1. Chapter 35
Chest Trauma
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

2. Objectives
Image source: Microsoft clipart

3. Anatomy of the Chest Cavity
The chest is the upper part of the trunk between the diaphragm and the neck. It contains the mediastinum and pleural cavities. The mediastinum is the area between the lungs that extends from the sternum to the vertebral column. The mediastinum includes all of the contents of the chest cavity (except the lungs), including the esophagus, trachea, heart, and large blood vessels. The right lung is in the right pleural cavity; the left lung is in the left pleural cavity.
The organs of the chest are protected by the rib cage and the upper portion of the spine. The rib cage includes the ribs, thoracic vertebrae, and the sternum. The ribs are connected to the vertebrae in back. All but two pairs of ribs are connected by cartilage to the sternum in the front. The rib cage encloses the lungs and heart. Damage to the ribs can result in damage to these organs.

4. Deadly and Potentially Deadly Chest Injuries
Tension pneumothorax
Open pneumothorax
Massive hemothorax
Cardiac tamponade
Flail chest
Pulmonary contusion
Myocardial contusion
Some injuries to the chest are immediately life-threatening and must be identified in the primary survey. Others are potentially life-threatening and need to be identified during the secondary survey.

5. Categories of Chest Injuries
Closed injuries
No break occurs in the skin over the chest wall
Usually the result of blunt trauma
Open chest injuries
Break in the skin over the chest wall
Injuries result from penetrating trauma
Chest injuries are categorized as closed or open injuries. In closed chest injuries, no break occurs in the skin over the chest wall. These injuries are usually the result of blunt trauma. Underlying structures, such as the heart, lungs, and great vessels, may sustain significant injury. In open chest injuries, a break occurs in the skin over the chest wall. These injuries result from penetrating trauma, such as gunshot wounds, stabbings, or an impaled object.

6. Closed Chest Injuries

7. Rib Fractures Common injury due to blunt chest trauma
May be associated underlying lung or heart injury
Seat belts occasionally cause injury
Rib fractures are a common injury resulting from blunt trauma to the chest. The presence of a rib fracture suggests significant force caused the injury. Rib fractures may be associated with injury to the underlying lung or the heart. Although seat belts have reduced the number of deaths and the severity of injuries due to motor vehicle crashes, they occasionally cause injury. For example, a properly worn three-point restraint harness can result in rib fractures. Lap belts can cause lumbar fractures and abdominal injuries, such as bruising or rupture of the intestines.

8. Rib Fractures Ribs 1-3 Protected by shoulder girdle
Fractures associated with significant trauma
Ribs 4-9
Most commonly fractured
The seriousness of a rib fracture increases with age, the number of fractures, and the location of the fracture. Ribs 1-3 are protected by the shoulder girdle. Fractures of ribs 1 and 2 are associated with significant trauma. These fractures are often associated with injury to the head, neck, spinal cord, lungs, and the major blood vessels. Ribs 4-9 are the most commonly fractured because these ribs are long, thin, and poorly protected. Fractures of ribs 5-9 on the right are associated with injury to the liver. Also consider the possibility of injury to underlying structures with lower rib fractures. For example, fractures of ribs 9-11 on the left are associated with rupture of the spleen. Multiple rib fractures may result in inadequate breathing and pneumonia. Posterior rib fractures are usually the result of deceleration incidents.

9. Rib Fractures Signs and Symptoms
Localized pain at the fracture site
Self-splinting of the injury
Pain on inspiration
Shallow breathing
Tenderness on palpation
Chest wall deformity
Crepitus
Swelling and/or bruising at fracture site
Possible subcutaneous emphysema
Localized pain at the fracture site that worsens with deep breathing, coughing, or moving
Self-splinting of the injury by holding the arm close to the chest
Pain on inspiration
Shallow breathing
Tenderness on palpation
Deformity of the chest wall
Crepitus
Swelling and/or bruising at the fracture site
Possible subcutaneous emphysema

10. Rib Fractures Emergency Care
Spinal stabilization if spinal injury suspected
Establish and maintain an open airway
Give oxygen
Encourage patient to breathe deeply
Do not apply tape or straps to the ribs or chest wall
Allow patient to self-splint
Perform ongoing assessments
To treat a patient with a rib fracture, perform the following steps:
Put on appropriate personal protective equipment (PPE).
If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard. Establish and maintain an open airway.
Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 liters per minute (L/min) if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered.
Encourage the patient to breathe deeply. Reassess breath sounds often while the patient is in your care.
Do not apply tape or straps to the ribs or chest wall. Applying tape or straps limits chest wall motion and reduces the effectiveness of ventilation.
Allow the patient to hold a pillow for comfort, if appropriate. Self-splinting will reduce pain, and a pillow will not provide excessive pressure to reduce ventilatory effectiveness. It also encourages deeper breathing, since the chest wall expands into the soft, padded surface.
Perform ongoing assessments as often as indicated during transport.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

11. Flail Chest
Occurs when two or more adjacent ribs are fractured in two or more places or when the sternum is detached
“Flail segment”
A flail chest occurs when two or more adjacent ribs are fractured in two or more places or when the sternum is detached. The section of the chest wall between the fractured ribs becomes free-floating because it is no longer in continuity with the thorax. This free-floating section of the chest wall is called the “flail segment.”

12. Flail Chest Paradoxical movement
The flail segment does not move with the rest of the rib cage when the patient attempts to breathe (paradoxical movement). When the patient inhales, the flail segment is drawn inward instead of moving outward. When the patient exhales, the flail segment moves outward instead of moving inward.

13. Flail Chest Life-threatening injury
Respiratory failure may occur due to:
Bruising of underlying lung and hemorrhage of the alveoli
Chest wall instability and pain
Interference with normal "bellows" action of the chest
A flail chest is a life-threatening injury. Flail chest most commonly occurs in MVCs (especially crushing rollover crashes) but may also occur because of falls from a height, assault, industrial accidents, or neonatal trauma during childbirth.
The forces necessary to produce a flail chest cause bruising of the underlying lung (pulmonary contusion). Although instability of the chest wall results in paradoxical movement of the chest wall during breathing, it is the bruising of the underlying lung and pain associated with breathing that contributes to hypoxia. Respiratory failure may occur due to:
Bruising of the underlying lung and associated hemorrhage of the alveoli, reducing the amount of lung tissue available for gas exchange
Instability of the chest wall and pain associated with breathing, leading to decreased ventilation and hypoxia
Interference with the normal "bellows" action of the chest, resulting in inadequate gas exchange
 A flail chest may be associated with other injuries including:
Bruising of the underlying lung (pulmonary contusion)
Bruising of the heart muscle (myocardial contusion)
Hemothorax
Pneumothorax

14. Flail Chest Signs and Symptoms
Crepitus
Breathing difficulty
Bruising of the chest wall
Increased heart rate (tachycardia)
Pain and self-splinting of the affected side
Increased respiratory rate (tachypnea)
Pain in the chest associated with breathing
Paradoxical chest wall movement
Signs and Symptoms of Flail Chest
Crepitus
Breathing difficulty
Bruising of the chest wall
Increased heart rate (tachycardia)
Pain and self-splinting of the affected side
Increased respiratory rate (tachypnea)
Pain in the chest associated with breathing
Paradoxical chest wall movement

15. Flail Chest Emergency Care
Keep on scene time to a minimum
Request Advanced Life Support (ALS) personnel early
Suspect associated spinal injuries
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
To treat a patient with a flail chest, perform the following steps:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of Advanced Life Support (ALS) personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
Suspect associated spinal injuries. Maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered. Monitor closely for development of a tension pneumothorax.
Continually monitor and reassess respiratory rate, rhythm, depth, and effort; vital signs (including pulse oximetry); degree of paradoxical chest movement; and skin temperature, color, and condition (moisture).
Treat for shock if indicated.
Transport promptly to the closest appropriate facility. Reassess, including vital signs, at least every 5 minutes en route.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

16. Simple Pneumothorax

17. Simple Pneumothorax Signs and Symptoms
Sudden onset of sharp pain in the chest associated with breathing
Shortness of breath
Difficulty breathing
Decreased or absent breath sounds on the affected side
Increased respiratory rate (tachypnea)
Increased heart rate (tachycardia)
Subcutaneous emphysema (may not be present)

18. Spontaneous Pneumothorax
Does not involve trauma to the lung
Two types
Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
A spontaneous pneumothorax is a type of pneumothorax that does not involve trauma to the lung. There are two types of spontaneous pneumothorax. A primary spontaneous pneumothorax occurs in people with no history of lung disease. This condition most commonly occurs in tall, thin men between the ages of 20 and 40. It rarely occurs in persons older than 40 years. A secondary spontaneous pneumothorax most often occurs as a complication of lung disease. Chronic obstructive pulmonary disease (COPD) is the most common underlying disorder. Other lung diseases associated with this condition include asthma, pneumonia, tuberculosis, and lung cancer. A secondary spontaneous pneumothorax usually occurs in older persons.

19. Spontaneous Pneumothorax
Typically occurs while at rest or during sleep
Usually caused by the rupture of a bleb
Small air- or fluid-filled sac in the lung
Common signs and symptoms
Sudden onset of chest pain on affected side
Shortness of breath
Increased respiratory rate
Cough
A spontaneous pneumothorax typically occurs while the patient is at rest or during sleep. It is usually caused by the rupture of a bleb (a small air- or fluid-filled sac) in the lung. Although they depend on the size of the pneumothorax, common signs and symptoms include a sudden onset of chest pain on the affected side, shortness of breath, an increased respiratory rate, and a cough. The patient’s chest pain may be described as dull, sharp, or stabbing.

20. Pneumothorax Emergency Care
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
Transport
Reassess often for signs of a tension pneumothorax
To treat a patient with a pneumothorax, perform the following steps:
Put on appropriate PPE.
If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard. If spinal injury is not suspected, place the patient in a position of comfort. Most patients will be more comfortable sitting up.
Establish and maintain an open airway.
Give oxygen. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered.
Transport promptly to the closest appropriate facility. Perform ongoing assessments as often as indicated. Reassess frequently for signs of a tension pneumothorax (explained in the next section).
Record all patient care information, including the patient’s medical history and all emergency care given on a PCR.

21. Tension Pneumothorax
Tension pneumothorax is a life-threatening injury. It can occur because of blunt or penetrating trauma or as a complication of treatment of an open pneumothorax. In an open pneumothorax, there is an open wound in the chest wall into the pleural cavity. In a tension pneumothorax, air enters the pleural cavity during inspiration and progressively builds up under pressure. The flap of injured lung acts as a one-way valve, allowing air to enter the pleural space during inspiration, but trapping it during expiration. The injured lung collapses completely. Pressure rises, forcing the trachea, heart, and major blood vessels to be pushed toward the opposite side. Shifting of the trachea from its normal midline position is called tracheal deviation (or tracheal shift). In a tension pneumothorax, the trachea shifts to the uninjured lung (the side opposite the injury). To effectively assess tracheal deviation, examine the trachea by feeling for the tubular shape of the trachea between your thumb and index finger just above the sternum in the suprasternal notch. Assessing above this area for tracheal deviation may not reveal a shift of the trachea even if it does exist. Because significant pressure must build up to cause tracheal deviation, it is a late physical examination finding. Shifting of the heart and major blood vessels from their normal position is called mediastinal shift. Shifting of the major blood vessels causes them to kink, resulting in a backup of blood into the venous system. The backup of blood into the venous system results in jugular venous distention (JVD), decreased blood return to the heart, and signs of shock.

22. Tension Pneumothorax Signs and Symptoms
Cool, clammy skin
Increased pulse rate
Cyanosis (late sign)
JVD
Decreased blood pressure
Severe respiratory distress
Agitation, restlessness, anxiety
Bulging of intercostal muscles on the affected side
Decreased or absent breath sounds on the affected side
Tracheal deviation toward the unaffected side (late sign)
Possible subcutaneous emphysema

23. Tension Pneumothorax Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
If an open chest wound was bandaged with an occlusive dressing, release the dressing
Treat for shock if indicated
Transport
Reassess often
Follow these steps when providing emergency care for a possible tension pneumothorax:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.
Treat for shock if indicated.
If an open chest wound was bandaged with an occlusive dressing, release the dressing. If air is present under tension, air will rush out of the wound. Once the air is released, reseal the wound again with a dressing taped on three sides.
Transport promptly to the closest appropriate facility, reassessing vital signs at least every 5 minutes en route.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

24. Hemothorax
A hemothorax is a collection of blood in the pleural cavity that may result from injury to the chest wall, the major blood vessels, or the lung because of penetrating or blunt trauma. Rib fractures are a common cause of a hemothorax. A hemothorax is often seen with a simple or tension pneumothorax.
The chest cavity can hold mL of blood. The term massive hemothorax is used to describe blood loss of more than 1500 milliliters (mL) in the chest cavity. A massive hemothorax is a life-threatening injury.

25. Hemothorax Signs and Symptoms
Cool, clammy skin
Weak, thready pulse
Restlessness, agitation, anxiety
Coughing up blood (hemoptysis) (may not occur)
Rapid, shallow breathing (tachypnea)
Flat neck veins (caused by hypovolemia)
Decreasing blood pressure (hypotension)
Decreased or absent breath sounds on the affected side

26. Hemothorax Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
Perform these steps when providing emergency care to a patient with a possible hemothorax:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.
Treat for shock if indicated.
Reassess frequently for development of a tension pneumothorax.
Transport promptly to the closest appropriate facility, reassessing vital signs at least every 5 minutes en route.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

27. Cardiac Tamponade
Cardiac tamponade is a life-threatening injury. It most frequently occurs because of penetrating chest trauma, but it can occur because of blunt trauma to the chest. Cardiac tamponade occurs when blood enters the pericardial sac because of:
Laceration of a coronary blood vessel
Ruptured coronary artery
Laceration of a chamber of the heart
Significant bruising of the heart (myocardial contusion)
The blood in the pericardial sac compresses the heart, decreasing the amount of blood the heart can pump out with each contraction

28. Cardiac Tamponade Signs and Symptoms
Cool, clammy skin
Normal breath sounds
Narrowing pulse pressure
Trachea in the midline position
Increased heart rate (tachycardia)
Cyanosis of the head, neck, and upper extremities
Muffled heart sounds (often difficult to assess in the field)
Distended neck veins (may not be present in hypovolemia)

29. Cardiac Tamponade Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization if suspected spinal injury
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
Perform the following steps to treat a patient with cardiac tamponade:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.
Treat for shock if indicated.
Transport promptly to the closest appropriate facility, reassessing vital signs at least every 5 minutes en route.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

30. Traumatic Asphyxia
Traumatic asphyxia occurs because of a severe compression injury to the chest, such as compression of the chest under a heavy object or between a vehicle’s seat and steering wheel. Blood backs up into the veins, venules, and capillaries of the head, neck, extremities, and upper torso, resulting in capillary rupture. The skin of the head and neck becomes deep red, purple, or blue. This characteristic finding is called hooding or a purple cape by EMS professionals.

31. Traumatic Asphyxia Signs and Symptoms
JVD
Swelling of the tongue and lips
Eyes that appear bloodshot and bulging
Deep red, purple, or blue discoloration of the head and neck (“hooding”)
Low blood pressure when compression is released
Normal-looking skin below the level of the crush injury (unless other injuries are present)

32. Traumatic Asphyxia Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
To treat a patient with traumatic asphyxia, perform the following steps:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
Suspect spinal injuries and multiple organ damage. Maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient’s breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered.
Control any bleeding, if present. If indicated, treat for shock.
Transport promptly to the closest appropriate facility, reassessing vital signs at least every 5 minutes en route. Monitor closely for development of a tension pneumothorax and/or cardiac tamponade.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

33. Pulmonary Contusion
A pulmonary contusion (bruising of the lung) is a potentially life-threatening injury. A pulmonary contusion occurs in about 75% of patients with flail chest. Most pulmonary contusions occur because of a rapid deceleration injury, such as a fall, high-speed motor vehicle crash (MVC), or other blunt trauma. It can also occur as a result of blunt trauma without rib fracture. A pulmonary contusion is often missed because of the presence of other associated injuries.
In a pulmonary contusion, the alveoli fill with blood and fluid because of bruising of the lung tissue. As a result, the area of the lung available for gas exchange is decreased. The severity of the patient’s signs and symptoms depends on the amount of lung tissue injured. Bleeding from a pulmonary contusion may result in a blood loss of mL.

34. Pulmonary Contusion Signs and Symptoms
Signs of blunt chest trauma
Restlessness, anxiety
Increased respiratory rate
Increased heart rate
Cough
Coughing up blood (hemoptysis)
Chest pain
Difficulty breathing
Cyanosis

35. Pulmonary Contusion Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
Reassess often
To treat a patient with a pulmonary contusion, perform the following steps:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
Suspect spinal injuries. Maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered.
Treat for shock if indicated.
Transport promptly to the closest appropriate facility, reassessing vital signs at least every 5 minutes en route.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

36. Myocardial Contusion

37. Myocardial Contusion Signs and Symptoms
Chest pain or discomfort
Increased or slowed heart rate
(Possibly) irregular heart rhythm
Signs and symptoms of a myocardial contusion include chest pain or discomfort, increased or slowed heart rate, and (possibly) an irregular heart rhythm.

38. Myocardial Contusion Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Give oxygen
Treat for shock if indicated
Transport
To treat a patient with a myocardial contusion, perform the following steps:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
Suspect spinal injuries. Maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Give oxygen. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.
Treat for shock if indicated.
Transport promptly to the closest appropriate facility, reassessing vital signs at least every 5 minutes en route.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

39. Commotio Cordis
Sudden cardiac death due to a blunt force injury to the chest
The blow to the chest causes ventricular fibrillation
The force of the blow typically ranges from mph
Commotio cordis (which means “disturbed or agitated heart motion”) is sudden cardiac death due to a blunt force injury to the chest (directly over the left ventricle of the heart) without causing any significant structural injury to the heart. The blow to the chest occurs at a certain point of a person’s heartbeat, causing ventricular fibrillation and sudden cardiac death. The force of the blow typically ranges from mph. Although cases of commotio cordis have been reported in individuals ranging from 3 months to 50 years of age, it occurs most frequently in males between 4 and 16 years of age, with an average age of 14 years.

40. Commotio Cordis Causes
Baseball
Hockey
Softball
Lacrosse
Karate
Basketball
Cricket
Martial arts
Boxing
Motor vehicle crash
Playful shadow boxing
Parent to child discipline
Gang rituals
Snowball
Pet dog (collie) head
Plastic (hollow) toy bat
Hiccups remedy
Fall on monkey bars
Since 1996, more than 180 cases of commotio cordis have been reported in the United States. The impact to the chest is most often from a baseball, but it has also been reported during hockey, softball, lacrosse, karate, and other sports activities in which a relatively hard projectile or bodily contact caused impact to the individual’s anterior chest. Infrequent cases have been associated with basketball, cricket, martial arts, boxing, and motor vehicle crashes. Interestingly, rare incidents of commotio cordis have been associated with playful shadow boxing, parent to child discipline, gang rituals, a snowball, a pet dog (collie) head, a plastic (hollow) toy bat, a hiccups remedy by a friend, and a fall on monkey bars.

41. Commotio Cordis
Patient typically found unresponsive, apneic, and pulseless.
Many patients are cyanotic.
Seizures have been observed in some individuals.
Bruising of the chest wall present in about one-third of patients.
Survival is most dependent on early resuscitation (within 1 to 3 minutes of the event), including CPR and defibrillation.
Once the individual sustains a blow to the center of the chest, he may collapse immediately or walk a couple of steps and then collapse. The patient is typically found to be unresponsive, apneic, and pulseless. Many patients are cyanotic. Seizures have been observed in some individuals at the time of collapse. Bruising of the chest wall at the site of impact is present in about one-third of patients. Survival is uncommon and is most dependent on early resuscitation (within 1 to 3 minutes of the event), including CPR and defibrillation.

42. Open Chest Injuries

43. Open Pneumothorax
An open pneumothorax is also called a sucking chest wound. It is a life-threatening injury that is caused by penetrating trauma. Air enters the chest cavity through an open wound in the chest wall into the pleural cavity. The severity of an open pneumothorax depends on the size of the wound. If the diameter of the chest wound is more than two-thirds the diameter of the patient’s trachea, air will enter the chest wound rather than through the trachea with each breath. A sucking or gurgling sound is heard as air moves in and out of the pleural space through the open chest wound. If the flap of chest wall closes during expiration, air will become trapped inside the pleural cavity. As air collects in the pleural cavity, pressure builds with each inspiration. This eventually results in a tension pneumothorax.

44. Open Pneumothorax Possible Causes
Blast injuries
Knife wounds
Impaled objects
Gunshot wounds
MVCs

45. Open Pneumothorax Signs and Symptoms
Shortness of breath
Increased heart rate
Pain at the site of injury
Increased respiratory rate
Subcutaneous emphysema
Sucking sound on inhalation
Open wound in the chest wall
Decreased breath sounds on the affected side

46. Open Pneumothorax Emergency Care
Keep on scene time to a minimum
Request an early response of ALS personnel
Spinal stabilization
Establish and maintain an open airway
Seal the open wound – tape on 3 sides
Give oxygen
Treat for shock if indicated
Transport
To treat a patient with an open pneumothorax, perform the following steps:
Put on appropriate PPE. Keep on scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.
Suspect spinal injuries. Maintain manual in-line stabilization until the patient is secured to a long backboard.
Establish and maintain an open airway.
Promptly close the chest wound with an airtight (occlusive) dressing. Plastic wrap and petroleum gauze are examples of dressings that may be used. Make sure that the dressing is large enough so that it is not pulled into the wound during inspiration. Tape the dressing on three sides (one-way valve). The dressing will be sucked over the wound as the patient inhales, preventing air from entering. The open end of the dressing allows air to escape as the patient exhales. If signs and symptoms of a tension pneumothorax develop after an airtight dressing has been applied, release the dressing. Reassess the patient’s airway, breathing, circulation, and mental status. If the patient’s breathing returns to normal, replace the airtight dressing and secure it in place over the wound by taping it in place on three sides.
Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered. Watch closely for development of a tension pneumothorax.
Control any external bleeding. Treat for shock if indicated.
Transport promptly to the closest appropriate facility. Reassess every five minutes.
Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

47. Questions?
Image source: Microsoft clipart