1. Chapter 35
Chest Trauma
EMS 475
DR SADIA FARHAN

2. Learning objectives
At the end of this lecture students must be able to:
Interpret the basics of clinical anatomy of thorax
Describe the basics of pathophysiology related to thoracic injuries
Interpret the immediate general management of patient with thoracic injuries
Recognize and differentiate between the fractures of thoracic cage
Outline the emergency field management of common injuries of lungs, heart and medistional structures
Prioritize and justify the referral of patient to trauma centre according to the assessment of thoracic trauma

3. Introduction Annually, thoracic trauma causes:
700,000 + emergency department visits
18,000+ deaths
One in four trauma deaths are due to thoracic injuries.
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4. Anatomy
Thorax—bony cage over chest organs

5. Anatomy Diaphragm inserts below 4th or 5th rib
Size/dimension of thoracic cavity varies during respiration

6. Anatomy Sternum Clavicle Scapula Consists of:
Superior manubrium
Central sternal body
Inferior xyphoid process
Clavicle
Connects to the manubrium and overlies the first rib
Scapula
Overlies posterior aspect of the upper thoracic cage

7. Anatomy 12 pairs of ribs attach to 12 thoracic vertebrae.
First 7 pairs attach directly to sternum
8–10 attach indirectly to sternum
11 and 12 are “floating ribs”

8. Anatomy Intercostal space houses: Intercostal muscles
Neurovascular bundle
Mediastinum contains:
Heart and great vessels
Esophagus
Lymphatic channels
Trachea
Mainstem bronchi
Vagus and phrenic nerves

9. Anatomy Heart resides inside pericardium
Anterior portion is the right ventricle
Mostly protected anteriorly by the sternum
Average cardiac output: volume of blood pumped by heart in one minute
stroke volume ×pulse rate/ min
70 × 70 = 4,900 mL/min

10. Anatomy Aorta: largest artery in body
Three points of attachment:
Annulus
Ligamentum arteriosum
Aortic hiatus
Lungs occupy most space in thoracic cavity
Lined with pleura
Pleura is separated by viscous fluid
Keeps lungs from collapsing on exhalation

11. Anatomy Diaphragm: primary breathing muscle
Breathing effort can be helped by accessory muscles.

12. Physiology Primary functions of thorax: Breathing process includes:
Maintain oxygenation and ventilation.
Maintain circulation.
Breathing process includes:
Delivery of oxygen to body
Elimination of carbon dioxide

13. Physiology Brain stimulates breathing via chemoreceptors.
If CO2 is too high, respiratory rate increases.
Hypoxic drive: secondary mechanism
Intercostal and accessory muscles pull chest wall away from the body as the diaphragm contracts downward.
Negative pressure draws air through mouth and nose to alveolar spaces.
Replaces air in the alveoli

14. Physiology
Blood is delivered by pulmonary circulation to capillaries adjacent to alveoli.
Has low O2 and high CO2 concentrations
Oxygenation process delivers O2 to blood
Ventilation: how CO2 leaves the body
CO2 diffuses down its concentration gradient and enters air within the alveoli.
Positive pressure is created within the thorax and air is exhaled.

15. Pathophysiology Traumatic injury to chest may compromise: Ventilation
Oxygenation
Circulation
Two mechanisms of injury:
Blunt
Penetrating
Two basic injury patterns
Closed
Open

16. Pathophysiology Blunt trauma may lead to:
Fracture of ribs, sternum, areas of chest wall
Bruise of lungs and heart
Damage to aorta
Broken ribs lacerating intrathoracic organs
Organs torn from attachment

17. Pathophysiology Thoracic trauma may impair cardiac output. Blood loss
Pressure change
Vital organ damage
Combination of these

18. Pathophysiology Ventilatory impairments can be rapidly fatal.
Shallow breathing reduces minute volume.
Air entering pleural space compresses lungs and decreases tidal volume.
Blood collection prevents full lung expansion.

19. Pathophysiology Other complications include:
Atelectasis reduces area for gas exchange.
Bruised lung tissue may cause hypoxemia.
Tearing or rupture of respiratory structures prevents O2 from reaching alveoli.

20. Scene Size-Up Be sure scene is safe to enter.
Follow standard precautions.
After identifying number of patients:
Triage patients and request resources.
Determine MOI if possible.

21. Primary Assessment Form a general impression. Airway and breathing
Assess level of consciousness.
Observe the neck for:
Accessory muscle use during breathing
Extended or engorged external jugular veins
Airway and breathing
Assess while performing spinal immobilization.
Signs of obstruction may include:
Stridor
Hoarseness
Alterations in mental status

22. Primary Assessment Airway and breathing (cont’d)
Abnormal findings may include:
Tachypnea
Hemoptysis
Retractions
Immediate manage airway impairment:
Manually immobilize patient.
Use jaw-thrust maneuver.
Identify and manage impairment of oxygenation and ventilation.

23. Primary Assessment Airway and breathing (cont’d)
Address life-threats first.
Apply occlusive dressing to penetrating injuries.
Assess ventilation and oxygenation.
Evaluate skin circulation.
Decreasing O2 saturation may indicate hypoxia.
Watch for impending tension pneumothorax signs.

24. Primary Assessment Circulation Check pulses.
Tachycardia is not always associated with hypovolemia.
Low heart rate does not rule out hypovolemia or shock.
Thready or weak pulse may suggest volume loss.

25. Primary Assessment Circulation (cont’d) Irregular pulse suggests:
Hypoxia
Hypoperfusion
Serious underlying injuries or shock
Auscultate the heart.
Note if heart sounds are easily heard or muffled.
If shock suggested, may not be from thorax.
Obtain history and complete physical.

26. Primary Assessment Transport decision
Priorities: patients with ABC problems
If signs of poor perfusion/
inadequate breathing:
Transport quickly.
Perform assessment en route.

27. History Taking May need to be done en route
Obtain relevant patient history (SAMPLE).
Questions about event should focus on MOI.

28. Secondary Assessment Includes a head-to-toe assessment
Check for injuries that may compromise ABCs.
Obtain full set of vitals.
Monitoring equipment can aid assessment
If chest injury is isolated with limited MOI, focus on:
Isolated injury
Patient’s complaint
Body region affected

29. Secondary Assessment If significant trauma affects multiple systems:
Perform full body scan using DCAP-BTLS.
Inspect region for deformities.
Palpate for tenderness.
Check for lacerations and swelling.

30. Reassessment Obtain repeated assessments of:
Vital signs
Oxygenation
Circulation
Breath sounds
If pneumothorax is suspected, patient should be considered unstable.
Reassess at least every 5 minutes.

31. Flail Chest May result from blunt force mechanisms
Two or more adjacent ribs fractured in two or more places
Segment becomes separated from chest wall

32. Flail Chest
Location and size affects degree that chest wall and air movement are impaired.
Flail sternum (most extreme)
Underlying pressure causes paradoxical movement of segment and rest of chest wall.
May not be initially apparent
Palpate for rib cage fractures and crepitus.

33. Flail Chest
Pneumothorax or hemothorax may occur if bone fragments are driven into the body.
Pain may prevent adequate tidal volume.
Limits the ability to compensate for flail segment
Management may involve:
Positive-pressure ventilation
Positive end-expiratory pressure

34. Flail Chest Assessment and management Signs and symptoms include:
Hypoxia
Hypercarbia
Pain
Palpation may reveal:
Crepitus
Tenderness
Dissection of air into tissue
Auscultation may reveal:
Decreased or absent breath sounds

35. Flail Chest Assessment and management (cont’d)
Poses a threat to patient’s ability to breathe
Intubation and positive-pressure ventilation may be needed.
Stabilization of flail segment is controversial.

36. Rib Fractures Most common thoracic injury
Pain contributes to:
Inadequate ventilation
Atelectasis
Pneumonia from inadequate respiration
Blunt trauma may result in fracture at:
Point of impact
Edge of object
Posterior angle of rib

37. Rib Fractures Associated injuries can be: Ribs 4–9 Ribs 9–11
Aortic injury
Tracheobronchial injury
Pneumothorax
Vascular injury
Ribs 9–11
Intra-abdominal injury

38. Rib Fractures Patients report: Exam shows: Pleuritic chest pain
Mild dyspnea
Exam shows:
Chest wall tenderness
Soft-tissue injury
Crepitus
Subcutaneous emphysema

39. Rib Fractures Assessment and management (cont’d)
Management focuses on:
ABCs and evaluating for other injuries
Administer supplemental O2
Gently splint chest wall.
Consider intravenous analgesic.

40. Sternal Fractures
One in 20 patients with blunt thoracic trauma can have sternal fracture
Associated with other injuries, including:
Myocardial contusions
Intra-abdominal injuries
Assessment and management
Patient reports pain over anterior part of chest.
Palpation may reveal:
Tenderness
Crepitus
Possible flail segment

41. Sternal Fractures Assessment and management (cont’d)
Perform an ECG rhythm analysis.
Supportive treatment only
ABCs
Manage associated injuries.
Analgesics

42. Clavicle Fractures One of the most common fractures
Assessment and management
Patient will:
Report pain in the shoulder
Usually hold arm across front of body
Splint fracture with a sling and swathe.
Apply gentle upward support to the olecranon process of the ulna.
Knot should be tied on the side of the neck

43. Br ak

44. Simple Pneumothorax Accumulation of air/gas in pleural cavity
Air enters through a hole in the chest wall or lung causes lung collapse on affected side
Delayed or improper treatment may lead to a tension pneumothorax

45. Simple Pneumothorax Assessment and management (cont’d)
Cover large open wounds immediately.
Nonporous dressing secured on three sides
Maintain ABCs, provide high-concentration O2.
If tension develops, dressing may need to be removed to release trapped air.

46. Open Pneumothorax
Occurs when chest wall defect allows air into thoracic space
Results from penetrating chest trauma
Negative pressure draws air into pleural space.
As size increases, lung loses ability to expand.

47. Open Pneumothorax
If hole is larger than glottis opening, air is likely to enter chest wall.
Creates a “sucking chest wound”

48. Open Pneumothorax Assessment and management
Signs and symptoms may include:
Tachycardia and tachypnea
Restlessness
Physical assessment shows:
Chest wall defect
Impaled object
Sucking chest wound
Bubbling wound
Subcutaneous emphysema

49. Open Pneumothorax Assessment and management (cont’d)
Treat immediately.
Convert wound to a closed injury.
Place on high-flow supplemental O2 via nonrebreathing mask.

50. Tension Pneumothorax
Life-threatening condition from air accumulation within interpleural space
Results from open or closed injury

51. Tension Pneumothorax
As air accumulates, pressure builds against surrounding tissue.
Compresses the lung, which diminishes:
Ability to oxygenate blood
Ability to eliminate CO2
Pressure causes eventual lung collapse and mediastinum to shift.
May exceed pressure in major venous structures
If venous return decreases, the body will increase heart rate.

52. Tension Pneumothorax Assessment and management
Classic signs may include:
Absence of breath sounds on affected side
Pulsus paradoxus
Tracheal deviation
Tachycardia is induced because blood cannot return to heart.
Accumulates in great vessels
Pressure pushes blood into jugular vein.

53. Tension Pneumothorax Assessment and management (cont’d)
During normal inspiration:
Negative pressure decreases blood return.
Preload and systolic blood pressure decrease.
Jugular veins are distended when engorged 1 to 2 cm above the clavicle.
May show:
trachea deviation from affected side
diminished breath sounds
pleuritic chest pain and dyspnea

54. Tension Pneumothorax Assessment and management (cont’d)
Administer immediate high-flow supplemental O₂.
Inspect the chest.
Cover open wounds with dressing.
If elevated pressure is suggested:
May need to perform a needle decompression

55. Hemothorax Occurs when blood accumulates within pleura
Commonly caused by lung parenchyma tearing
Collection of blood compresses and displaces lung

56. Hemothorax Hemopneumothorax Massive hemothorax
Blood and air in the pleural space
Massive hemothorax
Accumulation of more than 1,500 mL of blood within pleura

57. Hemothorax Assessment and management Signs include:
Ventilatory insufficiency
Hypovolemic shock
Findings that differentiate from other injuries:
Lack of tracheal deviation
Dullness on percussion
Flat neck veins with hypovolemia
Distended neck veins with increased pressure

58. Hemothorax Assessment and management (cont’d) Prehospital management:
Supportive care
Rapid transport
High-flow supplemental O2
Two large-bore peripheral IV

59. Pulmonary Contusion
Alveolar and capillary damage results from lung tissue compression against chest wall.
Injury may lead to:
Loss of fluid and blood into involved tissues
White blood cell migration into area
Local tissue edema
Local surfactant in alveoli is diluted.
Causes atelectasis
Delivery of O2 is reduced, causing hypoxia

60. Pulmonary Contusion Assessment and management
Hypoxia and CO2 retention may cause:
Respiratory distress
Tachycardia
Agitation
Auscultation may reveal:
Wheezes
Rhonchi
Rales
Diminished lung sounds

61. Pulmonary Contusion Assessment and management (cont’d)
Treatment includes:
Managing airway
Using caution when administering IV fluids
Administering small amounts of analgesics for pain

62. Cardiac Tamponade Excessive fluid in pericardial sac, causing
Compression of the heart
Decreased cardiac output

63. Cardiac Tamponade Hemodynamic effects determined by: Mortality varies.
Size of pericardium perforation
Rate of hemorrhage
Chamber of heart involved
Mortality varies.
Can occur in both medical and trauma conditons
Medical—slow fluid collection
Trauma—bleeding is rapid.

64. Cardiac Tamponade
Continued bleeding increases pressure in the pericardium.
Atria and vena cavae compress.
Preload delivery is drastically reduced.
Heart increases rate to compensate.

65. Cardiac Tamponade Assessment and management
30% diagnosed will have Beck triad:
Muffled heart tones
Hypotension
JVD
Classic finding: electrical alternans in ECG strip
Findings typical of shock, including:
Weak or absent peripheral pulses
Cyanosis
Tachycardia or tachypnea

66. Electrical alternans

67. Cardiac Tamponade Assessment and management (cont’d)
Treatment includes:
Assess and manage ABCs.
Ensure adequate O2 and establishing IV access.
Provide a rapid fluid bolus.
Rapidly transfer to trauma center.

68. Cardiac Tamponade versus Tension Pneumothorax

69. Myocardial Contusion
Sudden deceleration of chest wall may cause collision of heart to sternum.
Characterized by:
Local tissue contusion and hemorrhage
Edema
Cellular damage within myocardium

70. Myocardial Contusion Damage to myocardial tissues may cause:
Ectopic activity
Dysrhythmias
Structural changes may include:
Ventricular septal defect
Myocardial rupture or aneurysm
Coronary artery occlusion

71. Myocardial Contusion Assessment and management
Signs and symptoms include:
Sharp, retrosternal chest pain
Soft-tissue or bony injury in area
Crackles or rales on auscultation
Treatment includes:
Nonspecific supportive care
Fluid resuscitation
Consulting with medical control before administering antidysrhythmic agents

72. Commotio Cordis
Cardiac arrest caused by a direct blow to the thorax during the repolarization period
Result of chest wall impact directly over heart
Second most common cause of sudden cardiac death in young male athletes

73. Commotio Cordis Assessment and management
Signs and symptoms may include:
Unresponsiveness
Cyanotic
Tonic-clonic seizures
Survival rates increased because of:
Increased awareness
CPR preparation
Accessibility of AED at sporting events

74. Traumatic Aortic Disruption
Dissection or rupture of the aorta
Usually caused by crashes and falls
Aorta is injured at fixed points by shearing forces.
Impact causes the aortic arch to swing forward.
Tension and area rotation cause aorta to rupture at point of attachment.

75. Traumatic Aortic Disruption
If intima is torn, blood can dissect along the media.
Severe injuries may allow blood to leak from all layers.

76. Traumatic Aortic Disruption
Assessment and management
Symptoms vary and may include:
Tearing pain behind sternum or in the scapula
Hypovolemic shock
Dyspnea
Altered mental state
Recognition often from suspicion based on MOI
Assessment of extremity pulses is important

77. Traumatic Aortic Disruption
Assessment and management (cont’d)
Assess and manage ABCs.
Gradual IV hydration to treat hypotension
Do not use pressor agents.
Expedite transport to trauma center.

78. Great Vessel Injury
Great vessels protected by bony structures and other tissues (except for aorta)
Injuries more likely with penetrating trauma
Injuries may result in occlusion or artery spasm
.Presentation may include:
Pain
Pallor
Paresthesias
Pulselessness
Paralysis

79. Great Vessel Injury Assessment and management
If bleeding not prevented, presentation includes:
Hypovolemic shock
Hemothorax
Cardiac tamponade
Procedures for acute blood loss
Establish IV for hydration during transport.
Treat pericardial tamponade immediately.
Do not use pneumatic antishock garment.

80. Diaphragmatic Injuries
Occurs in a small percentage of trauma
Most occur on left side
Liver protects right side.
Recovery is inhibited by pressure differences between abdominal and thoracic cavities.

81. Diaphragmatic Injuries
Three phases:
Acute—begins at injury; ends with recovery from other injuries
Latent—entrapment of abdominal contents
Obstructive—abdominal contents herniate through defect
Tension gastrothorax
Herniation of abdominal contents into thoracic cavity, causing pressure to:
Compress lung on affected side.
Compromise circulatory function.

82. Diaphragmatic Injuries
© SIU Bio Med Comm./Custom Medical Stock Photo

83. Diaphragmatic Injuries
Assessment and management (cont’d)
Acute phase:
Hypotension
Tachypnea
Bowel sounds in chest
Chest pain
Absent breath sounds
Obstructive phase:
Nausea and vomiting
Abdominal pain
Constipation
Dyspnea
Abdominal distension

84. Diaphragmatic Injuries
Assessment and management (cont’d)
Management focus: maintaining oxygen and providing rapid transport
Elevate head of backboard.
Positive-pressure ventilation
NG tube placement (if allowed by protocol)
Definative surgical repair

85. Esophageal Injuries Rapidly fatal injury in GI system
Assessment and management
Signs and symptoms include:
Pleuritic chest pain
Subcutaneous emphysema
Associated tracheal injury
No specific therapy in the prehospital setting
Do not give anything orally.

86. Tracheobronchial Injuries
Rare, typically caused by penetrating injuries
High mortality rate
Allows for rapid movement of air into pleural space, causing a pneumothorax
May progress to tension pneumothorax

87. Tracheobronchial Injuries
Assessment and management
Presentation varies and may include:
Hoarseness
Dyspnea and tachycardia
Respiratory distress
Focuses on ABCs
Bag-bask ventilation instead of intubation
Avoid high ventilatory pressure.

88. Traumatic Asphyxia
Induced by traumatic injury that forcefully compresses the thoracic cavity
Causes pressure to major veins of the head, neck, and kidneys
Causes rupture of the capillary beds

89. Traumatic Asphyxia Assessment and management Physical findings:
Cyanosis of head, upper extremities, and torso
Ocular hemorrhage
Swollen and cyanotic facial structures
© Chuck Stewart, MD.

90. Traumatic Asphyxia Assessment and management (cont’d)
Provide high-flow supplemental O2.
Take cervical spine precautions.
Obtain IV access with two large-bore IV lines.
Transport to nearest trauma center.

91. Traumatic Asphyxia Assessment and management (cont’d)
Provide high-flow supplemental O2.
Take cervical spine precautions.
Obtain IV access with two large-bore IV lines.
Transport to nearest trauma center.

92. Summary
Thorax contains ribs, thoracic vertebrae, clavicle, scapula, sternum, heart, lungs, diaphragm, great vessels, esophagus, lymphatic channels, trachea, mainstem bronchi, and nerves.
Oxygenation, ventilation, and some aspects of circulation take place in the thorax.
Thoracic injuries can cause air or blood in the lungs or prevent organs from moving properly.

93. Summary
A thoracic trauma assessment begins with scene size-up and ABCs assessment.
When assessing breathing, note any injury to the thorax, which may indicate underlying injuries.
Consider ventilation and oxygenation adequacy.
Always consider spine stabilization.

94. Summary
Managing chest injuries includes maintaining airway, ensuring oxygenation and ventilation, supporting circulation, and transporting quickly.
Chest wall injuries include flail chest, rib fractures, sterna fractures, and clavicle fractures.
In flail chest, two or more ribs are broken in two or more places, which can result in a free-floating rib segment.

95. Summary
Flail chest management includes airway management and possible positive-pressure ventilation.
Rib fractures cause significant pain and may prevent adequate ventilation.
Rib fracture management should focus on the ABCs and gentle splinting of the chest.

96. Summary
Lung injuries include simple pneumothorax, open pneumothorax, tension pneumothorax, hemothorax, and pulmonary contusion.
In a pneumothorax, air leaks into the pleural space from an opening in the chest or the surface of the lung.
Management of a pneumothorax starts with the ABCs and high-concentration oxygen administration.

97. Summary
A tension pneumothorax results from air collection in the pleural space, and is a life-threatening condition.
Patients with a tension pneumothorax should be placed on high-flow supplemental oxygen via a nonrebreathing mask. Cover open wounds with a nonporous or occlusive dressing.

98. Summary
A hemothorax is the accumulation of blood between the parietal and visceral pleura.
If a patient with a hemothorax does not require airway intervention, place the patient on high-flow supplemental oxygen via a nonrebreathing mask.
A hemopneumothorax is the collection of both blood and air in the pleural space.

99. Summary
A pulmonary contusion occurs from compression of the lung, resulting in alveolar and capillary damage, edema, and hypoxia.
If a patient has a pulmonary contusion or cardiac tamponade, assess and manage the ABCs and consider administering IV fluids.
Myocardial injuries include cardiac tamponade, myocardial contusion, myocardial rupture, and commotio cordis.

100. Summary
Cardiac tamponade occurs when excessive fluid builds up in the pericardial sac around the heart, which compresses the heart and compromises stroke volume.
Treating cardiac tamponade begins by managing the ABCs, ensuring adequate oxygen delivery, and establishing IV access. Pericardiocentesis is the ultimate treatment option.

101. Summary
Myocardial contusion is blunt trauma to the heart, and may cause hemorrhage, edema, and cellular damage.
Management for myocardial contusion is supportive, but should also include cardiac monitoring and establishing IV access.
Myocardial rupture is perforation of one or more elements of the anatomy of the heart, occurring from blunt or penetrating trauma.

102. Summary
Management for myocardial rupture should include supportive care and rapid transport to a trauma center for a thoracotomy.
Commotio cordis occurs from a direct blow to the chest during a critical portion of the heart’s repolarization period.
ALS treatment for commotio cordis must follow standard ACLS guidelines for sudden cardiac arrest.

103. Summary
Vascular injuries include traumatic aortic disruption and great vessel injury.
Traumatic aortic disruption is the ripping of the aorta.
Management for traumatic aortic disruption focuses on symptom control.
Other injuries include diaphragmatic injuries, esophageal injuries, tracheobronchial injuries, and traumatic asphyxia.

104. Credits
Chapter opener: Courtesy of ED, Royal North Shore Hospital/NSW Institute of Trauma & Injury
Backgrounds: Blue–Jones & Bartlett Learning. Courtesy of MIEMSS; Gold–Jones & Bartlett Learning. Courtesy of MIEMSS; Green–Courtesy of Rhonda Beck; Red–© Margo Harrison/ShutterStock, Inc.
Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.