hi it's john uh from jacksonville again and we're going to cover chapter 30 chest injuries today we're going to talk about the recognition and management of blunt versus penetrating mechanisms open chest wounds and impaled objects the pathophysiology assessment and management of blunt versus penetrating mechanisms and what a hemothorax is we're going to talk about the pathophysiology assessment and management of a pneumothorax whether it be an open a simple or attention pneumo we're going to also do the same for cardiac tamponades rib fractures flailed chest and something called commotio cordis so about 1.2 million emergency department visits each year are from the result of chest trauma again chest injuries they involve anything that's really super important in your body like your heart lungs and the greater blood vessels in the center of your chest the results uh might be from a blunt trauma penetrating trauma or even both so immediately treat injuries that interfere with normal breathing so the abcs internal bleeding can compress on the lungs and the heart and air may collect in the chest preventing lung expansion so if it interferes with normal breathing functions we need to treat those injuries with ventilation it ventilation is the body's ability to move air in and out of the chest and lung tissue which is different from oxygenation oxygenation is the process of delivering oxygen to the blood by diffusion from the uv light following inhalation into the lungs so what you might have with a chest trauma is something that affects both the ventilation and oxygenation or one of the other so with the amp you have uh the thoracic skin the muscle the bones so again there's all these greater organs beneath the surface of your chest the neurovascular bundle lies closely along the lowest margin of each rib the pleura covers each lung and thoracic cavity and a small amount of pleural fluid between the parietal and visceral pleural allows the lungs to move freely against the inner chest wall during its in during respiration so when you're breathing you have these linings that move that are protecting your lungs and there's a fluid in there that keeps those those linings from rubbing against each other you have the vital organs like your heart uh and your lungs are protected by the ribs uh in the back it's it's connected in the back to the vertebrae uh and it's connected to the front and the sternum so again all these are items are protected by that rib cage the mediastinum that's in the middle can tears contains your heart greater vessels your esophagus and your trachea you know that the diaphragm is that muscle that separates the thoracic cavity from the abdominal cavity intercostal muscles again this is right on the respirations in your airway chapter the intercostal muscles and diaphragm contract during inhalation and during exhalation they relax the body should not have to work to breathe when in a resting state it should not have to work to exhale so the mechanics of ventilation again reviewing um this shows that the diaphragm lowers when you inhale and then when you exhale it just kind of flexes up or relaxes into a relaxed state it's when you exhale it's a passive thing when you inhale it's an active thing active work [Music] so patients with a spinal injury below c5 cervical 5 can still breathe from their diaphragm if they have a c3 injury they might lose the ability to breathe on their own so when you have the mechanics of ventilation you think about where there might be an injury tidal volume is the amount of air moved in and out of the lungs in a single breath and minute ventilation is tidal volume times how many breaths you take a minute so if you change either one of these numbers that really does affect the amount of air moving through your system so if you breathe faster or breathe slower if you don't have good inhalation or you can't inhale properly and you don't get a lot of air you're breathing shallow and and rapid it really does make a difference on how much air you're getting into your system so with chest injuries there's two different types open and closed uh again a closed injury is where the skin's not broken and it's typically caused by blood trauma i'm kind of thinking this again it looks like where he um the close chest injury usually is off blood trauma like this strikes a steering wheel or airbag it looks like a seat belt injury to me with this patient a closed chest injury can occur even when the seat belt is worn properly so with closed chest injuries you might have cardiac and pulmonary contusions if the heart is damaged it may not refill or pump out enough force to sustain the tissues of your body lung tissue bruising might result in an exponential loss of surface area so if you bruise your lungs you might lose that ability for oxygenation and rib fractures might cause further damage and impede on your taking a deep breath or your respirations with an open chest injury a knife a bullet piece of metal broken end of a fractured rib even again we're not going to attempt to move or remove any objects but again you have an opening in your chest wall blood trauma might cause ribs sternal and chest wall fractures heck even cpr could do that bruising of the lungs and heart damage to the aorta vital organs being torn from their attachment that might be in that collision where the third collision in a motor vehicle crash car versus tree person versus steering wheel now the organs keep going until they're acted upon signs and symptoms of a chest injury pain good pain aggravated or increased with breathe breathing bruising to the chest wall crepitus with palpation of penetrating injury to the chest and just plain old dyspnea or trouble breathing you might have hemoptysis or you're kind of spitting up blood failure of one or both sides of the chest to expand normally weak rapid pulse excuse me weak rapid pulse low blood pressure cyanosis of your lips and fingernails diminished breath sounds on one side and maybe even just low oxygen saturation so with chest injuries they'll typically have rapid and shallow respirations because it hurts to take a deep breath so if i'm having rapid and shallow respirations uh that and a patient's not going to have have good oxygenation they may not be moving in the air and then oscar will take multiple locations so we're going to listen at multiple locations for breath sounds when they're having shallow respirations you're seeing size up so we'll go through this with every chapter make sure the scene is safe for you your partner your patient your bystanders if it's a crime scene especially with gunshots and such your knife wounds to the chest don't disturb evidence if possible but ultimately our goal is patient care request pd uh call for als definitely call for als we think about the moi or the mechanism of injury crash fall an assault shooting stabbing whatever determine the number of patients this is really important well if you're going to a a nightclub for a shooting how many patients do i really have that makes a big difference even in a motor vehicle collision consider uh c-spine immobilization again because any penetrating trauma to the chest or back could uh have damage to our spine form a general impression looking for life threats note their level of consciousness and do a rapid physical exam looking for the big stuff we're assessing the abcs now okay we assess the airway consider c-spine stabilization jugular vein distension as part of our assessment in our trauma patient we're going to talk about that is breathing present or adequate look for d cap btls look for expansion of the chest while are they taking a deep breath both sides expand at the same rate in the same volume check for paradoxical motion or motion going in the opposite way than it should apply occlusive dressings to all penetrating injuries of the chest and we support ventilations reassess our ventilatory support look for decreasing oxygen saturations and look for an impending tension pneumothorax with circulation skin color condition and temperature assess and address those life threats or life-threatening bleeding uh we take care of that right away it says use direct pressure in a bulky dressing but again if it's an open chest one we want to use an occlusive dressing transport decision yep if there's a problem with the x's the a's the b's the c's they need to go right away we do that by looking at their skin color condition and temperature their level of consciousness this sense of impending doom you will sometime in your career have somebody look up at you and say i feel like i'm gonna die there's a really good chance they will it's that they know in their heart of hearts that they're gonna die deadly dozen chest injuries this is a really good list these are the reasons people die from chest injuries a huge huge uh list that sometimes we can do stuff for sometimes we can't uh others other than driving fast to the hospital so take a look at this list so history we check about the uh mechanism of injury signs and symptoms do the sample history again we focus on that mechanism of injury you know if they get shot in the chest past pertinent history is not did you ever been have you ever been shot before that's not past pertinent history we're looking for past medical history anything that would be applicable physical examination we're going to look up if you're having a isolated injury we focus on that injury so if they broke their their wrist okay we we look at the broken wrist what they're complaining about that they say they have pain in their wrist that's what we're really going to spend majority of our time but a chest injury we think about the anterior and posterior aspects of the chest wall and maybe they have a broken rib but that really truly can affect their respirations look for significant trauma like multiple systems uh do your decap btls if you've been shot one time there's a chance that you have three other bullet holes in you who knows check your vital signs every evaluate every five minutes if they're unstable if they're stable 15 minutes we're going to do a lot of assessment here on the chest that's going to be really specific to the chest we reassess our abcs our chief complaint in our primary uh assessment we always always reassess our interventions is the patient getting better getting worse or staying the same maybe we do spinal immobilization uh we control any bleeding put an occlusive dressing over penetrating trauma to the chest wall and think about it the bullet went in their chest and out their back again occlusive dressings when it comes to the chest we really want to treat for shock and a rapid transport and again communicate everything to the staff at the receiving hospital or with our paramedics that we intercept with so a pneumothorax let's talk about that now so pneumothorax is really what we always consider to be that collapsed lung and that's a buildup of air in the pleural space around the lung so blood passing through the collapsed portion of the lung is not oxygenated you may hear diminished absence or abnormal breast sounds so on the effected lung you might hear diminished absent or abnormal but on the good lung you're still going to hear good lung sounds and really what's happening is it's not going to get oxygen to the red blood cells we have a space of air surrounding that lung collapsing that lung so it cannot inflate properly so with an open chest wound we want to call we want to treat that a specific way so what we want to do is we want to use an occlusive dressing sometimes we call this that sucking chest wound if you will or an open pneumothorax whatever but we want to use an occlusive dressing an occlusive means that air cannot pass through it on occlusive dressings commercially made devices have this flutter valve which allows for pressure to come out of your chest but does not allow for air to enter into your chest from the outside that's how we need to treat an open chest wound it's it's letting air out of the chest and it's keeping air from going back into the chest a simple pneumothorax you know that's that may not be a really bad injury it might just be a fractured rib excuse me but in itself it's not necessarily life-threatening but it can get worse and it can deteriorate into what we call a tension pneumothorax with attention pneumothorax that airs building up around the lung it's putting pressure on that bad lung but it's also pushing all your major organs in your chest to the good side it's push it's the filling up like a balloon in your chest so it's pushing everything to one side and so that's going to create pressures on your greater vessels and your heart and your good lung see how it's pushing things over to the side and the one thing i want you to note is at the top where your trachea comes down it's kind of bending and it's bending towards the good lung so in a really severe tension pneumothorax you will see tracheal deviation or tracheal tugging if you will towards the good lung a hemothorax is just like a pneumothorax except we have blood instead of air so blood is filling up that sac not air and when you have both air and blood that's called a hemo pneumothorax and so again it's depending on what's filling up that sac can we really tell just by looking at somebody no not necessarily but we treat them both the same signs and symptoms of a hemo shock but we can't see any signs of shock decreased breast sounds that's just like a pneumo what is it what do we do we drive fast to the hospital they need surgical intervention a hemo pneumo that's air and blood both they need a hospital a cardiac tamponade is when the pericardium the sac that fills or that surrounds the heart fills up with blood or fluid it's not going to fill up with air it's going to fill up with blood or fluid and then that's going to put pressure on the heart so the heart can't pump efficiently and so this sac fills up with blood or fluid of some sort and it's pushing on the heart so it cannot fill with blood and pump them up efficiently so some of the signs and symptoms are bec's triad make sure that you study what vex triad is an altered mental status and what do we do for this we respond we support their ventilations and we do a rapid transport rib fractures it's really common in elderly people a fracture one or more excuse me one of the upper four ribs is a sign of a sustained a substantial excuse me mechanism of injury a fractured rib might cause a pneumo cause a hemoglobin hemoglobin but again we're not really sure signs and symptoms of a rib fracture localized tenderness and pain shallow respirations they hold that side of the rib because it really hurts when they breathe our treatment is going to be supplemental oxygen so a flailed chest is a is basically a section of ribs that are broken in two or more places and you have this kind of like free floating segment and it moves in the opposite direction when you breathe there's some really good videos on youtube and you just type in flail chester um or paradoxical motion or whatever and you'll see some really good videos on how it goes in the opposite direction and it can move out pretty far too how do we treat a flail chest maintain the airway give support if needed bag them if needed oxygen and really transport them to the hospital there's no real treatment for a flail chest bbm we used to say we would wrap the chest so that we'd keep that segment from moving but we don't do that any longer a lot of people would put too much tension on that wrap on the chest and that would restrict their breathing altogether think about serious internal damage from this flail chest other chest injury might be a pulmonary contusion okay so this might go with a flail chest but this is a bruising of your lung and so the alveoli become filled with blood which is bad because we need those via light open so that we can transport oxygen from the lungs to the blood and the bad stuff off so again if the alveoli are filled with blood you're going to lose the ability that for oxygenation sternal fractures again we think about what could be damaged beneath i had a lady with a sternal fracture just from uh pulling out of the drive-through at arby's and hitting a light post in the parking lot at a slow speed it can happen clavicle fractures uh that's the number one injured bone in a side impact motor vehicle collision so with that clavicle fracture you might have a pneumothorax also traumatic asphyxiation so a traumatic asphyxiation i kind of always think about the person who's trapped under the car they're working on a car in their driveway and the jack falls and the car lands on their chest and so what happens is is the blood becomes trapped in their their head and so you have this distended neck veins because the blood can't get back to the heart you have cyanosis of the face and neck and hemorrhaging in the eyes the white of the eyes so you can kind of see where this person has a pale chest but everything from his chest up is all purple and blue so obviously you're going to have something some type of injury to the heart and and bruising of the lungs so you're not going to have oxygenation there or the bellatory support excuse me ability abilities for the body to ventilate so we got to do that for them we need to bag them neither with supplemental oxygen if they're still alive and then monitor vital signs blunt myocardial injury so we have a bruising to the heart so the heart might not or skimmy the heart may be unable to maintain adequate pressure things that we look for is irregular pulse rate chest pain or discomfort caused by trauma again suspected and we have a severe blood injury to the chest monitor their blood pressure note that changes in their blood pressure and we're looking at the 120 over 80 becoming 130 over 70 140 over 60 see how it's kind of widening or it's dropping or whatever and then oxygen and transport there's another condition called commercial cortes this is really interesting so it's pretty much when you have a direct blow to the chest during a part of your heartbeat and what that does is when i hit you in the chest and it has to be the right exact time it will put you into ventricular fibrillation and into cardiac arrest it's like somebody being hit in the chest with a baseball and it has to be perfectly timed at the right part of your your heartbeat for that to actually work how do you treat it cpr and defibrillation it's very rare and then you might even have laceration or your great vessels and again we don't know these things but again signs of shock without any outward signs of hemorrhaging so you might need to do cpr bag them transport shock all kinds of things uh if they're still alive when the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration the resulting injury that kills almost one third of patients usually within seconds is a hemothorax aortic shearing a pneumothorax or a ruptured myocardium which one is it which one kills one third of the patients within seconds yeah if you're thinking big pipes and you bleed out really rapidly that's it the aortic shearing um all the rest are serious but not fatal within seconds signs and symptoms of a chest injury include all the following except hemoptysis asymmetric chest movement and increased pain with breathing so which one is not chest injury right meta-emesis that's the vomiting of blood so that usually has to do with something in the gi tract not the chest side excuse me during your assessment of patient who was stabbed you see an open wound to the left interior chest your most immediate action should be to place them on their affected side transport immediately assess for attention pneumo or cover the wound with an occlusive dressing i think everybody got jumped right on that one with a closer dressing yes we're not going to put gauze on very little bleeding occurs with chest injuries typically so you don't have to worry about controlling the bleeding necessarily we need to control the oxygen or the movement of air in and out of that chest wall when caring for a patient with a pneumothorax your most immediate concern should be hypovolemia intrathoracic bleeding ventilatory inadequacy or associated myocardial injury what's your most immediate concern with a pneumothorax right ventilatory management that's what we need to do they're not going to be ventilating properly with the pneumothorax they're not going to be able to um they can't increase the breaths or anything so we're going to have to worry about that for them what purpose does a one-way flutter valve serve when placed are used on a patient with an open pneumothorax it prevents air escape from within the chest cavity it allows the release of air trapped it only prevents air from entering into an open chest wound or it allows air to freely move in and out of the chest cavity excuse me so what is the answer right it relieves the air now if you look at c the answer c says it only prevents air from entering but it also allows air from being released so again it's not just from entering but it's also helping the air get out of the chest signs of a cardiac tamponade that's where we have that sack around the heart filled with blood or fluid all the following are signs except muffled heart tones a weak rapid pulse collapsed jugular veins a narrowing pulse pleasure all of them are cardiac tamponade except right the the collapse jugular veins we actually have jugular vein distension that's one of the things we assess on our trauma patient's neck jvd jugular vein distension and tracheal deviation we'll see tracheal deviation on attention pneumo we'll see jbd and attention new law you will that's why we it's important for us to look for those things on our trauma patients because it could indicate what's going on with them a patient experiences severe compression to the chest when trapped between a vehicle and a brick wall you suspect traumatic suspicion due to a hemorrhage in the sclera of his eyes and what other signs so what else would you see in a traumatic asphyxiation flat neck veins cyanosis in the face and neck asymmetric chest movement irregular heart rate so besides the blood in his eyes what else you're going to see yep you're going to see that cyanosis of his neck and his chest neck veins are going to be distended again you're going to have jvd jugular vein distention not flat neck veins 18 a 14 year old baseball player is hit in the chest with a line drive he is in cardiac arrest what probably happened to him myocardial contusion traumatic sex fixia commotio cortis or a hemothorax hit with a line drive in the chest he's in cardiac arrest it's commercial cordis all day long yep that's such a rare thing but it occurs being hit in the chest at the right time during your your cardiac cycle paradoxical chest movement is typically seen in patients with a flail chest a pneumothorax isolated rib fractures or a ruptured diaphragm paradoxical or movement that's in the opposite direction of it of the way it should be yep flail chest again uh it's two or more ribs broken in two or more places it creates this free-floating segment of ribs if you will if you kind of think about it and we have um blood vessels underneath each one of our ribs you think about what could be happening every with every breath it could be cutting more and more blood vessels and allowing for more bleeding internally also the last question a 40 year old man who was an unrestrained driver in a car that hit a tree at a high rate of speed he struck the steering wheel of this chest he has a large bruise over his sternum in an irregular pulse of 120 which means he's really tachycardic you should most be concerned with he has injured his myocardium has a collapsed lung and severe hypoxia extensive bleeding into the pericardial sac or is an extremely high risk for ventricular fibrillation he struck the steering wheel with his chest he has a large bruise over his sternum in an irregular pulse that's the only complaints right it's that myocardial contusion or the contusion or the bruising of his heart it causes that dysrhythmia and that dysrhythmia right now is something really fast and it could be ventricular tachycardia in other words his ventricles are are beating at a really fast rate so again we're not really sure let the paramedics figure that out um but again there's no other complaints about breathing it's all has to do with his heart so that's uh the chest chapter 30 chest injuries