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 The thoracic cavity extends from the lower end of the neck to the diaphragm, but an
injury to the chest may also injure structures in the abdomen. Always assume there
are chest and abdominal injuries when working with a patient who has a chest injury.
 The thorax contains many important structures such as the trachea and organs such as
the heart and lungs; therefore, chest injuries can have serious consequences, such as
adverse affects on the body’s ability to perform respiration and ventilation.
Respiratory alkalosis and respiratory acidosis can result.
 Thoracic trauma may impair cardiac output, decreasing blood pressure and perfusion
to vital organs. Bleeding into the thoracic cavity significantly increases the chance of
hypovolemia and hypoxia. Significant blood loss can disrupt critical processes.
 A patient with severe chest pain tends to breathe more shallowly. This further reduces
minute volume—the volume of air exchanged between the lungs and environment in
1 minute. If blood collects in the thoracic cavity, this can also prevent full expansion
of the lungs.
 A blow to the chest (blunt trauma) may fracture the ribs, the sternum, or whole areas
of the chest wall. Compression of these structures creates other problems, including
contusions of the lungs and the heart and possible damage to the aorta. Even if the
skin and chest wall are intact, the contents of the thorax may be injured.
 There are two types of chest injuries: penetrating, or open, injuries and blunt, or
closed, injuries. Specific chest injuries can include rib fractures, flail chest, sternal
fracture, clavicle fracture, commotio cordis, simple pneumothorax, open
pneumothorax, tension pneumothorax, hemothorax, hemopneumothorax, pulmonary
contusion, cardiac tamponade, myocardial contusion, myocardial rupture, traumatic
aortic disruption, penetrating wounds of the great vessels, diaphragmatic injury,
esophageal injury, tracheobronchial injuries, and traumatic asphyxia.
 Signs and symptoms of chest injury include pain at the site of injury or localized pain
that worsens with breathing; dyspnea; hemoptysis; failure of one or both sides of the
chest to expand normally with inspiration; rapid, weak pulse; low blood pressure; and
cyanosis around the lips or fingernail beds.
 Jugular vein distention suggests increased intravenous pressure that can occur with a
tension pneumothorax. Note that jugular vein distention must be measured with the
patient in a 45° semi-Fowler’s position.
 Note whether heart sounds are easily heard or muffled on auscultation. Muffled heart
sounds are an important clue of tension pneumothorax or cardiac tamponade.
 If the patient’s mental status permits, ask about a history of dyspnea, chest pain, other
areas of pain or discomfort, symptoms before the incident, history of
cardiorespiratory disease, any medications the patient may be taking, and in a motor
vehicle collision, whether restraints were used.
 Monitoring a patient’s ABCs is the primary management for all patients; this is no
different for the patient with thoracic injury. Occlude open chest wounds with an
occlusive dressing. Stabilize any flail segments. Use positive-pressure ventilation if
indicated. Consider definitive airway management. Maintain circulation and gain IV
access. Finally, call for additional backup if needed and provide rapid transport.
 IV fluid therapy during thoracic trauma should be closely monitored and administered
according to local protocol. The goal is to maintain adequate perfusion without
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causing a marked increase in blood pressure. Early recognition and prompt transport
to the closest, most appropriate facility are vital to patient survival.
Any injury to the thoracic cavity may disrupt normal cardiac function. Always treat
the patient based on advanced cardiac life support and local protocols. Consider
aggressive airway management.
Multiple rib fractures, with or without a fracture of the sternum, often result in a
condition called flail chest, in which a portion of the chest wall is detached from the
thoracic cage and moves paradoxically during respiration.
A flail chest causes painful breathing and requires respiratory support and
supplemental high-flow oxygen. It may help to immobilize the flail segment with a
bulky dressing. Remember to never tape around the entire circumference of the
thorax because this may impede breathing. Do not use heavy objects such as
sandbags.
If a sternal fracture is present, expect to find pain and tenderness over the sternum,
and crepitus on palpation.
If a clavicle fracture is present, it should be splinted with a sling and swathe. Clavicle
fracture can lead to neurovascular compromise.
Commotio cordis is cardiac arrest that results from a patient receiving a blow during
the heart’s repolarization period. Such a patient may present with ventricular
fibrillation that responds positively to defibrillation provided within the first 2
minutes.
Simple pneumothorax is the accumulation of air in the pleural space, occurring when
air enters a hole in the chest wall or lung. The lung collapses as pressure builds in the
pleural space. Cover open chest wounds with an occlusive dressing and manage the
ABCs.
Spontaneous pneumothorax can occur in people with weak areas on the surface of the
lungs. The patient will experience sudden, sharp pain and shortness of breath without
known cause.
Open pneumothorax is a pneumothorax in which the pleural space is in contact
directly with the atmosphere. The opening causes increased thoracic pressure and the
lung collapses. Sucking sounds may be heard on inhalation; this is often called a
sucking chest wound.
Seal a sucking chest wound with an occlusive dressing. If the patient shows signs of a
tension pneumothorax, burp the dressing (raise one side of the dressing to allow air to
escape).
A tension pneumothorax can also occur in a closed, blunt injury of the chest in which
a fractured rib lacerates the surface of the lung or as a result of the paper bag
syndrome. Look for increasing respiratory distress, shock, jugular vein distention, and
decreased breath sounds on the affected side. Remember, tracheal deviation is a late
sign. Manage the ABCs and use positive-pressure ventilation sparingly. In the event
of a closed tension pneumothorax, call for paramedic backup because needle chest
decompression will need to be performed.
Hemothorax occurs when blood accumulates between the parietal and visceral pleura
of the lung. This condition is life threatening. Look for signs and symptoms of shock
and decreased breath sounds on the affected side. Manage the ABCs, provide oxygen
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and positive-pressure ventilation as needed, give a fluid bolus if needed, and provide
rapid transport.
Pulmonary contusion is bruising of the lung and may result along with fractured ribs.
Treatment is supportive. Be sure not to overhydrate the patient because this could
create increased pulmonary edema and bleeding.
Cardiac tamponade is the collection of blood in the pericardium, the fibrous sac
surrounding the heart. This prevents the heart from pumping effectively because the
pericardium is nonelastic. Signs include a weak pulse and the Beck triad: narrowing
pulse pressure, distended neck veins, and muffled heart sounds. Definitive treatment
includes a pericardiocentesis performed in the hospital. Manage the ABCs, provide
oxygen, and be cautious with positive-pressure ventilation because this may cause a
tension pneumothorax. Provide a rapid fluid bolus to maintain cardiac output and
provide rapid transport.
Myocardial contusion is bruising of the heart muscle. This is a significant injury.
Heart failure can result. Maintain a high suspicion for serious injury in patients who
experienced blunt chest trauma. Pulse may be irregular but life-threatening
arrhythmias are uncommon. Limit fluids if signs of heart failure are present.
Myocardial rupture is acute perforation of any portion of the heart. This is life
threatening and requires aggressive care of the ABCs and rapid transport.
Traumatic aortic disruption is dissection or rupture of the aorta. Recognition often
comes from a high index of suspicion based on the mechanism of injury. Assessment
may reveal retrosternal or interscapular pain described as “tearing,” ischemic pain of
the extremities, and hoarseness or stridor, among others. Management includes
maintaining the ABCs and taking care not to overhydrate and increase bleeding.
Laceration of the large blood vessels in the chest can cause a fatal hemorrhage.
Suspect such a laceration in any patient with a chest wound who shows signs of
shock, even if you see little blood; it may be collecting within the chest cavity. The
thorax will sound dull (hyporesonant) to percussion. Provide immediate transport—a
few minutes can be the difference between life and death.
The diaphragm can be injured when the chest is injured, but signs and symptoms can
be subtle. Findings include scaphoid abdomen, dullness to percussion, and there may
be bowel sounds in the affected side of the thorax. Provide rapid transport.
Esophageal injury may occur and like most chest injuries, is life threatening. Signs
may include local tenderness, subcutaneous emphysema, and resistance of the neck
on passive motion. Again, provide rapid transport.
Tracheobronchial injuries are rare but can be a significant cause of mortality. A tear
can occur anywhere along the tracheobronchial tree and result in rapid movement into
the pleural space. If this occurs, the tension pneumothorax will not respond to needle
chest decompression.
Traumatic asphyxia occurs when a patient experiences sudden, severe compression
injury to the chest, causing a rapid increase in intrathoracic pressure. This injury
squeezes the chest and blood backs up into the head and neck, causing the appearance
of distended neck veins, cyanosis in the face and upper part of the neck, bulging eyes,
and swelling or hemorrhage of the conjunctiva. Skin below the area of compression
remains normal color.
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As always, have an automated external defibrillator ready and be prepared to provide
CPR because chest injuries are often serious and the patient may go into cardiac arrest
at any time.