Chest Trauma

Chest TraumaPrepared By: Bill MilanNREMT-P, CCEMT-P

ObjectivesAnatomy of ThoraxMain Causes of Chest InjuriesS/S of Chest InjuriesDifferent Types of Chest InjuriesTreatments of Chest Injuries

Anatomy of the chestTwo Lungs (right and left)HeartDiaphragm

Anatomy of the chestPleural Space

Anatomy of the chest

Main Causes of Chest TraumaBlunt Trauma- Blunt force to chest.

Penetrating Trauma- Projectile that enters chest causing small or large hole.

Compression Injury- Chest is caught between two objects and chest is compressed.

Injuries of chestSimple/Closed PneumothoraxOpen PneumothoraxTension PneumothoraxFlail ChestCardiac TamponadeTraumatic Aortic RuptureTraumatic AsphyxiaDiaphragmatic Rupture

Simple/Closed PneumothoraxOpening in lung tissue that leaks air into chest cavityBlunt trauma is main causeMay be spontaneousUsually self correcting

S/S of Simple/Closed PneumothoraxChest PainDyspneaTachypneaDecreased Breath Sounds on Affected Side

Treatment for Simple/Closed PneumothoraxABCs with C-spine controlAirway Assistance as neededIf not contraindicated transport in semi-sitting positionProvide supportive careContact Hospital and/or ALS unit as soon as possible

BLS Plus CareCardiac MonitorIV access and Draw Blood SamplesProvide Airway Management which includes possible IntubationMonitor for Development of Tension Pneumothorax

Open PneumothoraxOpening in chest cavity that allows air to enter pleural cavityCauses the lung to collapse due to increased pressure in pleural cavityCan be life threatening and can deteriorate rapidly

Open Pneumothorax

Open PneumothoraxInhale

Open PneumothoraxExhale

Open PneumothoraxInhale

Open PneumothoraxExhale

Open PneumothoarxInhale

Open PnuemothoraxInhale

S/S of Open PneumothoraxDyspneaSudden sharp painSubcutaneous EmphysemaDecreased lung sounds on affected sideRed Bubbles on Exhalation from wound ( a.k.a. Sucking chest wound)

Subcutaneous EmphysemaAir collects in subcutaneous fat from pressure of air in pleural cavityFeels like rice crispies or bubble wrapCan be seen from neck to groin area

Sucking Chest Wound

Treatment for Open PneumothoraxABCs with c-spine control as indicatedHigh Flow oxygen Listen for decreased breath sounds on affected sideApply occlusive dressing to woundNotify Hospital and ALS unit as soon as possible

Occlusive Dressing

Occlusive DressingAsherman Chest Seal

BLS Plus CareMonitor Heart RhythmEstablish IV Access and Draw Blood SamplesAirway Control that may include IntubationMonitor for Tension Pneumothorax

Tension PneumothoraxAir builds in pleural space with no where for the air to escapeResults in collapse of lung on affected side that results in pressure on mediastium,the other lung, and great vessels

Tension PneumothoraxEach time we inhale,the lung collapses further. Thereis no place for the air toescape..

Tension PneumothoraxHeart is beingcompressedThe trachea ispushed tothe good side

S/S of Tension PneumothoraxAnxiety/RestlessnessSevere DyspneaAbsent Breath sounds on affected sideTachypneaTachycardiaPoor ColorAccessory Muscle UseJVDNarrowing Pulse PressuresHypotensionTracheal Deviation(late if seen at all)

Treatment of Tension PneumothoraxABCs with c-spine as indicatedHigh Flow oxygen including BVMTreat for S/S of ShockNotify Hospital and ALS unit as soon as possibleIf Open Pneumothorax and occlusive dressing present BURP occlusive dressing

BLS Plus CareMonitor Cardiac RhythmEstablish IV access and Draw Blood SamplesAirway control including IntubationNeedle Decompression of Affected Side

Needle DecompressionLocate 2-3 Intercostal space midclavicular lineCleanse area using aseptic techniqueInsert catheter ( 14g or larger) at least 3 in length over the top of the 3rd rib( nerve, artery, vein lie along bottom of rib)Remove Stylette and listen for rush of airPlace Flutter valve over catheterReassess for Improvement

Needle Decompression

Flutter ValveAsherman Chest Seal makes good Flutter Valve .Also can use a Finger from a Latex Glove Or A Condom works also

HemothoraxOccurs when pleural space fills with bloodUsually occurs due to lacerated blood vessel in thoraxAs blood increases, it puts pressure on heart and other vessels in chest cavityEach Lung can hold 1.5 liters of blood

Hemothorax

HemothoraxMay put pressure on the heart

HemothoraxLots of blood vesselsWhere does the blood come from.

S/S of HemothoraxAnxiety/RestlessnessTachypneaSigns of ShockFrothy, Bloody SputumDiminished Breath Sounds on Affected SideTachycardiaFlat Neck Veins

Treatment for HemothoraxABCs with c-spine control as indicatedSecure Airway assist ventilation if necessary General Shock Care due to Blood lossConsider Left Lateral Recumbent position if not contraindicatedRAPID TRANSPORTContact Hospital and ALS Unit as soon as possible

BLS Plus CareMonitor Cardiac RhythmEstablish Large Bore IV preferably 2 and draw blood samplesAirway management to include IntubationRapid TransportIf Development of Hemo/Pneumothorax needle decompression may be indicated

Flail ChestThe breaking of 2 or more ribs in 2 or more places

Flail Chest

S/S of Flail ChestShortness of BreathParadoxical MovementBruising/SwellingCrepitus( Grinding of bone ends on palpation)

Flail Chest is a True Emergency

Treatment of Flail ChestABCs with c-spine control as indicatedHigh Flow oxygen that may include BVMMonitor Patient for signs of Pneumothorax or Tension PneumothoraxUse Gloved hand as splint till bulky dressing can be put on patientContact hospital and ALS Unit as soon as possible

Bulky Dressing for splint of Flail ChestUse Trauma bandage and Triangular Bandages to splint ribs.Can also place a bag of D5W on area and tape down. (The only good use of D5W I can find)

BLS Plus CareMonitor Cardiac RhythmEstablish IV accessAirway management to include IntubationObserve for patient to develop Pneumothorax and even worse Tension PneumothoraxIf Tension Develops Needle Decompress affected sideRapid Transport! Remember a True Emergency

Pericardial TamponadeBlood and fluids leak into the pericardial sac which surrounds the heart.As the pericardial sac fills, it causes the sac to expand until it cannot expand anymorepericardial sac

Pericardial TamponadeOnce the pericardial sac cant expand anymore, the fluid starts putting pressure on the heart

Now the heart cant fully expand and cant pump effectively.

Pericardial TamponadeWith poor pumping the blood pressure starts to drop.The heart rate starts to increase to compensate but is unableThe patients level of conscious drops, and eventually the patient goes in cardiac arrest

S/S of Pericardial TamponadeDistended Neck VeinsIncreased Heart RateRespiratory Rate increasesPoor skin colorNarrowing Pulse PressuresHypotensionDeath

Treatment of Pericardial TamponadeABCs with c-spine control as indicatedHigh Flow oxygen which may include BVMTreat S/S of shockRapid TransportNotify Hospital and ALS Unit as soon as possible

BLS Plus CareCardiac MonitorLarge Bore IV access Rapid TransportWhat patient needs is pericardiocentesis, Although not accepted practice in KY pre-hospital setting( exception is that the Flight nurses of STATCARE may perform this procedure in KY)

PericardiocentesisUsing aseptic technique, Insert at least 3 needle at the angle of the Xiphoid Cartilage at the 7th ribAdvance needle at 45 degree towards the clavicle while aspirating syringe till blood return is seenContinue to Aspirate till syringe is full then discard blood and attempt again till signs of no more bloodClosely monitor patient due to small about of blood aspirated can cause a rapid change in blood pressure

Pericardial Tamponade

Is A Dire Emergency

Traumatic Aortic RuptureThe heart, more or less, justhangs from the aortic archMuch like a big pendulum.

If enough motion is placed onthe heart (i.e.. DecelerationFrom a motor vehicle accident, striking a tree while skiing etc) the heart may tear away from the aorta.

Traumatic Aortic RuptureThe chances of survival arevery slim and are based on thedegree of the tear.

If there is just a small tear thenthe patient may survive. If theaorta is completely transectedthen the patient will die instantaneously

S/S Of Traumatic Aortic RuptureBurning or Tearing Sensation in chest or shoulder bladesRapidly dropping Blood PressurePulse Rapidly IncreasingDecreased or loss of pulse or b/p on left side compared to right sideRapid Loss of Consciousness

Treatment of Traumatic Aortic RuptureABCs with c-spine control as indicatedHigh Flow oxygen that may include BVM Treatment for ShockRAPID TRANSPORTContact Hospital and ALS Unit As soon as possible

BLS Plus CareMonitor Cardiac RhythmLarge Bore IV therapy probably 2 and draw blood samplesAirway management that may include IntubationRAPID TRANSPORTWHAT PATIENT NEEDS IS BRIGHT LIGHTS AND COLD STEEL

Traumatic AsphyxiaResults from sudden compression injury to chest cavityCan cause massive rupture of Vessels and organs of chest cavityUltimately Death

S/S of Traumatic AsphyxiaSevere DyspneaDistended Neck VeinsBulging, Blood shot eyesSwollen Tounge with cyanotic lipsReddish-purple discoloration of face and neckPetechiae

Treatment for Traumatic AsphyxiaABCs with c-spine control as indicatedHigh Flow oxygen including use of BVMTreat for shockCare for associated injuriesRapid TransportContact Hospital and ALS Unit as soon as possible

BLS Plus CareCardiac MonitorEstablish IV Access and draw blood samplesAirway control including IntubationRapid transport

Diaphragmatic RuptureA tear in the Diaphragm that allows the abdominal organs enter the chest cavityMore common on Left side due to liver helps protect the right side of diaphragm Associated with multipile injury patients

Diaphragm Rupture

S/S of Diaphragmatic RuptureAbdominal PainShortness of AirDecreased Breath Sounds on side of ruptureBowel Sounds heard in chest cavity

Treatment of Diaphragmatic RuptureABCs with c-spine control as indicatedHigh Flow oxygen which may include BVMTreat Associated InjuriesRapid TransportContact Hospital and ALS Unit as soon as possible

BLS Plus CareCardiac Monitor Establish IV access and draw blood samplesAirway management including IntubationObserve for Pneumothorax due to compression on lung by abdominal contentsPossible insertion of NG tube to help decompress the stomach to relieve pressureRapid transport, Patient needs BRIGHT LIGHTS AND COLD STEEL

SummaryChest Injuries are common and often life threatening in trauma patients. So, Rapid identification and treatment of these patients is paramount to patient survival. Airway management is very important and aggressive management is sometimes needed for proper management of most chest injuries.

When Minutes MatterStatcare phone number: 1-888-729-9111Statcare web site:www.statcare.org

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Chest Trauma

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