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Chapter 15

Thoracic Trauma

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Objectives

• There are no 1985 objectives for this chapter.

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Thoracic Injuries

• Damage to heart, lungs, and great blood vessels• Internal bleeding• Pressure changes

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Anatomy & Physiology: Review of the Thorax

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Organs of the Chest

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Anatomy of the Thorax

• Protection provided by the following:– Ribs– Intercostal muscles– Diaphragm– Sternocleidomastoid– Trapezius– Rhomboids– Lastissimus dorsi– Pectoralis major

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Physiology

• Respiration• C3,C4,C5• Chemical receptors• Diffusion• pH• Buffer system

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Injuries of the Chest

• Open Chest Injuries– Caused by penetrating trauma

• Closed Chest Injuries– Caused by blunt trauma

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Pathophysiology of Thoracic Trauma

• Cardiac output• Ventilatory efficiency• Gas exchange

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Assessment Findings (1 of 2)

• Failure of the chest to expand normally

• Rapid, weak pulse and low blood pressure

• Cyanosis around the lips or fingernail beds

• Pain at the site of injury• Pain aggravated by or

increased with breathing• Dyspnea• Hemoptysis

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Assessment Findings (2 of 2)

• DCAP-BTLS• Chest wall movement• Paradoxical movement• Hemoptysis• Shock• Cyanosis

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Complications of Chest Injuries

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Management

• ABCs• C-spine control• Occlude open wounds• 2 large-bore IVs• Fluid bolus• Rapid transport

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Chest Wall Injuries (1 of 8)

• Rib Fractures– They are very common in the elderly.– 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.

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Chest Wall Injuries (2 of 8)

• Assessment Findings of Rib Fractures– Localized tenderness– Pain on inspiration– Self splinting– Point tenderness– Crepitus

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Chest Wall Injuries (3 of 8)

• Flail Chest– Three or more ribs fractured in two or more places,

the sternum is fractured along with several ribs.– A segment of the chest wall may be detached from

the rest of the thoracic cage.– Creates paradoxical movement.

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Chest Wall Injuries (4 of 8)

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Chest Wall Injuries (5 of 8)

– Flail Chest (cont.)• Breathing is extremely painful and patient rarely receives

adequate oxygenation.• Care includes the following:

– Maintaining the airway

– Providing respiratory support

– Performing ongoing assessment

– Immobilizing flail segment

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Chest Wall Injuries (6 of 8)

• Assessment Findings for Flail Chest– Expose and examine the chest for DCAP-BTLS.– Check for accessory muscle use.– Paradoxical motion.– Tachycardia and tachypnea.– Immobilize the flail segment.

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Chest Wall Injuries (7 of 8)

• Sternal Fracture– Deceleration injury– Myocardial contusion or rupture– Pulmonary contusion– Flail chest– Vascular disruption

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Chest Wall Injuries (8 of 8)

• Assessment Findings of Sternal Fracture– Localized pain– Crepitus on palpation– Tachypnea – Cardiac compromise

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Injury to the Lung (1 of 14)

• Simple Pneumothorax– Air accumulates in the pleural space.– Air enters through a hole in the chest wall.

• The lung may collapse in a few seconds or a few hours.

– An open or penetrating wound to the chest is called a sucking chest wound.

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Injury to the Lung (2 of 14)

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Injury to the Lung (3 of 14)

• Spontaneous Pneumothorax– Some people are born with or develop weak areas on

the surface of the lungs.– Occasionally, the area will rupture spontaneously,

allowing air into the pleural space. – Patient experiences sudden chest pain and trouble

breathing.– Consider a spontaneous pneumothorax for a patient

with chest pain without cause.

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Injury to the Lung (4 of 14)

• Assessment Findings of Pneumothorax– Tachypnea– Tachycardia– Decreased or absent breath sounds– Hyperresonance– Pleuritic chest pain

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Injury to the Lung (5 of 14)

• Open Pneumothorax– Clear and manage the

airway.– Provide oxygen.– Seal an open wound

with an occlusive dressing.

– Depending on local protocol, tape down all four sides or create a flutter valve.

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Injury to the Lung (6 of 14)

• Assessment Findings of Open Pneumothorax– Penetration of chest wall– Sucking sound may be heard– Tachycardia– Tachypnea– Decreased or absent breath sounds– Subcutaneous emphysema

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Injury to the Lung (7 of 14)

• Tension Pneumothorax– Can result from sealing all four sides of the dressing

on a sucking chest wound.– Can also result from a fractured rib puncturing the

lung or bronchus.– Can also result from a spontaneous pneumothorax.

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Injury to the Lung (8 of 14)

– Hypotension– Tracheal deviation– Tachycardia– Narrowed pulse pressure– Subcutaneous

emphysema– Jugular venous distension– Hyperresonance

• Assessment Findings of Tension Pneumothorax– Absent breath sounds– Dyspnea– Tachypnea– Respiratory distress– Extreme anxiety– Cyanosis– Bulging of the intercostal

muscles

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Injury to the Lung (9 of 14)

• Care for Tension Pneumothorax – If a tension pneumothorax develops from sealing an

open chest wound, partly remove the dressing to let the air escape.

– If there is no open wound, follow local protocol.

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Injury to the Lung (10 of 14)

• Hemothorax– Collection of blood in the pleural space.– Suspect Hemothorax if the following are seen:

• Signs and symptoms of shock• Decreased breath sounds on affected side

– If both air and blood are present in the pleural space, it is a hemopneumothorax.

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Injury to the Lung (11 of 14)

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Injury to the Lung (12 of 14)

• Assessment Findings for Hemothorax– Respiratory compromise– Sign and symptoms of shock– Decreased or absent breath sounds– Dullness on percussion

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Injury to the Lung (13 of 14)

• Pulmonary Contusions– Bruising of the lung.– Develops over hours.– Alveoli fill with blood, and fluid accumulates in the

lung, causing hypoxia.– Provide oxygen and ventilatory support.

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Injury to the Lung (14 of 14)

• Assessment Findings for Pulmonary Contusions– Tachypnea– Tachycardia– Hemoptysis– Respiratory distress– Dyspnea– Cyanosis– Evidence of blunt chest trauma

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Myocardial Injuries (1 of 3)

• Pericardial Tamponade– Blood or other fluids collect in the pericardium.– Signs and symptoms include the following:

• Very soft and faint heart tones• Tachycardia with a weak pulse• Low blood pressure• Respiratory distress• Decrease in difference between systolic and diastolic blood

pressure• Jugular vein distention (JVD)

– Provide oxygen and transport quickly.

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Myocardial Injuries (2 of 3)

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Myocardial Injuries (3 of 3)

• Myocardial Contusion– Bruising of heart muscle.– Pulse is often irregular.– There is no prehospital treatment for this condition.– Check patient’s pulse and note irregularities.– Provide supplemental oxygen and transport

immediately.

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Vascular Injuries (1 of 2)

• Aortic Dissection and Rupture– Shearing of the aortic– Very high mortality rate– Retrosternal or interscapular pain– Dyspnea– Absent pulses

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Vascular Injuries (2 of 2)

• Penetrating Wounds of the Great Vessels– The superior vena cava, the inferior vena cava, the

pulmonary arteries and veins, and the aorta are contained in the chest.

– Injury to these vessels can cause fatal hemorrhaging.– Treatment includes the following:

• CPR• Ventilatory support• Supplemental oxygen• Transport immediately

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Other Thoracic Injuries (1 of 4)

• Diaphragmatic Injury– Caused by high pressure compression– Bowel obstruction and strangulation– Tachypnea– Tachycardia– Respiratory distress– Dullness to percussion

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Other Thoracic Injuries (2 of 4)

• Esophageal Injury– Most common with penetration trauma– Can occur with violent emesis, cancer, or anatomic

distortions– Pain– Fever– Hoarseness– Subcutaneous emphysema

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Other Thoracic Injuries (3 of 4)

• Tracheobronchial Injuries– Tear can occur anywhere along the tracheobronchial

tree– Tension pneumothorax refractory to needle

decompression– Tachypnea– Tachycardia– Subcutaneous emphysema– Hemoptysis

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Other Thoracic Injuries (4 of 4)

• Traumatic Asphyxia– Sudden, severe compression of chest– Produces rapid increase in pressure within chest– Results in neck vein distention, cyanosis, and

bleeding into the eyes– Provide supplemental oxygen and monitor vital signs– Transport immediately

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Management of Thoracic Injuries

• Manage ABCs – Intubate as needed.• Supplemental oxygen.• 2 large-bore Ivs.• Rapid transport to appropriate facility.• Always follow local protocols.