1. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Division 3 Trauma Emergencies

2. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 25 Thoracic Trauma

3. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Introduction to Thoracic Trauma Thoracic Anatomy Pathophysiology of Thoracic Trauma Assessment of Thoracic Trauma Management of Thoracic Trauma

4. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chest Injuries Directly responsible for more than 20% of all traumatic deaths (regardless of mechanism) Account for about 16,000 deaths per year in the United States

5. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Statistics Chest injuries are the second leading cause of trauma deaths each year. Most thoracic injuries (90% of blunt trauma and 70% to 85% of penetrating trauma) can be managed without surgery.

6. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Classifications of Chest Injuries Skeletal injury Pulmonary injury Heart and great vessel injury Diaphragmatic injury

7. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Classification Mechanism of Injury (1 of 2) Blunt thoracic injuries Forces distributed over a large area –Deceleration –Compression

8. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Classification Mechanism of Injury (2 of 2) Penetrating thoracic injuries –Forces are distributed over a small area. –Organs injured are usually those that lie along the path of the penetrating object.

9. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Injury Patterns (1 of 2) General types –Open injuries –Closed injuries

10. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Injury Patterns (2 of 2) Cardiovascular Pleural and pulmonary Mediastinal Diaphragmatic Esophageal Penetrating cardiac trauma Blast injury Confined spaces Shock wave Thoracic cage

11. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy (1 of 2) Skin Bones –Thoracic cage –Sternum –Thoracic spine

12. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

13. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

14. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy (2 of 2) Muscles –The respiratory muscles contract in response to stimulation of the phrenic and intercostal nerves. Trachea Bronchi Lungs

15. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

16. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vascular Anatomy (1 of 4) Arteries –Aorta –Carotid –Subclavian –Intercostal

17. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vascular Anatomy (2 of 4) Veins –Superior vena cava –Inferior vena cava –Subclavian –Internal jugular

18. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vascular Anatomy (3 of 4) Pulmonary –Arteries –Veins

19. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vascular Anatomy (4 of 4) Heart –Ventricles –Atria –Valves –Pericardium

20. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy (1 of 2) Mediastinum –The area between the lungs Heart Trachea Vena cavae Pulmonary artery Aorta Esophagus Lymph nodes

21. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy (2 of 2) Physiology –Ventilation—the mechanical process of moving air into and out of the lungs –Respiration—the exchange of oxygen and carbon dioxide between the outside atmosphere and the cells of the body

22. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

23. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology (1 of 2) Impairments in cardiac output –Blood loss –Increased intrapleural pressures –Blood in the pericardial sac –Myocardial valve damage –Vascular disruption

24. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology (2 of 2) Impairments in gas exchange –Atelectasis –Contused lung tissue –Disruption of the respiratory tract

25. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment Findings (1 of 3) Pulse –Deficit –Tachycardia –Bradycardia Blood pressure –Narrowed pulse pressure –Hypertension –Hypotension –Pulsus paradoxus

26. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment Findings (2 of 3) Respiratory rate and effort –Tachypnea –Bradypnea –Labored –Retractions –Other evidence of respiratory distress

27. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment Findings (3 of 3) Skin –Diaphoresis –Pallor –Cyanosis –Open wounds –Ecchymosis –Other evidence of trauma

28. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment (Neck) Position of trachea Subcutaneous emphysema Jugular venous distention Penetrating wounds

29. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment (Chest) Contusions Tenderness Asymmetry Lung sounds –Absent or decreased –Unilateral –Bilateral –Location –Bowel sounds in hemothorax

30. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Abnormal Percussion Finding Hyperresonance–Air Hyporesonance–Fluid

31. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment ECG ST/T wave elevation or depression –Conduction disturbances –Rhythm disturbances

32. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ History Dyspnea Chest pain Associated symptoms –Other areas of pain or discomfort –Symptoms before incident Past history of cardiorespiratory disease Use of restraint in motor vehicle crash

33. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management Airway and ventilation –High-concentration oxygen –Pleural decompression –Endotracheal intubation –Needle cricothyrotomy –Surgical cricothyrotomy –Positive-pressure ventilation –Occlude open wounds –Stabilize chest wall

34. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Circulation Manage cardiac dysrhythmias Intravenous access

35. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pharmacological Analgesics Antidysrhythmics

36. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Nonpharmacological Needle thoracostomy Tube thoracostomy—in-hospital management Pericardiocentesis—in-hospital management

37. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Transport Considerations Appropriate mode Appropriate facility

38. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Skeletal Injury Clavicular fractures –Clavicle the most commonly fractured bone –Isolated fracture of the clavicle seldom a significant injury Common causes –Children who fall on their shoulders or outstretched arms –Athletes involved in contact sports

39. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Clavicular Fractures (1 of 2) Treatment –Usually accomplished with a sling and swathe or a clavicular strap that immobilizes the affected shoulder and arm –Usually heals well within 4 to 6 weeks Signs and symptoms –Pain –Point tenderness –Evident deformity

40. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Clavicular Fractures (2 of 2) Complications –Injury to the subclavian vein or artery from bony fragment penetration, producing a hematoma or venous thrombosis (rare)

41. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Rib Fractures Incidence –Infrequent until adult life –Significant force required –Most often elderly patients

42. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

43. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Rib Fractures Morbidity/Mortality Can lead to serious consequences. Older ribs are more brittle and rigid. There may be associated underlying pulmonary or cardiovascular injury.

44. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Rib Fractures Pathophysiology Most often caused by blunt trauma—bowing effect with midshaft fracture Ribs 3 to 8 are fractured most often (they are thin and poorly protected) Respiratory restriction as a result of pain and splinting Intercostal vessel injury Associated complications –First and second ribs are injured by severe trauma –Rupture of the aorta –Tracheobronchial tree injury –Vascular injury

45. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Multiple Rib Fractures (1 of 2) Atelectasis Hypoventilation Inadequate cough Pneumonia

46. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Multiple Rib Fractures (2 of 2) Assessment findings –Localized pain –Pain that worsens with movement, deep breathing, coughing –Point tenderness Most patients can localize the fracture by pointing to the area (confirmed by palpation). –Crepitus or audible crunch –Splinting on respiration

47. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Rib Fractures Complications Splinting, which leads to atelectasis and ventilation-perfusion mismatch (ventilated alveoli that are not perfused or perfused alveoli that are not ventilated)

48. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Rib Fractures Management Airway and ventilation –High-concentration oxygen –Positive-pressure ventilation –Encourage coughing and deep breathing Pharmacological –Analgesics Nonpharmacological –Non-circumferential splinting

49. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Rib Fractures Transport Considerations Appropriate mode Appropriate facility

50. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Flail Chest Incidence –Most common cause: vehicular crash –Falls from heights –Industrial accidents –Assault –Birth trauma

51. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Flail Chest Morbidity/Mortality Significant chest trauma Mortality rates 20% to 40% due to associated injuries Mortality increased with –Advanced age –Seven or more rib fractures –Three or more associated injuries –Shock –Head injuries

52. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Flail Chest Pathophysiology (1 of 2) Two or more adjacent ribs fractured in two or more places producing a free- floating segment of chest wall Flail chest usually results from direct impact.

53. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

54. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Flail Chest Pathophysiology (2 of 2) Respiratory failure due to: –Underlying pulmonary contusion The blunt force of the injury typically produces an underlying pulmonary contusion. –Associated intrathoracic injury –Inadequate bellows action of the chest

55. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

56. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Flail Chest Assessment Findings Chest wall contusion Respiratory distress Paradoxical chest wall movement Pleuritic chest pain Crepitus Pain and splinting of affected side Tachypnea Tachycardia Possible bundle branch block on ECG

57. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Flail Chest Management Airway and ventilation –High-concentration oxygen. –Positive-pressure ventilation may be needed. Reverses the mechanism of paradoxical chest wall movement Restores the tidal volume Reduces the pain of chest wall movement Assess for the development of a pneumothorax –Evaluate the need for endotracheal intubation. –Stabilize the flail segment (controversial).

58. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sternal Fractures Incidence –Occurs in 5% to 8% of all patients with blunt chest trauma –A deceleration compression injury –Steering wheel –Dashboard –A blow to the chest; massive crush injury –Severe hyperflexion of the thoracic cage

59. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

60. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sternal Fractures Morbidity/Mortality 25% to 45% mortality rate High association with myocardial or lung injury –Myocardial contusion –Myocardial rupture –Cardiac tamponade –Pulmonary contusion

61. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sternal Fractures Pathophysiology Associated injuries cause morbidity and mortality. –Pulmonary and myocardial contusion –Flail chest Seriously displaced sternal fractures may produce a flail chest. –Vascular disruption of thoracic vessels –Intra-abdominal injuries –Head injuries

62. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sternal Fractures Management Airway and ventilation –High-concentration oxygen Circulation—restrict fluids if pulmonary contusion suspected Pharmacological—analgesics Nonpharmacological—allow chest wall self- splinting Transport considerations –Appropriate mode –Appropriate facility Psychological support/communication strategies

63. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Injury Closed (simple) pneumothorax –Incidence 10% to 30% in blunt chest trauma Almost 100% with penetrating chest trauma –Morbidity/mortality Extent of atelectasis Associated injuries –Pathophysiology Caused by the presence of air in the pleural space A common cause of pneumothorax is a fractured rib that penetrates the underlying lung.

64. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Closed (Simple) Pneumothorax May occur in the absence of rib fractures from: –A sudden increase in intrathoracic pressure generated when the chest wall is compressed against a closed glottis (the paper-bag effect) Results in an increase in airway pressure and ruptured alveoli, which lead to a pneumothorax Small tears self-seal; larger ones may progress. The trachea may tug toward the affected side. Ventilation/perfusion mismatch.

65. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

66. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Closed Pneumothorax Assessment Findings Tachypnea Tachycardia Respiratory distress Absent or decreased breath sounds on the affected side Hyperresonance Decreased chest wall movement Dyspnea Chest pain referred to the shoulder or arm on the affected side Slight pleuritic chest pain

67. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Closed Pneumothorax Management (1 of 2) Airway and ventilation –High-concentration oxygen. –Positive-pressure ventilation if necessary. –If respiration rate is 28 per minute, ventilatory assistance with a bag-valve mask may be indicated.

68. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Closed Pneumothorax Management (2 of 2) Nonpharmacological –Needle thoracostomy Transport considerations –Position of comfort (usually partially sitting) unless contraindicated by possible spine injury –Appropriate mode –Appropriate facility

69. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Incidence –Usually the result of penetrating trauma Gunshot wounds Knife wounds Impaled objects Motor vehicle collisions Falls

70. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

71. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Morbidity/Mortality Severity is directly proportional to the size of the wound. –Profound hypoventilation can result. –Death is related to delayed management.

72. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Pathophysiology (1 of 2) An open defect in the chest wall (>3 cm) –If the chest wound opening is greater than two-thirds the diameter of the trachea, air follows the path of least resistance through the chest wall with each inspiration. –As the air accumulates in the pleural space, the lung on the injured side collapses and begins to shift toward the uninjured side.

73. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Pathophysiology (2 of 2) Very little air enters the tracheobronchial tree to be exchanged with intrapulmonary air on the affected side, which results in decreased alveolar ventilation and decreased perfusion. The normal side also is adversely affected because expired air may enter the lung on the collapsed side, only to be rebreathed into the functioning lung with the next ventilation. May result in severe ventilatory dysfunction, hypoxemia, and death unless rapidly recognized and corrected.

74. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Assessment Findings To-and-fro air motion out of the defect A defect in the chest wall A penetrating injury to the chest that does not seal itself A sucking sound on inhalation Tachycardia Tachypnea Respiratory distress Subcutaneous emphysema Decreased breath sounds on the affected side

75. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Management (1 of 2) Airway and ventilation: –High-concentration oxygen. –Positive-pressure ventilation if necessary. –Assist ventilations with a bag-valve device and intubation as necessary. –Monitor for the development of a tension pneumothorax. Circulation—treat for shock with crystalloid infusion.

76. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Open Pneumothorax Management (2 of 2) Nonpharmacological –Occlude the open wound—apply an occlusive petroleum gauze dressing (covered with sterile dressings) and secure it with tape.

77. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Associated Injuries –A penetrating injury to the chest –Blunt trauma –Penetration by a rib fracture –Many other mechanisms of injury

78. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Morbidity/Mortality Profound hypoventilation can result. Death is related to delayed management. An immediate, life-threatening chest injury.

79. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Pathophysiology (1 of 2) Occurs when air enters the pleural space from a lung injury or through the chest wall without a means of exit. Results in death if it is not immediately recognized and treated. When air is allowed to leak into the pleural space during inspiration and becomes trapped during exhalation, an increase in the pleural pressure results.

80. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Pathophysiology (2 of 2) Increased pleural pressure produces mediastinal shift. Mediastinal shift results in: –Compression of the uninjured lung –Kinking of the superior and inferior vena cava, decreasing venous return to the heart, and subsequently decreasing cardiac output

81. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Assessment Findings (1 of 3) Extreme anxiety Cyanosis Increasing dyspnea Difficult ventilations while being assisted Tracheal deviation (a late sign) Hypotension Identification is the most difficult aspect of field care in a tension pneumothorax.

82. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Assessment Findings (2 of 3) Tachycardia Diminished or absent breath sounds on the injured side Tachypnea Respiratory distress

83. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Assessment Findings (3 of 3) Bulging of the intercostal muscles Subcutaneous emphysema Jugular venous distention (unless hypovolemic) Unequal expansion of the chest (tension does not fall with respiration) Hyperresonnace to percussion

84. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Physical Findings

85. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Management (1 of 5) Emergency care is directed at reducing the pressure in the pleural space. Airway and ventilation: –High-concentration oxygen –Positive pressure ventilation if necessary Circulation—relieve the tension pneumothorax to improve cardiac output.

86. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Management (2 of 5) Nonpharmacological –Occlude open wound –Needle thoracostomy –Tube thoracostomy—in-hospital management Pleural decompression should only be employed if the patient demonstrates significant dyspnea and distinct signs and symptoms of tension pneumothorax.

87. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Management (3 of 5) Needle thoracostomy

88. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Management (4 of 5) Tension pneumothorax associated with penetrating trauma –May occur when an open pneumothorax has been sealed with an occlusive dressing. –Pressure may be relieved by momentarily removing the dressing (air escapes with an audible release of air). After the pressure is released, the wound should be resealed.

89. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Tension Pneumothorax Management (5 of 5) Tension pneumothorax associated with closed trauma –If the patient demonstrates significant dyspnea and distinct signs and symptoms of tension pneumothorax: Provide thoracic decompression with either a large- bore needle or commercially available thoracic decompression kit. Insert a 2-inch 14- or 16-gauge hollow needle or catheter into the affected pleural space. Usually the second intercostal space in the midclavicular line Insert the needle just above the third rib to avoid the nerve, artery, and vein that lie just beneath each rib.

90. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax (1 of 2) If this condition is associated with pneumothorax, it is called a hemopneumothorax.

91. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax (2 of 2) Incidence –Associated with pneumothorax. –Blunt or penetrating trauma. –Rib fractures are frequent cause.

92. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Morbidity/Mortality A life-threatening injury that frequently requires urgent chest tube placement and/or surgery Associated with great vessel or cardiac injury –50% of these patients will die immediately. –25% of these patients live 5 to 10 minutes. –25% of these patients may live 30 minutes or longer.

93. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Pathophysiology (1 of 2) Accumulation of blood in the pleural space caused by bleeding from –Penetrating or blunt lung injury –Chest wall vessels –Intercostal vessels –Myocardium

94. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Pathophysiology (2 of 2) Hypovolemia results as blood accumulates in the pleural space.

95. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Assessment Findings (1 of 2) Tachypnea Dyspnea Cyanosis –Often not evident in hemorrhagic shock Diminished or decreased breath sounds on the affected side

96. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Assessment Findings (2 of 2) Hyporesonance (dullness on percussion) on the affected side Hypotension Narrowed pulse pressure Tracheal deviation to the unaffected side (rare) Pale, cool, moist skin

97. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Physical Findings

98. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemothorax Management Airway and ventilation –High-concentration oxygen –Positive-pressure ventilation if necessary –Ventilatory support with bag-valve mask, intubation, or both Circulation –Administer volume-expanding fluids to correct hypovolemia –Nonpharmacological—tube thoracostomy (in- hospital management) –Transport considerations Appropriate mode Appropriate facility

99. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemopneumothorax Pathophysiology—pneumothorax with bleeding in the pleural space –Assessment—findings and management are the same as for hemothorax. –Management—management is the same as for hemothorax.

100. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Contusion A pulmonary contusion is the most common potentially lethal chest injury. Incidence Blunt trauma to the chest The most common injury from blunt thoracic trauma. 30% to 75% of patients with blunt trauma have pulmonary contusion. Commonly associated with rib fracture High-energy shock waves from explosion High-velocity missile wounds Rapid deceleration A high incidence of extrathoracic injuries Low velocity—ice pick

101. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Contusion Morbidity/Mortality May be missed due to the high incidence of other associated injuries Mortality—between 14% and 20%

102. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Contusion Assessment Findings Tachypnea Tachycardia Cough Hemoptysis Apprehension Respiratory distress Dyspnea Evidence of blunt chest trauma Cyanosis

103. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Contusion Management Airway and ventilation: –High-concentration oxygen –Positive-pressure ventilation if necessary Circulation—restrict IV fluids (use caution restricting fluids in hypovolemic patients). Transport considerations.

104. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Asphyxia Incidence –A severe crushing injury to the chest and abdomen Steering wheel injury Conveyor belt injury Compression of the chest under a heavy object

105. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Asphyxia Pathophysiology A sudden compressional force squeezes the chest. An increase in intrathoracic pressure forces blood from the right side of the heart into the veins of the upper thorax, neck, and face. Jugular veins engorge and capillaries rupture.

106. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Asphyxia Assessment Reddish-purple discoloration of the face and neck (the skin below the face and neck remains pink). Jugular vein distention. Swelling of the lips and tongue. Swelling of the head and neck. Swelling or hemorrhage of the conjunctiva (subconjunctival petechiae may appear). Hypotension results once the pressure is released.

107. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Asphyxia Management Airway and ventilation –Ensure an open airway. –Provide adequate ventilation. Circulation –IV access. –Expect hypotension and shock once the compression is released. Transport considerations –Appropriate mode. –Appropriate facility.

108. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Heart and Great Vessel Injury Myocardial contusion (blunt myocardial injury) – Incidence The most common cardiac injury after a blunt trauma to the chest Occurs in 16% to 76% of blunt chest traumas Usually results from motor vehicle collisions as the chest wall strikes the dashboard or steering column Sternal and multiple rib fractures common

109. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Heart and Great Vessel Injury Morbidity/Mortality A significant cause of morbidity and mortality in the blunt trauma patient –Clinical findings are subtle and frequently missed due to: Multiple injuries that direct attention elsewhere Little evidence of thoracic injury Lack of signs of cardiac injury on initial examination

110. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Heart and Great Vessel Injury Assessment Findings (1 of 2) Retrosternal chest pain ECG changes –Persistent tachycardia –ST elevation, T wave inversion –Right bundle branch block –Atrial flutter, fibrillation –Premature ventricular contractions –Premature atrial contractions

111. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Heart and Great Vessel Injury Assessment Findings (2 of 2) New cardiac murmur Pericardial friction rub (late) Hypotension Chest wall contusion and ecchymosis

112. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Heart and Great Vessel Injury Management Airway and ventilation—high-concentration oxygen Circulation—IV access Pharmacological –Antidysrhythmics –Vasopressors Transport considerations –Appropriate mode –Appropriate facility Psychological support/communication strategies

113. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Incidence –Rare in blunt trauma –Penetrating trauma –Occurs in less than 2% of all chest traumas

114. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Morbidity/Mortality Gunshot wounds carry higher mortality than stab wounds. Lower mortality rate if isolated tamponade is present.

115. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Anatomy and Physiology Pericardium –A tough fibrous sac that encloses heart –Attaches to the great vessels at the base of the heart –Two layers: The visceral layer forms the epicardium. The parietal layer is regarded as the sac itself.

116. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Pathophysiology (1 of 2) A blunt or penetrating trauma may cause tears in the heart chamber walls, allowing blood to leak from the heart. –If the pericardium has been torn sufficiently, blood leaks into the thoracic cavity. If 150 to 200 mL of blood enters the pericardial space acutely, pericardial tamponade develops.

117. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Pathophysiology (2 of 2) Increased intrapericardial pressure: –Does not allow the heart to expand and refill with blood –Results in a decrease in stroke volume and cardiac output Myocardial perfusion decreases due to pressure effects on the walls of the heart and decreased diastolic pressures. Ischemic dysfunction may result in infarction. Removal of as little as 20 mL of blood may drastically improve cardiac output.

118. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Assessment Findings (1 of 3) Tachycardia Respiratory distress Narrowed pulse pressure Cyanosis of the head, neck, and upper extremities

119. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Assessment Findings (2 of 3) Beck’s triad –Narrowing pulse pressure –Neck vein distention –Muffled heart sounds

120. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Assessment Findings (3 of 3) Kussmaul’s sign—a rise in venous pressure with inspiration when spontaneously breathing ECG changes

121. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Physical Findings

122. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pericardial Tamponade Management Airway and ventilation Circulation—IV fluid challenge Nonpharmacological—pericardiocentesis (in-hospital management) Transport considerations –Appropriate mode –Appropriate facility –Psychological support/communication strategies

123. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Aortic Rupture Incidence –Blunt trauma Rapid deceleration in high-speed motor vehicle crashes Falls from great heights Crushing injuries 15% of all blunt trauma deaths

124. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Aortic Rupture Morbidity/Mortality 80% to 90% of these patients die at the scene as a result of massive hemorrhage. –About 10% to 20% of these patients survive the first hour. Bleeding is tamponaded by surrounding adventitia of the aorta and intact visceral pleura. Of these, 30% have rupture within 6 hours.

125. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Aortic Rupture Pathophysiology Patients who are normotensive should have limited replacement fluids to prevent an increase in pressure in the remaining aortic wall tissue. – Transport considerations Appropriate mode Appropriate facility Psychological support/communication strategies

126. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Aortic Rupture Assessment Findings (1 of 2) Upper-extremity hypertension with absent or decreased amplitude of femoral pulses –Thought to result from compression of the aorta by the expanding hematoma Generalized hypertension –Secondary to increased sympathetic discharge About 25% have a harsh systolic murmur over the pericardium or interscapular region Paraplegia with a normal cervical and thoracic spine (rare) Retrosternal or interscapular pain

127. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Aortic Rupture Assessment Findings (2 of 2) Dyspnea Dysphagia Ischemic pain of the extremities Chest wall contusion

128. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Aortic Rupture Management Airway and ventilation: –High-concentration oxygen –Ventilatory support with spinal precautions Circulation—do not over-hydrate.

129. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diaphragmatic Rupture Incidence Penetrating trauma –Blunt trauma –Injuries to the diaphragm account for 1% to 8% of all blunt injuries. 90% of injuries to the diaphragm are associated with high-speed motor vehicle crashes.

130. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diaphragmatic Rupture Anatomy Review The diaphragm is a voluntary muscle that separates the abdominal cavity from the thoracic cavity. –The anterior portion attaches to the inferior portion of the sternum and the costal margin. –Attaches to the 11th and 12th ribs posteriorly. –The central portion is attached to the pericardium. –Innervated via the phrenic nerve.

131. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diaphragmatic Rupture Rupture can allow intra-abdominal organs to enter the thoracic cavity, which may cause the following: –Compression of the lung with reduced ventilation –Decreased venous return –Decreased cardiac output –Shock

132. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diaphragmatic Rupture Pathophysiology Can produce very subtle signs and symptoms Bowel obstruction and strangulation Restriction of lung expansion –Hypoventilation –Hypoxia Mediastinal shift –Cardiac compromise –Respiratory compromise

133. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diaphragmatic Rupture Management Airway and ventilation –High-concentration oxygen –Positive-pressure ventilation if necessary –Caution: positive pressure may worsen the injury Circulation—IV access Nonpharmacological—do not place patient in Trendelenburg position Transport considerations –Appropriate mode –Appropriate facility

134. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diaphragmatic Rupture Assessment Findings Tachypnea Tachycardia Respiratory distress Dullness to percussion Scaphoid abdomen (hollow or empty appearance) –If a large quantity of the abdominal contents are displaced into the chest Bowel sounds in the affected hemithorax Decreased breath sounds on the affected side Possible chest or abdominal pain

135. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Summary Introduction to Thoracic Trauma Thoracic Anatomy Pathophysiology of Thoracic Trauma Assessment of Thoracic Trauma Management of Thoracic Trauma