foreign are described as either open or closed what do you guys think defines something as open or closed in general when we're talking medical terminology I suppose the outside world it's not necessary that a bone is broken or anything like that it's whether it's exposed to the outside world so open to the outside world or closed okay so it's basically is the skin punctured right what are some causes of chest injuries that are going to be open chest injuries do you think laceration potentially yeah gunshots dabbing wounds penetrating injuries for the most part yeah things like that um what's our big concern with an open chest injury probably an air air accumulation where it shouldn't be right so closed chest injuries will cause pulmonary and cardiac contusions so bruising of the lungs and bruising of the heart itself what does the term hemoptysis mean coughing up blood so a lot of internal chest injuries will cause coughing up blood so hemoptysis so look for things like that with the when you're talking about that mechanism of injury in a trauma situation so a car accident they take a blow to the chest of any kind we're going to look for those signs and symptoms that pain in general bruising deformities discoloration over the chest hemoptysis in general those are what we're going to look for with closed chest injuries it's really important in a lot of people especially that are newer they don't want to expose their patients and I can understand why right it might seem weird that they are complaining of this pain where a seat belt came across their chest and you might not like they're talking to you in full sentences but it's important to actually expose that injury and get eyes on it because I've been burned a few times where you you're like oh they're fine they're talking in full senses whatever and then you get to the hospital like yeah they have like four broken ribs and have a pneumothorax or something like that right so all always get eyes on an injury no matter what as minor as it may seem remove that shoe if they're complaining of an ankle and foot pain take a look at that injury because you want to make sure that you're exposing patients and actually visualizing that injury as well as palpating it and assessing it does that make sense okay and one of the like just trainers came over and said boss to take the shoe off or anything because of whatever stabilizing the pressure and all that but we didn't know what it was because she was on so so I can see why they see what happens right it's going to get taken off at the hospital anyways and we're kind of in the situation where we're getting them to the hospital and I'd say like a lay person situation a situation where they're like at a school or something like that they're not going to want to cause any further injury at all so they're not going to want to take the shoe off um essentially what we would do is probably cut the shoelaces don't cut the shoe if you can't if you're if you can take the shoe off assess it visualize it wrap it with some like an ice pack over the top so what we do need to assess injuries right another thing I see with a lot of like newer people is if they have an injury or they're complaining of something is they'll assess everything but that injury right like so why didn't we assess their elbow their complaining of elbow pain like well I didn't want to hurt them anymore well you can still assess people without causing further injury so when people are complaining of an injury as much as it might suck we still have to assess that injury it doesn't mean okay try to straighten your arm out and wiggle it around if you're complaining of elbow pain but at least palpating above that injury making sure we're not missing like a humeral fracture palpate the bones below that elbow palpate the elbow itself to see if it's out of place place so and then assessing CMS like we've talked about with the joint and long bone immobilization it's kind of the similar assessment assessing that distal circulation or in the case of you know chest and abdominal injuries we're going to do a thorough assessment on top of visualizing that actual injury it doesn't mean okay I should have been a little bit worse but it doesn't mean everybody complaining of like chest pain I'm gonna be like oh sorry hold on and cut their clothes off it's literally like okay let's just take a quick look and like unbutton a couple buttons or something like that it's within reason right we're not going to be like all right strip naked we got to see what this looks like right it's totally within reason keep their modesty get them into the back of the ambulance um and just make sure we're you know patient privacy um So within reason so uh yeah as far as like we're going we'll go into like hip injuries later but um chest injury patients may be taking short shallow breaths due to the injury or pain caused by the injury so we need to make sure we pay close attention to their ABC so if you can't take those full breaths because say you have a rib injury things like that that tidal volume is going to be less they're going to have less of a reserved volume okay so they're much more susceptible to not being able to breathe appropriately and start to de-sat things like that so we need to be on top of relistening the lung sounds reassessing our ABCs high flow oxygen just be a little bit more aggressive if they're taking those really short shallow breaths and be aware that they may be more prone to decompensate if they're not breathing appropriately the big thing we worry about with chest injuries the main injury we're really concerned with is a pneumothorax so a pneumothorax is an accumulation of air in the pleural cavity so it's not necessarily always going to be like a hole in the lung itself it's more of accumulation in this pleural Sac here so between the lung and the lining of the chest wall so what it is is air accumulates here and collapses that lung because of the pressure it's exerting on the lung generally it's caused by some sort of uh penetrating injury 85 percent I think plus of penetrating injuries cause a pneumothorax so if you have a penetrating wound gunshot victim stab victim uh impalement of some sort it's going to probably cause pneumothorax so just be aware of that that's why a mechanism comes in play so often but ribs themselves in an enclosed chest injury ribs themselves can actually lacerate lung tissue connect and can cause a pneumothorax itself so it doesn't always have to be some penetrating external trauma the ribs themselves can cause lacerations they can cause pneumothorax they can cause that collapse lung also known as Ada Lex stasis so why is a new with thorax so bad one obviously with this lungs not working appropriately oh sorry I thought I was doing something wrong but I forget it's not live exactly right so not only does this lung not working it's causing increased intra-thoracic pressure we talked a little bit about this last week right intra-thoracic pressure will cause decreased blood flow return to the heart itself for multiple reasons so one if there's increased pressure it's going to potentially move that mediastinum over so this is the mediastinum the middle of the chest where the heart and great vessels sit so when there's increased inner thoracic pressure one it's gonna decrease blood flow to the heart because it's not that negative pressure moving everything in but two it's going to physically move that mediastinum over to the non-affected side so if you can imagine all these vessels are going to get slightly kinked a little bit and we're going to have decreased blood flow return to the heart what else do we have a switch from negative pressure to positive pressure ventilations using a BBM it's not as impactful as a pneumothorax but when we increase from a patient's own ventilations to a BBM positive pressure ventilations it causes a bit of a decrease in that cardiac output because of that in decrease inner increased inner thoracic pressure decreased blood flow returned back to the heart so when we use a BVM a lot of times what you end up seeing is their blood pressure will drop a little bit their heart rate may increase a little bit because we're actually dropping their blood pressure by introducing positive pressure ventilations so an open chest wound is commonly called a sucking chest wound what do we do about that um a seal yeah throw a seal on it how are we going to know where to throw a seal on it if you walk up and they're bleeding from their chest there's a gunshot victim stabbing victim what's like the first thing we really need to do if they're still conscious control bleeding expose them this is a situation where you were you have to find all the holes right expose them find the holes control any bleeding slap a chest seal on them anybody that has an open wound from their neck down to their hips front and back we're going to throw a seal on it okay a chest seal or an occlusive dressing so neck chest belly even not necessarily lower belly but upper abdomen and in the back we're always going to throw a chest seal on it why do you think that is why would we throw a chestion on the abdomen or the flank especially in a gunshot victim why do you think that is what happens to a bullet once it ends enters the body cavity Bounce Around fragments you never know what it's going to hit once it enters the body so even if the entry wound is down low uh you don't know where that bullet has been inside their body and what else do we need to look for when we see an entry wound and where are we going to look for an exit wound anywhere it can go anywhere like I said once it enters that body cavity in general it's going to travel on a straight path until it hits something but if it hits a bone it can travel up and down the spine we need to assess for the entry wound as well as the Exit Wounds that way we can potentially throw a c on it control any bleeding that we can and so that's why it may seem silly again but if you see like entry wound here we need to expose them fully to look for an exit wound anywhere because it could go anywhere so just be aware if you see an entry wound assess for an exit wound strip them and flip them I think I talked about a few weeks ago that's where that really comes into play uh finding that entry in the exit wound so signs and symptoms of a pneumothorax what do you think you're going to see if this lung isn't working very well struggling to breathe so difficulty breathing one-sided chest rise what's the medical term for that unilateral chest rise okay so paradoxical is where the chest is moving two different directions whereas unilateral only one side of the chest is moving at this at one time what else what about their spo2 it's going to decrease gonna drop what about their heart rate increase okay what about their blood pressure why because their heart's pumping faster so your heart rate pumps faster so your blood pressure increases yeah your cardiac outputs decrease your heart rate's increasing so your blood pressure is going to drop what kind of shock are they in so uh that's what stage of shock so what type of shock are they in destructive good it's physically obstructing the blood flow from the heart the heart's pumping just fine but there's an obstruction that's stopping the heart from pumping appropriately or uh the blood flow return to and from the heart what about lung sounds what are you gonna hear on this side decrease right agonal lung sounds is that a thing I heard someone say it decreased decreased or absent lung sounds good if that lung is collapsed and it's just air here this air isn't necessarily moving with every breath right it's just going into that chest cavity we're not going to hear lung sounds because we only hear lung sounds by air moving in and out of that alveoli so the alveoli are totally collapsed we're not going to hear lung sounds so we're going to have absent or decrease lung sounds which I can tell you now those are the most difficult lung sounds to pick up on are diminished lung sounds because they're going to be normal it's not like there's wheezes or rails or something to really pick up on it's just more quiet than normal so that's why it's so important that we're listening to lung sounds when you come to class you're listening to lung sounds on every patient when you're out on the field because it's the things like this that you need to pick up on that you need to know what normal is like to recognize what is abnormal foreign I think there's a slide next this next slide hold on okay yeah no I don't have a sign in I foreign that I've used in the past yes so this is a paradoxical movement this is a good example of a closed chest injury where they have a flail chest and paradoxical movement some of these videos are pretty grainy overall if you see this you can almost assume they have some sort of pneumothorax these are going to be more of a closed chest injuries a lot of times this has got an entry right here obviously as you can see this one's a little bit more subtle but this side of the chest is going and this side is going out kind of opposite of what it should be doing this is called a flail chest we'll have a slide about it here in just a minute so right here when the chest is supposed to be expanding basically it goes the ribs come in not good these are all closed chest injuries a little bit more difficult to pick up on another one what this is like you see this is a very obvious one so you can see right here what do you think caused that yeah this is gonna be a broken rib a bunch of Brokers what do you think what injury pattern do you think cause that if it's kind of going across his chest seat belt with a foil chest um is it just a is it just the diaphragm doing the chest Contracting or is it still the uh intercostal muscles it's still going to be everything like everything's trying to work appropriately it's just not stable anymore because the ribs are actually broken so I have a picture coming up here in just a second that'll show but going back a little bit I'll have to go back to full chest in just a second but going back to pneumothorax in general they all start as a simple pneumothorax so this is just a buildup of air in the plural space but not enough to cause cardiac complications okay this is just a simple buildup of area in the chest cavity where it shouldn't be but not enough where it's causing that mediastinal shift not causing those heart rate changes blood pressure changes this is kind of the lead up to what we call a tension pneumothorax a simple pneumothorax is something we need to recognize they'll still have pain over the area probably still going to have a little bit of a lower spo2 maybe some difficulty breathing but in general they're not going to have the decreased cardiac output quite yet okay and then poor tall skinny young men here unfortunately tall skinny young men are very susceptible to spontaneous pneumothorax so this is just they don't really know what caused it it's just like a weakness in the chest wall and essentially what happens is just one day you're walking down the street and then you're you get a pneumothorax and they don't know why so next time you have that little rib cramp that's it it's done you're having a pneumothorax so uh I'm sorry but yeah next time you're out running uh yeah so spontaneous pneumothorax can progress into attention but in general it's not considered life-threatening usually very minor injury but it is something that can occur so simple pneumothoraxes are caused by blunt force trauma the vast majority of the time especially in the case of broken ribs I have seen them be caused by things like pneumonia and infections because it causes uh that lubricant that's on your pleural cavity between your lip your ribs and that pleural space and infection will cause that to be inflamed and it can actually cause a pneumothorax for a medical reason so people with pneumonia are actually susceptible to simple pneumothoraxes as well just to be aware of that it's not always going to be a trauma situation even though the vast majority of times it is so as EMTs we need to be able to recognize in pneumothorax what do we do about a simple closed pneumothorax there's no chestios that they're on nothing supplemental oxygen get them to the hospital they need surgery okay there's not a whole lot we're going to do even as a paramedic for a simple pneumothorax I'm probably not going to do anything quite yet I'm gonna I'm gonna wait until they get worse right so this is just more of a matter of recognizing the situation now the big thing that we're worried about in a pneumothorax is a tension pneumothorax so an attention pneumothorax the pressure in the chest has caused the mediastinum to shift to the unaffected side so this is a patient's right over here patients left we have the collapsed lung right here so in general it should take up this whole space but it's collapsed all the way to this size there's so much pressure on this side of the chest that it's shifted that mediastinum over okay now look what else is Shifting what is this right here what's that big open yeah that's your trachea okay is this your trachea or your windpipe look how it's shifting over okay that's called tracheal deviation okay so tracheal deviation is a late sign of attention pneumothorax so absent lung sounds on the affected side or diminished depending on how bad it is tachycardia low blood pressure low spo2 tracheal deviation as well as jbd who can tell me what jvd is jugular venous distension it's pretty obvious once you see it for the first time but that's jvd could pop an IV in that from across the room like a lawn dart just yeah jvd distended jugular veins this guy it's incredible so if you see that you got to start asking yourself why okay what are some other causes of jvd cardiac tamponade okay tension pneumothorax what's another one we haven't really talked about it a whole lot but if you've really read the book you might know think of like backup of blood due to a medical reason congestive heart failure yeah congestive heart failure can cause jvd not generally to this level this guy is probably not doing well uh but in general it's going to look more like this just more of a swollen jugular vein so hemothorax what's the difference between a pneumothorax and a hemothorax exactly so this is the same concept of a pneumo but it's caused by accumulation of blood in the thorax so under every one of our ribs there's a vein in artery and a nerve okay and so when we get broken ribs or some sort of penetrating injury we're bleeding from probably one of those veins arteries or nerves it's not always going to be the great vessels of the heart the you know the vena cava or anything like that or the aorta it could be the veins arteries veins or arteries that are underlying the each rib so will bleed heavily from those they'll bleed into the chest cavity even broken ribs can cause this that's why those can potentially be a serious situation it can cause hypovolemic shock as well as obstructive shock what is hypovolemic shock so I'm going to explain that one to me a little bit Lacy loss of fluids right a lot like hemorrhaging right yeah loss of fluid low volume essentially is what it means so they will have hypovolemic shock as well as obstructive shock they're going to have two types of shock at one time what do you think their lungs are going to sound like so imagine this but instead of air this is fluid what do you think it's going to sound like kind of a trick question so once again we're not moving air through this pleural cavity right that you're only going to hear the lung sounds if it's moving through the lungs so once again you're going to have absent or diminished lung sound so you're not going to be able to necessarily tell hemothorax from a pneumothorax in the field we can just kind of assume they essentially mean the same thing to us that we're going to have to potentially get ALS involved needle decompression get them to the hospital um we are not going to be able to necessarily tell if it's a hemothorax or a pneumothorax but on that note a patient can have both okay so they can have a hemothorax they can have a pneumothorax or they can have a hemo pneumo which is an accumulation of air and blood in the chest cavity so that'd be it's a real bad day and they can have a double hemo pneumo double pneumothorax double hemothorax just depending on how bad the situation is um so it's not always going to be one lung what happens to the trachea and all that stuff when it's both lungs affected it's it's probably just going to go to the more affected side first and then just kind of end up in the center but um that would be an interesting situation where you're probably not going to be able to ventilate that person you're probably not going to do a whole lot at all in all reality they're going to be a traumatic cardiac arrest before we probably even get there exactly yeah so it's a it's a hemothorax and a pneumothorax combined so hemo pneumo they combined both of these so hemo pneumothorax foreign so treating an open chest wound the definitive treatment for a pneumothorax is a chest tube or a collapsed lung in general a lot of times they'll end up it's a chest tube is what that you will get in the ER uh flight paramedics can do chest tubes but other than that only in the ER they're going to get a chest tube so we're not going to do that in the field we just need to recognize an open chest wound treat it right away with chest seal and oxygen and then rapid transport to the hospital it's a matter of recognition in the field getting ALS involved so that the paramedics into a needle decompression and then in the ER they're going to get a chest tube in that it's the fifth between the fifth and the sixth rib and the mid-axillary space so it's going to be like right here I actually have one from when I was a baby so it's pretty easy for me to point out but it's gonna be like right here and they will potentially do that on both sides if they have to but you can see they have uh blood or whatever the case may be inside that lung is going to come out and it can be a lot of blood sometimes have you ever seen them crack a chest open in the ER okay it's an interesting process that's the next step they would do if the chest tube wasn't working so just know they're going to get a chest tube but we can't do those in the field so be aware of that I showed you the video of the needle decompression a couple weeks ago right or last week okay uh also along the lines of chest injuries we're going to have a cardiac tamponade we talked about that last week what's the Triad jugular rain distension narrowing pulse pressure and tachycardium okay what's the name of it Vex Triad so Beck's Triad means cardiac tamponade you can also look for muffled heart tones so the pericardium which is this little blue lining right here in a normal heart will fill up with blood if the heart gets struck hard enough or there's some sort of penetrating injury or sometimes an infection so pneumonia can also cause a cardiac tamponade essentially what that does is that fills up with blood and squeezes the heart but not in the way it wants to be squeezed so it's not going to pump as efficiently so this decreases the amount of space the heart has to fill and contract that's why it that pulse pressure Narrows it never gets fully it never pumps fully and never gets fully emptied so the pulse pressure is going to narrow and this will lead to decreased cardiac output and so the Bex Triad guarantee you that'll be at least one test question it'll be on the nremt the nrmt loves the Bex Triad I don't know why but they do but that means cardiac tamponade tell me what the fact s right yeah tachycardia muffled heart tones and jvd tachycardia or low blood pressure sometimes they're interchangeable with that Bex Triad muffled heart tones and jvd yjvd somebody Angelica isn't it because there's a Crusher exactly yeah so there's pressure in that heart so it's going to back up somewhere right up into the jugular veins good is it because is it the left is it the left atrium that isn't functioning or is it left ventricle that's the whole heart so if you look at it like this the entire heart's being compressed it's not necessarily heart failure it's just a physical obstruction of the heart so it's compressing the entire heart to go back into the heart and circulate through the body so right yep okay this will be a test question who just left Marcus okay uh flail chest this is a definition that you'll see a flailed chest is three or more consecutive ribs that are broken in more than one spot remember that definition this causes a floating section of chest wall I've only seen a couple probably three of these four of these Maybe they're really interesting to see and this leads to paradoxical movement of the chest remember where unilateral is one side of the chest Rising while the other side is not moving paradoxical is opposite movement of the chest so one side of that chest is moving in one side is moving out opposite of each other and the treatment is positive pressure ventilation so BBM use Marcus this is a test question just so you know okay so three or more ribs consecutive ribs not just three random ribs three or more consecutive ribs broken and two or more or sorry more than one spot so two or more places and I'll show you a picture here oh well here's another video I think that was the one we already saw so this part of the chest is moving in this one's moving as it normally really should so it's in your book as well but a flail segment is three or more ribs so one two three broken in two or more places so this section of the chest is essentially just floating there what do you think could also happen with the flail segment when you have these shards of bone sitting in your chest puncture a lung hemo pneumo you have those veins arteries and nerves that run under every rib so when that's exposed it's going to lacerate those veins and those arteries so hemothorax pneumothorax things like that as well as just respiratory insufficiency because you don't have that structure overall to take that deep breath when you have three or more broken ribs in with the flail chest like that the book says two or more the book says two or more promise you on the test it's gonna be three or more of the National Registry definition and if that is ends up being wrong then I'll give you that point back but it's always been three or more on the tests so CPR is going to cause C prayer will cause basically a separation of the sternum from all of this cartilage right here so you're not technically breaking ribs necessarily but it's very easy to break ribs say out here so I guess you could but in general it's probably it's going to crack the ribs out here you're not going to break them in two or more spots but yeah you'll definitely separate this cartilage and it is I'll never forget the first time I did CPR it was disgusting um yeah thicker only costal or intercostal what's up hostile or enter possible which part so you have your intercostal muscles the oh I think it's called the costal cartilage because it's not in between your ribs it'll heal back eventually yeah costal cartilage yeah okay thanks and just for you so you guys know these presentations while they're not on canvas these are made from the book presentations so we just kind of paired it down so all the information is in canvas with these presentations we've just paired it down to what we think is important essentially so close what's cracking the chest if you're squeamish don't look uh someone got way too excited I don't actually know it's really hard to find good medical videos so generally if I find when I save them somewhere but we're obviously not going to watch well essentially what they do is they open up the chest and they'll stop bleeding directly they'll find the source of whatever's bleeding and then uh stop it directly with clamps and cauterization and such it's surgery in the ER basically it's like the first step it's a really dirty version of surgery but yeah anyways so yeah that's kind of how what it is not super important that we need to know it but just that's something that will happen you might hear that term a lot traumatic asphyxia this is a sudden compression of the chest restricting restricting expansion of the chest and leading to asphyxia so think of like a blunt force injury compression of that entire chest so steering wheel into the chest things like that but to a point not just where it stops but it's like it's such a force that it's a very sudden compression of the entire chest um think of like semi into a car right like not just the steering wheel itself but it's the force of everything going directly into that chest or something falling onto a patient uh can lead to blunt force injuries of the heart and lungs so what we're going to look for is jvd cyanosis to the face and then the key note comparing this to a lot of things is hemorrhage of the sclera of the eye patikiai generally this is a very high level of fatality like in almost every time they're not going to be alive at least they're not going to be conscious this is a very fatal injury to have because essentially the compress your entire chest so your chest it didn't work right it's gonna cause all that pressure to go up to your head that's why you get that Hemorrhage of the sclera you've seen that it's not pretty yeah uh choking victims will get uh petechia Hemorrhage of the sclera same kind of reasoning is that increased pressure to the eye so you'll see that with choking victims as well or strangulation victims not choking strangulation that is an actual legal term I found out last year uh they call it strangulation in court not choking because choking is like choking on food and then every everybody's famous or famous favorite one is commodio Cordis I had a student a couple years ago that every time we were like reviewing for a test after this I was like all right causes a chest pain caused the shortest breath he was like commodio Cordis every time without fail commodio Cordis is a blunt force chest injury at a certain point in the cardiac cycle that will put a patient into a cardiac dysrhythmia typically the patient goes into v-fib which our aeds recognize and causing a sudden cardiac arrest and it's been found to respond very well to defibrillation so these are the types of patients that yes they went into cardiac arrest but they're easy to get back the classic example of commodio Cordis is like the little Leaguer that takes a line drive to the chest goes into cardiac arrest usually a healthy person it just happens to be at the wrong time take a direct shot to the chest right during a specific part of the cardiac cycle and then it sends them into cardiac arrest it's called a Q on T phenomenon so it's like right in between two heartbeats essentially there's a s it's called the absolute refractory period of the T cycle where if something happens right then it can send them into cardiac arrest not that won't be on your test don't worry about that but that's just what it is this is what v-fib looks like on the monitor no organization at all right there's nothing this is just random squiggle lines the bad lines okay so does anybody have questions on chest injuries it's open or closed put seals on it if you're worried about it high flow oxygen BVM if needed get ALS and Route if they need to decompress a chest and get them to the hospital right