Chapter 23 Thoracic Trauma

Objectives 23.1 List the major anatomical structures of the thoracic cavity. 23.2 Describe the basic physiology of thoracic structures. continued

Objectives 23.3 Describe the pathology of the following thoracic injuries: flail chest pneumothorax hemothorax tension pneumothorax sucking chest wound pericardial tamponade continued

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.

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

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. Discussion Points: Often patients will try to minimize their injuries, and may resist attention they think is unnecessary. Discuss why spinal stabilization is considered in this case knowing the injury is to the ribs with breathing concerns. Discuss what MOIs might lead to similar injuries in which spinal issues may not be of concern.

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 Discussion Points: Often students think of the lungs as large balloons, rather than a sponge, which is how they actually appear. If models of the thoracic organs are available to you, they are excellent teaching tools for this class. continued

Anatomy and Physiology of the Chest The anatomy of the chest cavity. continued

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 Discussion Points: Remind students that the lungs are passive participants in the breathing process and that the function of the muscles is to change the volume of the thoracic cavity, with pressure differentials doing the real work of breathing. Much of the injury information relates to disturbances of those pressure differentials.

Chest Injuries Closed Open Indirect Inertia Blunt trauma Fall or collision Open Penetration of chest Compression Indirect Inertia Deceleration Discussion Points: Open and closed injuries are a review. Pay special attention to Indirect and Inertia as these are ‘hidden’ injuries that the OEC tech will have to treat based on signs and symptoms with little or no apparent external trauma. Similar injuries were discussed in Chapter 21 regarding brain and spinal cord injuries that might also present with no apparent injury.

Types of Chest Injuries Contusions Fractures and dislocations Flail chest Pnuemothorax/ Hemothorax Pericardial tamponade Aortic tear or rupture Commotio cordis Traumatic asphyxia Discussion Point: Each injury is discussed in more detail on the slides that follow.

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 Discussion Point: Note that the extent of injury is directly related to the force causing the contusion and can be minor to life threatening.

Contusions A pulmonary contusion is a bruise on the lung tissue that causes the alveoli to fill with fluid and blood.

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 Discussion Points: See if someone in the class has or wants to share a rib fracture story. If no one in the class has one, point out that this type injury is very painful. Inform students that patients may not want any help if they have found a comfortable position. Note that the most serious injuries that result from the fractures or dislocations are to internal organs. continued

Fractures and Dislocations A flail chest is when each of two or more adjacent ribs are fractured in two or more places. continued

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 Discussion Points: The injuries listed above are ones that are difficult to incur, and are therefore serious. The text notes that the sternum may separate from the ribs during CPR and as a result of injury. The chapter in the text emphasizes the importance of the upper area of the thorax—it is represented by the ‘scv’ joint.

Pneumothorax Air in the pleural space Trauma (blunt or penetrating) Spontaneous Compressive forces Discussion Points: This injury has many forms and levels of severity. The issue of air in the pleural space interrupts the negative pressure of the thorax, thus compromising the breathing process. Include details from the text in your discussion. continued

Pneumothorax Penetrating wounds create differential pressure Sucking chest wound Collapsed lung possible Blow to chest may cause lung to burst Discussion Points: This injury has many forms and levels of severity. The issue of air in the pleural space interrupts the negative pressure of the thorax, thus compromising the breathing process. Include details from the text in your discussion.

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 Discussion Points: Tension pneumothorax may have no external signs, which may concern OEC techs. Discuss rescue breathing. Normally we expect ventilation support to improve the patient’s condition, not make it worse, but this could be an important clue to the problem. continued

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) Discussion Point: The signs and symptoms on this slide are a comprehensive list that relate to tension pneumothorax as a broad category of injury. continued

Tension Pneumothorax continued Three complications of chest injuries. (a) Open pneumothorax. (b) Tension pneumothorax. (c) Hemothorax. continued

Tension Pneumothorax Subcutaneous emphysema Air under the skin – Rice Krispies® crackling Discussion Point: Consider including emphysema which is covered in the text.

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 Discussion Points: Hemothorax often represents life-threatening issues. Relate this to the serious blunt trauma injuries previously mentioned, as well inertia injuries (i.e., aortic rupture) later on in this presentation.

Hemothorax Three complications of chest injuries. (a) Open pneumothorax. (b) Tension pneumothorax. (c) Hemothorax.

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 Discussion Points: Main points of this injury are listed here. Additional details from the text will cover this topic thoroughly. continued

Pericardial Tamponade Pain, shortness of breath, neck vein distention are early signs and symptoms Muffled heart sounds, drop in pulse pressure come later Discussion Points: Main points of this injury are listed here. Additional details from the text will cover this topic thoroughly.

Pericardial Tamponade The physical findings of pericardial tamponade.

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 Discussion Points: OEC techs encounter many deceleration injuries. The chapter notes that although uncommon, aortic rupture and dissection can be lethal. Any injury with chest pain should be transported to definitive medical care.

Aortic Rupture and Dissection (a) The progression of an aortic aneurysm to aortic rupture. (b) Aortic dissection.

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 Discussion Points: Purpose of this slide is to make students aware of commotio cordis. Popular media may have addressed this when reporting on student athletes who have died as a result of being hit in the chest with a baseball; students may not have known what this injury was called.

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 Discussion Point: This could result from an avalanche burial, or as the text mentions, being under a car or other heavy object that has fallen on a person’s chest.

Traumatic Asphyxia Traumatic asphyxia.

Environmental Factors Altitude can complicate thoracic injuries Descent in elevation is necessary Helicopter evacuation may be contra-indicated with thoracic injuries

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. Discussion Points: How would you convince the snowboarder to allow cervical stabilization? What do his vitals tell you? What complications should you be looking for? Students may ask about whether it is more important to deal with breathing issues or spinal immobilization, and they are mutually exclusive, and/or how you can do both. The guidelines will be covered in the management section. Discuss complications as a review of issues presented so far.

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 Discussion Point: Important: If the chest injury impairs breathing or shows signs and symptoms of other major concerns, the secondary exam should be abridged in favor of immediate transport. continued

Assessment Use L. A. P. method Monitor through ongoing assessment Discussion Point: Discuss the three parts of the L.A.P. method as explained in the text. L—Look A—Auscultate P—Palpate

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 Discussion Points: “Load and go” is the logical extension of the suspended secondary exam with severe symptoms. See text for additional details on oxygen, ventilations, and occlusive dressing. continued

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 Discussion Points: This slide covers the management/treatment of injuries which may occur with thoracic injuries. See text for situations in which you might remove an impaled object, as well as the comfort and breathing needs of patients in the toboggan and in the patrol room, especially if the patient is not on a backboard. Consider this for discussion with the class. continued

Management Taping an occlusive dressing on three sides of a sucking chest wound helps prevent a tension pneumothorax. continued

Management Match transport position to patient’s breathing needs Treat/position for shock

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. Discussion Point: What care was given? How was this patient transported? Why? What do his changes in vital signs tell you? This person was placed on a backboard because of the MOI. His vitals indicate that there is more to his injury than just the bruising on his chest such as pneumothorax. Rapid transport is advised.

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. Discussion Points: Discuss with students the major points of the chapter. continued

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. Discussion Points: Discuss with students the major points of the chapter.