Chapter 30: Chest Injuries

Common Shows for Trauma Assessment NYS

• Treatment for open chest wounds

  • — — or — — with flapper valve

  • Ventilate with a ——

• Treatment for flail chest

  • — — ventilations along with patient’s rhythm of inhalation

  • Flail segment shows as — movement

• Pneumothorax

  • Ventilate with a ——

• Exsanguination

  • First always apply — —-

  • — or — gauze depending on location

• Airway obstruction

  • — or —

chest seal, occlusive dressing, BVM

positive pressure, inhalation, paradoxical

BVM

direct pressure, tourniquet, hemostatic

suction remove

Introduction

• Chest trauma causes more than 1.2 million emergency department visits each year.

• Chest injuries can involve the heart, lungs, and great blood vessels.

• May be the result of blunt trauma, penetrating trauma, or both

• Immediately treat injuries that interfere with normal breathing function.

  • Internal bleeding can compress the —- and —-.

  • Air may collect in the —-, preventing lung —-.

lungs heart, chest , expansion

Anatomy and Physiology

• Ventilation: the body’s ability to move —- in and out of the chest and lung tissue

• Oxygenation: the process of delivering —- to the —- by diffusion from the — following inhalation into the lungs

• Injuries may affect ventilation and/or oxygenation.

• Thoracic skin, muscle, and bones

  • Similarities to other regions

  • Also unique features to allow for ventilation, such as striated muscle

air, O2, blood, alveoli,

Anatomy and Physiology

• The — bundle lies closely along the lowest margin of each rib.

• The — covers each lung and the thoracic cavity.

  • A small amount of pleural fluid between the parietal and visceral pleura allows the lungs to move freely against the inner chest wall during respiration.

• Vital organs, such as the heart, are protected by the —-.

  • Connected in the back to the —-

  • Connected in the front to the —

• The mediastinum contains the —, — —, —, and —.

• The diaphragm is a muscle that separates the — cavity from the — cavity.

neurovascular, pleura, ribs, vertebrae, sternum, heart great vessels esophagus trachea, thoracic, abdominal

Mechanics of Ventilation

• The intercostal muscles and diaphragm —- during inhalation (—- pressure)

• The intercostal muscles and the diaphragm — during exhalation.

• The body should not have to —- to breathe when in a resting state.

• Patients with a spinal injury below —- can still breathe from the diaphragm.

• Patients with a spinal injury above —- may lose the ability to breathe.

• Tidal volume is the amount of air moved into or out of the lungs in a —- —-.

• Minute ventilation is calculated by multiplying the —- —- by the number of —- — ——.

  • Changing either number affects the amount of air moving through the system.

contract, negative, relax, work, C5, C3, single breath, tidal volume, breaths per minute,

Injuries of the Chest

• Two types: open and closed

• Closed chest injury

  • Skin is —- broken; Generally caused by — trauma

  • Can cause significant — and —- contusion

  • If the heart is damaged, it may not be able to —- with blood or blood may not be pumped with enough —- out of the heart.

  • Lung tissue bruising can result in exponential loss of — —-.

  • Rib fractures may cause further damage.

• Open chest injury

  • Object —- the chest wall itself.

  • Knife, bullet, piece of metal, or broken end of fractured rib

  • Do not attempt to move or remove the object.

not, blunt, cardiac pulmonary, refill, force, surface area, penetrates,

Injuries of the Chest

• Blunt trauma to the chest may cause:

  • Rib, sternum, and chest wall fractures

  • Bruising of the lungs and heart

  • Damage to the aorta

  • Vital organs to be torn from their attachment in the chest cavity

• Chest injury patients often have — and — respirations.

  • — to take a deep breath

  • Patient may not be — air.

  • Auscultate multiple locations to assess for adequate breath sounds.

rapid shallow, hurts, moving, 

Injuries of the Chest

• Signs and symptoms

  • Pain at the site of injury

  • Localized pain aggravated or increased with —

  • Bruising to the chest wall

  • — with palpation of the chest

  • Penetrating injury to the chest

  • —

  • Hemoptysis

  • Failure of one or both sides of the chest to — normally with inspiration

  • — and — pulse and — blood pressure

  • — around the lips or fingernails

  • — breath sounds on one side

  • — oxygen saturation

breathing, crepitus, dyspnea, expand, rapid weak low, cyanosis, diminished low 

Scene Size-up

• Scene safety and standard precautions

  • Ensure the scene is safe for you, your partner, your patient, and bystanders.

  • If the area is a crime scene, do not disturb evidence if possible.

  • Request law enforcement for scenes involving violence.

  • Call for ALS early.

• Mechanism of injury

  • Chest injuries are common in motor vehicle crashes, falls, industrial accidents, and assaults.

  • Determine the number of patients.

  • Consider spinal immobilization.

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Primary Assessment

• Form a general impression.

  • Address life-threatening hemorrhage immediately. 

  • Note the patient’s level of consciousness.

  • Perform a rapid physical examination.

• Airway and breathing

  • Ensure that the patient has a clear and patent airway.

  • Consider early cervical spine stabilization if appropriate.

  • Are jugular veins —-?

  • Is breathing present and adequate?

  • Inspect for DCAP-BTLS.

  • Look for —- expansion of the chest wall.

  • Check for —- motion.

  • Apply —- dressings to all penetrating injuries.

  • Support ventilations.

  • Reassess the effectiveness of ventilatory support.

  • Be alert for decreasing oxygen saturation.

  • Be alert for impending —- pneumothorax.

distended, equal, paradoxical, occulusive, tension

Primary Assessment

• Circulation

  • Pulse rate and quality

  • Skin color and temperature

  • Address life-threatening bleeding immediately, using direct pressure and a bulky dressing.

• Transport decision

  • Priority patients are those with a problem with their XABCs.

  • Pay attention to subtle clues:

    • Appearance of the skin

    • Level of consciousness

    • A sense of impending doom in the patient

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Secondary Assessment

• Physical examinations

  • For an isolated injury, focus on:

    • Isolated injury

    • Patient’s complaint

    • Body region affected

    • Location and extent of injury

    • Anterior and posterior aspects of the chest wall

    • Changes in respirations

  • For significant trauma likely affecting multiple systems, start with a rapid physical examination.

  • Use DCAP-BTLS to determine the nature and extent of the injury. 

• Vital signs

  • Assess pulse, respirations, blood pressure, skin condition, oxygen saturation, and pupils.

  • Reevaluate every 5 minutes or less.

  • Pulse and respiratory rates may decrease in later stages of the chest injury.

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Reassessment

• Repeat the primary assessment.

• Reassess the chief complaint.

• Reevaluate:

  • Airway

  • Breathing

  • Pulse

  • Perfusion

  • Bleeding

• Interventions

  • Reassess vital signs and observe trends.

  • Provide appropriate spinal stabilization when indicated.

  • Maintain an open airway.

  • Control significant, visible bleeding.

  • Place an occlusive dressing over penetrating trauma to the chest wall.

  • Provide aggressive treatment for shock and rapid transport.

  • Do not delay transport to complete non–life-saving treatments.

• Communicate all relevant information to the staff at the receiving hospital.

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Pneumothorax

• Commonly called a collapsed lung

• Accumulation of —- in the —- space

  • Blood passing through the collapsed portion of the lung is not —-.

  • You may hear —, —, or — breath sounds.

air, pleural, oxygenated, diminished, absent, abnormal

Pneumothorax

Open chest wound

• Often called an —- pneumothorax or a —- chest wound

• Wounds must be rapidly sealed with an —- dressing or a —- — with a flutter valve (one way valve) to prevent a —- pneumothorax

  • Carefully monitor the patient for tension pneumothorax.

• Every open chest wound gets occlusive dressing or chest seal

  • If using occlusive dressing, leave a space of unsecured dressing to let air flow in and out

open, sucking, occlusive, chest seal, tension,

Pneumothorax

• Simple pneumothorax

  • Does not result in major changes in the patient’s —- physiology

  • Commonly due to blunt trauma that results in fractured —-

  • Can often worsen, deteriorate into —- pneumothorax, or develop complications

cardiac, blunt, ribs, tension 

Pneumothorax

Tension pneumothorax

• Results from ongoing —- —- in the pleural space that can't escape

• Increased —— in the chest:

  • Causes complete collapse of the —- lung

  • Mediastinum is pushed into the opposite — —-

    • Will see —- —- on the —- side of the lung that collapsed

    • Tracheal deviation is a —— sign of a tension pneumothorax

• Commonly caused by a blunt injury where a fractured — lacerates a —- or —-

• Not much we can do when this happens

  • We have to bag them to allow them to breathe but it will inevitably worsen the tension pneumothorax

  • Request ALS

air accumulation, pressure, other, pleural cavity, tracheal deviation, opposite, late, rib, lung bronchus

Hemothorax

• — collects in the — space from bleeding around the — — or from a — or — —.

• Signs and symptoms

  • — without any obvious external bleeding or apparent reason for shock

  • — breath sounds on the affected side

  • Will NOT hear gurgling sounds because blood is not —-

• Prehospital treatment

  • Rapid transport

• Hemopneumothorax: the presence of —- and —- in the pleural space

• Best treatment is —- —- ventilations but definitive care is surgery

blood pleural, ribcage, lung, great vessel, shock, decreased, aerated, air blood, positive pressure

Cardiac Tamponade

• Protective membrane (—-) around the heart fills with —- or —.

• The heart cannot pump an adequate —- of blood (cannot —- properly)

  • Can cause —- shock 

• Signs and symptoms

  • Beck triad

    • —

    • — heart sounds

    • — blood pressure

  • — mental status

• Prehospital treatment

  • Support ventilations

  • Rapidly transport

• Definitive care is drainage at hospital

pericardium, blood, fluid, amount, refill, obstructive, JVD, muffled, decreasing, altered 

Rib Fractures

• Common, particularly in —- people

• While palpating chest can feel —- (grinding of bones together)

• A fracture of one of the — — ribs is a sign of a — MOI.

• A fractured rib may cause a ——, —-, or —.

• Signs and symptoms

  • Localized tenderness and pain when breathing

  • —, — respirations

  • Patient holding the affected portion of the rib cage

• Prehospital treatment includes supplemental oxygen.

older, crepitus, upper four, significant, pneumothorax, hemothorax, hemopneumothorax, breathing, rapid shallow,

Flail Chest

• Caused by — rib fractures that — a segment of the — —

  • — or more ribs broken in — or more places

  • Will become out of —- with the rest of the ribcage

  • Will move —- during inhalation and move —- during exhalation (— of other ribs)

    • —/— movement

    • This will interfere with —- changes in pleural cavity needed to draw air in via —- pressure

• Detached portion moves — of normal

• Prehospital treatment

  • Maintain the airway.

  • Provide respiratory support, if needed.

  • Give supplemental oxygen

  • provide —- —- ventilations even when conscious 

  • Perform ongoing assessments for complications.

compound, detach, chest wall, 3, 2, sync, inwards, outward, opposite, paradoxical/seesaw, pressure, negative, opposite, positive pressure 

Flail Chest

• Treatment may include —- —- ventilation with a —-

• Restricting chest wall movement is no longer recommended. 

• Flail chest may indicate serious —- damage or —- injury.

• Only treatment is positive pressure ventilations EVEN IF CONSCIOUS

  • Must time ventilations with their inhalations if conscious, otherwise they will not be able to fill their lungs due to paradoxical movement interfering with negative pressure in lungs

positive pressure, BVM, internal spinal,

Other Chest Injuries

Pulmonary contusion

• Should always be suspected in a patient with a —- —-

• Pulmonary alveoli become filled with —-, leading to —- (little to no gas exchange)

• Prehospital treatment

  • Supplemental oxygen and — — ventilation as needed

Other fractures

• Sternal fractures

  • Create an increased index of suspicion for —- injury

  • This requires —- force to occur, so expect cardiac and pulmonary —- or other serious injury in chest alongside it

• Clavicle fractures

  • Possible damage to —- —

  • Suspect — —- fractures in medial clavicle fractures

    • Due to overlap of clavicle and upper ribs

  • Be alert to —- development.

flail chest, blood, hypoxia, positive pressure, organ, significant, contusions, neurovascular, bundle, upper rib, pneumothorax 

Other Chest Injuries

Traumatic asphyxia

• This occurs when enough force applied to chest that it pushes all of the —— out of the heart and aorta down into the —- and up into the —-

  • Dramatically increases —- in the head resulting in many vessels in the neck and higher —-

  • — mortality rate

• Characterized by —- neck veins, —- in the face and neck, and —- in the sclera of the eye

• Suggests an underlying injury to the —- and possibly a —- contusion

• Prehospital treatment

  • Ventilatory support and supplemental oxygen

  • Monitor vital signs during immediate transport.

blood, body, head, pressure, blowing, high

distended, cyanosis, hemorrhage, heart, pulmonary,

Other Chest Injuries

Blunt myocardial injury

• Bruising of the heart —

  • Signs and symptoms will be similar to an —- because less blood will be able to get to parts of the heart causing —- of those tissues

  • Since caused by trauma DO NOT GIVE ASPIRIN

• The heart may be unable to maintain adequate blood —-.

• Signs and symptoms

  • — pulse rate

  • Chest — or discomfort

• Suspect it in all cases of severe —- injury to the chest.

• Prehospital treatment

  • Carefully monitor the —-.

  • Note changes in — —.

  • Provide supplemental oxygen and transport immediately. 

muscle, MI hypoxia, pressure, irregular, pain, blunt pulse blood pressure

Other Chest Injuries

Commotio cordis

• Injury caused by a sudden, direct blow to the —- during a critical portion of the —-

• Always results in immediate —- —-

  • Textbook says "may result"

• Results in ventricular ——, which is often responsive to defibrillation and early initiation of CPR.

chest, heartbeat, cardiac arrest, fibrillation 

Other Chest Injuries

Laceration of the great vessels

• May result in rapidly fatal —-

• Prehospital treatment

  • Cardiopulmonary resuscitation (CPR)

  • Ventilatory support and supplemental oxygen, if needed

  • Immediate transport

  • Be alert for shock.

  • Monitor for changes in baseline vital signs.

• If inferior or superior vena cava, or aorta shears they will die within minutes

hemorrhage

When the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration, the resulting injury that kills almost one-third of patients, usually within seconds, is:

a hemothorax. 

aortic shearing.

a pneumothorax.

a ruptured myocardium. 

aortic shearing.

Signs and symptoms of a chest injury include all of the following, EXCEPT:

hemoptysis. 

hematemesis. 

asymmetric chest movement. 

increased pain with breathing. 

hematemesis

During your 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.

transport immediately.

assess the patient for a tension pneumothorax. 

cover the wound with an occlusive dressing. 

cover the wound with an occlusive dressing. 

When caring for a patient with signs of a pneumothorax, your MOST immediate concern should be:

hypovolemia. 

intrathoracic bleeding. 

ventilatory inadequacy. 

associated myocardial injury. 

ventilatory inadequacy. 

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 the release of 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.

It allows the release of air trapped in the pleural space.

Signs of a cardiac tamponade include all of the following, EXCEPT:

muffled heart tones. 

a weak, rapid pulse. 

collapsed jugular veins.

narrowing pulse pressure.

collapsed jugular veins.

A patient experienced a severe compression to the chest when trapped between a vehicle and a brick wall. You suspect traumatic asphyxia due to the hemorrhage into the sclera of his eyes and which other sign?

Flat neck veins

Cyanosis in the face and neck

Asymmetric chest movement

Irregular heart rate

Cyanosis in the face and neck

A 14-year-old baseball player was hit in the chest with a line drive. He is in cardiac arrest. Which of the following is the most likely explanation?

Myocardial contusion

Traumatic asphyxia

Commotio cordis

Hemothorax 

Commotio cordis

Paradoxical chest movement is typically seen in patients with:

a flail chest.

a pneumothorax.

isolated rib fractures.

a ruptured diaphragm. 

a flail chest.

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. 

has injured his myocardium.