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Thoracic Trauma

Temple CollegeEMS Professions

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Chest Trauma

Second leading cause of trauma deaths after head injury

About 20% of all trauma deaths

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Chest Trauma

Initial exam directed toward: Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade

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Rib Fracture

Most common chest injuryMore common in adults than childrenEspecially common in elderlyRibs form rings

Consider possibility of break in two places

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Rib Fracture

Most commonly 5th to 9th ribsPoor protection

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Rib Fracture

Fractures of 1st, 2nd ribs require high force

Frequently have injury to aorta or bronchi30% will die

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Rib Fracture

Fractures of 8th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen Kidneys

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Rib Fracture

Signs and Symptoms Localized pain, tenderness Increases when patient:

CoughsMovesBreathes deeply

Chest wall instability Deformity, discoloration Associated pneumo or hemothorax

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Rib Fracture

Management High concentration O2

Splint using pillow, swathes Encourage patient to breath deeply

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Rib Fracture

Management Monitor elderly and COPD patients

carefullyBroken ribs can cause

decompensationPatients will fail to breath deeply and

cough, resulting in poor clearance of secretions

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Flail Chest

Two or more adjacent ribs broken in two or more places

Produces free-floating chest wall segment

Usually secondary to blunt traumaMore common in older patients

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Flail Chest

Signs and Symptoms Paradoxical movement

May NOT be present initially due to intercostal muscle spasms

Be suspicious in any patient with chest wall:

•Tenderness•Crepitus

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Flail Chest

Consequences Pain, leading to decreased ventilation Increased work of breathing Contusion of lung

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Flail Chest

Management Establish airway Suspect spinal injuries Assist ventilation with BVM and

oxygen Stabilize chest wall

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Simple Pneumothorax

Air in pleural space Partial or complete lung

collapse occurs

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Simple Pneumothorax

Causes Chest wall penetration Fractured rib lacerating lung Paper bag effect May occur spontaneously following:

ExertionCoughingAir Travel

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Simple Pneumothorax

Signs and Symptoms Pain on inhalation Difficulty breathing Tachypnea Decreased or absent breath sounds

Severity of symptoms depends on size of pneumothorax, speed of lung collapse,

and patient’s health status

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Simple Pneumothorax

Management Establish airway Suspect spinal injury based on

mechanism High concentration O2 with NRB Assist decreased or rapid respirations

with BVM Monitor for tension pneumothorax

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Open Pneumothorax

Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance air will

enter there than through trachea

“Sucking Chest Wound”

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Open Pneumothorax

Management Close hole with occlusive dressing High concentration O2

Assist ventilations Consider transport on injured side Monitor for tension pneumothorax

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Tension Pneumothorax

One-way valve forms in lung or chest wall

Air enters pleural space; cannot leaveAir is trapped in pleural spacePressure risesPressure collapses lung

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Tension Pneumothorax

Trapped air pushes heart, lungs away from injured side

Vena cavae become kinkedBlood cannot return to heartCardiac output falls

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Tension Pneumothorax

Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation Decreased breath sounds Hyperresonance to percussion Cyanosis Subcutaneous emphysema

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Tension Pneumothorax

Signs and Symptoms Rapid, weak pulse Decreased BP Tracheal shift away from injured side Jugular vein distension

Early dyspnea/hypoxia - Late shock

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Tension Pneumothorax

Management Secure airway High concentration O2 with NRB If available, request ALS intercept for

pleural decompression

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Hemothorax

Blood in pleura spaceMost common result of major chest

wall traumaPresent in 70 to 80% of penetrating,

major non-penetrating chest trauma

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Hemothorax

Signs and Symptoms Rapid, weak pulse Cool, clammy skin Restlessness, anxiety Thirst Chills Hypotension Collapsed neck veins

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Hemothorax

Signs and Symptoms Decreased breath sounds Dullness to percussion Dyspnea Ventilatory failure

Shock precedes ventilatory failure

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Hemothorax

Management Secure airway Assist breathing with high

concentration O2

Rapid transport

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Traumatic Asphyxia

Blunt force to chest causes Increased intrathoracic pressure Backward flow of blood out of heart into

vessels of upper chest, neck, head

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Traumatic Asphyxia

Signs and Symptoms Possible sternal fracture or central flail chest Shock Purplish-red discoloration of:

HeadNeckShoulders

Blood shot, protruding eyes Swollen, cyanotic lips

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Traumatic Asphyxia

Name given because patients looked like they had been strangled or hanged

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Traumatic Asphyxia

Management Airway with C-spine control Assist ventilations with high

concentration O2

Spinal stabilization Rapid transport

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Cardiovascular Trauma

Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise

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Myocardial Contusion

Bruise of heart muscleMost common blunt cardiac injuryUsually due to steering wheel impact

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Myocardial Contusion

Behaves like acute MI May produce arrhythmias May cause cardiogenic shock,

hypotension

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Myocardial Contusion

Signs and Symptoms Cardiac arrhythmias after blunt chest

trauma Angina-like pain unresponsive to

nitroglycerin Chest pain independent of respiratory

movementSuspect in all blunt chest trauma

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Myocardial Contusion

Management High concentration O2

Transport Consider ALS intercept

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Cardiac Tamponade

Rapid accumulation of blood in space between heart, pericardium

Heart compressed Blood entering heart decreasesCardiac output falls

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Cardiac Tamponade

Signs and Symptoms Hypotension unresponsive to

treatment Increased central venous pressure

(distended neck/arm veins in presence of decreased arterial BP)

Small quiet heart (decreased heart sounds)

Beck’s Triad

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Cardiac Tamponade

Signs and Symptoms Narrowing pulse pressure Pulsus paradoxicus

Radial pulse becomes weak or disappears when patient inhales

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Cardiac Tamponade

Management Secure airway High concentration O2

Rapid transport Definitive treatment is

pericardiocentesis followed by surgery

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Traumatic Aortic Aneurysm

Caused by sudden decelerations, massive blunt force: Vehicle collisions Falls from heights Crushing chest trauma Blunt chest trauma Animal kicks

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Traumatic Aortic Aneurysm

Rupture usually occurs just beyond left subclavian artery

Attachment of aorta to pulmonary artery at this point produces shearing force on aortic arch

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Traumatic Aortic Aneurysm

Signs and Symptoms Increased BP in arms in absence of head

injury Decreased femoral pulses with full arm

pulses Respiratory distress Ache in chest, shoulders, lower back,

abdomen. (Only 25% of patients)Detection requires high index of suspicion

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Traumatic Aortic Aneurysm

Management High concentration oxygen Assist ventilation Suspect spinal injury Rapid transport

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Associated Abdominal Trauma

Diaphragm forms dome that extends up into rib cage

Trauma to chest below 4th rib = Abdominal injury until proven otherwise