Chest Injuries

Chapter 30: Chest Injuries

National EMS Education Standard Competencies

• Trauma: Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Chest Trauma Overview

• Recognition and Management of Different Mechanisms

  • Blunt Trauma: Caused by impact such as motor vehicle crashes or falls. (pp. 1095–1097, 1102–1110)

  • Penetrating Trauma: Caused by shootings, stabbings, or industrial injuries. (pp. 1095–1097, 1102–1110)

    • Types of Chest Injuries:

      • Open chest wound (pp. 1095–1096)

      • Impaled object (pp. 1095–1096)

• Key Conditions

  • Hemothorax: Blood accumulation in the pleural cavity (pp. 1097–1102, 1105)

  • Pneumothorax: Presence of air in the pleural cavity (pp. 1102–1105)

    • Types of Pneumothorax:

      • Open (pp. 1102–1104)

      • Simple (p. 1104)

      • Tension (pp. 1104–1105)

  • Cardiac Tamponade: Accumulation of fluid around the heart (pp. 1105–1107)

  • Rib Fractures (pp. 1107)

  • Flail Chest (pp. 1107–1108)

  • Commotio Cordis (p. 1109)

Knowledge Objectives

1. Explain the mechanics of ventilation in relation to chest injuries. (pp 1094–1095)

2. Differentiate between open and closed chest injuries. (pp 1095–1096)

3. Recognize signs of chest injury. (pp 1096–1097)

4. Manage suspected chest injuries, including:

   • Pneumothorax

   • Hemothorax

   • Cardiac tamponade

   • Rib fractures

   • Flail chest

   • Pulmonary contusion

   • Traumatic asphyxia

   • Blunt myocardial injury

   • Commotio cordis

   • Laceration of great vessels (pp 1102–1110)

5. Recognize complications accompanying chest injuries (pp 1102–1110)

6. Explain complications of open pneumothorax (sucking chest wound). (pp 1102–1104)

7. Differentiate between pneumothorax (open, simple, tension) and hemothorax. (pp 1102–1105)

8. Describe complications of cardiac tamponade (pp 1105–1107)

9. Describe complications of rib fractures. (p 1107)

10. Describe complications of flail chest. (pp 1107–1108)

Skills Objectives

1. Assess a patient with suspected chest injury. (pp 1097–1102)

2. Demonstrate management of a patient with sucking chest wound. (pp 1103–1104)

Introduction to Chest Injuries

• Chest injuries are frequently encountered by EMTs.

• CDC reports over 1.2 million emergency department visits annually due to chest trauma in the U.S.

• Serious injuries can occur due to the presence of the heart, lungs, and major blood vessels in the chest cavity.

• Injuries may result from:

  • Blunt trauma: Motor vehicle crashes, or falls.

  • Penetrating trauma: Shootings or stabbings.

• Importance of immediate treatment to prevent permanent damage due to hypoxia or internal bleeding.

• Internal bleeding can compress lungs or heart.

• Quick action by EMTs can make the difference between recovery and death.

Anatomy and Physiology of the Chest

• Ventilation vs. Oxygenation:

  • Ventilation: Movement of air in and out of the lungs; critical for maintaining oxygen supply.

  • Oxygenation: Delivery of oxygen to blood from alveoli; essential for cellular function.

• Chest Anatomy:

  • The thoracic cage extends from the neck to the diaphragm.

  • Diaphragm: Rises high, potentially injuring organs such as the liver, spleen, or stomach during penetrating injuries.

  • The lungs (right has 3 lobes; left has 2) are covered by the pleura, creating surface tension essential for lung movement.

• Intercostal Muscles:

  • Found between ribs; enable rib cage expansion during inhalation.

  • Children may rely more on diaphragm (belly breathing) due to underdeveloped intercostal muscles.

• Neurovascular Bundle: Situated below each rib, this configuration is critical as damage can cause hemothorax.

• Mediastinum: Contains the heart, trachea, esophagus, and great vessels. A crucial area that can be compromised by injuries.

Mechanics of Ventilation

• Upon inhalation:

  • Intercostal muscles contract, expanding rib cage; the diaphragm contracts, lowering intrathoracic pressure and allowing air influx.

• During exhalation:

  • Muscles relax, returning tissues to normal positions and forcing air out.

• Tidal Volume: Amount of air moved during a single breath; approx. 500 mL; affects minute ventilation or minute volume.

  • $ext{Minute Volume} (MV) = Tidal Volume (TV) imes Breaths ext{ per minute}$

  • Example: Normal rate of 12 breaths/min and 500 mL results in:
    $ext{MV} = 500 ext{ mL} imes 12 ext{ breaths/min} = 6000 ext{ mL (6 L)}$

  • Increasing breaths or volume increases MV and vice versa.

• Bag-Mask Device: Should be used cautiously to avoid overinflation and related complications (e.g., gastric distention).

Types of Chest Injuries

1. Open vs. Closed Injuries:

   • Closed Injury: Skin is intact; typically from blunt force.

   • Open Injury: Skin is penetrated; can lead to immediate complications and requires urgent care.

2. Blunt Trauma Effects:

   • Likely leads to rib/fracture injury, cardiac and pulmonary contusions, and significant vascular damage.

   • Severe injuries can lead to thoracic aorta rupture, causing rapid death.

3. Penetrating Trauma Effects:

   • Immediate risk of significant internal damage.

   • Impaled Objects: Should NOT be removed as they may control bleeding; leave for surgical intervention.

Assessment of Chest Injuries

Scene Size-Up

• Assess for safety, hazards, and mechanism of injury (MOI).

• Alert ALS if violence is suspected or patient requires advanced care.

Primary Assessment

• Address life-threatening hemorrhage first; then assess airway and breathing.

• Look for DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling).

• Ensure effective ventilation and oxygenation; auscultate lungs for breath sounds.

• Signs of injury to be aware of:

  • Tachypnea: Rapid breathing.

  • Dyspnea: Difficulty breathing.

  • Cyanosis: Blue tinge around lips/nails; indicates poor oxygenation.

  • Jugular Vein Distention (JVD): Suggestive of tension pneumothorax or cardiac tamponade.

Secondary Assessment

• Focus on chest injuries; observe for symmetry of chest wall movement and crepitus which indicates rib fractures.

• Palpate for pain, tenderness, and deformities.

• Verify breath sounds; decreased sounds indicate possible complications like pneumothorax.

Specific Chest Injuries and Management

Pneumothorax

• Definition: Air enters pleural space, potentially causing lung collapse.

• Symptoms: Dyspnea, increased heart rate, diminished breath sounds.

• Treatment:

  • Administer high-flow oxygen.

  • Monitor vital signs and prepare for transport to advanced care if necessary.

Tension Pneumothorax

• Acute and life-threatening increase in pleural space pressure obstructing lung expansion and venous return to the heart.

• Symptoms: Marked respiratory distress, absent breath sounds on affected side, JVD, tracheal deviation.

• Treatment: Immediate decompression via needle thoracotomy and high-flow oxygen.

Hemothorax

• Definition: Blood accumulation in the pleural space.

• Indicative of internal bleeding, may not always be visible externally.

• Requires rapid transport and surgical intervention.

Cardiac Tamponade

• Definition: Accumulation of fluid around the heart leading to reduced cardiac output.

• Signs (Beck's Triad): JVD, narrowing pulse pressure, muffled heart sounds.

• Immediate supportive care and transport required for surgical intervention.

Rib Fractures

• Results in localized pain, rapid shallow breathing, and can lead to significant internal injuries.

• Fractured ribs can lacerate lung tissue leading to pneumothorax.

Flail Chest

• Occurs with multiple rib fractures leading to paradoxical movement of the chest wall.

• Causes severe respiratory distress; requires high-flow oxygen and sometimes assisted ventilation.

Traumatic Asphyxia

• Caused by sudden chest compression; exhibits characteristic signs such as cyanosis and neck vein distension.

• Requires immediate ventilation support and monitoring.

Commotio Cordis

• A sudden blow to the chest causing cardiac arrest due to rhythm disruption; usually seen in sports injuries.

• Requires rapid CPR and defibrillation.

Laceration of Great Vessels

• Results in high-risk, often fatal hemorrhage. Immediate transport and CPR as needed are crucial.

Treatment Protocols

• Always ensure high-flow oxygen for chest injuries, while also monitoring vital signs.

• Prepare for rapid transport especially if conditions worsen or if tension pneumothorax is suspected.

• Patient Reassessment: Frequent checks to adjust treatment based on patient responses during transport.

Notes on Special Populations

• Older Patients: Increased risk for rib fractures due to fragile bones; may compensate poorly for respiratory distress.

• Children: More susceptible to severe trauma due to flexible rib cages, may not visibly fracture, and require careful observation for signs of respiratory distress.

Vital Vocabulary

• Cardiac Tamponade: Compression of the heart due to fluid buildup in the pericardial sac.

• Flail Chest: Segment of chest wall detached due to multiple rib fractures.

• Hemothorax: Collection of blood within the pleural cavity.

• Open Pneumothorax: Penetrating chest injury whereby air enters and exits the pleural space creating a sucking wound.

• Tension Pneumothorax: Accumulation of air causing increasing intrathoracic pressure resulting in impaired cardiac output.

References

• Khouzam RN, Al-Mawed S, Farah V, Mizeracki A. Next-generation airbags and the possibility of negative outcomes due to thoracic injury. Can J Cardiol. 2014 Apr;30(4):396-404.

• National Association of Emergency Medical Technicians. PHTLS: Prehospital Trauma Life Support. 9th ed. Burlington, MA: Jones & Bartlett Learning; 2019.

• National Highway Traffic Safety Administration. National Emergency Medical Services Education Standards. DOT HS 811 077A. ems.gov.

Summary Questions

1. What injuries commonly result from blunt chest trauma?

2. Describe management steps for a patient with suspected pneumothorax.

3. What are signs indicating worsening conditions in a patient with a tension pneumothorax?

4. How should you proceed with treatment in identified critical injuries?