1. Presence Regional EMS System April 2015
Thoracic Trauma
Presence Regional EMS System
April 2015

2. Objectives Outline the normal anatomy and physiology of the chest.
Describe the mechanics of ventilation.
Discuss the assessment findings in thoracic trauma.
Compare and contrast the assessment findings and prehospital management of: flail chest, open pneumothorax, hemothorax, tension pneumothorax, cardiac tamponade, myocardial contusion, pulmonary contusion and rib fracture

3. Thoracic Trauma Thoracic injury is common. 50% of multiple trauma
25% of trauma deaths
Potentially fatal thoracic injuries saved by rapid recognition and intervention.
Many require surgical intervention

4. Organs of the Chest

5. Structures of the Chest

6. Ventilation Physical act of moving air into and out of the lungs
Lungs require the movement of the chest and supporting structures to expand.

7. Ventilation
The intercostal muscles (between the ribs) contract during inhalation.
The diaphragm contracts at the same time.

8. Ventilation
The intercostal muscles and the diaphragm relax during exhalation.
The body should not have to work to breathe when in a resting state.

9. Ventilation Hypoxia is a common endpoint in thoracic injury
Injuries that interfere with the ability of the patient to ventilate or oxygenate must be addressed quickly.

10. Tissue Hypoxia Tissue hypoxia results from:
Inadequate oxygen delivery secondary to airway obstruction
Hypovolemia from blood loss
Ventilation/perfusion mismatch from lung parenchymal injury
Pleural pressure changes from tension pneumothorax
Pump failure from severe myocardial injury

11. Injuries to the Chest Closed chest injuries Caused by blunt trauma
Open chest injuries
Caused by penetrating trauma

12. Signs and Symptoms Dyspnea Pain at site of injury Hemoptysis
Failure of chest to expand normally
Rapid, weak pulse and low blood pressure
Cyanosis around lips or fingernails
Pain at site of injury
Pain aggravated by increased breathing
Bruising to chest wall
Crepitus with palpation of chest
Penetrating injury to chest

13. Injuries to the Chest
When dealing with chest trauma, remember that the following conditions must be supported immediately:
Airway inadequacy (blood, vomitus, foreign bodies, etc.)
Breathing insufficiency (poor minute ventilation)
Circulatory compromise (hemorrhage, hypoperfusion)
These must be supported immediately cause they present as a threat to the body’s vital function (airway, breathing, and circulation).

14. General Emergency Care for Thoracic Trauma
In-line stabilization of C-spine
Open and maintain airway
Assess breathing
If adequate, apply high flow oxygen
If inadequate, begin PPV immediately
Assess circulation and treat for shock if necessary
Care for chest injuries includes:
1. Maintain an open airway. Take in-line stabilization and open the airway, using a jaw thrust if spinal injury is suspected. If the patient’s condition continues to deteriorate, it may be necessary to insert a nasopharyngeal or oropharyngeal airway. Suction any secretions, blood, or vomitus. Remember that signs of inadequate breathing may occur from an occluded airway and not necessarily from a worsening chest injury. Continuously reassess the airway.
2. Continue oxygen therapy. Because most chest injuries produce disturbances in oxygen and carbon dioxide exchange in the lungs, the cells may not be receiving an adequate amount of oxygen. This leads to cellular hypoxia (oxygen deficiency). It is essential that high flow oxygen (at 15 lpm) is continuously administered to all patients with suspected chest injury.
3. Reevaluate breathing status. Chest injuries can cause sudden and rapid deterioration. You should carefully and continuously reassess the breathing status and circulation. If at any time signs of inadequate breathing appear, immediately begin positive pressure ventilation with supplemental oxygen.
4. Stabilize an impaled object in place. If an impaled object is found, do not remove it. Stabilize the object with bulky gauze and bandages to prevent excessive movement.
5. Completely immobilize the patient if spinal injury is suspected. A cervical spinal immobilization collar must be applied and the patient must be immobilized to a backboard with straps and a head immobilization device.
6. Treat the patient for shock (hypoperfusion) if signs and symptoms are present. Many chest injuries involve blood loss or cardiac compromise from compression of the heart.
5-2.8 Discuss the emergency medical care considerations for a patient with a penetrating chest injury.

15. Flail Chest Segment of chest wall detached from rest of thoracic cage
Occurs when:
Three or more ribs are fractured in two or more places.
Sternum is fractured along with several ribs
Creates paradoxical motion

16. Flail Chest Treatment Assist ventilation Possible intubation
Load-and-go
Stabilize flail segment
Monitor for:
Pulmonary contusion
Hemothorax
Pneumothorax
Intubation and positive pressure ventilation are best stabilization. This is usually not possible, as patient is usually awake with an intact gag reflex.
Flail may contribute to development of pulmonary contusion, hemothorax, pneumothorax.
Consider intubation early in order to provide positive end-expiratory pressure.
Continuous positive airway pressure (CPAP) could be used in non-intubated patient.
(Courtesy of Stanley Cooper, EMT-P )

17. Open Pneumothorax “Sucking chest wound” Air enters pleural space
Ventilation impaired
Hypoxia results
Signs and symptoms
Proportional to size of defect
NOTE: See also Figure 6-10.
Normal ventilation involves negative pressure being generated inside chest by diaphragmatic contraction.
As air is drawn through upper airway, lungs expand.
With a large open chest wound (larger than trachea or about size of patient's little finger), the path of least resistance for airflow is through the chest wall defect.
Air going in and out of this opening makes a sucking sound, and bubbles on expiration.
This air will enter only pleural dead space. It will not enter the lung and therefore will not contribute to oxygenation of blood. Ventilation is impaired, and hypoxia results.

18. Open Pneumothorax Treatment
Close chest wall defect with an occlusive dressing
Load-and-go
Use impervious material taped on three sides.
Consider the collection of drainage when deciding which sides to tape.
The Asherman chest seal can be used to seal a sucking chest wound or can be placed over a decompressing needle.

19. Hemothorax Collection of blood in the pleural space Signs/symptoms:
Anxiety and confusion
Neck veins
Flat: hypovolemia
Distended: mediastinal compression
Breath sounds decreased
Dull if percussed
Shock
IMAGE: Figure 6-14 Massive hemothorax.
NOTE: See also Table 6-1.
Discuss pathophysiology and diagnosis.
Blood in pleural space is a hemothorax.
A massive hemothorax occurs as a result of at least a 1,500 cc blood loss into thoracic cavity. Each thoracic cavity may contain up to 3,000 cc of blood.
As blood accumulates within the pleural space, the lung on the affected side is compressed. If enough blood accumulates (rare), the mediastinum will be shifted away from the hemothorax. The inferior and superior vena cava and contralateral lung are compressed. Thus, ongoing blood loss is complicated by hypoxemia.

20. Hemothorax

21. Hemothorax Treatment Load-and-go Treat for shock Fluid administration
Titrate to peripheral pulse (80-90 mmHg)
Monitor for:
Tension hemopneumothorax
Fluid administration to increase blood pressure,may increase bleeding.
Titration of fluid resuscitation is important.
If tension hemopneumothorax develops acute chest decompression is required.

22. Tension Pneumothorax
Can occur from sealing all four sides of the dressing on a sucking chest wound
Can also occur from a fractured rib puncturing the lung or bronchus
Can also result from a spontaneous pneumothorax

23. Tension Pneumothorax

24. Tension Pneumothorax Signs and symptoms: Dyspnea Anxiety Tachypnea
Distended neck veins
Tracheal deviation (rare)
Breath sounds diminished
Hypertympany if percussed
Shock with hypotension
IMAGE: Figure 6-15 Tension pneumothorax.
NOTE: See also Figure 6-19.
Tension pneumothorax is a circulatory (obstructive) emergency.
Occurs when a one-way valve is created from either blunt or penetrating trauma. Air can enter but not leave pleural space.
This causes an increase in intrathoracic pressure, which will collapse the affected lung and will then exert pressure on the mediastinum.
This pressure will eventually collapse the superior and inferior vena cava, resulting in a loss of venous return to the heart.
A shift of the trachea and mediastinum away from the side of the tension pneumothorax will also compromise ventilation of other the lung, although this is a late phenomenon and usually cannot be detected except by x-ray.

25. Tension Pneumothorax Tension pneumothorax Decompress affected side
Respiratory distress and cyanosis
Loss of radial pulse
Decreasing level of consciousness
Load-and-go
NOTE: Decompression is discussed in skill station.
Stress that loss of breath sounds on one side does not make a diagnosis of tension pneumothorax.
A needle decompression is a temporary, but life-saving, measure.
(Courtesy of Louis B. Mallory, MBA, REMT-P)

26. Needle Decompression Anterior approach
Identify the 2nd or 3rd intercostal space on the anterior chest at the midclavicular line
Insertion site should be slightly lateral to the midclavicular line
Insert the needle into the intercostal space at a 90°angle to the superior border of the third rib
Catheter size should be 14 gauge or larger and 6-9 cm long

27. Needle Decompression Lateral approach:
Identify the intersection of the nipple (fourth rib) and anterior axillary line
Insert needle into the intercostal space at a 90 angle to the superior border of the 4th rib
Catheter size should be 14 gauge or larger and 6-9 cm ( in) long

28. Cardiac Tamponade Signs and symptoms Beck's triad Hypotension
Neck veins distended
Heart sounds muffled
Paradoxical pulse
Breath sounds equal
IMAGE: Figure 6-17 Cardiac tamponade.
Discuss pathophysiology and diagnosis.
The pericardial sac is an inelastic membrane that surrounds the heart. If blood collects rapidly between heart and pericardium from a cardiac injury, ventricles of the heart will be compressed. A small amount of pericardial blood may compromise cardiac filling. As compression of ventricles increases, the heart is less able to refill, and cardiac output falls.

29. Cardiac Tamponade
Blood or other fluids collect in the pericardium.

30. Cardiac Tamponade Treatment Load-and-go Treat for shock
Fluid administration
Titrate to peripheral pulse (80–90 mmHg)
Monitor and treat dysrhythmias
Monitor for:
Hemothorax
Pneumothorax
Fluid administration may increase bleeding.
If available perform a 12-lead ECG (including V4R).

31. Myocardial Contusion Most common cardiac injury
Blunt anterior chest injury
Same as myocardial infarction
Chest pain
Dysrhythmias
Cardiogenic shock (rare)
Treat as cardiac tamponade
IMAGE: Figure 6-20 Myocardial contusion.
Myocardial contusion is a potentially lethal lesion resulting from blunt chest injury.
The chest pain may be difficult to differentiate from associated musculoskeletal discomfort that patient also suffers as a result of injury.
If available a 12-lead ECG should be performed.

32. Pulmonary Contusion Bruising of the lung Common from blunt trauma
Hours to develop
Marked hypoxemia
Provide oxygen and ventilatory support.
A very common chest injury resulting from blunt trauma, a pulmonary contusion takes hours to develop and rarely develops during prehospital care, unless very long transport times or delayed discovery of victim occurs.
Contusion of lung may produce marked hypoxemia.
Management consists of intubation and/or assisted ventilation if indicated, oxygen administration, transport, and IV insertion.

33. Rib Fracture Most frequent chest injury
A fractured rib may lacerate the surface of the lung
Patients will avoid taking deep breaths and breathing will be rapid and shallow
The patient often holds the affected side to minimize discomfort
Administer oxygen
Monitor for:
Pneumothorax
Hemothorax

34. Summary Chest injuries common Often life-threatening
Require prompt recognition
Require prompt intervention
Frequently require load-and-go
Airway and oxygenation always priority
Frequent Ongoing Exams

35. Review Answer the following questions as a group.
If doing this CE individually, please your answers to:
Use “April 2015 CE” in subject box.
You will receive an confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book.
IDPH site code #: E1215

36. 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.

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

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

39. 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.

40. 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

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

42. Review
During your rapid trauma 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.
administer oxygen and transport at once.
assess the patient for a tension pneumothorax.
cover the wound with a non-porous dressing.

43. Review
An unrestrained 18 year old male is involved in an MVC. You find him behind the bent steering wheel. He is unconscious, pale, cool and clammy, with labored respirations of 30 and shallow. His radial pulse is weak at 120, he has flat neck veins, trachea is midline, an asymmetrical chest with absent breath sounds on the left. You assume he has a:
Cardiac tamponade
Tension pneumothorax
Massive hemothorax
Simple pneumothorax

44. Review
Which of the following is an acceptable location to insert a needle when decompressing a tension pneumothorax?
Directly under the bottom of the second rib, midclavicular
Directly under the bottom of the third rib, midaxillary
Directly over the top of the fourth rib, midaxillary
Directly over the top of the third rib, midclavicular

45. Review
A 34-year-old female was struck by a motor vehicle and is found unconscious with asymmetrical chest wall movement and a flail segment on the right. Following delegation of c-spine control and opening the airway, the NEXT intervention should be:
Cervical collar placement
Needle decompression
Bag-mask ventilation
Transport immediately

46. Answers A C B D