2Anatomy and Physiology (1 of 5) Ventilation is the body’s ability to move air in and out of the chest and lung tissue.Respiration is the exchange of gases in the alveoli of the lung tissue.The chest (thoracic cage) extends from the lower end of the neck to the diaphragm.
3Anatomy and Physiology (2 of 5) Thoracic skin, muscle, and bonesSimilarities to other regionsAlso unique features to allow for ventilation, such as skeletal muscle
4Anatomy and Physiology (3 of 5) The neurovascular bundle lies closely along the lowest margin of each rib.The pleura covers each lung and the thoracic cavity.Surfactant allows the lungs to move freely against the inner chest wall during respiration.
5Anatomy and Physiology (4 of 5) Vital organs, such as the heart, are protected by the ribs.Connected in the back to the vertebraeConnected in the front to the sternum
6Anatomy and Physiology (5 of 5) The mediastinum contains the heart, great vessels, esophagus, and trachea.A thoracic aortic aneurysm can develop in this area of the chest.The diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity.
7Mechanics of Ventilation (1 of 4) The intercostal muscles (between the ribs) contract during inhalation.The diaphragm contracts at the same time.The intercostal muscles and the diaphragm relax during exhalation.The body should not have to work to breathe when in a resting state.
9Mechanics of Ventilation (3 of 4) Patients with a spinal injury below C5 can still breathe from the diaphragm.Patients with a spinal injury above C3 may lose the ability to breathe.
10Mechanics of Ventilation (4 of 4) Minute ventilation (minute volume)Amount of air moved through the lungs in 1 minuteNormal tidal volume × respiratory ratePatients with a decreased tidal volume will have an increased respiratory rate.
11Injuries of the Chest (1 of 7) Two types: open and closedIn a closed chest injury, the skin is not broken.Generally caused by blunt traumaSource: Courtesy of ED, Royal North Shore Hospital/NSW Institute of Trauma & Injury
12Injuries of the Chest (2 of 7) Closed chest injury (cont’d)Can cause significant cardiac and pulmonary contusionIf the heart is damaged, it may not be able to refill with or receive blood.Lung tissue bruising can result in exponential loss of surface area.Rib fractures may cause further damage.
13Injuries of the Chest (3 of 7) In an open chest injury, an object penetrates the chest wall itself.Knife, bullet, piece of metal, or broken end of fractured ribDo not attempt to move or remove object.
14Injuries of the Chest (4 of 7) Blunt trauma to the chest may cause:Rib, sternum, and chest wall fracturesBruising of the lungs and heartDamage to the aortaVital organs to be torn from their attachment in the chest cavity
15Injuries of the Chest (5 of 7) Signs and symptoms:Pain at the site of injuryLocalized pain aggravated or increased with breathingBruising to the chest wallCrepitus with palpation of the chestPenetrating injury to the chestDyspnea
16Injuries of the Chest (6 of 7) Signs and symptoms (cont’d):HemoptysisFailure of one or both sides of the chest to expand normally with inspirationRapid, weak pulseLow blood pressureCyanosis around the lips or fingernails
17Injuries of the Chest (7 of 7) Chest injury patients often have rapid and shallow respirations.Hurts to take a deep breathThe patient may not be moving air.Auscultate multiple locations to assess for adequate breath sounds.
19Scene Size-up (1 of 2) Scene safety Ensure the scene is safe for you, your partner, your patient, and bystanders.If the area is a crime scene, do not disturb evidence.Request law enforcement for scenes involving violence.Use gloves and eye protection.
20Scene Size-up (2 of 2) Mechanism of injury/nature of illness Chest injuries are common in motor vehicle crashes, falls, and assaults.Determine the number of patients.Consider spinal immobilization.
21Primary Assessment (1 of 8) Form a general impression.Note the patient’s level of consciousness.Perform a rapid scan.Obvious injuriesAppearance of bloodDifficulty breathingCyanosisIrregular breathing
22Primary Assessment (2 of 8) Form a general impression (cont’d).Perform a rapid scan (cont’d).Chest rise and fall on only one sideAccessory muscle useExtended or engorged jugular veinsAssess the ABCs.Assess overall appearance.
23Primary Assessment (3 of 8) Airway and breathingEnsure that the patient has a clear and patent airway.Consider early cervical spine stabilization.Are jugular veins distended?Is breathing present and adequate?Inspect for DCAP-BTLS.
24Primary Assessment (4 of 8) Airway and breathing (cont’d)Look for equal expansion of the chest wall.Check for paradoxical motion.Apply occlusive dressing to all penetrating injuries.Support ventilations.
25Primary Assessment (5 of 8) Airway and breathing (cont’d)Reassess the effectiveness of ventilatory support.Be alert for decreasing oxygen saturation.Be alert for impending pneumothorax.
26Primary Assessment (6 of 8) CirculationPulse rate and qualitySkin color and temperatureAddress life-threatening bleeding immediately, using direct pressure and a bulky dressing.
27Primary Assessment (7 of 8) Transport decisionPriority patients are those with a problem with their ABCs.Pay attention to subtle clues, such as:The appearance of the skinLevel of consciousnessA sense of impending doom in the patient
28Primary Assessment (8 of 8) Transport decision (cont’d)Table 27-1 lists the “deadly dozen” chest injuries.
29History Taking (1 of 2) Investigate the chief complaint. Further investigate the MOI.Identify signs, symptoms, and pertinent negatives.SAMPLE historyFocus on the MOI.
30History Taking (2 of 2) SAMPLE history (cont’d) A basic evaluation should be completed:Signs and symptomsAllergiesMedicationsPertinent medical problemsLast oral intakeEvents leading to the emergency
31Secondary Assessment (1 of 3) Physical examinationsPerform a full-body scan.For an isolated injury, focus on:Isolated injuryPatient’s complaintBody region affectedLocation and extent of injuryAnterior and posterior aspects of the chest wallChanges in respirations
32Secondary Assessment (2 of 3) Physical examinations (cont’d)For significant trauma, use DCAP-BTLS to determine the nature and extent of the thoracic injury.Quickly assess the entire patient from head to toe.
33Secondary Assessment (3 of 3) Vital signsAssess pulse, respirations, blood pressure, skin condition, and pupils.Reevaluate every 5 minutes or less.Pulse and respiratory rates may decrease in later stages of the chest injury.Use a pulse oximeter to recognize any downward trends in the patient’s condition.
34Reassessment (1 of 4) Repeat the primary assessment. Reassess the chief complaint.AirwayBreathingPulsePerfusionBleeding
35Reassessment (2 of 4) Interventions Provide complete spinal immobilization for patients with suspected spinal injuries.Maintain an open airway.Control significant, visible bleeding.Place an occlusive dressing over penetrating trauma to the chest wall.
36Reassessment (3 of 4) Interventions (cont’d) Manually stabilize a flail segment using a bulky dressing.Provide aggressive treatment for shock and transport patients with signs of hypoperfusion.Do not delay transport to complete nonlifesaving treatments.
37Reassessment (4 of 4) Communication and documentation Communicate all relevant information to the staff at the receiving hospital.Describe all injuries and the treatment given.
38Pneumothorax (1 of 10) Commonly called a collapsed lung Accumulation of air in the pleural spaceBlood passing through the collapsed portion of the lung is not oxygenated.You may hear diminished, absent, or abnormal breath sounds.
42Pneumothorax (5 of 10) Open chest wound (cont’d) A flutter valve is taped on only three sides.Carefully monitor the patients for tension pneumothorax.
43Pneumothorax (6 of 10) Spontaneous pneumothorax Caused by structural weakness rather than traumaWeak area (“bleb”) can rupture spontaneously, letting air into the pleural space.Suspect it in patients with sudden, unexplained chest pain and shortness of breath.
44Pneumothorax (7 of 10) Simple pneumothorax Does not result in major changes in the patient’s physiologyCommonly due to blunt trauma that results in fractured ribsCan often worsen, deteriorate into tension pneumothorax, or develop complications
45Pneumothorax (8 of 10) Tension pneumothorax Results from significant air accumulation in the pleural spaceIncreased pressure in the chest causes:Complete collapse of the unaffected lungMediastinum to be pushed into the opposite pleural cavity
46Pneumothorax (9 of 10) Tension pneumothorax (cont’d) Commonly caused by a blunt injury in which a fractured rib lacerates the lung or bronchus
50Hemothorax (3 of 3) Signs and symptoms Prehospital treatment: ShockDecreased breath sounds on the affected sidePrehospital treatment:Rapid transportThe presence of air and blood in the pleural space is a hemopneumothorax.
51Cardiac Tamponade (1 of 3) Protective membrane (pericardium) around the heart fills with blood or fluidThe heart cannot adequately pump the blood.
53Cardiac Tamponade (3 of 3) Signs and symptomsBeck’s triadAltered mental statusPrehospital treatmentSupport ventilations.Rapidly transport.
54Rib Fractures (1 of 2) Common, particularly in older people A fracture of one of the upper four ribs is a sign of a very substantial MOI.A fractured rib may cause a pneumothorax or a hemothorax.
55Rib Fractures (2 of 2) Signs and symptoms Localized tenderness and pain when breathingRapid, shallow respirationsPatient holding the affected portion of the rib cagePrehospital treatment includes supplemental oxygen.
56Flail Chest (1 of 3)Caused by compound rib fractures that detach a segment of the chest wallDetached portion moves opposite of normal
57Flail Chest (2 of 3) Prehospital treatment Maintain the airway. Provide respiratory support, if needed.Give supplemental oxygen.Reassess for complications.
58Flail Chest (3 of 3) To immobilize a flail segment: Tape a bulky dressing or pad against that segment of the chest.Have the patient hold a pillow against the chest wall.Flail chest may indicate serious internal damage or spinal injury.
59Other Chest Injuries (1 of 8) Pulmonary contusionShould always be suspected in a patient with a flail chestPulmonary alveoli become filled with blood, leading to hypoxiaPrehospital treatmentRespiratory support and supplemental oxygenRapid transport
60Other Chest Injuries (2 of 8) Other fracturesSternal fracturesIncreased index of suspicion for organ injuryClavicle fracturesPossible damage to neurovascular bundleSuspect upper rib fractures in medial clavicle fractures.Be alert to pneumothorax development.
62Other Chest Injuries (4 of 8) Traumatic asphyxia (cont’d)Suggests an underlying injury to the heart and possibly a pulmonary contusionPrehospital treatment:Ventilatory support and supplemental oxygenMonitor vital signs during immediate transport.
63Other Chest Injuries (5 of 8) Blunt myocardial injuryBruising of the heart muscleThe heart may be unable to maintain adequate blood pressure.Signs and symptomsIrregular pulse rateChest pain or discomfort
64Other Chest Injuries (6 of 8) Blunt myocardial injury (cont’d)Suspect it in all cases of severe blunt injury to the chest.Prehospital treatmentCarefully monitor the pulse.Note changes in blood pressure.
65Other Chest Injuries (7 of 8) Commotio cordisInjury caused by a sudden, direct blow to the chest during a critical portion of the heartbeatMay result in immediate cardiac arrestVentricular fibrillation responds to defibrillation within the first 2 minutes of the injury.
66Other Chest Injuries (8 of 8) Laceration of the great vesselsMay result in rapidly fatal hemorrhagePrehospital treatmentVentilatory support, if neededImmediate transportBe alert for shock.Monitor for changes in baseline vital signs.