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

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Presentation on theme: "National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter 23 Thoracic Trauma."— Presentation transcript:

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

2 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 23.1 List the major anatomical structures of the thoracic cavity Describe the basic physiology of thoracic structures. continued

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

4 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 23.4 List the signs and symptoms of various thoracic injuries Describe and demonstrate how to assess the chest for trauma, using the L.A.P. method Describe and demonstrate the emergency management of a sucking chest wound.

5 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Topics Anatomy and Physiology of the Chest Chest Injuries Assessment Management Chapter Summary

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

7 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Anatomy and Physiology of 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 continued

8 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Anatomy and Physiology of the Chest continued

9 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Anatomy and Physiology of 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

10 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chest Injuries Closed ◦ Blunt trauma ◦ Fall or collision Open ◦ Penetration of chest ◦ Compression Indirect Inertia ◦ Deceleration

11 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Types of Chest Injuries Contusions Fractures and dislocations Flail chest Pnuemothorax/ Hemothorax Pericardial tamponade Aortic tear or rupture Commotio cordis Traumatic asphyxia

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

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

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

15 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Fractures and Dislocations continued

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

17 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Pneumothorax Air in the pleural space ◦ Trauma (blunt or penetrating) ◦ Spontaneous ◦ Compressive forces continued

18 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Pneumothorax Penetrating wounds create differential pressure ◦ Sucking chest wound ◦ Collapsed lung possible Blow to chest may cause lung to burst

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

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

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

22 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Tension Pneumothorax Subcutaneous emphysema ◦ Air under the skin – Rice Krispies ® crackling

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

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

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

26 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Pericardial Tamponade Pain, shortness of breath, neck vein distention are early signs and symptoms Muffled heart sounds, drop in pulse pressure come later

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

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

29 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Aortic Rupture and Dissection

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

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

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

33 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Environmental Factors Altitude can complicate thoracic injuries Descent in elevation is necessary Helicopter evacuation may be contra- indicated with thoracic injuries

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

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

36 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Assessment Use L. A. P. method Monitor through ongoing assessment

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

38 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Management Use occlusive dressing with sucking chest wound Spinal involvement needs backboard Control bleeding in usual manner Splint flail segments Consider patient comfort with O 2, BVM Leave impaled objects in place continued

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

40 National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Management Match transport position to patient’s breathing needs Treat/position for shock

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

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

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


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