MASTER TEACHING NOTES
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Detailed Lesson Plan
Chapter 34
Chest Trauma
75–90 minutes
Case Study Discussion
Teaching Tips
Discussion Questions
Class Activities
Media Links
Knowledge Application
Critical Thinking Discussion
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
I.
5
5
5
Master Teaching Notes
Introduction
Case Study Discussion
A. During this lesson, students will learn about assessment and emergency
medical care for a patient suffering from chest trauma.
B. Case Study
1. Present Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed.

How will you begin the process of
determining the patient’s problem?
 What are the priorities for managing this
call?
II. The Chest—Anatomy of the Chest
A. Thoracic cavity and pleural lining
1. Visceral pleura—Innermost layer; in contact with lungs
2. Parietal pleura—Outermost layer; in contact with thoracic wall
B. Ribs—Bony cage around respiratory and circulatory organs
C. Diaphragm—Separates thoracic and abdominal cavities
D. Mediastinum
E. Trachea—Conduit to the lungs
F. Venae cavae—Veins that collect and return the blood to the heart
G. Aorta—Artery carrying blood from the heart to the body
H. Esophagus—Tubelike structure that connects pharynx to stomach
I. Heart
Teaching Tip
III. The Chest—General Categories of Chest Injuries
A. Open chest injury (penetrating chest wound)
1. Causes
a. Gunshot
b. Knife
c. Any hard, sharp object (screwdriver, ice pick, and so on)
2. Effects
a. Bullet wound
i. Tiny entrance wound
Teaching Tip
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
Use the anatomical models to review the
structures of the chest.
Discussion Questions
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What structures are in the mediastinum?
How is the contact between the pleural
layers important to lung expansion and
inhalation?
Draw a grid on the white board with types of
chest injuries at the top and rows for signs,
symptoms, pathophysiology, and treatment
at the left. Give students time to review the
chapter material and notes. Then have
students come to the board and fill in the
grid. When the grid is complete, review it
with the class, comparing and contrasting
PAGE 1
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
ii. Extensive internal damager from ricochet
iii. Exit wound, if bullet does not lodge itself in the body (larger than
entrance wound)
b. Injuries to heart—Ineffective pumping, severe blood loss
c. Injuries to major vessels—Can result in immediate death
d. Injuries to respiratory system
i. Lungs rendered unable to inflate
ii. Pneumothorax (air in the chest cavity)
iii. Sucking chest wound
B. Closed chest injury—Blunt trauma with no open wound
1. Injury to lungs, heart, great vessels, respiratory tract, diaphragm,
esophagus
2. Flail segment (two or more adjacent ribs broken in two or more places)
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IV. The Chest—Specific Chest Injuries
A. Flail segment
1. Two or more adjacent ribs are fractured in two or more places.
2. This produces a freely moving section of the chest wall.
3. The flail segment displays paradoxical movement (movement in
opposite direction from the rest of the chest wall) during breathing.
4. Paradoxical movement is created by pressure of inhalation and
exhalation.
5. The underlying contusion to the lungs is more serious than the broken
ribs because it reduces patient’s air intake and leads to hypoxia (oxygen
deficiency).
6. To stabilize, splint and treat with positive pressure ventilation.
B. Pulmonary contusion
1. Patient suffers from bleeding within the lung tissue.
2. Bleeding occurs in and around the alveoli and into the interstitial space
between the alveoli and capillaries.
3. Pulmonary contusion leads to severe hypoxia and can lead to death.
4. Pulmonary contusion is often seen with a flail segment injury.
5. Other signs and symptoms include shortness of breath, cyanosis, and
signs of blunt trauma to the chest.
6. Oxygenate by nonrebreather mask at 15 lpm if breathing is adequate or
by positive pressure ventilation with supplemental oxygen if breathing is
inadequate.
C. Pneumothorax
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
the various injuries.
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access information
about rib fractures and flail chest.
Discussion Questions
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How does a flail segment interfere with
ventilation?
 How does pulmonary contusion interfere
with gas exchange?
Critical Thinking Discussion
What could the sudden compression of the
chest do to the heart valves? What signs
and symptoms might you find in association
with these consequences?
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access information
about pulmonary contusions.
PAGE 2
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
1. Air accumulates in the pleural cavity, causing lung collapse on the
injured side of the chest.
2. Pneumothorax is usually due to either blunt or penetrating trauma.
3. Spontaneous pneumothorax
a. Occurs with no trauma or other external cause
b. Usually the result of a bleb (weak area on surface of lung)
c. Bleb ruptures and allows air into thoracic cavity.
d. Common among smokers and emphysema patients
e. Signs and symptoms
i. Dyspnea (shortness of breath)
ii. Respiratory distress
iii. Sharp chest pain
iv. Absent breath sounds on one side
D. Open pneumothorax (sucking chest wound)
a. An open pneumothorax is the result of a blow from a penetrating
object.
b. Air may be heard escaping or entering through the wound.
c. An open pneumothorax has the same signs and symptoms as a
closed one, plus the presence of an open chest wound.
d. Treat by immediately occluding, first with your gloved hand, then
with an occlusive dressing.
E. Tension pneumothorax
1. A tension pneumothorax is an immediately life-threatening condition.
2. A tension pneumothorax continues to trap air and thus collapses the
injured lung.
3. The mediastinum begins to shift to the uninjured side.
4. The uninjured lung, heart, and large veins are compressed.
5. This results in poor cardiac output, ineffective ventilation, inadequate
oxygenation, and severe hypoxia.
6. Signs and symptoms include rapid deterioration, severe respiratory
distress, shock, and absent breath sounds on the injured side.
7. If these symptoms develop after you have treated for an open
pneumothorax, lift the occlusive dressing to allow air to escape and
transport immediately.
F. Hemothorax
1. The thoracic cavity is filled with air.
2. The lung collapses as the blood continues to collect.
3. Blunt or penetrating trauma may cause a hemothorax.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
Discussion Question
What are the signs and symptoms of a
pneumothorax?
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access information
about pneumothorax.
PAGE 3
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
4. The injury may be open or closed.
5. Severe blood loss often results in severe shock, with signs of respiratory
distress developing later.
6. The patient will often produce pink or red frothy sputum when coughing.
7. Treatment is the same as for pneumothorax and shock.
G. Traumatic asphyxia
1. Severe and sudden compression of the thorax causes a rapid increase
in pressure in the chest.
2. The sternum and ribs severely compress the heart and lungs.
3. This causes a backflow of blood from the right ventricle into the head,
shoulders, and chest.
4. Signs and symptoms
a. Bluish or purple discoloration of face, head, neck and shoulders
b. Jugular vein distention
c. Bloodshot eyes protruding from eye sockets
d. Cyanotic and swollen tongue and lips
e. Bleeding of the conjunctivae (area under lower eyelids)
5. Provide emergency care for chest wounds and treat for shock.
H. Cardiac contusion
1. Occurs when the heart is violently compressed between the sternum
and spinal column
2. An actual bruise may occur to the heart wall.
3. The heart wall may be ruptured.
4. The electrical conduction system of the heart may be disturbed.
5. The right ventricle is the most likely to be injured.
6. Signs and symptoms
a. Chest pain or discomfort
b. Evidence of blunt trauma to the chest (bruises, swelling, crepitation,
deformity)
c. Tachycardia (rapid heart rate)
d. Irregular pulse
7. Transport promptly.
I. Pericardial tamponade
1. Blunt or penetrating trauma (usually from a knife or similar object) may
cause bleeding into the pericardial sac (tough fibrous sac that surrounds
the heart).
2. Since the sac cannot expand much, the heart is compressed.
3. Cardiac output drops significantly, and blood backs up in the veins.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
Discussion Question
What is the pathophysiology of traumatic
asphyxia?
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access information
about cardiac tamponade.
PAGE 4
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
4. This condition is life threatening and requires prompt recognition and
transport.
5. Signs and symptoms will worsen.
a. Jugular vein distention
b. Signs of shock (hypoperfusion)
c. Tachycardia (can be extreme)
d. Decreased blood pressure
e. Narrow pulse pressure (less than 30 mmHg)
f. Weak pulses (radial pulses will diminish or disappear)
J. Rib injury
1. Broken ribs are not life threatening but can cause life-threatening
damage to other structures and organs.
2. The ribs most commonly fractured are the third through the eighth; the
most common fracture site is the lateral aspect of the chest.
3. The fracture may lacerate the intercostal artery or vein and cause
internal bleeding.
4. Rib fractures are less common in children because their cartilage is
more resilient than an adult’s.
5. Signs and symptoms of rib fracture
a. Severe pain with movement and breathing
b. Crepitation
c. Tenderness upon palpation
d. Deformity of the chest wall
e. Inability to breathe deeply
f. Coughing
g. Tachypnea (rapid breathing)
6. To treat a simple rib fracture
a. Place the patient’s arm over the injury site and apply a sling and
swathe to hold it in place.
b. Give the patient a pillow to hold over the injury to splint it manually.
c. Do not completely wrap the chest or apply the swathe snugly.
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V. The Chest—Assessment-Based Approach: Chest Trauma
A. Scene size-up
1. Do not enter the scene of a shooting or stabbing until the police tell you
it is safe.
2. Take necessary Standard Precautions.
3. Wear gloves and eye protection.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
Discussion Question
What signs help you to distinguish between
a tension pneumothorax and a pericardial
tamponade?
Knowledge Application
Given a variety of chest injury scenarios,
students should be able to identify patient’s
injuries and provide both general supportive
and injury-specific management.
PAGE 5
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
4. Ask bystanders what happened.
5. Scan the scene for details that might reveal the mechanism of injury.
a. Was the patient involved in a sports accident?
b. Was there a fight?
c. Is there any evidence that a shooting took place?
d. Was the patient involved in an auto collision?
e. Was the patient crushed between two objects, or was he run over?
f. Was an explosion involved?
B. Primary assessment
1. Form a general assessment of the patient’s condition.
a. Is he severely cyanotic?
b. Is he in extreme respiratory distress?
c. Is he breathing shallowly and rapidly?
d. Is he holding his arms tightly against his chest?
e. Does he appear to be in extreme pain?
f. Are there any open wounds to his chest?
g. Does his chest move unevenly when he breathes?
2. If you suspect a chest injury, expose and examine the patient’s chest.
3. If you discover an open chest wound, immediately seal it with your
gloved hand.
4. If there is paradoxical movement
a. Immediately place your gloved hand over the flail segment to splint it
in an inward position.
b. Administer positive pressure ventilation.
5. Determine the patient’s mental status.
6. Inspect the patient’s airway for blood or other obstructions, and listen
and feel for air movement.
7. Perform the jaw-thrust maneuver to open the patient’s airway, if
necessary.
8. Listen to the patient’s speech pattern for indications of severe respiratory
distress (gasping for breath).
9. Administer oxygen with a nonrebreather mask at 15 lpm if patient is
breathing adequately.
10. Immediately begin positive pressure ventilation with supplemental
oxygen if the patient is not breathing adequately.
11. Any chest injury is a high priority for transport.
12. If you suspect a shooting or stabbing, log roll the patient to assess his
posterior body for a second (entrance or exit) life-threatening wound.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
PAGE 6
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
C. Secondary assessment
1. Inspect and palpate for other injuries (deformities, contusions, abrasions,
punctures, and so on).
2. Assess the patient’s breathing status; be sure that he is receiving
enough oxygen or ventilation.
3. Assess the neck for subcutaneous emphysema, jugular vein distention,
and tracheal deviation.
4. If you suspect a spine injury, apply a cervical spine immobilization collar.
5. Expose the patient’s chest by cutting his clothing; inspect the chest
thoroughly for any open wounds.
6. If you see signs of a flail segment, provide positive pressure ventilation.
7. Look for any signs that blunt force was applied to the chest.
8. Palpate the chest, checking for equal movement on both sides,
paradoxical movement, swelling, and deformities.
9. Determine if the breath sounds are clear and equal, or decreased or
absent on one or both sides.
10. Inspect the abdomen for excessive muscle movement during breathing.
11. Assess the baseline vital signs.
12. If the patient is responsive, obtain a history from him; if he is
unresponsive, try to gather information from bystanders.
13. Be alert for the following signs and symptoms of major chest trauma.
a. Cyanosis to the fingernails or fingertips, lips, or face
b. Dyspnea (shortness of breath/difficulty breathing)
c. Tachypnea (abnormally rapid breathing) or bradypnea (abnormally
slow breathing)
d. Contusions, lacerations, punctures, swelling, or other obvious signs
of trauma
e. Hemoptysis (coughing up blood or bloodstained sputum)
f. Signs of shock
g. Tracheal deviation
h. Paradoxical movement of a segment of the chest wall
i. Open wound that may or may not produce a sucking sound
j. Subcutaneous emphysema
k. Distended jugular veins
l. Absent or decreased breathing sounds upon auscultation
m. Pain at the injury site
n. Failure of the chest to expand normally during inhalation
o. Peripheral pulses that become extremely weak or absent during
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
PAGE 7
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
D.
E.
F.
G.
Master Teaching Notes
inhalation
p. Drop of 10 mmHg or more in systolic blood pressure during
inhalation
General emergency care—Chest trauma
1. Maintain an open airway.
2. Continue oxygen therapy.
3. Reevaluate breathing status.
4. Completely immobilize the patient if you suspect spine injury.
5. Treat for shock if signs and symptoms are present.
Emergency medical care—Open chest wound
1. Immediately seal the open wound with your gloved hand.
2. Apply an occlusive dressing (such as plastic wrap from an oxygen mask)
to seal the wound.
3. Continually assess the patient’s respiratory status.
4. Be alert for the signs and symptoms of complications.
a. Difficultly breathing
b. Tachypnea (abnormally rapid breathing)
c. Severely decreased or absent breath sounds on the injured side
d. Cyanosis
e. Tachycardia (abnormally rapid heart rate)
f. Decreasing blood pressure; narrowing pulse pressure
g. Jugular vein distention (late sign)
h. Tracheal deviation (late sign)
i. Unequal movement of the chest wall
j. Extreme anxiety and apprehension
k. Increased resistance to positive pressure ventilation
5. If you observe complications, lift a corner of the occlusive dressing to
allow air to escape for a few seconds; repeat as often as needed.
Emergency medical care—Flail segment
1. Place your hand over the flail segment to splint it in an inward position.
2. If the patient is not breathing adequately, initiate positive pressure
ventilation during primary assessment.
3. Alternatively, place bulky dressings, a pillow, or a towel over the
unstable segment, or secure the patient’s arm to his body, to stabilize
the injury.
Reassessment
1. Evaluate the effectiveness of your treatment.
2. Assess for further deterioration of the patient’s condition.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34
PAGE 8
Chapter 34 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
3. At any sign of deterioration (increasing breathing difficulty, worsening
cyanosis, and so on), repeat the rapid secondary assessment, looking
for injuries that you missed.
4. Reassess and record vital signs.
VI. The Chest—Summary: Assessment and Care—Chest Trauma
10
A. Review possible assessment findings and emergency care for chest injuries.
B. Review Figures 34-17 and 34-18.
VII. Follow-Up
10
Case Study Follow-Up Discussion
A. Answer student questions.
B. Case Study Follow-Up
1. Review the case study from the beginning of the chapter.
2. Remind students of some of the answers that were given to the
discussion questions.
3. Ask students if they would respond the same way after discussing the
chapter material. Follow up with questions to determine why students
would or would not change their answers.
C. Follow-Up Assignments
1. Review Chapter 34 Summary.
2. Complete Chapter 34 In Review questions.
3. Complete Chapter 34 Critical Thinking.
D. Assessments
1. Handouts
2. Chapter 34 quiz
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 34

What injury would best explain the
patient’s presentation?
 What is the explanation for the sudden
resistance to ventilation?
Class Activity
Alternatively, assign each question to a
group of students and give them several
minutes to generate answers to present to
the rest of the class for discussion.
Teaching Tips

Answers to In Review and Critical
Thinking questions are in the appendix
to the Instructor’s Wraparound Edition.
Advise students to review the questions
again as they study the chapter.
 The Instructor’s Resource Package
contains handouts that assess student
learning and reinforce important
information in each chapter. This can be
found under mykit at
www.bradybooks.com.
PAGE 9