1. Chapter 27
Chest Injuries

2. National EMS Education Standard Competencies (1 of 5)
Trauma
Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

3. National EMS Education Standard Competencies (2 of 5)
Chest Trauma
Recognition and management of:
Blunt versus penetrating mechanisms
Open chest wound
Impaled object

4. National EMS Education Standard Competencies (3 of 5)
Chest Trauma (cont’d):
Pathophysiology, assessment, and management of:
Blunt versus penetrating mechanisms
Hemothorax

5. National EMS Education Standard Competencies (4 of 5)
Chest Trauma (cont’d):
Pathophysiology, assessment, and management of:
Pneumothorax
Open
Simple
Tension

6. National EMS Education Standard Competencies (5 of 5)
Chest Trauma (cont’d)
Pathophysiology, assessment, and management of:
Cardiac tamponade
Rib fractures
Flail chest
Commotio cordis

7. Introduction (1 of 2)
Each year in the United States, chest trauma causes more than:
700,000 emergency department visits
18,000 deaths
Chest injuries can involve the heart, lungs, and great blood vessels.

8. Introduction (2 of 2)
Immediately treat injuries that interfere with normal breathing function.
Internal bleeding can compress the lungs and heart.
Air may collect in the chest, preventing lung expansion.

9. Anatomy 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.

10. Anatomy and Physiology (2 of 5)
Thoracic skin, muscle, and bones
Similarities to other regions
Also unique features to allow for ventilation, such as skeletal muscle

11. Anatomy 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.

12. Anatomy and Physiology (4 of 5)
Vital organs, such as the heart, are protected by the ribs.
Connected in the back to the vertebrae
Connected in the front to the sternum

13. Anatomy 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.

14. Mechanics 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.

15. Mechanics of Ventilation (2 of 4)

16. Mechanics 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.

17. Mechanics of Ventilation (4 of 4)
Minute ventilation (minute volume)
Amount of air moved through the lungs in 1 minute
Normal tidal volume × respiratory rate
Patients with a decreased tidal volume will have an increased respiratory rate.

18. Injuries of the Chest (1 of 7)
Two types: open and closed
In a closed chest injury, the skin is not broken.
Generally caused by blunt trauma
Source: Courtesy of ED, Royal North Shore Hospital/NSW Institute of Trauma & Injury

19. Injuries of the Chest (2 of 7)
Closed chest injury (cont’d)
Can cause significant cardiac and pulmonary contusion
If 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.

20. Injuries 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 rib
Do not attempt to move or remove object.

21. Injuries of the Chest (4 of 7)
Blunt trauma to the chest may cause:
Rib, sternum, and chest wall fractures
Bruising of the lungs and heart
Damage to the aorta
Vital organs to be torn from their attachment in the chest cavity

22. Injuries of the Chest (5 of 7)
Signs and symptoms:
Pain at the site of injury
Localized pain aggravated or increased with breathing
Bruising to the chest wall
Crepitus with palpation of the chest
Penetrating injury to the chest
Dyspnea

23. Injuries of the Chest (6 of 7)
Signs and symptoms (cont’d):
Hemoptysis
Failure of one or both sides of the chest to expand normally with inspiration
Rapid, weak pulse
Low blood pressure
Cyanosis around the lips or fingernails

24. Injuries of the Chest (7 of 7)
Chest injury patients often have rapid and shallow respirations.
Hurts to take a deep breath
The patient may not be moving air.
Auscultate multiple locations to assess for adequate breath sounds.

25. Patient Assessment Patient assessment steps Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

26. Scene 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.

27. Scene 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.

28. Primary Assessment (1 of 8)
Form a general impression.
Note the patient’s level of consciousness.
Perform a rapid scan.
Obvious injuries
Appearance of blood
Difficulty breathing
Cyanosis
Irregular breathing

29. Primary Assessment (2 of 8)
Form a general impression (cont’d).
Perform a rapid scan (cont’d).
Chest rise and fall on only one side
Accessory muscle use
Extended or engorged jugular veins
Assess the ABCs.
Assess overall appearance.

30. Primary Assessment (3 of 8)
Airway and breathing
Ensure 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.

31. Primary 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.

32. Primary 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.

33. Primary Assessment (6 of 8)
Circulation
Pulse rate and quality
Skin color and temperature
Address life-threatening bleeding immediately, using direct pressure and a bulky dressing.

34. Primary Assessment (7 of 8)
Transport decision
Priority patients are those with a problem with their ABCs.
Pay attention to subtle clues, such as:
The appearance of the skin
Level of consciousness
A sense of impending doom in the patient

35. Primary Assessment (8 of 8)
Transport decision (cont’d)
Table 27-1 lists the “deadly dozen” chest injuries.

36. History Taking (1 of 2) Investigate the chief complaint.
Further investigate the MOI.
Identify signs, symptoms, and pertinent negatives.
SAMPLE history
Focus on the MOI.

37. History Taking (2 of 2) SAMPLE history (cont’d)
A basic evaluation should be completed:
Signs and symptoms
Allergies
Medications
Pertinent medical problems
Last oral intake
Events leading to the emergency

38. Secondary Assessment (1 of 3)
Physical examinations
Perform a full-body scan.
For an isolated injury, focus on:
Isolated injury
Patient’s complaint
Body region affected
Location and extent of injury
Anterior and posterior aspects of the chest wall
Changes in respirations

39. Secondary 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.

40. Secondary Assessment (3 of 3)
Vital signs
Assess 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.

41. Reassessment (1 of 4) Repeat the primary assessment.
Reassess the chief complaint.
Airway
Breathing
Pulse
Perfusion
Bleeding

42. Reassessment (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.

43. Reassessment (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.

44. Reassessment (4 of 4) Communication and documentation
Communicate all relevant information to the staff at the receiving hospital.
Describe all injuries and the treatment given.

45. Pneumothorax (1 of 10) Commonly called a collapsed lung
Accumulation of air in the pleural space
Blood passing through the collapsed portion of the lung is not oxygenated.
You may hear diminished, absent, or abnormal breath sounds.

46. Pneumothorax (2 of 10)

47. Pneumothorax (3 of 10) Open chest wound
Often called an open pneumothorax or a sucking chest wound
Wounds must be rapidly sealed with a sterile occlusive dressing.

48. Pneumothorax (4 of 10)

49. Pneumothorax (5 of 10) Open chest wound (cont’d)
A flutter valve is taped on only three sides.
Carefully monitor the patients for tension pneumothorax.

50. Pneumothorax (6 of 10) Spontaneous pneumothorax
Caused by structural weakness rather than trauma
Weak area (“bleb”) can rupture spontaneously, letting air into the pleural space.
Suspect it in patients with sudden, unexplained chest pain and shortness of breath.

51. Pneumothorax (7 of 10) Simple pneumothorax
Does not result in major changes in the patient’s physiology
Commonly due to blunt trauma that results in fractured ribs
Can often worsen, deteriorate into tension pneumothorax, or develop complications

52. Pneumothorax (8 of 10) Tension pneumothorax
Results from significant air accumulation in the pleural space
Increased pressure in the chest causes:
Complete collapse of the unaffected lung
Mediastinum to be pushed into the opposite pleural cavity

53. Pneumothorax (9 of 10) Tension pneumothorax (cont’d)
Commonly caused by a blunt injury in which a fractured rib lacerates the lung or bronchus

54. Pneumothorax (10 of 10)

55. Open Chest Injuries
Difficult to tell what is injured from entrance wound
Assume all wounds are life-threatening
Open wounds allow air into chest
Sets imbalance in pressure
Causes lung to collapse
Point to Emphasize: Due to the potential for damage to underlying vital structures and disruption of normal breathing, an open chest wound is a true emergency.
Talking Points: Open chest wounds usually mean that the skin and chest wall are penetrated by an object.
Discussion Topic: Define open and closed chest injuries. What determines whether a chest injury is open or closed?
Class Activity: Use common household items to create a model of the mechanics of breathing. Discuss how the body moves air.

56. Assessment: Open Chest Wound
“Sucking chest wound”
Direct entrance wound to chest
May or may not be a sucking sound
May be gasping for air
Discussion Topic: Describe the pathophysiology of a sucking chest wound. How does this injury interfere with breathing?

57. Treatment: Open Chest Wounds
Maintain open airway
Seal wound
Occlusive dressing
Administer oxygen
Treat for shock
Immediate transport
Consider ALS
Point to Emphasize: Care for an open chest wound involves sealing the wound to prevent air from entering the chest cavity. Care also may include application of a dressing that will allow air to escape the chest cavity while preventing air from entering.
Talking Points: An open chest wound is a true emergency that requires rapid initial care and immediate transport.
Knowledge Application: Use a manikin and simulate an open chest wound. Have students demonstrate the proper application of an occlusive dressing. Use various materials to create dressings.
Critical Thinking: Chest injuries are sealed to prevent air from entering the chest cavity. In what other areas of the body might it be appropriate to apply occlusive dressings to open injuries?

58. Think About It
Does the patient’s chest injury need to be treated during the primary assessment?
Does the open chest injury require an occlusive dressing?
Does the patient’s injury necessitate immediate transport to a trauma center?
Talking Points: As students consider these questions, round out their discussion with description of real-life situations.

59. Injuries Within the Chest Cavity
Flutter Valve
Point to Emphasize: Serious injuries can occur within the chest cavity itself, and these injuries often are not apparent on the outside. EMTs should evaluate mechanism of injury and should recognize the specific signs of these life-threatening problems.
Talking Points: A pneumothorax occurs when air enters the chest through an external wound or a punctured lung. This may cause the lung to collapse due to the shift in pressure. A tension pneumothorax occurs when air builds in the chest and has no avenue to escape. The jugular veins distend and as a late sign the trachea will shift away from the affected side. A hemothorax is a similar condition when the chest fills with blood instead of air. Treating an open chest wound is best done with an occlusive dressing sealed on three sides to allow a “flutter” effect allowing air out but not in.

60. Hemothorax (1 of 3)
Blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel.

61. Hemothorax (2 of 3)

62. Hemothorax (3 of 3) Signs and symptoms Prehospital treatment:
Shock
Decreased breath sounds on the affected side
Prehospital treatment:
Rapid transport
The presence of air and blood in the pleural space is a hemopneumothorax.

63. Cardiac Tamponade (1 of 3)
Protective membrane (pericardium) around the heart fills with blood or fluid
The heart cannot adequately pump the blood.

64. Cardiac Tamponade (2 of 3)

65. Cardiac Tamponade (3 of 3)
Signs and symptoms
Beck’s triad
Altered mental status
Prehospital treatment
Support ventilations.
Rapidly transport.

66. Rib 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.

67. Rib Fractures (2 of 2) Signs and symptoms
Localized tenderness and pain when breathing
Rapid, shallow respirations
Patient holding the affected portion of the rib cage
Prehospital treatment includes supplemental oxygen.

68. Closed Chest Injuries Flail Chest Paradoxical Motion
Point to Emphasize: Flail chest is a fracture of two or more consecutive ribs in two or more places. This injury can create an unstable chest wall and can lead to inadequate breathing.
Talking Points: In a closed chest injury, the skin is not broken. Injuries commonly cause damage to heart, lungs, and great vessels that are not readily detectable. A flail chest occurs from blunt trauma with a resulting fracture to two or more consecutive ribs. Paradoxical motion occurs when a flail segment moves in the opposite direction of the chest during respiration.
Class Activity: Obtain a rack of ribs from a butcher or supermarket. Apply blunt force trauma and discuss injury patterns.
Knowledge Application: Have students work in small groups. Assign each group a specific chest injury. Have the group research and present on pathophysiology, signs, symptoms, and treatment.
Paradoxical Motion

69. Assessment: Flail Chest
Mechanism of injury
Difficulty breathing/hypoxia
Chest wall muscle contraction
Talking Points: Mechanism of injury causing blunt trauma to the chest wall is capable of creating a flail segment in the chest. The patient will have difficulty breathing, which over time will cause hypoxia. The chest wall muscles will initially tighten to splint the area but will eventually cause fatigue and make the flail segment more visible. A visible segment is a late sign.
Discussion Topic: Describe the pathophysiology of a flail chest. How does this injury interfere with breathing?

70. Treatment: Flail Chest
Primary assessment for life threats
Administer oxygen
Use bulky dressing to stabilize flail segment
Monitor patient for respiratory rate and depth
Assist ventilations if too shallow

71. Flail Chest (1 of 3)
Caused by compound rib fractures that detach a segment of the chest wall
Detached portion moves opposite of normal

72. Flail Chest (2 of 3) Prehospital treatment Maintain the airway.
Provide respiratory support, if needed.
Give supplemental oxygen.
Reassess for complications.

73. Flail 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.

74. Other Chest Injuries (1 of 8)
Pulmonary contusion
Should always be suspected in a patient with a flail chest
Pulmonary alveoli become filled with blood, leading to hypoxia
Prehospital treatment
Respiratory support and supplemental oxygen
Rapid transport

75. Other Chest Injuries (2 of 8)
Other fractures
Sternal fractures
Increased index of suspicion for organ injury
Clavicle fractures
Possible damage to neurovascular bundle
Suspect upper rib fractures in medial clavicle fractures.
Be alert to pneumothorax development.

76. Other Chest Injuries (3 of 8)
Traumatic asphyxia
Characterized by distended neck veins, cyanosis in the face and neck, and hemorrhage in the sclera of the eye
Sudden, severe compression of the chest, producing a rapid increase in pressure
Source: © Chuck Stewart, MD.

77. Other Chest Injuries (4 of 8)
Traumatic asphyxia (cont’d)
Suggests an underlying injury to the heart and possibly a pulmonary contusion
Prehospital treatment:
Ventilatory support and supplemental oxygen
Monitor vital signs during immediate transport.

78. Traumatic Asphyxia
Sudden compression of chest forcing blood out of organs and rupturing blood vessels
Neck and face are a darker color than rest of the body
May cause bulging eyes, distended neck veins, broken blood vessels in face

79. Other Chest Injuries (5 of 8)
Blunt myocardial injury
Bruising of the heart muscle
The heart may be unable to maintain adequate blood pressure.
Signs and symptoms
Irregular pulse rate
Chest pain or discomfort

80. Other Chest Injuries (6 of 8)
Blunt myocardial injury (cont’d)
Suspect it in all cases of severe blunt injury to the chest.
Prehospital treatment
Carefully monitor the pulse.
Note changes in blood pressure.

81. Cardiac Tamponade
Direct injury to heart causing blood to flow into the pericardial sac around the heart
Pericardium is a tough sac that rarely leaks
Increased pressure on heart so chambers cannot fill
continued

82. Cardiac Tamponade Blood backs up into veins
Usually a result of penetrating trauma
Distended neck veins
Shock and narrowed pulse pressure

83. Other Chest Injuries (7 of 8)
Commotio cordis
Injury caused by a sudden, direct blow to the chest during a critical portion of the heartbeat
May result in immediate cardiac arrest
Ventricular fibrillation responds to defibrillation within the first 2 minutes of the injury.

84. Other Chest Injuries (8 of 8)
Laceration of the great vessels
May result in rapidly fatal hemorrhage
Prehospital treatment
Ventilatory support, if needed
Immediate transport
Be alert for shock.
Monitor for changes in baseline vital signs.

85. Aortic Injury Aorta is the largest blood vessel in the body
Penetrating trauma can cause direct damage
Blunt trauma can sever or tear the aorta
Damage can cause high-pressure bleeding; often fatal
continued

86. Aortic Injury Patient complains of pain in chest, abdomen, or back
Signs of shock
Differences in blood pressure between right and left arms

87. Commotio Cordis Uncommon condition
Trauma to chest when heart is vulnerable
Ventricular fibrillation (VF)
Treat like VF patient: CPR, defibrillation
Talking Points: An example of such a condition a young athlete who tries to catch a baseball, but misses. The ball strikes the patient in the center of the chest and the patient collapses in cardiac arrest.
Discussion Topic: What is commotio cordis? How is it different from other traumatic injuries to the chest?
Knowledge Application: Use programmed patients to simulate chest injuries. Have teams of students practice assessment and treatment.

88. Summary (1 of 7)
A penetrating chest injury can penetrate the lung and diaphragm and injure the liver or stomach.
Closed chest injuries are often the result of blunt force trauma, and open injuries are the result of some object penetrating the skin and/or chest wall.

89. Summary (2 of 7)
Blunt trauma may result in fractures to the ribs and the sternum.
Injuries that interfere with the ability of the patient to ventilate or oxygenate must be addressed quickly.

90. Summary (3 of 7)
Penetrating injury to the chest may allow air to enter the pleural space, causing pneumothorax. Cover the wound with an occlusive dressing.
A penetrating injury that creates a hole in the chest wall is called an open pneumothorax or sucking chest wound.

91. Summary (4 of 7)
A spontaneous pneumothorax may be the result of rupture of a weak spot on the lung, allowing air to enter the pleural space and accumulate.
A simple pneumothorax is a result of blunt trauma resulting in fractured ribs.

92. Summary (5 of 7)
A pneumothorax may progress to a tension pneumothorax and cause cardiac arrest.
Hemothorax is the result of blood accumulating in the pleural space. A hemopneumothorax is the presence of air and blood in the pleural space.

93. Summary (6 of 7)
A flail chest segment (two or more ribs broken in two or more places) should be immobilized with a large bulky dressing.
All patients with chest injuries should receive high-flow oxygen or ventilation with a bag-mask device.

94. Summary (7 of 7)
Pulmonary contusion, which is bruising of or injury to lung tissue after traumatic injury, may interfere with oxygen exchange in the lung tissue.
Traumatic asphyxia is sudden, severe compression of the chest.
Myocardial contusion describes bruising of the heart muscle.

95. Chapter Review

96. Chapter Review
An open chest or abdominal wound is considered to be one that penetrates not only the skin but the chest and abdominal wall to expose internal organs.
Open chest and abdominal wounds are life threatening.
continued

97. Chapter Review A flail chest is characterized by paradoxical motion.
Seal an open chest wound with an occlusive dressing taped on three sides to make a one-way valve.
Closed chest wounds are difficult to distinguish.
continued

98. Chapter Review
A patient who collapses in cardiac arrest after a force to the center of the chest should receive CPR.
If a patient develops signs of tension pneumothorax, arrange immediately for ALS intercept.
continued

99. Chapter Review
When solid abdominal organs are injured, life threatening amounts of blood loss can occur.
When hollow abdominal organs are injured, their contents spill into the abdominal cavity causing irritation.

100. Remember
Blunt trauma, penetrating trauma, and compression are mechanisms that can injure the chest and abdomen.
Open or closed pertains to the integrity of the chest or abdominal wall after injury.
Seal open chest wounds to prevent air from entering the chest cavity.
continued

101. Remember
Closed chest and abdominal wounds bear a high risk for underlying organ system damage and internal bleeding. Use mechanism of injury and patient assessment to recognize the signs and symptoms of shock.
continued

102. Remember
EMTs should learn signs and symptoms, and treatment procedures for specific chest and abdominal injuries.

103. Questions to Consider
Is the patient’s breathing adequate, inadequate, or absent?
Is the patient displaying signs of shock?
Is there an open wound in the chest that needs to be sealed?
continued

104. Questions to Consider
Is the patient displaying signs of a tension pneumothorax?
Is there an open wound in the abdomen that needs to be dressed and covered?

105. Critical Thinking
You are caring for a patient who was shot in the chest with a nail gun. You applied an occlusive dressing around the wound. The patient is suddenly deteriorating. He is having extreme difficulty breathing and his color has worsened.
continued

106. Critical Thinking
Breath sounds have become almost totally absent on the side with the impaled nail. What complication might you suspect is causing his worsening condition? How could this be corrected?

107. Review
When the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration, the resulting injury that kills almost one third of patients, usually within seconds, is:
a hemothorax.
aortic shearing.
a pneumothorax.
a ruptured myocardium.

108. Review
Answer: B
Rationale: When the chest impacts the steering wheel following rapid forward deceleration, aortic injuries (shearing or rupture) are the cause of death in nearly two thirds of patients. The aorta is the largest artery in the body; when it is sheared from its supporting structures or ruptures outright, exsanguination (bleeding to death) occurs—usually within a matter of seconds.

109. Review (1 of 2)
When the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration, the resulting injury that kills almost one third of patients, usually within seconds, is:
a hemothorax. Rationale: This is a serious injury, but is not fatal in seconds.
aortic shearing. Rationale: Correct answer

110. Review (2 of 2)
When the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration, the resulting injury that kills almost one third of patients, usually within seconds, is:
a pneumothorax. Rationale: This is a serious injury, but is not fatal in seconds.
a ruptured myocardium. Rationale: This is a serious injury, but not common.

111. Review
Signs and symptoms of a chest injury include all of the following, EXCEPT:
hemoptysis.
hematemesis.
asymmetrical chest movement.
increased pain with breathing.

112. Review
Answer: B
Rationale: Signs and symptoms of a chest injury include, among others, bruising to the chest, chest wall instability, increased pain with breathing, asymmetrical (unequal) chest movement if a pneumothorax is present, and hemoptysis (coughing up blood) if intrapulmonary bleeding is occurring. Hematemesis (vomiting blood) indicates bleeding in the gastrointestinal tract—usually the esophagus or stomach—not the chest cavity.

113. Review (1 of 2)
Signs and symptoms of a chest injury include all of the following, EXCEPT:
hemoptysis. Rationale: Hemoptysis is coughing up blood or blood-tinged sputum.
hematemesis. Rationale: Correct answer

114. Review (2 of 2)
Signs and symptoms of a chest injury include all of the following, EXCEPT:
asymmetrical chest movement. Rationale: This may indicate a flailed chest or pneumothorax.
increased pain with breathing. Rationale: A chest injury will cause the presence of pain during inspiratory or expiratory chest wall movement.

115. Review
During your assessment of a patient who was stabbed, you see an open wound to the left anterior chest. Your MOST immediate action should be to:
position the patient on the affected side.
transport immediately.
assess the patient for a tension pneumothorax.
cover the wound with an occlusive dressing.

116. Review
Answer: D
Rationale: If you encounter an open chest wound, you must cover it with an occlusive dressing. This will prevent air from moving in and out of the wound. After the dressing is applied, however, you must monitor the patient for signs of a developing tension pneumothorax.

117. Review (1 of 2)
During your assessment of a patient who was stabbed, you see an open wound to the left anterior chest. Your MOST immediate action should be to:
position the patient on the affected side. Rationale: This is not the most immediate action.
transport immediately. Rationale: Transport should take place once life threats have been managed

118. Review (2 of 2)
During your assessment of a patient who was stabbed, you see an open wound to the left anterior chest. Your MOST immediate action should be to:
assess the patient for a tension pneumothorax. Rationale: You must monitor for signs of a developing pneumothorax.
cover the wound with an occlusive dressing. Rationale: Correct answer

119. Review
When caring for a patient with signs of a pneumothorax, your MOST immediate concern should be:
hypovolemia.
intrathoracic bleeding.
ventilatory inadequacy.
associated myocardial injury.

120. Review
Answer: C
Rationale: A pneumothorax occurs when air enters the pleural space and progressively collapses the lung. This impairs the ability of the lung to move air in and out (ventilate). As the lung collapses further, ventilatory efficiency decreases, resulting in hypoxemia; this should be your most immediate concern. Some patients with a pneumothorax may also experience intrathoracic bleeding and associated myocardial injury, depending on the mechanism of injury and the force of the trauma.

121. Review (1 of 2)
When caring for a patient with signs of a pneumothorax, your MOST immediate concern should be:
hypovolemia. Rationale: This may be indicated by the signs and symptoms of shock.
intrathoracic bleeding. Rationale: The patient may experience this, but inadequate ventilation is your immediate concern.

122. Review (2 of 2)
When caring for a patient with signs of a pneumothorax, your MOST immediate concern should be:
ventilatory inadequacy. Rationale: Correct answer
associated myocardial injury. Rationale: The patient may experience this, but inadequate ventilation is your immediate concern

123. Review
What purpose does a one-way “flutter valve” serve when used on a patient with an open pneumothorax?
It prevents air escape from within the chest cavity.
It allows a release for air trapped in the pleural space.
It only prevents air from entering an open chest wound.
It allows air to freely move in and out of the chest cavity.

124. Review
Answer: B
Rationale: A one-way flutter valve is used to treat patients with an open pneumothorax (sucking chest wound), and serves two purposes: it allows air trapped in the pleural space to escape during exhalation, and it prevents air from entering the pleural space during inhalation. These combined effects alleviate pressure on the affected lung, which allows it to reexpand.

125. Review (1 of 2)
What purpose does a one-way “flutter valve” serve when used on a patient with an open pneumothorax?
It prevents air escape from within the chest cavity Rationale: It allows air to exit the chest.
It allows a release for air trapped in the pleural space Rationale: Correct answer

126. Review (2 of 2)
What purpose does a one-way “flutter valve” serve when used on a patient with an open pneumothorax?
It only prevents air from entering an open chest wound Rationale: It prevents air from entering and allows air to exit the chest.
It allows air to freely move in and out of the chest cavity Rationale: It allows air to move out freely and prevents air from entering.

127. Review
Signs of a cardiac tamponade include all of the following, EXCEPT:
muffled heart tones.
a weak, rapid pulse.
collapsed jugular veins.
narrowing pulse pressure.

128. Review
Answer: C
Rationale: Cardiac tamponade, which is almost always caused by penetrating chest trauma, occurs when blood accumulates in the pericardial sac. This impairs the heart’s ability to contract and relax; as a result, the systolic blood pressure decreases and the diastolic blood pressure increases (narrowing pulse pressure). Because the heart cannot adequately eject blood, it backs up beyond the right atrium, resulting in jugular venous distention. In some cases, heart tones may be muffled or distant. Other signs include a weak, rapid pulse and hypotension.

129. Review (1 of 2)
Signs of a cardiac tamponade include all of the following, EXCEPT:
muffled heart tones. Rationale: This is an assessment finding with cardiac tamponade.
a weak, rapid pulse. Rationale: This is an assessment finding with cardiac tamponade.

130. Review (2 of 2)
Signs of a cardiac tamponade include all of the following, EXCEPT:
collapsed jugular veins. Rationale: Correct answer
narrowing pulse pressure. Rationale: This is an assessment finding with cardiac tamponade.

131. Review
After experiencing penetrating trauma to the chest, your patient’s blood pressure is 110/80 mm Hg. Which of the following repeat blood pressures is MOST indicative of a cardiac tamponade?
116/74 mm Hg
100/90 mm Hg
128/60 mm Hg
140/80 mm Hg

132. Review
Answer: B
Rationale: Among the other signs of a cardiac tamponade, a narrowing of the pulse pressure (the difference between the systolic and diastolic pressure) may be observed. Of the choices in this question, the blood pressure of 100/90 mm Hg has a pulse pressure of only 10 mm Hg, which is less than any of the other values listed.

133. Review (1 of 2)
After experiencing penetrating trauma to the chest, your patient’s blood pressure is 110/80 mm Hg. Which of the following repeat blood pressures is MOST indicative of a cardiac tamponade?
116/74 mm Hg Rationale: The pulse pressures are not narrowed.
100/90 mm Hg Rationale: Correct answer

134. Review (2 of 2)
After experiencing penetrating trauma to the chest, your patient’s blood pressure is 110/80 mm Hg. Which of the following repeat blood pressures is MOST indicative of a cardiac tamponade?
128/60 mm Hg Rationale: The pulse pressures are not narrowed.
140/80 mm Hg Rationale: The pulse pressures are not narrowed.

135. Review
During your assessment of a patient with a closed chest injury, you should NOT intentionally assess for:
bruising.
deformities.
crepitus.
breath sounds.

136. Review
Answer: C
Rationale: Crepitus, the sound made (or sensation felt) when broken bone ends rub together, is not intentionally assessed for in patients with any injury; it is a coincidental finding that should be documented. Intentionally assessing for crepitus—which involves moving or manipulating the injured area—may worsen the injury and should be avoided.

137. Review (1 of 2)
During your assessment of a patient with a closed chest injury, you should NOT intentionally assess for:
bruising. Rationale: This may be seen on inspection.
deformities. Rationale: This may be visualized during the inspection of a patient’s chest.

138. Review (2 of 2)
During your assessment of a patient with a closed chest injury, you should NOT intentionally assess for:
crepitus. Rationale: Correct answer
breath sounds. Rationale: EMTs must assess for adequate lung sounds.

139. Review Paradoxical chest movement is typically seen in patients with:
a flail chest.
a pneumothorax.
isolated rib fractures.
a ruptured diaphragm.

140. Review
Answer: A
Rationale: Paradoxical chest movement occurs when an area of the chest wall bulges out during exhalation and collapses during inhalation. This type of abnormal chest movement is seen in patients with a flail chest—a condition in which several adjacent ribs are fractured in more than one place, resulting in a free-floating segment of fractured ribs.

141. Review (1 of 2)
Paradoxical chest movement is typically seen in patients with:
a flail chest. Rationale: Correct answer
a pneumothorax. Rationale: This will produce unilateral chest wall movement.

142. Review (2 of 2)
Paradoxical chest movement is typically seen in patients with:
isolated rib fractures. Rationale: This will produce pain, but not irregular chest wall movement.
a ruptured diaphragm. Rationale: This typically occurs on the left side. You may hear bowel sounds over the lower chest area.

143. Review
A 40-year-old man, who was the unrestrained driver of a car that hit a tree at a high rate of speed, struck the steering wheel with his chest. He has a large bruise over the sternum and an irregular pulse rate of 120 beats/min. You should be MOST concerned that he:
has injured his myocardium.
has a collapsed lung and severe hypoxia.
has extensive bleeding into the pericardial sac.
is at extremely high risk for ventricular fibrillation.

144. Review
Answer: A
Rationale: A myocardial contusion, or bruising of the heart muscle, is usually the result of blunt trauma—specifically to the center of the chest. In some cases, the injury may be so severe that it renders the heart unable to maintain adequate cardiac output; as a result, blood pressure falls. The pulse rate is often irregular; however, lethal cardiac dysrhythmias such as ventricular tachycardia and ventricular fibrillation are uncommon.

145. Review (1 of 2)
A 40-year-old man, who was the unrestrained driver of a car that hit a tree at a high rate of speed, struck the steering wheel with his chest. He has a large bruise over the sternum and an irregular pulse rate of 120 beats/min. You should be MOST concerned that he:
has injured his myocardium. Rationale: Correct answer
has a collapsed lung and severe hypoxia. Rationale: This will produce an absence or decrease of breath sounds and unilateral chest wall expansion.

146. Review (2 of 2)
A 40-year-old man, who was the unrestrained driver of a car that hit a tree at a high rate of speed, struck the steering wheel with his chest. He has a large bruise over the sternum and an irregular pulse rate of 120 beats/min. You should be MOST concerned that he:
has extensive bleeding into the pericardial sac. Rationale: This will produce muffled heart sounds and decreased cardiac output.
is at extremely high risk for ventricular fibrillation. Rationale: Lethal dysrhythmias are uncommon.

147. Credit Chapter Opener: © PHT/Photo Researchers, Inc.
Background slide images: © Jones & Bartlett Learning. Courtesy of MIEMSS.