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Thoracic Trauma
Temple CollegeEMS Professions
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Chest Trauma
Second leading cause of trauma deaths after head injury
About 20% of all trauma deaths
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Chest Trauma
Initial exam directed toward: Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade
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Rib Fracture
Most common chest injuryMore common in adults than childrenEspecially common in elderlyRibs form rings
Consider possibility of break in two places
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Rib Fracture
Most commonly 5th to 9th ribsPoor protection
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Rib Fracture
Fractures of 1st, 2nd ribs require high force
Frequently have injury to aorta or bronchi30% will die
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Rib Fracture
Fractures of 8th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen Kidneys
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Rib Fracture
Signs and Symptoms Localized pain, tenderness Increases when patient:
CoughsMovesBreathes deeply
Chest wall instability Deformity, discoloration Associated pneumo or hemothorax
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Rib Fracture
Management High concentration O2
Splint using pillow, swathes Encourage patient to breath deeply
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Rib Fracture
Management Monitor elderly and COPD patients
carefullyBroken ribs can cause
decompensationPatients will fail to breath deeply and
cough, resulting in poor clearance of secretions
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Flail Chest
Two or more adjacent ribs broken in two or more places
Produces free-floating chest wall segment
Usually secondary to blunt traumaMore common in older patients
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Flail Chest
Signs and Symptoms Paradoxical movement
May NOT be present initially due to intercostal muscle spasms
Be suspicious in any patient with chest wall:
•Tenderness•Crepitus
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Flail Chest
Consequences Pain, leading to decreased ventilation Increased work of breathing Contusion of lung
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Flail Chest
Management Establish airway Suspect spinal injuries Assist ventilation with BVM and
oxygen Stabilize chest wall
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Simple Pneumothorax
Air in pleural space Partial or complete lung
collapse occurs
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Simple Pneumothorax
Causes Chest wall penetration Fractured rib lacerating lung Paper bag effect May occur spontaneously following:
ExertionCoughingAir Travel
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Simple Pneumothorax
Signs and Symptoms Pain on inhalation Difficulty breathing Tachypnea Decreased or absent breath sounds
Severity of symptoms depends on size of pneumothorax, speed of lung collapse,
and patient’s health status
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Simple Pneumothorax
Management Establish airway Suspect spinal injury based on
mechanism High concentration O2 with NRB Assist decreased or rapid respirations
with BVM Monitor for tension pneumothorax
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Open Pneumothorax
Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance air will
enter there than through trachea
“Sucking Chest Wound”
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Open Pneumothorax
Management Close hole with occlusive dressing High concentration O2
Assist ventilations Consider transport on injured side Monitor for tension pneumothorax
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Tension Pneumothorax
One-way valve forms in lung or chest wall
Air enters pleural space; cannot leaveAir is trapped in pleural spacePressure risesPressure collapses lung
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Tension Pneumothorax
Trapped air pushes heart, lungs away from injured side
Vena cavae become kinkedBlood cannot return to heartCardiac output falls
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Tension Pneumothorax
Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation Decreased breath sounds Hyperresonance to percussion Cyanosis Subcutaneous emphysema
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Tension Pneumothorax
Signs and Symptoms Rapid, weak pulse Decreased BP Tracheal shift away from injured side Jugular vein distension
Early dyspnea/hypoxia - Late shock
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Tension Pneumothorax
Management Secure airway High concentration O2 with NRB If available, request ALS intercept for
pleural decompression
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Hemothorax
Blood in pleura spaceMost common result of major chest
wall traumaPresent in 70 to 80% of penetrating,
major non-penetrating chest trauma
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Hemothorax
Signs and Symptoms Rapid, weak pulse Cool, clammy skin Restlessness, anxiety Thirst Chills Hypotension Collapsed neck veins
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Hemothorax
Signs and Symptoms Decreased breath sounds Dullness to percussion Dyspnea Ventilatory failure
Shock precedes ventilatory failure
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Hemothorax
Management Secure airway Assist breathing with high
concentration O2
Rapid transport
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Traumatic Asphyxia
Blunt force to chest causes Increased intrathoracic pressure Backward flow of blood out of heart into
vessels of upper chest, neck, head
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Traumatic Asphyxia
Signs and Symptoms Possible sternal fracture or central flail chest Shock Purplish-red discoloration of:
HeadNeckShoulders
Blood shot, protruding eyes Swollen, cyanotic lips
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Traumatic Asphyxia
Name given because patients looked like they had been strangled or hanged
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Traumatic Asphyxia
Management Airway with C-spine control Assist ventilations with high
concentration O2
Spinal stabilization Rapid transport
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Cardiovascular Trauma
Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise
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Myocardial Contusion
Bruise of heart muscleMost common blunt cardiac injuryUsually due to steering wheel impact
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Myocardial Contusion
Behaves like acute MI May produce arrhythmias May cause cardiogenic shock,
hypotension
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Myocardial Contusion
Signs and Symptoms Cardiac arrhythmias after blunt chest
trauma Angina-like pain unresponsive to
nitroglycerin Chest pain independent of respiratory
movementSuspect in all blunt chest trauma
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Myocardial Contusion
Management High concentration O2
Transport Consider ALS intercept
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Cardiac Tamponade
Rapid accumulation of blood in space between heart, pericardium
Heart compressed Blood entering heart decreasesCardiac output falls
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Cardiac Tamponade
Signs and Symptoms Hypotension unresponsive to
treatment Increased central venous pressure
(distended neck/arm veins in presence of decreased arterial BP)
Small quiet heart (decreased heart sounds)
Beck’s Triad
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Cardiac Tamponade
Signs and Symptoms Narrowing pulse pressure Pulsus paradoxicus
Radial pulse becomes weak or disappears when patient inhales
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Cardiac Tamponade
Management Secure airway High concentration O2
Rapid transport Definitive treatment is
pericardiocentesis followed by surgery
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Traumatic Aortic Aneurysm
Caused by sudden decelerations, massive blunt force: Vehicle collisions Falls from heights Crushing chest trauma Blunt chest trauma Animal kicks
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Traumatic Aortic Aneurysm
Rupture usually occurs just beyond left subclavian artery
Attachment of aorta to pulmonary artery at this point produces shearing force on aortic arch
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Traumatic Aortic Aneurysm
Signs and Symptoms Increased BP in arms in absence of head
injury Decreased femoral pulses with full arm
pulses Respiratory distress Ache in chest, shoulders, lower back,
abdomen. (Only 25% of patients)Detection requires high index of suspicion
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Traumatic Aortic Aneurysm
Management High concentration oxygen Assist ventilation Suspect spinal injury Rapid transport
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Associated Abdominal Trauma
Diaphragm forms dome that extends up into rib cage
Trauma to chest below 4th rib = Abdominal injury until proven otherwise
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