transport immediately.
Blunt Myocardial Injury
• Bruising of heart muscle
• Pulse is often irregular.
• There is no prehospital treatment for
this condition.
• Check patient’s pulse and note
irregularities.
• Provide supplemental oxygen and
transport immediately.
Pericardial Tamponade (1 of 2)
• Blood or other fluids collect in the pericardium.
Pericardial Tamponade (2 of 2)
• Signs and symptoms:
– Very soft and faint heart tones
– Weak pulse
– Low blood pressure
– Decrease in difference between systolic and
diastolic blood pressure
– Jugular vein distention (JVD)
• Provide oxygen and transport quickly.
Laceration of the Great Vessels
• The superior vena cava, inferior vena cava,
pulmonary arteries and veins, and aorta are
contained in the chest.
• Injury to these vessels can cause fatal hemorrhage.
• Treatment includes:
– CPR
– Ventilatory support
– Supplemental oxygen
– Transport immediately.
Review
1. A 40-year-old man, who was the unrestrained
driver of a car that hit a tree at a high rate of
speed, struck the steering wheel with his chest.
He has a large bruise over the sternum and an
irregular pulse rate of 120 beats/min. You should
be MOST concerned that he:
A. has injured his myocardium.
B. has a collapsed lung and severe hypoxia.
C. has extensive bleeding into the pericardial sac.
D. is at extremely high risk for ventricular fibrillation.
Review
Answer: A
Rationale: A myocardial contusion, or bruising of the
heart muscle, is usually the result of blunt trauma—
specifically to the center of the chest. In some
cases, the injury may be so severe that it renders
the heart unable to maintain adequate cardiac
output; as a result, blood pressure falls. The pulse
rate is often irregular; however, lethal cardiac
dysrhythmias such as ventricular tachycardia and
ventricular fibrillation are uncommon.
Review
1. A 40-year-old man, who was the unrestrained driver of a car that
hit a tree at a high rate of speed, struck the steering wheel with
his chest. He has a large bruise over the sternum and an irregular
pulse rate of 120 beats/min. You should be MOST concerned that
he:
A. has injured his myocardium.
Rationale: Correct answer
B. has a collapsed lung and severe hypoxia.
Rationale: This will produce an absence or decrease of breath sounds
and unilateral chest wall expansion.
C. has extensive bleeding into the pericardial sac.
Rationale: This will produce muffled heart sounds and decreased
cardiac output.
D. is at extremely high risk for ventricular fibrillation.
Rationale: Lethal dysrhythmias are uncommon.
Review
2. Paradoxical chest movement is typically seen in
patients with:
A. a flail chest.
B. a pneumothorax.
C. isolated rib fractures.
D. a ruptured diaphragm.
Review
Answer: A
Rationale: Paradoxical chest movement occurs when
an area of the chest wall bulges out during
exhalation and collapses during inhalation. This
type of abnormal chest movement is seen in
patients with a flail chest—a condition in which
several adjacent ribs are fractured in more than
one place, resulting in a free-floating segment of
fractured ribs.
Review
2. Paradoxical chest movement is typically seen in patients with:
A. a flail chest.
Rationale: Correct answer
B. a pneumothorax.
Rationale: This will produce unilateral chest wall movement.
C. isolated rib fractures.
Rationale: This will produce pain, but not irregular chest wall
movement.
D. a ruptured diaphragm.
Rationale: This typically occurs on the left side. You may hear
bowel sounds over the lower chest area.
Review
3. Signs of a pericardial tamponade include all of the
following, EXCEPT:
A. muffled heart tones.
B. a weak, rapid pulse.
C. collapsed jugular veins.
D. narrowing pulse pressure.
Review
Answer: C
Rationale: Pericardial tamponade, which is almost
always caused by penetrating chest trauma, occurs
when blood accumulates in the pericardial sac.
This impairs the heart’s ability to contract and relax;
as a result, the systolic BP decreases and the
diastolic BP increases (narrowing pulse pressure).
Because the heart cannot adequately eject blood, it
backs up beyond the right atrium, resulting in
jugular venous distention. In some cases, heart
tones may be muffled or distant. Other signs
include a weak, rapid pulse and hypotension.
Review
3. Signs of a pericardial tamponade include all of the following,
EXCEPT:
A. muffled heart tones.
Rationale: This is an assessment finding with pericardial
tamponade.
B. a weak, rapid pulse.
Rationale: This is an assessment finding with pericardial
tamponade.
C. collapsed jugular veins.
Rationale: Correct answer
D. narrowing pulse pressure.
Rationale: This is an assessment finding with pericardial
tamponade.
Review
4. After experiencing penetrating trauma to the chest,
your patient’s blood pressure is 110/80 mm Hg.
Which of the following repeat blood pressures is
MOST indicative of a pericardial tamponade?
A. 116/74 mm Hg
B. 100/90 mm Hg
C. 128/60 mm Hg
D. 140/80 mm Hg
Review
Answer: B
Rationale: Among the other signs of a pericardial
tamponade, a narrowing of the pulse pressure (the
difference between the systolic and diastolic
pressure) may be observed. Of the choices in this
question, the blood pressure of 100/90 mm Hg has
a pulse pressure of only 10 mm Hg, which is less
than any of the other values listed.
Review
4. After experiencing penetrating trauma to the chest, your
patient’s blood pressure is 110/80 mm Hg. Which of the
following repeat blood pressures is MOST indicative of a
pericardial tamponade?
A. 116/74 mm Hg
Rationale: The pulse pressures are not narrowed.
B. 100/90 mm Hg
Rationale: Correct answer
C. 128/60 mm Hg
Rationale: The pulse pressures are not narrowed.
D. 140/80 mm Hg
Rationale: The pulse pressures are not narrowed.
Review
5. When caring for a patient with signs of a
pneumothorax, your MOST immediate concern
should be:
A. hypovolemia.
B. intrathoracic bleeding.
C. ventilatory inadequacy.
D. associated myocardial injury.
Review
Answer: C
Rationale: A pneumothorax occurs when air enters
the pleural space and progressively collapses the
lung. This impairs the ability of the lung to move
air in and out (ventilate). As the lung collapses
further, ventilatory efficiency decreases, resulting
in hypoxemia; this should be your most immediate
concern. Some patients with a pneumothorax may
also experience intrathoracic bleeding and
associated myocardial injury, depending on the
mechanism of injury and the force of the trauma.
Review
5. When caring for a patient with signs of a pneumothorax, your
MOST immediate concern should be:
A. hypovolemia.
Rationale: This may be indicated by the signs and symptoms of
shock.
B. intrathoracic bleeding.
Rationale: The patient may experience this, but inadequate
ventilation is your immediate concern.
C. ventilatory inadequacy.
Rationale: Correct answer
D. associated myocardial injury.
Rationale: The patient may experience this, but inadequate
ventilation is your immediate concern
Review
6. What purpose does a one-way “flutter valve” serve
when used on a patient with an open
pneumothorax?
A. It prevents air escape from within the chest cavity
B. It allows a release for air trapped in the pleural
space
C. It only prevents air from entering an open chest
wound
D. It allows air to freely move in and out of the chest
cavity
Review
Answer: B
Rationale: A one-way flutter valve is used to treat
patients with an open pneumothorax (sucking chest
wound), and serves two purposes: it allows air
trapped in the pleural space to escape during
exhalation and prevents air from entering the
pleural space during inhalation. These combined
effects alleviate pressure on the affected lung,
which allows it to reexpand.
Review
6. What purpose does a one-way “flutter valve” serve when used on a
patient with an open pneumothorax?
A. It prevents air escape from within the chest cavity
Rationale: It allows air to exit the chest.
B. It allows a release for air trapped in the pleural space
Rationale: Correct answer
C. It only prevents air from entering an open chest wound
Rationale: It prevents air from entering and allows air to exit the chest.
D. It allows air to freely move in and out of the chest cavity
Rationale: It allows air to move out freely and prevents air from
entering.
Review
7. When the chest impacts the steering wheel during
a motor-vehicle crash with rapid deceleration, the
resulting injury that kills almost one-third of
patients, usually within seconds, is:
A. a hemothorax.
B. aortic shearing.
C. a pneumothorax.
D. a ruptured myocardium.
Review
Answer: B
Rationale: When the chest impacts the steering wheel
following rapid forward deceleration, aortic injuries
(shearing or rupture) are the cause of death in nearly
two-thirds of patients. The aorta is the largest artery in
the body; when it is sheared from its supporting
structures or ruptures outright, exsanguination
(bleeding to death) occurs—usually within a matter of
seconds. Myocardial rupture is not a common injury,
although it would be equally as fatal. Hemothorax and
pneumothorax—both of which are life-threatening
injuries—are usually not fatal within seconds.
Review
7. When the chest impacts the steering wheel during a motorvehicle crash with rapid deceleration, the resulting injury that
kills almost one-third of patients, usually within seconds, is:
A. a hemothorax.
Rationale: This is a serious injury, but is not fatal in seconds.
B. aortic shearing.
Rationale: Correct answer
C. a pneumothorax.
Rationale: This is a serious injury, but is not fatal in seconds.
D. a ruptured myocardium.
Rationale: This is a serious injury, but not common.
Review
8. Signs and symptoms of a chest injury include all of
the following, EXCEPT:
A. hemoptysis.
B. hematemesis.
C. asymmetrical chest movement.
D. increased pain with breathing.
Review
Answer: B
Rationale: Signs and symptoms of a chest injury
include, among others, bruising to the chest, chest
wall instability, increased pain with breathing,
asymmetrical (unequal) chest movement if a
pneumothorax is present, and hemoptysis
(coughing up blood) if intrapulmonary bleeding is
occurring. Hematemesis (vomiting blood) indicates
bleeding in the gastrointestinal tract—usually the
esophagus or stomach—not the chest cavity.
Review
8. Signs and symptoms of a chest injury include all of the
following, EXCEPT:
A. hemoptysis.
Rationale: Hemoptysis is coughing up blood or blood tinged
sputum.
B. hematemesis.
Rationale: Correct answer
C. asymmetrical chest movement.
Rationale: This may indicate a flailed chest or pneumothorax.
D. increased pain with breathing.
Rationale: A chest injury will cause the presence of pain during
inspiratory or expiratory chest wall movement.
Review
9. During your rapid trauma assessment of a patient
who was stabbed, you see an open wound to the
left anterior chest. Your MOST immediate action
should be to:
A. position the patient on the affected side.
B. administer oxygen and transport at once.
C. assess the patient for a tension pneumothorax.
D. cover the wound with a non-porous dressing.
Review
Answer: D
Rationale: Since you are performing a rapid trauma
assessment, you have already performed an initial
assessment, which involved administering high-flow
oxygen or assisted ventilation. If you encounter an
open chest wound, your most immediate action should
be to cover it with a non-porous (occlusive) dressing.
This will prevent air from moving in and out of the
wound. After the dressing is applied, however, you
must monitor the patient for signs of a developing
tension pneumothorax; if needed, lift one corner of the
occlusive dressing to allow air escape from the chest
cavity.
Review
9. During your rapid trauma assessment of a patient who was
stabbed, you see an open wound to the left anterior chest. Your
MOST immediate action should be to:
A. position the patient on the affected side.
Rationale: This is not the most immediate action.
B. administer oxygen and transport at once.
Rationale: Oxygen administration and ventilatory assistance is
completed in the initial assessment.
C. assess the patient for a tension pneumothorax.
Rationale: You must monitor for signs of a developing
pneumothorax.
D. cover the wound with a non-porous dressing.
Rationale: Correct answer
Review
10. During your assessment of a patient with a closed
chest injury, you should NOT intentionally assess
for:
A. bruising.
B. deformities.
C. crepitation.
D. breath sounds.
Review
Answer: C
Rationale: Crepitus, the sound made (or sensation
felt) when broken bone ends rub together, is not
intentionally assessed for in patients with any
injury; it is a coincidental finding that should be
documented. Intentionally assessing for crepitus—
which involves moving or manipulating the injured
area—may worsen the injury and should be
avoided.
Review
10. During your assessment of a patient with a closed chest injury,
you should NOT intentionally assess for:
A. bruising.
Rationale: This may be seen on inspection.
B. deformities.
Rationale: This may be visualized during the inspection of a
patient’s chest.
C. crepitation.
Rationale: Correct answer
D. breath sounds.
Rationale: EMS providers must assess for the presence of or lack
of adequate lung sounds.