Chest Injuries
Chapter 27
Review anatomy of the chest:
Mechanics of Ventilation:
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Inspiration
–
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Intercostal muscles contract and diaphragm flattens.
Expiration
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Intercostal muscles and diaphragm relax; tissues move back to normal position.
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Phrenic nerves exit the spinal cord at C3, C4, and C5.
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Spinal cord injury below C5
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Loss of ability to move intercostal muscles
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Diaphragm can still contract; patient can still breathe.
Spinal cord injury at C3 or higher
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No ability to breathe
*note that a spinal cord injury below c-5 results in paralysis below the shoulders
Injuries to the Chest:
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Closed chest injuries
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Caused by blunt trauma
Open chest injuries
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Caused by penetrating trauma
Signs and Symptoms:
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Pain at site of injury
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Pain aggravated by increased breathing
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Bruising to chest wall
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Crepitus with palpation of chest
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Penetrating injury to chest
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Dyspnea
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Hemoptysis
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Failure of chest to expand normally
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Rapid, weak pulse and low blood pressure
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Cyanosis around lips or fingernails
Scene Size Up:
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Observe for hazards
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Do not disturb potential evidence
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Put several pairs of gloves in your pocket.
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Consider spinal immobilization
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Ensure that police are on scene if incident involved violence
Initial Assessment:
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General impression
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Quickly evaluate ABCs
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Difficulty speaking may indicate several problems
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Patients with significant chest injuries will look sick
Airway and breathing
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Ensure that patient has a clear, patent airway
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Protect the spine
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Inspect for DCAP-BTLS
Inspection (AB):
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Decreased breath sounds usually indicate significant damage to a lung
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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:
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Apply an occlusive dressing to any penetrating chest injury
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Stabilize paradoxical motion with a large bulky dressing and 2'' tape
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Apply oxygen via nonrebreathing mask at 15 L/min
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Provide positive pressure ventilations if breathing is inadequate
Circulation (C):
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Assess patient’s pulse
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Consider aggressive treatment for shock
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Internal bleeding can quickly cause death
Transport Decision:
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Rapidly transport if patient has problems with ABCs.
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Pay attention to subtle clues.
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Skin signs
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Level of consciousness
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Sense of impending doom
Focused History and Physical Exam:
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Focused physical exam
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For a patient with isolated chest injury and limited MOI
Rapid physical exam
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For a patient with a significant MOI
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Use DCAP-BTLS
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Do not focus just on the chest wound
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Obtain baseline vital signs
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Obtain SAMPLE history quickly
Interventions:
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Provide complete spinal immobilization
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Maintain open airway; be prepared to suction
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Provide assisted ventilations if needed
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Control bleeding
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Place occlusive dressing over penetrating chest wound
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Stabilize flail segment with a bulky dressing
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Treat aggressively for shock
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Do not delay transport
Detailed Physical Exam:
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Perform enroute to the Hospital if time allows
Ongoing Assessment:
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Assess effectiveness of interventions
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Reassess vital signs
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Communication and documentation
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Communicate with hospital early if patient has significant MOI
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Describe injuries and treatment given
Complications of Chest Injuries:
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A pneumothorax occurs when air leaks into the space between the pleural surfaces.
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Air accumulates in the pleural space
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Air enters through a hole in the chest wall
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The lung may collapse in a few seconds or a few minutes
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An open or penetrating wound to the chest is called a sucking chest wound
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Treat with a flutter valve dressing
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Spontaneous Pneumothorax
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Some people are born with or develop weak areas on the surface of the lungs
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Occasionally, the area will rupture spontaneously, allowing air into the pleural space
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Patient experiences sudden chest pain and trouble breathing
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Consider a spontaneous pneumothorax for a patient with chest pain without cause
Tension Pneumothorax
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Can occur from sealing all four sides of the dressing on a sucking chest wound
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Can also occur from a fractured rib puncturing the lung or bronchus
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Can also result from a spontaneous pneumothorax
Signs and Symptoms
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Respiratory distress
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Distended neck veins
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Tracheal deviation
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Tachycardia
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Low blood pressure
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Cyanosis
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Decreased lung sounds
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Treatment
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If a tension pneumothorax develops from sealing an open chest wound, partly remove the dressing to
let the air escape.
•
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If there is no open wound, follow local protocol
Hemothorax- Collection of blood in the pleural space
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Suspect if the following are seen:
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Signs and symptoms of shock
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Decreased breath sounds on affected side
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If both air and blood are present in the pleural space, it is a hemopneumothorax
Rib Fractures:
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They are very common in the older people.
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A fractured rib may lacerate the surface of the lung
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Patients will avoid taking deep breaths and breathing will be rapid and shallow
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The patient often holds the affected side to minimize discomfort
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Administer oxygen
Flail Chest:- Segment of chest wall detached from rest of thoracic cage
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Occurs when:
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Three or more ribs are fractured in two or more places.
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Sternum is fractured along with several ribs.
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Creates paradoxical motion
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Treatment:
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Maintain airway
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Provide respiratory support with BVM if needed
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Perform ongoing assessments for pneumothorax and other respiratory complications
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Immobilize flail segment
Pulmonary Contusions:
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Bruising of the lung
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Develops over hours
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Alveoli fill with blood, and edema accumulates in the lung, causing hypoxia
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Provide oxygen and ventilatory support
Traumatic Asphyxia:- Sudden, severe compression of chest
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Produces rapid increase in pressure within chest
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Results in neck vein distention, cyanosis, and bleeding into the eyes
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Provide supplemental oxygen and monitor vital signs
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Transport immediately
Blunt Myocardial Injury:
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Bruising of heart muscle
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Pulse is often irregular
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There is no prehospital treatment for this condition
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Check patient’s pulse and note irregularities
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Provide supplemental oxygen and transport immediately
Pericardial Tamponade- Blood or other fluids collect in the pericardium
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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:
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The superior vena cava, inferior vena cava, pulmonary arteries and veins, and aorta are contained in the chest
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Injury to these vessels can cause fatal hemorrhage
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Treatment includes:
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CPR
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Ventilatory support
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Supplemental oxygen
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Transport immediately