Chest Injuries

Chapter 27

Organs of the Chest

Structures of the Chest

Mechanics of Ventilation

• Inspiration– Intercostal muscles contract and diaphragm flattens.

• Expiration– Intercostal muscles and diaphragm relax; tissues move back

to normal position.• 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

• Pain aggravated by increased breathing

• Bruising to chest wall

• Crepitus with palpation of chest

• Penetrating injury to chest

• Dyspnea

• Hemoptysis

• Failure of chest to expand normally

• Rapid, weak pulse and low blood pressure

• Cyanosis around lips or fingernails

Scene Size Up

• 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

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 (AB)

• 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 (C)

• 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

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 enroute 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

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

• Flutter valve dressing

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

• 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

• Signs and Symptoms– Respiratory distress– Distended neck veins– Tracheal deviation– Tachycardia– Low blood pressure– Cyanosis– Decreased lung sounds

• Treatment

– 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

• 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

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

• 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

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

• Blood or other fluids collect in the pericardium

Pericardial Tamponade

• 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