Chest and Abdominal Trauma Case Studies Case #1 Scenario: EMS is dispatched to a 2-car MVC with head on collision. The posted speed limit is marked at 40 MPH. Upon EMS arrival to the scene an unrestrained adult driver is found inside the vehicle with noted + steering wheel deformity. The patient is A & O X 3 but appears restless and agitated. On assessment the following is noted: Airway: Patent Breathing: RR: fast; labored with asymmetric chest expansion and use of accessory muscles but no paradoxical movement; left side appears hyperinflated and does not move. Breath sounds absent on left, diminished on right; no adventitious sounds. No open wounds; trachea midline. SpO 2 86%, EtCO 2 27. Circulation: JVD present; radial pulses absent; carotid pulses fast, weak and thready; equal bilaterally. C/O severe chest pain & difficulty breathing Disability/LOC: Eyes open spontaneously, pt is awake, alert & oriented to voice & is able to move all extremities to command; PERL, EMS notes an abrasion to L anterior chest; the pt is A & O but restless & agitated. Pain: 9/10 VS: BP 84/60, P 116, R 24 Questions Answers 1. What two immediate life-threats should be suspected based on this presentation? 2. Which one is most likely based on the mechanism of injury? What is the pathophysiology and the classic clinical findings of this injury? 3. What is the mechanism of death in this injury? 4. What temporizing life-saving procedure must be performed immediately? 5. What equipment will you need? 6. What landmarks must you find? 7. At what angle is insertion performed? If you hit bone, should you go over or under? Why? 8. What should happen after penetration into the pleural space? 9. Will this procedure re-expand the collapsed lung? Why or why not? 10. What is the difference between a simple pneumothorax and a tension pneumothorax?
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Breathing: RR:fast;laboredwithasymmetricchestexpansionanduseofaccessorymusclesbutnoparadoxicalmovement; left side appears hyperinflated and does not move. Breath sounds absent on left,diminishedonright;noadventitioussounds.Noopenwounds;tracheamidline.SpO286%,EtCO227.
Circulation: JVDpresent; radialpulsesabsent; carotidpulses fast,weakand thready;equalbilaterally. C /Oseverechestpain&difficultybreathing
Chest and Abdominal Trauma Case Studies Page 4 NWC EMSS CE November 2015
Case#4Scenario:YouarecalledtoarestraineddriverinaMVConexpressway.Thereis15-20inchesofmetalintrusioninatthe dashboard due to a frontal impact. The windshield is broken and the steering wheel is bent. The patient iscomplainingofseveresubsternalchestpain.Heisholdinghisarmagainsthischesttosplintwhenhebreathes.
Onprimaryassessmentyounotethefollowing:
Airway: PatentBreathing: Dyspneic; RR rapid, shallow and labored with redness and abrasions to the chest wall; no
Chest and Abdominal Trauma Case Studies Page 5 NWC EMSS CE November 2015
Case#5Scenario:A50y/orestraineddriverofasinglevehiclecrashwhodroveofftheroadandlaterallyhitintoatreeat40mph on the drivers side. Upon arrival, assessment reveals the car to be a vintage model with only the lap beltavailable.Thereforethepatientisslumpedsidewaysintothecenterofthevehicle,moaning.
asnotedabove;bleedingcomingfrommouthwithlooseteeth.Neck: Tracheamidline;jugularveinsflat.Chest: No injury noted to chest with equal chest expansion; no paradoxicalmovements. EKG: ST with
PVCs.Abdomen: abdominal exam with point tenderness to palpation to R and LLQ with positive guarding and
1. Chestinjuriesarecommonoccurrencesfollowingbluntandpenetratingtrauma.2. Isolated chest trauma is uncommon; themajority of these patientswill have additional
a. Usuallyassociatedwithanurbansettingb. Commonlyduetogunshotwoundsandknifewounds
(1) Low velocity gunshotwounds: Hand guns - 12-25%mortality. Sterile,woundonlyalongtrackofmissile.
(2) High velocity gunshot wounds: Military and hunting rifles. Cavitationmaycreatetissuedamage15timesthediameterofthebullet.Allthesewoundswillrequireoperativedebridementatthehospital.
(3) Shot gunwounds: Result in varyingwound typesdependingonpelletsize,choke,anddistancefromthevictim.
(5) Impalementinjuries8. Isolated chest trauma is uncommon (16%); 84% of these patients will have additional
injuriesB. Morbidityandmortality
1. Thoracicinjuriesarethesecondleadingcauseoftraumamortalityoccurringin15-25%ofalltrauma-relateddeaths(about12,000peryearintheU.S.).Mostdeathsaresecondaryto heart and great vessel trauma causing exsanguinating hemorrhage and respiratoryfailure.
3. Chest injuries are often associated with abdominal injuries and are a significantcontributor to fatal outcomes in an additional 25%-50% of cases. They are the leadingcauseofpreventabletraumadeath.
D. Basicapproachtomajorthoracictraumaremainsunchanged,butthetreatmentofseveralinjurieshaveundergoneanevolutionintherecentpast:1. Pericardialtamponade2. Aortictransection3. Bluntcardiacinjury4. Pulmonarycontusionandflailchest
E. Preventioneffortshavethepotentialtoreducetheincidenceofthoracicinjuries:1. Firearmsafety2. Sportstraining3. Seatbeltuse,passiverestraintsystems4. Decreasedspeedlimits5. Community/legalactivityregardingdrunkdriving,etc.6. Violencepreventioneducationi.e.,conflictresolutionskills
II. ReviewthoracicanatomyfromRespiratoryA&PandCardiacA&PlecturesIII. Generalpathophysiologyofchestinjuries
A. Impairmentsinventilatoryefficiency1. Painrestrictingchestexcursion2. Airorbloodenteringthepleuralspace3. Chestwallfailstomoveinunison4. Ineffectivediaphragmaticcontraction
B. Impairmentsingasexchange1. Hypoxia:ResultsfrominadequateO2deliverytotissues2. Pulmonaryventilation/perfusionmismatch:i.e.-contusion,hematoma,alveolarcollapse3. Changes in intrathoracic pressure relationships: tension/open pneumothorax or severe
and/or perfusion problem especially if objective criteria support these findings, e.g., decreasedoxygen saturation, change in capnogram, or pulse deficits. Do not initially attribute abnormalfindingtodrugsorethanolabuseuntillife-threateningproblemshavebeenruledout.
C. Ifcervicalspinestatus isunclear,spinemotionrestrictionmustbemaintained ifamechanismofinjurysuggestspotentialc-spineinjury.
D. Etiologyofinadequateventilations/impairedgasexchange1. Ventilationdeficiencies:Pulmonary,musculoskeletal,orneurologic
Chest and Abdominal Trauma Case Studies Page 8 NWC EMSS CE November 2015
3. Determineoxygenationstatusa. Clinical presentation i.e. mental status, skin color (cyanosis of the lips or nail
beds)etc.b. Pulseoximetry(SpO2)
4. Neckveinsa. Normalanatomiclocationofneckveins
(1) External jugulars are above the clavicle and cross over thesternocleidomastoidmuscles.
(2) Internal jugulars run parallel to the sternocleidomastoidmuscles nearthecarotidarteries.
(3) If apatient ispositionedata45° angle, thevenouspulses shouldnotascendmorethanonetotwocmabovetheclavicle.
b. Markedly distended neck veins occur when blood cannot drain into the rightatria. Inthepresenceofchesttrauma,JVDmayindicatetensionpneumothoraxorcardiactamponade.
Chest and Abdominal Trauma Case Studies Page 9 NWC EMSS CE November 2015
c. Aclosedpneumothoraxprogressivelyaccumulatesairwithinthepleuralspaceoninspirationthatcannotescapeonexpiration,creatingaone-wayvalve.
d. This accumulation produces an increase in intrapleural pressure (tension) thatcollapsesthelungontheaffectedsideanddepressesthediaphragm.
e. Whenpressureinthepleuralspaceexceedspressureintheatriaandvenacavae,theycollapse.Thiscreatesamechanicalobstructionofbloodreturntotherightheart resulting in markedly decreased preload and cardiac output –OBSTRUCTIVESHOCK
f. Then…Rising intrathoracic pressure depresses diaphragm& shiftsmediastinumawayfromaffectedside,furthercompressingvenacavae&compromisingintactlungsooppositesidebecomespressuredaswell
g. Hemodynamicdysfunctionproduceshypoxiaandobstructiveshock.h. Life-threatening emergency due to cardiovascular compromise. Must be
a. Inspection(1) Complaintofseverepainwithbreathing(pleuriticchestpain)(2) Restlessness,severeanxiety,agitation(3) Dyspnea,tachypnea,retractionsandothersignsofrespiratorydistress(4) Asymmetric chest movement, hyperdistended hemithorax on the
(2) Proceduralsteps:Insertneedleata90degreeangletothechestwall inthe2ndor3rd ICS inthemidclavicularlinetoreleaseairunderpressureinpleuralspace.USEEXTREMECAREinselecting the correct site and inserting the needle using the correctanglesoitpenetratesintothepleuralspace.
(4) Once in place, remove the needle and leave only the catheter in thechest.A retainedneedlehas thepotential topenetrate theheartoraventilatedlung.
(5) Release of pressurized air should relieve the patient’s acute distress,improve ventilations, and re-establish venous return (and thus
Chest and Abdominal Trauma Case Studies Page 10 NWC EMSS CE November 2015
peripheralpulses)butitwillnotre-expandthelung(breathsoundswillstill be absent).Will need a chest tube at the hospital to expand thelung.
(6) Frequently reassess catheter patency.May need to repeat procedurewithadditionalneedle.
c. Venousaccess;IVNSupto1Ld. Time-sensitivepatient–needsexpeditioustransporttoaLevelItraumacenter
5. Complicationsa. Pneumothoraxifmisdiagnosedpriortoprocedureb. Hemothoraxifapulmonary,internalmammaryorintercostalvesselistransectedc. Lunglacerationd. If tensionpneumothoraxpresentsunrecognizedand thereforenot treated, the
patient's condition may deteriorate to pulseless electrical activity (PEA) andrespiratory-cardiacarrest
6. How can you tell the difference between a pneumothorax & tension pneumothorax(bothhaveabsentbreathsounds)?
a. Penetrating trauma through the chest wallcreates an opening allowing air to enter theintrathoraciccavitythatdependsonnegativepressures and intact pleural membranes toallow inspiration through thetracheobronchialtree.(1) Sincechestwallandpleuralintegrity
is lost, the involved lungparadoxically collapses oninspirationandexpandsminimallyduringexpirationmovingair in andoutofthedefect,producinga"sucking"sound.
(2) Criticaldiameter:Airisgas,soitflowsalongthepathofleastresistance(high→lowpressure).Ifthewoundapproximates2/3thediameterofthetrachea,resistancetoairflowthroughtherespiratorytractmaybegreater than through the open wound, so air preferentially movesthrough the chest wall defect into the pleural space instead of thetrachea to equalize intrathoracic and atmospheric pressure duringventilatoryattempts.
(3) Increased intrapleural pressure leads to lung collapse on the affectedsidewithpossiblemediastinalshift
a. TheSMITHPAPYRUS,writtensometimearound3,000B.C.,containstheearliestrecognized reference to "thoracic trauma".Work describes 58 patients (2 hadthoracic injuries). Recommended treatment for penetrating injury was freshmeat poultice the first day, followed by grease, honey and lint on subsequentdays
b. If detectable, there is an immediate life-threat. Convert to a closedpneumothorax.Immediatelycoverwithglovedhand.Then…(1) Askacooperativepatienttomaximallyexhaleorcough(2) Immediately apply occlusive dressing (Vaseline gauze, plastic wrap,
defib pad or commercial device). Dressings should be at least 3 or 4timesthesizeofthedefect.
ofocclusivedressing.c. Intubateifnecessaryandmonitorventilationsd. Oxygen 12-15 L/NRM; assist with BVM as necessary. Use positive pressure
ventilationswith caution inpatientswhohavepenetrating chestwounds.Highventilatory pressuresmay force air from an injured bronchus into an adjacentopenpulmonaryvein,producingsystemicairemboli.Thismayaccountformanyof the dysrhythmias and sudden deaths that occur in patients with severepenetratingchestwounds.
e. AdministersedativescautiouslyperOLMCtoallowforcontrolofventilationsf. Tension pneumothorax usually does not occur in the presence of an open
pneumothorax but may develop ifpenetratingwoundhasaone-way flapor issealedwithanocclusivedressing.If patient becomes dyspneic and BPdrops, assess for tensionpneumothorax and temporarily lift orremovedressingtoreleasepressure.
g. Assess need for needle pleuraldecompression if no improvementfollowingremovalofdressing
h. Noprobingofwounds(1) Givesnoinformation(2) Maycreateafalsepassage(3) Precipitateshemorrhage(4) Mayconvertaclosedtoanopenpneumothorax
C. Flailchest1. Mostsevereformofbluntchestwallinjury.2. Mechanismofinjury:usuallyduetobluntchesttrauma
a. HighspeedMVCb. Fallsc. Auto-pedestriantraumad. Motorcycletraumae. Severecompressiontrauma
3. Pathophysiology
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a. Flailchestoccurswhentwoormoreadjacentribsand/orcartilagesonbothsidesof an impact point are broken at two points resulting in a freely mobile or"floating"segment.
b. Maybeidentifiedbylocationorsize(1) Anterior,posterior,orlateral(2) Separationof thesternumfromadjacentbrokenribsorcostochondral
joints:sternalflailchestc. Freesegmentmovesseparatelyand intheoppositedirection (paradoxically) to
the rest of the thoracic wallduringtheventilatorycycle.
d. Paradoxicalmotionoftheflail
segment interferes with thenormal inspiratory/expiratorycycle due to the lack of bonysupport and changes inintrathoracicpressures.
e. Subatmospheric intrathoracic pressure during inspiration pulls the segmentinward. Positive intrathoracic pressures during expiration move the segmentoutward.
f. The most significant life-threat accompanying flail chest is the insult to lungparenchymathatcreatesapulmonarycontusion.Contusedlungproducesmorethan the normal amount of interstitial and intra-alveolar fluid resulting inimpaired gas exchange. Pulmonary contusion occurs in 30-75% of all bluntthoracictrauma(East,2006)andisthemajorcauseofrespiratorycompromise.
g. Localeffects(1) Lacerationtolungtissue(2) Hemorrhage-filledalveoli(3) Reducedcomplianceleadingtoreducedventilation(4) Increased shunt fracture with decrease in pO2 and increase in AaDO2
h. Pain from multiple rib fractures discourages breathing effort. Even if madeinitially, fatigue, CNS depression, or increased tracheobronchial secretions willeventuallyoutweighanypatientefforts.
i. Hypoventilation,impairedoxygendiffusion,pulmonaryphysiologicshuntingandvenous admixture results in a decreased PaO2, decreased lung compliance,decreased tidal volume and vital capacity, and decreased venous return withventilation/perfusion (VA/Q) mismatch. CO2 retention results in hypercarbia.Impairedcoughresultsinatelectasis.
4. Morbidity/mortalitya. Forces sufficient to produce a flail chest, are also sufficient to cause
pneumothoraxandseriousinjurytotheunderlyinglung.b. Mortality rates of 10% to 20% are typically accompanied by a significant
b. Gainairwaycontrol;suction.(1) Intubation andmechanical ventilation should be avoided (East, 2006).
Mechanical ventilation should beused to correct abnormalities of gasexchangeratherthantoovercomeinstabilityofthechestwall.
(2) Clinical signs of progressive fatigue and deterioration should promptintubationandmechanicalventilations.(a) Respiratoryrate>35or<8breaths/min(b) PaO2<60mmHgatFiO2>50%(c) PaCO2>50mmHgatFiO2>50%
c. CPAP:AtrialofmaskCPAPshouldbeconsideredinalert,compliantpatientswithmarginal respiratory status regimen (EAST, 2006). No external mechanicalstabilizationorsplintingoftheflailsegmentisindicated.(1) WhyisCPAPhelpful?
(2) ContraindicationsforCPAP:(a) DecreasedLOC(b) Unabletomaintainpatentairway(c) Aspirationrisk;inabilitytoclearsecretions(d) Needforimmediateintubation(e) Needforventilatoryassistance(f) ECGinstability(g) Evidenceofpneumothorax(h) Gastricdistention(i) ↑ICP(j) Facial trauma/burns or recent surgery to face/mouth that
effectsofpaini.e.,splinting,atelectasis,andhypoventilation.Somepatientsmaydesaturate purely from inadequate pain management. Use of narcotic agentsmaydecreasetherespiratorydrive,worsenhypoxia,andcause↓BPandshouldbeusedwithextremecautioninthepresenceofchesttrauma.Balanceriskwithbenefit in the field. Alternative pain interventions are used at the hospital likeepiduralanalgesiaandlocalnerveblocks.
h. Noexternalsplintingindicatedi. If patient suffers a cardiac arrest: an impedance thresholddevice (ResQPod) is
contraindicated7. Complications
a. **Flail chest servesas a red flag for significantunderlying intrathoracic injury,usually pulmonary contusion. Also suspect intrathoracic injuries such ashemothoraxandpneumothorax.SuspectifSpO2remains<90despite15LO2.
b. Pneumoniamay occur secondary to a combination of factors: hypoventilation,intubation,aspiration,inadequatepainmanagement,atelectasis,andpoolingofsecretions.
c. Prolonged tracheal intubation can lead to associated complications such astrachealstenosis,vocalcordparalysis,andvocalcordulceration.
d. Long-termsymptomsincludecomplaintsofdyspneaandchestpain.VI. C:Circulation=Injuriesthatjeopardizecirculation/perfusion
A. Assessforhemodynamicstability1. Mental status: Restlessness, progressive agitation, mental confusion and irrational or
(regular/irregular), location (carotid, femoral, or radial), symmetry, deficit, or loss oninhalation (pulsusparadoxus). Tachycardia isnot specific toonecause,butmaygiveanindicationofshock.
a. Heartsoundsarebestnotedoverthefollowingareas:(1) Mitralvalve:5thleftintercostalspace(LICS)inthemidclavicularline(2) Tricuspidvalve:lowerleftsternalborderatthe4thintercostalspace(3) Aorticvalve:2ndrightintercostalspaceatthesternalborder(4) Pulmonicvalve:2ndleftintercostalspaceatthesternalborder
a. Heart sounds are often difficult to assess while examining the multiplytraumatized patient. However,muffled or distant heart tones are noteworthybecausethisfindingmayindicatecardiactamponadeoratensionpneumothoraxwithsignificantmediastinalshift.
6. ShiftofapicalimpulseB. Because many of the organs in the chest are so vascular, hemorrhagic shock is a common
complication. The lungsarea lowpressure system.Continuoushemorrhage indicates ruptureofmajorvessel.1. Chest trauma patients in shock had a mortality of 7%. If respiratory distress was also
In addition, 15% hadmyocardial contusion and 7% had SCIwhich can contribute to hypotension from decreasedmyocardialcontractilityanddiminishedsympathetictone.
b. Penetratingchesttrauma(1) Intrathoracicbleeding(74%)oftenfrommultiplesites:
1. Definition: Tamponade comes from the French word, "tampon", meaning "to plug".Pericardialtamponadeliterallymeansapluginthepericardialsac.Itpracticallymeansanaccumulation of blood and/or clot in the pericardium causing an increase inintrapericardialpressure.
2. Etiology: Can occur with blunt or penetrating trauma, however, penetrating is morecommon from small projectiles (ice pick or stilettoknife).Becauseblunttraumacausessuchalargetear,the patient generally exsanguinates before the lesioncansealover.
3. Epidemiologya. Incidence
(1) Occurs in less than 2% of chesttrauma
(2) Tamponade occurs in 10% ofpatients with blunt chest trauma(Yamamotoetal,2005).
b. Morbidity/mortality(1) Estimatedmortality15-60%(2) Gunshotwoundscarryhighermortalitythanstabwounds(3) Lowermortalityifisolatedtamponadeispresent(4) Clinical severity depends on pericardial compliance, rate of fluid
a. Thepericardiumisatough,fibroussac,enclosingtheheartandattachingtothegreatvesselsatthebaseastheyleavetheheart
b. Visceralandparietal layersservetoanchortheheart, restrictingexcessmotionduringaccelerationorrepositioningofthebody.Theyalsopreventkinkingofthegreatvessels.
c. Thespacebetweenthelayersisa“potentialspace”d. Parietal,fibrousportionisnon-distensible.Spaceisnormallyfilledwith30-50ml
of straw-colored fluid secreted by the visceral pericardium. Fluid provideslubrication,lymphaticdrainageandimmunologicprotectionfortheheart.
5. Pathogenesisofpericardialtamponadea. Bleeding from the myocardium or
coronary arteries accumulates in thepericardialsac.Thepericardiumhasanon-linear pressure compliance curve. In
Chest and Abdominal Trauma Case Studies Page 16 NWC EMSS CE November 2015
b. Intraumaticinjury,rapidlyaccumulatingamountsof>50mLcanoveraperiodofminutes to hours increases intrapericardial pressure and overcomes thecompliancecurveasthereisnotimeforthetissuestostretchandaccommodatefor theexcess fluid.Themostcompressible structureswithin thesaccollapse -atria,greatveins.
c. The combinationof pressure and vascular collapsedecreases venous return totherightsideoftheheart (preload),restrictsdiastolicexpansionandfillingandreducesstrokevolume.
d. Initially, mechanisms such as an increased heart rate, increased myocardialcontractility, and an increase in ventricular filling pressure are used tocompensateforthedecreaseinstrokevolume(CO=SVXHR).
e. Once the limits of compensation are reached, further increases in pericardialvolumecauseasevereimpairmentofcardiacfunctioning.
f. Myocardialperfusiondecreasesduetopressureeffectsonthewallsoftheheartanddecreaseddiastolicpressures.
g. Ischemicdysfunctionmayresultininfarctionh. Becauseofthedynamicsofthepressurecompliancecurve,removalofaslittleas
20to50mlofbloodmaydrasticallyimprovecardiacoutputi. Samemechanism of death as a tension pneumothorax = Inadequate venous
returnanddecreasedCO.6. Assessment
a. Clinicalpresentationdependsontheinteractionbetweenpericardialcompliance,rateoffluidaccumulation,andtheamountoffluidpresentinthepericardium.
b. Beck'striad:advancedstagesseeninonly30%ofpatients(1) JVD(firstsign):Kussmaul’ssign(neckveinsfillduringinspiration,empty
duringexpiration)(2) Decreased arterial pressure (Systolic BP less than100mmHg); pulsus
c. Evidenceofshock/hypoxemia(1) Thready/absentperipheralpulses (PEA):peripheralpulse0 (absent)or
1+ (thready of a 4+ scale). Cardiac arrest may occur secondarily tounrecognizedpericardial tamponade. Patientswhosurvivearrestmaysustain other complications such as sepsis, anoxic encephalopathy, orischemicbowelifthearrestisprolonged
a. Gainairwaycontrol;12-15Loxygenb. IVNStoachieveaminimumSBPof80.c. MonitorforPEA:TreatperTraumaticArrestSOPwhileenroute.d. Pericardiocentesis is a controversial temporizing interventiondue to the riskof
possiblecardiacdamage.Itmayelicitmarkedimprovementinthepatientwhoishemodynamicallycompromisedifenoughbloodisremovedfromthepericardialsac to allow right heart filling again. This procedure is NOT done in the NWCEMSS.
e. PrepareresuscitativeequipmentD. Massivehemothorax
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1. Definition: Accumulationof 1500mLormoreblood in thepleural space (Class III or IVhemorrhage).Pleuralspacescanholdtheentirebloodvolume.
Chest and Abdominal Trauma Case Studies Page 18 NWC EMSS CE November 2015
b. 12-15Loxygen;assistventilationsasnecessaryc. InsertlargeboreperipheralIVlined. AdministerNStocorrecthypotensiontominimumacceptablelevels(SBP80with
penetratingtraumaand90withblunttrauma).Ifhypotensionlastslessthan30minutes,mortalitymayonlybe11%.Ifhypotensionisprolonged:mortalityrisesto40%-50%.Ifpatienthasunderlyingdisease& is 65 years or older, the mortality withhypotension for > 30 minutes may be over90%.
e. Hospitals will insert chest tubes, perhapsautotransfuse the patient and determine ifrapidoperativeinterventionisnecessary.
E. Myocardialrupture1. Associatedwith immediate traumaordelayed for2-3
weeks2. Associated with blunt trauma as the heart is compressed between the sternum and
once thought.Anyblow to thechest, regardlessof its intensityorvelocityor force is capableofproducing cardiac arrest, especially in younger children whose rib cages are narrow and haveunderdeveloped chest muscles. Patients have experienced death due to a blow from softballs,baseballs,hollowtoybaseballbats, snowballs, chestblowsduringshadowboxing,playingwithafamilydogortryingtoremedyhiccups(Cooke,2002).
G. Traumaticasphyxia1. Pathophysiology
a. Suddencompressionalforcesqueezesthechestb. Vascularpressureincreasesinthehead,neck,andkidneysc. Jugularveinsengorge,capillariesrupture
2. Clinicalpresentationa. Inspection
(1) Bluntchesttrauma,mayhaveflail(2) Profoundshock(3) Cyanosisofface,neck,andshoulder(4) Swellingorhemorrhageof the conjunctiva;mayexhibit exophthalmos
D. Continue to use maneuvers of inspection, palpation, percussion and auscultation to detectadditionalinjuries.1. Chest wall injuries are characterized by pain, ineffective ventilation, and secretion
retention2. Injuries to the lung includepulmonarycontusionsandhematomas.Bothcausebleeding
(1) Isthmusatligamentumarteriosum 85%(2) Aorticannulus 9%(3) Diaphragm 3%(4) Other 3%
c. Whenthebodyisinmotionandcomestoasuddenhalt,shearingforcesorstresson fixation points cause tears of the intimal layer at points of attachment or
Chest and Abdominal Trauma Case Studies Page 20 NWC EMSS CE November 2015
thinningwhichallowsittoseparatefromthemedia.d. Mediaandadventitiaaremoreelasticandmaynottearinitiallye. Blood dissects between the two layers causing a bulge on the vessel (false
aneurysm).4. Assessment
a. In those who are not immediately exsanguinating, the physical exam may beunremarkable. There are no specific symptoms… patients present with a vastspectrumofclinicalfindings.Maintainahighindexofsuspicion.
b. Inspection(1) Complaintofretrosternalchestorinterscapularpain(80%)(2) Ischemicpainoftheextremities(3) Signsofhypovolemicshock;pallor(4) Severedyspnea,stridor(5) Decreasinglevelofconsciousness,restlessness,apprehensiveness(6) Dysphagia(fromhematoma-inducedesophagealcompression)(7) Hoarseness(fromhematoma-inducedlaryngealcompression)
c. Palpation(1) Pulsedifferentialbetweenarmsorgreaterpulseamplitudeinarmsthan
in legs (may reflect ruptured descending aorta), decreased or absentfemoralpulses
(2) Trachealshift(3) Tachycardia.
d. Auscultation(1) Hypotension-25%duetoleakageandhypovolemia(2) Hypertension-25%duetostretchingofsympatheticnervesintheaorta
e. Besuspiciousif:(1) +physicalexam;decreasedBPtolowerlimbs;(2) 1st-2ndribfracture;(3) sternalfracture;or(4) significantdeceleration>35mph.
5. ClinicalS&Sa. Respiratorydistressb. Signsofpericardialtamponadec. Physicalevidenceofmajorchesttraumae.g.,steeringwheelimprintonchestd. Pulse differential between arms or between upper and lower extremities:
BP may complete the separation or rupture the remaining vascular walls.
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Permissivehypotensionispreferred.d. Monitorthepatient'sresponsetofluidadministration;VSe. Monitorfordysrhythmiasandalterationsinconsciousnessf. Time sensitive patient. They need immediate surgical intervention. Transport
3. Morbidity: Rarely fatal alone, but may cause significant morbidity. Mortality: 8-20%;deaths secondary to dysrhythmias or ventricular failure. May be the most commonunsuspectedvisceralinjuryfoundafterfatalcrashes.
a. Chiefcomplaint isoftenretrosternalchestpainorshortnessofbreath:typicallysharp and well localized but may mimic ischemic pain. Often difficult todistinguishfromchestwallpain.
b. Inspect forecchymosisonanteriorchest,complaintof retrosternalangina,andsigns of hemodynamic instability and cardiogenic shock (but be aware thatpatientmaybeasymptomatic).
c. Palpateforpointtenderness,crepitusoversternumorribsd. Auscultateforcrackles,hearttonesandforapericardialfrictionrub;S3gallope. ECGs: Abnormal in 40%-80% of contusions, but abnormal in 50% of patients
withoutcontusionswithchesttrauma.(1) Cardiac injury causes alterations in cardiac depolarization and
repolarizationandcardiacischemia.ECGchangesareoftennotedwithin24 hours and return to normal in a much shorter time than thoseproduced by myocardial infarction. Most resolve spontaneously,without treatment. One of the limitations of the conventional ECG isthat the recordings are dominated by the larger mass of the leftventricle,while themore anteriorly placed RV is themore commonlyinjured chamber. The ECG is therefore not a sensitive or specificindicator ofMC. Use only to increase index of suspicion. There is notypicalECGpatternforcardiaccontusion.
(2) Dysrhythmias: 90% present at impact. Should revert to normal in 3-4months.(a) Persistenttachycardia(b) DeathinfieldcausedbyVTorVF(c) Atrialflutter/fib(d) PACs,PVCs-frequentlyresolvebyarrivalathospital
b. Alveolarandcapillarydamagec. WBCandplateletaggregationinpulmonaryvesselsleadstoreleaseofvasoactive
substancesd. Loss of pulmonary capillary integrity with increased membrane permeability;
movement ofwater andplasmaproteins into alveolar and interstitial spaces =interstitialedemaandcongestiveatelectasis
e. Surfactantdilutionresultsindecreasedlungcompliancef. The amount of oxygen delivered across the pulmonary capillary bed in the
injured segment is decreased resulting in hypoxemia and carbon dioxideretention.
g. Hypoxiacausesreflexthickeningofmucoussecretions(1) Bronchiolarobstruction(2) Atelectasis
h. If the contusion is large, thebody compensatesby vasoconstrictingpulmonaryblood flow and increasing cardiac output to shunt blood around the area ofminimaloxygenation.There isdeceased functional reservecapacitydue to this
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pulmonary shunting which causes mixed venous blood to be returned to theheartresultinginfurtherhypoxemia.
5. Assessmenta. The adverse effects of pulmonary contusion usually do not become clinically
evidentuntil24hoursafterinjury.b. Inspection
(1) Signs of respiratory distress, dyspnea, tachypnea, restlessness,apprehension
a. Incidence:Rare:lessthan3%ofchesttraumab. Trachealinjuriesareusuallycausedbypenetratingtraumac. Bronchialinjuriesareusuallycausedbydeceleration(blunt)mechanismsd. Morbidity/mortality: High mortality rate: greater than 30% due to associated
airway obstruction. Majority of the patients die at the scene secondary toasphyxia.
(1) Tracheobronchial rupture/tear via blunt trauma occurs secondary tocrushing or compressive injury that causes a sudden decrease in
Chest and Abdominal Trauma Case Studies Page 26 NWC EMSS CE November 2015
anterior/posterior diameter and increase in lateral diameter (i.e., lapbelt across the throat inMVC). Since the lungsmaymove laterally inresponse to the force, the trachea/bronchimay transect secondary toexceededstretch.
(2) Thecricoidringandcarinaserveasfixedpointsforthetrachea.Whenthere is an acute acceleration/deceleration force, a shearing force isproducedatthesefixedpointsandcreatesatrachealinjury.
(4) Rapid increase in intrathoracic pressures concomitant with a closedglottis may produce a "blowout" injury to the trachea with a linearrupture.(Similartomechanismprecipitatingclosedpneumothorax.)
K. Sternalfracture1. Epidemiology
a. Incidence:5-8%ofallthoracicinjuriesb. Mechanism of injury is anterior blunt chest trauma at or below the
manubriosternal junction. Classic example is when the chest hits the steeringwheelordashboardinanMVC.Otherinjurymechanismsincludedirectblowtothesternumorcompressionofthesternumassociatedwithhyperflexionsternalinjury
c. Potential lifethreatening injuries includemyocardialcontusion,cardiacrupture,cardiactamponade,orseverepulmonaryinsult
d. Morbidity/mortality(1) 25-45%mortality(2) Highassociationwithmyocardialorlunginjury
b. Morbidity/mortality:Dependsonextentofatelectasisandassociatedinjuries
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c. Classificationofpneumothoraxisdeterminedbythedegreeofcollapse:(1) Small:15%orlessoccupationofthepleuralcavity(2) Moderate:15%-60%occupationofthepleuralcavity(3) Large:60%orgreateroccupationofthepleuralcavity
a. Incidenceandsignificance(1) Most common thoracic injury; seen in more than 50% of cases with
significant blunt chest trauma. Significant chiefly because the paininvolvedinhibitsthepatientfromtakingadequatebreaths.
(2) Pediatric patients have cartilaginous ribs that bend easily. Theyexperiencedecreasedincidenceoffractures,butincreasedincidenceofpulmonaryinjury.
(3) Geriatricpatientshavecalcifiedribsthatarelessflexibleandmoreeasilyfractured. Also tend to have increased morbidity due to co-morbidconditionsanddecreasedpulmonaryreserves.
b. Etiology(1) Causedbydirectblowstothechest:Mechanismusuallyassociatedwith
(4) Morbidityincreaseswiththenumberoffractures,extremesofage,andassociated chronic respiratory or cardiac conditions - especially in theelderly. Two or more rib fractures are associated with an increasedincidenceofinternalinjury
2. Pathophysiologya. Becausetheribsarepartofaring,whenaribbreaks…b. Decreasedminuteventilationduetosplintingfrompainc. Whenever a person breathes shallowly, for any reason, the alveoli do not get
fullyinflated;littlebylittle,theybegintocollapseandtheprogressiveatelectasismakes the lungs more vulnerable to pneumonia. Additionally, there may bedecreased surfactant production that normally lowers surface tension andfacilitates alveolar opening. This results in shunting of blood to nonventilatedalveoli that can lead to arterial hypoxemia, plugging of proximal airways,segmentalandlobarcollapse,pneumonia,andbronchiectasis.
3. Concomitantinjuriesa. 1st through 3rd ribs take great force to fracture. Assoc. w/ fractures of neck,
clavicle, scapula, and great vessel injury (subclavian artery/vein, aortic injury)severe intrathoracic injury (tracheobronchial injury, aortic rupture, and othervascularinjuries,especiallyifmultipleribsareinvolved.
b. Fractures of the ninth, tenth, and eleventh ribs are associated withintraabdominal injury: lower left rib fractures: splenic injury; lower right ribfractures:liverinjury.
c. Sternal fracturesareassociatedwithpulmonarycontusionand/orbluntcardiacinjury
6. Complicationsa. Pneumo/hemothoraxduetolacerationofbronchiorintercostalarteriesb. Pneumomediastinumc. Tensionpneumothoraxd. Non-unionoffracture;Costochondralseparatione. Pneumonia(largeprobleminelderly)f. Neurologicdeficitsiflacerationofintercostalnervesg. Pitfall: Do not underestimate the severe pathophysiology of rib fractures,
a. Optimizeventilations topreventatelectasis andpneumonia. Encouragepatienttocoughanddeepbreathe.Splintchestwithpillow.
b. Administeranalgesicstofacilitatechestwallmotion.CJM:S10;S15
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