EMS 30: Chest Injuries

Priority in chest trauma

Immediately treat injuries that interfere with normal breathing

Neurovascular bundle

Runs along the inferior border of each rib and contains an artery, vein, and nerve

Pleura

Membrane covering the lungs and lining the thoracic cavity

Pleural fluid

Small amount of fluid between the pleural layers that reduces friction during breathing

Diaphragm

Primary muscle of breathing that separates the thoracic and abdominal cavities

Normal inhalation

The diaphragm and intercostal muscles contract, expanding the chest cavity

Normal exhalation

The diaphragm and intercostal muscles relax, allowing passive exhalation

Spinal cord injury below C5

The diaphragm usually continues to function, allowing spontaneous breathing

Spinal cord injury above C3

May result in complete loss of the ability to breathe

Closed chest injury

Blunt chest trauma that may cause pulmonary contusion, cardiac contusion, rib fractures, or internal organ injury without an open wound

Common blunt chest injuries

Rib fractures, sternal fractures, pulmonary contusions, cardiac contusions, aortic injury, and torn great vessels

Signs of significant chest trauma

Chest pain, pain with breathing, bruising, crepitus, dyspnea, hemoptysis, unequal chest expansion, tachycardia, hypotension, cyanosis, diminished breath sounds, and low SpO₂

Typical breathing pattern in chest trauma

Rapid, shallow respirations

Chest trauma assessment

Look for jugular vein distention, consider spinal precautions, inspect the entire chest, and monitor oxygen saturation

Treatment of penetrating chest wounds

Immediately apply an occlusive dressing

Monitor after chest injury

Continuously reassess breathing, oxygen saturation, and signs of tension pneumothorax

Pneumothorax

Air in the pleural space causing partial or complete lung collapse

Simple pneumothorax

Air in the pleural space without significant impairment of circulation

Open pneumothorax

Sucking chest wound allowing air to enter the pleural space through the chest wall

Treatment of sucking chest wound

Seal immediately with an occlusive dressing

Flutter valve dressing

One-way occlusive dressing that allows air to escape but prevents air from entering

Tension pneumothorax

Progressive accumulation of air under pressure in the pleural space causing respiratory and circulatory compromise

Signs of tension pneumothorax

Severe respiratory distress, absent or diminished breath sounds on one side, hypotension, JVD, cyanosis, and worsening hypoxia

Hemothorax

Blood collecting in the pleural space

Signs of hemothorax

Shock without obvious external bleeding and decreased breath sounds on the affected side

Hemopneumothorax

Presence of both blood and air in the pleural space

Cardiac tamponade

Blood or fluid accumulating within the pericardial sac and preventing adequate cardiac filling

Flail chest

Two or more adjacent ribs fractured in two or more places creating a free-floating chest segment

Paradoxical movement

Flail chest segment moves inward during inhalation and outward during exhalation

Treatment of flail chest

Provide oxygen and positive-pressure ventilation with a bag-mask device if needed

Pulmonary contusion

Bruising of the lung causing blood to fill the alveoli and resulting in hypoxia

Sternal fracture

Suggests a significant mechanism of injury and raises suspicion for underlying heart or lung injury

Clavicle fracture concern

Possible injury to the neurovascular bundle and associated upper rib fractures

Traumatic asphyxia

Crushing chest injury causing distended neck veins, facial cyanosis, and subconjunctival hemorrhage

Blunt myocardial injury

Bruising of the heart muscle causing chest pain, irregular pulse, or hypotension

Commotio cordis

Sudden cardiac arrest caused by a blunt blow to the chest during a vulnerable phase of the cardiac cycle

Laceration of the great vessels

Life-threatening tear of major thoracic blood vessels causing rapid internal hemorrhage and shock