CHAPTER 23T H O R A C I C T R A U M A

OBJECTIVES

23.1 List the major anatomical structures of the thoracic cavity.

23.2 Describe the basic physiology of thoracic structures.

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OBJECTIVES

23.3 Describe the pathology of the following thoracic injuries:

a. flail chestb. pneumothoraxc. hemothoraxd. tension pneumothoraxe. sucking chest woundf. pericardial tamponade

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OBJECTIVES

23.4 List the signs and symptoms of various thoracic injuries.

23.5 Describe and demonstrate how to assess the chest for trauma, using the L.A.P. method.

23.6 Describe and demonstrate the emergency management of a sucking chest wound.

ANATOMY AND PHYSIOLOGYOF THE CHEST

Thorax: Protected by bony structures

Two major organs: Lungs (trachea, and esophagus)

Aveoli, capillary nets Pleuras: visceral and parietal

Heart and great vessels Pericardium

ANATOMY AND PHYSIOLOGYOF THE CHEST

Diaphragm is the primary muscle of respiration Controlled by two phrenic nerves located at C3, C4, and C5 Assisted by intercostals

Breathing process Lungs fill and empty due to pressure changes within the chest as muscles

contract and relax Gas exchanges in aveoli

CHEST INJURIES

Closed Blunt trauma Fall or collision

Open Penetration of chest Compression

Indirect

Inertia Deceleration

TYPES OF CHEST INJURIES

Contusions

Fractures and dislocations

Flail chest

Pnuemothorax/ Hemothorax

Pericardial tamponade

Aortic tear or rupture

Commotio cordis

Traumatic asphyxia

CONTUSIONS

External from minor blunt trauma

Pulmonary = lung tissue bruise Fluid/blood in alveoli compromise

gas exchange, leads to hypoxia Occurs often with rib fractures

Myocardial = heart bruise Less effective contractions Arrhythmia Cardiogenic shock

FRACTURES AND DISLOCATIONS

Suspect internal damage

Painful – self splinted often

Rib May lacerate lung tissues

Flail chest Two or more ribs/fractures Paradoxical motion Hypoxia

FRACTURES AND DISLOCATIONS

Scapula Severe trauma Serious internal injury

Sternum Severe underlying organ damage Severe trauma – entire flail segment

Sternoclavicular joint Posterior dislocation puts pressure on the great vessels to the heart

PNEUMOTHORAX

Air in the pleural space Trauma (blunt or penetrating) Spontaneous Compressive forces

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PNEUMOTHORAX

Penetrating wounds create differential pressure Sucking chest wound Collapsed lung possible

Blow to chest may cause lung to burst

TENSION PNEUMOTHORAX

Pressurized air in pleural space From burst or punctured lung

Organs are compressed, lungs may collapse

Vena cava may collapse

Life threatening

Rescue breathing (BVM) may cause or make worse

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TENSION PNEUMOTHORAX

May occur spontaneously – no trauma

Signs and Symptoms Shortness of breath Jugular vein distention (JVD) Low BP Cyanosis Decreased lung sounds Tracheal deviation (late sign)

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TENSION PNEUMOTHORAX

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TENSION PNEUMOTHORAX

Subcutaneous emphysema Air under the skin – Rice Krispies® crackling

HEMOTHORAX

Blood in pleural space Blunt or penetrating injury

Arterial bleeding leads to hypovolemic shock

Hemopneumothorax = blood and air in pleural space Multi-system trauma Life threatening

HEMOTHORAX

PERICARDIAL TAMPONADE

Bleeding/fluid inside the pericardial sac Blunt or penetrating trauma Rupture of a cardiac vessel Bacterial sepsis, viral infection

Pressure on heart impairs function

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PERICARDIAL TAMPONADE

Pain, shortness of breath, neck vein distention are early signs and symptoms

Muffled heart sounds, drop in pulse pressure come later

PERICARDIAL TAMPONADE

AORTIC RUPTURE AND DISSECTION

Often lethal

Deceleration/inertia injury

Massive bleeding/hypovolemic shock and death

Partial thickness tear may lead to aneurysm, later rupture

Signs and symptoms are acute chest or back pain, signs of profound shock

AORTIC RUPTURE AND DISSECTION

COMMOTIO CORDIS

Sudden cardiac death due to blunt thoracic trauma that interrupts the electrical activity of the heart, usually following a direct blow to the chest

TRAUMATIC ASPHYXIA

Pressure on chest wall prevents expansion

Compressive injury as from avalanche

Massive rib cage fractures where chest is unable to expand

Ruptured blood vessels in face, neck, and eyes causing discolorations

TRAUMATIC ASPHYXIA

ENVIRONMENTAL FACTORS

Altitude can complicate thoracic injuries

Descent in elevation is necessary

Helicopter evacuation may be contra-indicated with thoracic injuries

ASSESSMENT

Standard assessment procedures to start – ABCDs and vitals

Observe skin color and neck veins

Look for self-splinting

If breathing is a major concern, suspend secondary exam and transport

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MANAGEMENT

Sever symptoms - “Load and go”

Do CPR, use AED

Open airway of avalanche victim ASAP

High flow oxygen, assist ventilations Worsening condition here = tension pneumothorax

L —Look A —Auscultate P —Palpate

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MANAGEMENT

Use occlusive dressing with sucking chest wound

Spinal involvement needs backboard

Control bleeding in usual manner

Splint flail segments

Consider patient comfort with O2, BVM

Leave impaled objects in place

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MANAGEMENT

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MANAGEMENT

Match transport position to patient’s breathing needs

Treat/position for shock

SUMMARY

Both blunt and penetrating chest injuries can be life threatening.

Maintain a high index of suspicion for chest injury based on the mechanism of injury.

Assess the entire chest, including the upper back and armpits. Provide oxygen to any patient with a suspected chest injury.

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CHAPTER SUMMARY

Treat sucking chest wounds with an occlusive dressing.

If the condition of a hypoxic patient with chest trauma worsens, consider a tension pneumothorax.