Thoracic Trauma

1
Thoracic Trauma

• Temple College
• EMS Professions

2
Chest Trauma

• Second leading cause of trauma deaths after head
  injury
• About 20 of all trauma deaths

3
Chest Trauma

• Initial exam directed toward
• Open pneumothorax
• Flail chest
• Tension pneumothorax
• Massive hemothorax
• Cardiac tamponade

4
Rib Fracture

• Most common chest injury
• More common in adults than children
• Especially common in elderly
• Ribs form rings
• Consider possibility of break in two places

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Rib Fracture

• Most commonly 5th to 9th ribs
• Poor protection

6
Rib Fracture

• Fractures of 1st, 2nd ribs require high force
• Frequently have injury to aorta or bronchi
• 30 will die

7
Rib Fracture

• Fractures of 8th to 12th ribs can damage
  underlying abdominal solid organs
• Liver
• Spleen
• Kidneys

8
Rib Fracture

• Signs and Symptoms
• Localized pain, tenderness
• Increases when patient
• Coughs
• Moves
• Breathes deeply
• Chest wall instability
• Deformity, discoloration
• Associated pneumo or hemothorax

9
Rib Fracture

• Management
• High concentration O2
• Splint using pillow, swathes
• Encourage patient to breath deeply

10
Rib Fracture

• Management
• Monitor elderly and COPD patients carefully
• Broken ribs can cause decompensation
• Patients will fail to breath deeply and cough,
  resulting in poor clearance of secretions

11
Flail Chest

• Two or more adjacent ribs broken in two or more
  places
• Produces free-floating chest wall segment
• Usually secondary to blunt trauma
• More common in older patients

12
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

14
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
• Exertion
• Coughing
• Air 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
patients 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 leave
• Air is trapped in pleural space
• Pressure rises
• Pressure collapses lung

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Tension Pneumothorax

• Trapped air pushes heart, lungs away from injured
  side
• Vena cavae become kinked
• Blood cannot return to heart
• Cardiac 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
25
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 space
• Most common result of major chest wall trauma
• Present 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
• Head
• Neck
• Shoulders
• 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

34
Cardiovascular Trauma

• Any patient with significant blunt or penetrating
  trauma to chest has heart/great vessel injury
  until proven otherwise

35
Myocardial Contusion

• Bruise of heart muscle
• Most common blunt cardiac injury
• Usually due to steering wheel impact

36
Myocardial Contusion

• Behaves like acute MI
• May produce arrhythmias
• May cause cardiogenic shock, hypotension

37
Myocardial Contusion

• Signs and Symptoms
• Cardiac arrhythmias after blunt chest trauma
• Angina-like pain unresponsive to nitroglycerin
• Chest pain independent of respiratory movement

Suspect in all blunt chest trauma
38
Myocardial Contusion

• Management
• High concentration O2
• Transport
• Consider ALS intercept

39
Cardiac Tamponade

• Rapid accumulation of blood in space between
  heart, pericardium
• Heart compressed
• Blood entering heart decreases
• Cardiac output falls

40
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)

Becks Triad
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Cardiac Tamponade

• Signs and Symptoms
• Narrowing pulse pressure
• Pulsus paradoxicus
• Radial pulse becomes weak or disappears when
  patient inhales

42
Cardiac Tamponade

• Management
• Secure airway
• High concentration O2
• Rapid transport
• Definitive treatment is pericardiocentesis
  followed by surgery

43
Traumatic Aortic Aneurysm

• Caused by sudden decelerations, massive blunt
  force
• Vehicle collisions
• Falls from heights
• Crushing chest trauma
• Blunt chest trauma
• Animal kicks

44
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

45
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
46
Traumatic Aortic Aneurysm

• Management
• High concentration oxygen
• Assist ventilation
• Suspect spinal injury
• Rapid transport

47
Associated Abdominal Trauma

• Diaphragm forms dome that extends up into rib
  cage
• Trauma to chest below 4th rib Abdominal injury
  until proven otherwise

48
PowerPoint Source

• Slides for this presentation from Temple College
  EMS http//www.templejc.edu/dept/ems/pages/power
  point.html