National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter 23 Thoracic Trauma

National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ

BRADY

Chapter 23

Thoracic Trauma


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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 chest

b. pneumothorax

c. hemothorax

d. tension pneumothorax

e. sucking chest wound

f. 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.


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Topics

Anatomy and Physiology of the Chest Chest Injuries Assessment Management Chapter Summary


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Case Presentation

A snowboarder enters the half pipe and slams into the rail on the top deck and slides down the wall. When you arrive the patient is sitting up, complaining of difficulty breathing, but resisting attempts to maintain manual spinal stabilization.


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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

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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


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Chest Injuries

Closed◦ Blunt trauma◦ Fall or collision

Open◦ Penetration of chest◦ Compression

Indirect Inertia

◦ Deceleration


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Types of Chest Injuries

Contusions Fractures and dislocations Flail chest Pnuemothorax/ Hemothorax Pericardial tamponade Aortic tear or rupture Commotio cordis Traumatic asphyxia


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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


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Contusions


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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 continued


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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


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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


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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 continued


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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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Subcutaneous emphysema◦ Air under the skin – Rice Krispies®

crackling


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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


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Hemothorax


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

Muffled heart sounds, drop in pulse pressure come later


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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


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Aortic Rupture and Dissection


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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


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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


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Traumatic Asphyxia


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Environmental Factors

Altitude can complicate thoracic injuries

Descent in elevation is necessary Helicopter evacuation may be contra-

indicated with thoracic injuries


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Case Update

You maintain cervical spine stabilization while you assess the patient. The airway is open, there is no external bleeding, circulation to all extremities is normal, and his mental status is normal He has moderate difficulty breathing and pain at the rib cage. He has shallow respirations at 28 per minute even after receiving oxygen. His pulse is 102 BPM.


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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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Assessment

Use L. A. P. method Monitor through ongoing assessment


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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 continued


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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


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Case Disposition

You immobilize the patient’s spine on a long spine board, load him into a toboggan transport him to the first-aid room. His pulse has increased to 114, the blood pressure is 100/70, and the respiratory rate is 28 on high-flow oxygen. You show the paramedics a large bruise on the upper chest wall that extends beneath the patient’s armpit. The patient is transported by air.


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Chapter 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.

Documents

National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter 23 Thoracic Trauma