Copyright © 2007, 2004, by Mosby, Inc., an affiliate of ...brainspew.com/advanced/emt/notes/Chapter_027.pdf · Title: Microsoft PowerPoint - Chapter_027.ppt Author: manoj.naik Created

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Slide 1Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Chest and Abdominal TraumaChest and Abdominal TraumaChapter 27Chapter 27


Anatomy and Physiology Anatomy and Physiology of the Chestof the Chest


Anatomy and Physiology Anatomy and Physiology of the Chestof the Chest

Henry: EMT Prehospital Care, Revised 3rd Edition Lecture Notes

Chapter 27: Chest and Abdominal Trauma

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

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Thoracic CavityThoracic Cavity

Subdivided into two smaller spacesSubdivided into two smaller spacesMediastinumMediastinum –– in centerin center

•• Contains heart, great vessels, esophagus, trachea, Contains heart, great vessels, esophagus, trachea, nervesnerves

Pleural spaces Pleural spaces –– on either side of on either side of mediastinummediastinum


Chest Trauma Chest Trauma ––Mechanisms of injuryMechanisms of injury

BluntBlunt

Sudden deceleration of chest wall against a fixed Sudden deceleration of chest wall against a fixed objectobject

PenetrationPenetration


Rib FracturesRib FracturesMost often the result of blunt traumaMost often the result of blunt trauma

Isolated rib fracture usually not a serious emergencyIsolated rib fracture usually not a serious emergency

Can puncture lung or blood vesselCan puncture lung or blood vesselPneumothorax, Pneumothorax, hemothoraxhemothorax, flail chest, flail chest

Lower rib fractures may injure abdominal organsLower rib fractures may injure abdominal organsLiver, spleen, kidneysLiver, spleen, kidneys


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Case HistoryCase History

You respond to an MVC to find a 65-year-old female victim of a front end collision. She is complaining of severe chest pain and dyspnea. She is pale, cyanotic, and diaphoretic. You notice that the steering wheel is deformed.


Flail ChestFlail Chest

Two or more ribs fractured in two or more Two or more ribs fractured in two or more placesplaces

Paradoxical chest movementParadoxical chest movement

Look for signs of underlying injury (e.g., Look for signs of underlying injury (e.g., pneumothorax)pneumothorax)


Flail Chest Flail Chest –– ManagementManagement

Splint chest wallSplint chest wallBlanket, towel, sheetBlanket, towel, sheetRigid splintRigid splint

PositivePositive--pressure ventilationpressure ventilationWhen hypoventilation is present and patient can tolerateWhen hypoventilation is present and patient can tolerateRestores adequate ventilationRestores adequate ventilationOtherwise nonrebreather deviceOtherwise nonrebreather device


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Traumatic AsphyxiaTraumatic AsphyxiaSevere compression of thoraxSevere compression of thorax

HighHigh--velocity or steering wheel injuries, heavy weight dropped on velocity or steering wheel injuries, heavy weight dropped on chestchest

Heart compressed; blood driven to thorax and neckHeart compressed; blood driven to thorax and neckEcchymosisEcchymosis and edemaand edemaLifeLife--threatening injurythreatening injury

Look for associated injuries to lungs and chest wallLook for associated injuries to lungs and chest wall

Management: highManagement: high--concentration oxygen, possible PPVconcentration oxygen, possible PPV


Traumatic AsphyxiaTraumatic Asphyxia



You respond to a call for “difficulty breathing” to find a 19-year-old male complaining of dyspnea and chest pain. He states that it started suddenly while he was running. His breathing difficulty has gotten worse over the last hour.


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PneumothoraxPneumothorax

Occurs when air enters visceral and parietal pleuraOccurs when air enters visceral and parietal pleuraCollapses lungCollapses lung

Less alveolar surface for diffusion of oxygenLess alveolar surface for diffusion of oxygenResults in hypoxiaResults in hypoxiaTwo mechanismsTwo mechanisms

TraumaTraumaSpontaneous ruptureSpontaneous rupture


TraumaticTraumatic

Penetrating Penetrating MissileMissileSharp objectSharp objectBroken ribBroken rib

BluntBluntPerson takes deep breath just before auto collisionPerson takes deep breath just before auto collision

•• ““Paper bag effectPaper bag effect””


SpontaneousSpontaneous

Ruptured bleb in lung tissueRuptured bleb in lung tissue

Young, muscular males Young, muscular males

COPD patientsCOPD patients


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Open PneumothoraxOpen Pneumothorax


Open Pneumothorax Open Pneumothorax ––Assessment and RecognitionAssessment and Recognition

Sucking woundSucking wound

DyspneaDyspnea

PleuriticPleuritic chest painchest pain


Open Pneumothorax Open Pneumothorax ––Assessment and Recognition Assessment and Recognition

Absent or diminished breath sounds on affected side Absent or diminished breath sounds on affected side

Signs of respiratory distressSigns of respiratory distress

Subcutaneous emphysemaSubcutaneous emphysema

Historical profileHistorical profile


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Open Pneumothorax Open Pneumothorax ––ManagementManagement

Check ABCs.Check ABCs.

Administer oxygen; positiveAdminister oxygen; positive--pressure ventilation, if needed pressure ventilation, if needed (carefully).(carefully).Seal wound with airtight dressing on three sides.Seal wound with airtight dressing on three sides.

Place patient in position of comfort.Place patient in position of comfort.

Transport to definitive care.Transport to definitive care.


Closed PneumothoraxClosed Pneumothorax

Also called simple pneumothoraxAlso called simple pneumothorax

ManagementManagementHighHigh--concentration oxygen; possible PPVconcentration oxygen; possible PPVTransport without delay.Transport without delay.

•• Watch for signs of a developing tension pneumothorax.Watch for signs of a developing tension pneumothorax.



You respond to an MVC and find a 32-year-old female involved in victim of a front end collision complaining of severe chest pain and dyspnea. She is pale, cyanotic, and diaphoretic. The police on scene says she was fine when they arrived but she suddenly started to become “very sick.”


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Tension PneumothoraxTension Pneumothorax


Tension PneumothoraxTension Pneumothorax

Air trapped within pleural spaceAir trapped within pleural spaceActs as a oneActs as a one--way valveway valveIncreased Increased intrathoracicintrathoracic pressurepressureCan collapse superior and inferior vena Can collapse superior and inferior vena cavaecavae

•• Reduces blood return to heartReduces blood return to heartCauses profound shockCauses profound shock


Tension Pneumothorax Tension Pneumothorax ––Assessment and RecognitionAssessment and Recognition

Increasing respiratory distress Increasing respiratory distress and cyanosisand cyanosis

Breath sounds absent on Breath sounds absent on affected sideaffected side

Distended neck veinsDistended neck veins

Tracheal shiftTracheal shift

Signs of shockSigns of shock


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Tension Pneumothorax Tension Pneumothorax ––ManagementManagement

If airtight dressing was applied, remove dressingIf airtight dressing was applied, remove dressingReapply dressing after air escapes.Reapply dressing after air escapes.Watch for further tension.Watch for further tension.

Transport immediately.Transport immediately.

Consider ALS intercept (for needle decompression).Consider ALS intercept (for needle decompression).


HemothoraxHemothorax

Blood within the pleural spaceBlood within the pleural spaceThorax has the capacity for massive blood loss.Thorax has the capacity for massive blood loss.

Physiologic effectsPhysiologic effectsPrimary effect Primary effect –– hypovolemichypovolemic shockshockMay exist with or without an associated pneumothoraxMay exist with or without an associated pneumothoraxMay occur due to penetrating injuries or to rib fracturesMay occur due to penetrating injuries or to rib fractures


HemothoraxHemothorax ––Assessment and RecognitionAssessment and Recognition

Signs of Signs of hypovolemichypovolemic shockshockDelayed or absent capillary refill (children)Delayed or absent capillary refill (children)Pale, cool, sweaty skinPale, cool, sweaty skinTachycardiaTachycardiaRapid and shallow breathingRapid and shallow breathing


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HemothoraxHemothorax ––Assessment and RecognitionAssessment and Recognition

Breath sounds absent on the affected sideBreath sounds absent on the affected side

HemoptysisHemoptysis (coughing blood)(coughing blood)

Hypotension (late sign)Hypotension (late sign)

Altered mental state (late sign)Altered mental state (late sign)

Cardiovascular collapse (cardiac arrest)Cardiovascular collapse (cardiac arrest)


HemothoraxHemothorax –– ManagementManagement

Establish a patent airway.Establish a patent airway.

Suction available to manage Suction available to manage hemoptysishemoptysis

HighHigh--concentration oxygen; possible PPVconcentration oxygen; possible PPV

Transport immediately.Transport immediately.


Pulmonary ContusionPulmonary Contusion

From severe blows to chest wallFrom severe blows to chest wall

Can result in swelling and fluid buildupCan result in swelling and fluid buildupDecreases diffusion of oxygen into capillariesDecreases diffusion of oxygen into capillaries

ManagementManagementHighHigh--concentration oxygenconcentration oxygen


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Cardiac Cardiac TamponadeTamponade

Fluid accumulation in the pericardial sac Fluid accumulation in the pericardial sac caused by bleeding or fluid losscaused by bleeding or fluid loss

May result from blunt or penetrating traumaMay result from blunt or penetrating trauma


Cardiac Cardiac TamponadeTamponade ——Physiologic EffectsPhysiologic Effects

Bleeding places pressure on atria, ventricles, Bleeding places pressure on atria, ventricles, and vena cava.and vena cava.

Venous return is obstructed. Venous return is obstructed. Interferes with the normal dynamics of contraction.Interferes with the normal dynamics of contraction.

Cardiac output is decreased.Cardiac output is decreased.


Cardiac Cardiac TamponadeTamponade ——Assessment and RecognitionAssessment and Recognition

Penetrating wound or Penetrating wound or precordialprecordial contusion may be present.contusion may be present.

Signs of shockSigns of shock

Decreased pulse pressureDecreased pulse pressure

Muffled heart soundsMuffled heart sounds

Distended neck veinsDistended neck veins


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Cardiac Cardiac TamponadeTamponade ——ManagementManagement

Early recognition and rapid hospital Early recognition and rapid hospital intervention intervention –– most essentialmost essential



You respond to a “man down” to find a 20-year-old construction worker who fell 30 feet from a rooftop. He is complaining of pain in his chest and back. He is pale and diaphoretic. His pulse is 130 and thready. He is responsive to painful but not verbal stimuli.


Aortic TearAortic TearComplete tear results in Complete tear results in exsanguinationexsanguination and death.and death.

Partial tear causes leak and hemorrhage.Partial tear causes leak and hemorrhage.

HypovolemicHypovolemic shock is main problem.shock is main problem.

Mortality is very high from massive hemorrhage.Mortality is very high from massive hemorrhage.80% die within first hour80% die within first hour


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Abdominal TraumaAbdominal Trauma


Anatomy and Physiology Anatomy and Physiology of the Abdomenof the Abdomen




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Abdominal InjuriesAbdominal InjuriesLarge vessels and highly vascular organs within abdomenLarge vessels and highly vascular organs within abdomen

Rapid blood loss and deathRapid blood loss and deathMaintain high level of suspicionMaintain high level of suspicion

May be from blunt or penetrating traumaMay be from blunt or penetrating trauma

Primary goal Primary goal Recognize lifeRecognize life--threatening injuries.threatening injuries.Administer essential life support.Administer essential life support.Transport without delay (requires surgical intervention).Transport without delay (requires surgical intervention).


Mechanism of InjuryMechanism of Injury

Blunt traumaBlunt traumaCompression injuriesCompression injuriesDeceleration injuriesDeceleration injuriesSeat belt injuriesSeat belt injuries

Penetrating traumaPenetrating trauma


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AssessmentAssessment

Scene sizeScene size--upupObtain MOIObtain MOI

Initial assessmentInitial assessmentLook for signs of Look for signs of hypovolemiahypovolemia


AssessmentAssessment

Focused history and physical examinationFocused history and physical examinationLook for bruises, tire marks, seat belt marks.Look for bruises, tire marks, seat belt marks.Is abdomen distended?Is abdomen distended?DCAPDCAP--BTLSBTLSPalpate abdomen for tenderness and guarding.Palpate abdomen for tenderness and guarding.

•• Save painful area for last.Save painful area for last.Palpate iliac crest.Palpate iliac crest.

•• If pelvic bones move, stop examination.If pelvic bones move, stop examination.


AssessmentAssessmentFocused history and physical examination (continued)Focused history and physical examination (continued)

Associated head or spinal injuries may present with loss of painAssociated head or spinal injuries may present with loss of painperception.perception.SAMPLE historySAMPLE historyElderly?Elderly?History of medications that slow heart rate?History of medications that slow heart rate?Signs of alcohol or drugsSigns of alcohol or drugs


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ManagementManagement

Management occurs in hospital.Management occurs in hospital.

Treat for shock.Treat for shock.

Transport without delay.Transport without delay.


Special ConsiderationsSpecial Considerations

EviscerationEviscerationDo not attempt to put organs back in abdomen.Do not attempt to put organs back in abdomen.

•• Cover with moist, sterile dressing or airtight dressing.Cover with moist, sterile dressing or airtight dressing.

Transport in supine position with hips and legs Transport in supine position with hips and legs flexed with pillow under knees.flexed with pillow under knees.


EviscerationEvisceration


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Special ConsiderationsSpecial Considerations

Urinary tract injuriesUrinary tract injuriesLook for bruises over flank.Look for bruises over flank.Injuries to pelvis can cause bladder or urethral tears.Injuries to pelvis can cause bladder or urethral tears.

Injuries to male genitaliaInjuries to male genitaliaMay result in lacerations, bruising, avulsion, or amputationMay result in lacerations, bruising, avulsion, or amputation

Injuries to female genitaliaInjuries to female genitaliaMay occur from direct trauma or straddle injuriesMay occur from direct trauma or straddle injuries


Acute AbdomenAcute Abdomen

Recent onset of abdominal painRecent onset of abdominal pain

Requires early diagnosis and surgical Requires early diagnosis and surgical interventionintervention


Acute Abdomen Acute Abdomen ––AssessmentAssessment

Identify life threats and transport immediately.Identify life threats and transport immediately.

Initial assessmentInitial assessmentIf shock present, rapid transport.If shock present, rapid transport.Establish and maintain patent airway.Establish and maintain patent airway.Administer highAdminister high--concentration oxygen.concentration oxygen.Place patient in position of comfort, if not contraindicated.Place patient in position of comfort, if not contraindicated.


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Focused historyFocused historyGather SAMPLE history with OGather SAMPLE history with O--PP--QQ--RR--SS--T approach.T approach.


SAMPLE History for SAMPLE History for Patients with Abdominal ComplaintsPatients with Abdominal Complaints




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Focused physical examinationFocused physical examinationLook for findings associated with abdominal Look for findings associated with abdominal complaints.complaints.

•• Jaundice in sclera or skin?Jaundice in sclera or skin?•• Signs of dehydration?Signs of dehydration?

Ask patient to point to area of pain.Ask patient to point to area of pain.•• Palpate that quadrant last.Palpate that quadrant last.


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Copyright © 2007, 2004, by Mosby, Inc., an affiliate of ...brainspew.com/advanced/emt/notes/Chapter_027.pdf · Title: Microsoft PowerPoint - Chapter_027.ppt Author: manoj.naik Created