hello and welcome to chapter 30 chest injuries of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand how to manage a patient with chest trauma you will learn how to recognize life threats associated with these injuries and how to provide immediate intervention the curriculum includes a detailed description of the anatomy and physiology of the chest and underlying organs as well as the pathophysiology complications assessment and management of chest injury age-related issues are discussed specific to pediatric and geriatric trauma this chapter also provides information on incidents including morbidity and mortality and a detailed discussion of blunt versus penetrating and open trauma specific injuries discussed include sucking chest wounds pneumothorax tension pneumothorax hemothorax flailed chest and pericardial tamponade so let's get started chest trauma causes more than 1.2 million emergency department visits each year injuries can involve the heart lungs and great vessels may be a result of blunt trauma penetrating trauma or both emts must treat any injuries that interfere with the body's mechanisms of normal breathing without delay internal bleeding can collect in the chest cavity compressing the heart and lungs an air may collect in the chest and prevent the lungs from expanding let's talk a little bit about the anatomy and physiology remember the difference between ventilation and oxygenation ventilation is the body's ability to move air in and out of the chest and lung tissue oxygenation is the process of delivering oxygen in the blood by diffusion from the alveoli following inhalation into the lungs injuries affecting the patient's ventilation and oxygenation are serious and may be life-threatening the chest otherwise known as the thoracic cage extends from the lower end of the neck to the diaphragm a penetrating injury to the chest may also penetrate the lung and diaphragm and injure the liver spleen or stomach thoracic skin muscle and bones have similarities to skin muscle and bones and other regions of the body unique features such as striated or skeletal muscle allow for ventilation okay so intercostal muscles extend between ribs and these are not yet developed in very young children who tend to breathe from the diaphragm this is also known as belly breathing they're inverted from the spinal nerves and they allow the chest to expand on contraction and the active portion of ventilation to occur the neurovascular bundle is a network of nerves arteries and veins lying closely along the inferior of and slightly posterior to the longest margin of each rib it can be a source of significant bleeding into the pleural space the pleura covers each of the lungs and the thoracic cavity the parental pleura is the inner lining of the chest wall and the visceral pleura covers the lung a small amount of pleural fluid between the parential and the visceral pleura allows the lungs to move freely against the inner chest wall as a person breathes the ribs are connected in the back to the vertebrae and in the front to the sternum the trachea divides into the left and right mean bronchi stem bronchi which supply air to the lungs the thoracic cage contains the heart and the great vessels the aorta the right and left subclavian arteries and their branches the pulmonary arteries and the superior and inferior vena cava the mediastinum is the central part of the chest containing the heart great vessels esophagus and trachea the diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity so let's talk about the mechanics of ventilation the intercostal muscles and that's between the ribs contract during inhalation the diaphragm contracts or flattens at the same time the inner thoracic pressure inside the chest decreases creating a negative pressure differential allowing air into the lungs the intercostal muscles and diaphragms relax during exhalation allowing air to be exhaled the illustration on this slide shows the anatomy of the thoracic cavity during inspiration and expiration a patient whose spinal cord is injured below c5 may lose the power to move the intercostal muscles the diaphragm should still contract the patient will still be able to breathe because of the phrenic nerves remain intact and the patients with a spinal injury at c3 or above can lose the ability to breathe entirely tidal volume is the amount of air moved into or out of the lungs in each single breath the average tidal volume is approximately 500 milliliters minute volume is calculated by multiplying the tidal volume by the number of breaths in a minute changing either of these numbers affects the amount of air moving through the system the average bag mass device can deliver 1000 to 1500 milliliters of air over ventilation can cause gastric distension and impair lung function over ventilation can also increase intrathoracic pressure reducing venous return to the heart and thereby reducing cardiac output injuries to the chest there are two basic types of chest injuries and these are open or closed in chest injuries closed chest injuries the skin is not broken they are generally caused by blunt trauma they often cause significant contusions in cardiac muscle or otherwise known as a cardiac contusion and lung tissue and this is a pulmonary contusion if the heart is damaged it may not be able to refill with blood or blood may not be able to be pumped with enough force out of the heart this results in cardiogenic shock lung tissue bruising can result in exponential loss of surface area it could lead to decreased oxygen and carbon dioxide exchange and it can cause hypoxic and over hypercarbic states rib fractures can lacerate lung tissues and cause further vessel damage with every chest wall movement and it can rapidly lead to hypovolemic shock in an open chest injury an object penetrates the chest wall itself this causes instant damage but symptoms develop over time an impelled object remains in place do not attempt to move or remove an object may be occluding a hole in a punctual vessel removing it would cause heavy bleeding and it may cause damage during the removal blunt trauma to the chest may fracture the ribs sternum and chest wall bruise the lungs and the heart and even damage the aorta almost one-third of the people killed immediately in car crashes die as a result of penetrating rupture of the aorta signs and symptoms of a chest injury include pain at the site of the injury pain localized at the site of the injury that is aggravated or increased with breathing bruising to the chest wall crepitus with palpation of the chest or any penetrating injury to the chest or dipsnia failure of one or both sides of the chest expand normally with inspiration rapid weak pulse and low blood pressure cyanosis around the lips or fingernails diminished breath sounds on one side or low oxygen saturation patients with chest injuries often have tachypnea and this is rapid respirations and shallow restorations because it hurts to take a deep breath so let's begin our patient assessment scene size up of course scene safety and standard precautions are important if the area is a crime scene do not disturb the evidence if possible request the assistance of law enforcement for scans or scenes involving violence if needed call for electrical utility fire department and advanced life support units early determine the mechanism of injury chest injuries are common in motor vehicle crashes falls industrial accidents and assaults determine the number of patients and consider spinal stabilization okay then you're going to form your primary assessment within that primary assessment is that general impression and you want to look for life-threatening hemorrhaging when present and it should be addressed immediately even before airway concerns note the patient's level of consciousness and perform a rapid physical exam then it's the a and the b and then the c so let's do the a and the b first airway and breathing ensure that the patient has a clear and patent airway consider early cervical spinalization with blood trauma okay so note whether the jugular veins are distension they're distended and this is a sign of pressure on the heart determine whether breathing is present and adequate and inspect for dcap btls look for equal expansion of the chest wall check for paradoxical motion and an abnormality associated with multiple fractured ribs apply an exclusive dressing to all penetrating injuries to the chest apply oxygen with a non re breather at 15 liters and provide positive pressure ventilation at 100 percent if breathing is inadequate be alert for decreasing oxygen saturation be alert for signs of impending tension pneumothorax next we're going to talk about circulation so assess the pulse and determine whether it is present and adequate if the pulse is too fast or too slow or if the skin is pale cool or clammy consider the patient to be in shock and then address life-threatening external bleeding immediately transport decision so priority transports are those who have a problem with their airway breathing or circulation so pay attention to subtle clues appearance of the skin the level of consciousness a sense of impending doom in the patient and when in doubt transport the patient rapidly to the hospital table 31 lists the deadly dozen chest injuries okay so on this table it lists those injuries okay next is going to be your history taking so investigate that chief complaint further investigate the mechanism of injury and identify associated signs and symptoms and pertinent negatives questions should focus on the mechanism of injury speed of the vehicle or height of the fall use of safety equipment type of weapon number of penetrating wounds and then get your sample history and complete a basic evaluation if time allows then we have that secondary assessment so for trauma we're going to do a physical exam for an isolated injury of course we're going to focus on that isolated injury or the patient's chief complaint or the body reason of body region affected ensure wounds are identified and bleeding is controlled locate and the extent of the injury assessment of all underlying systems anterior and posterior aspects of the chest wall and changes in the patient's ability to maintain adequate respirations for significant trauma likely affecting multi-systems start with a rapid physical exam and use dcap btls to determine the nature and extent of the thoracic injury then vital signs so assess pulse respiration blood pressure skin condition oxygen saturation and pupils re-evaluate the patient every five minutes or less a rapid pulse or respiratory rate may indicate that the chest injury is causing a decrease in available oxygen or hypoxia or blood loss resulting in decreased red blood cells increased work of breathing may be identified by the use of accessory muscles in the face neck and chest and pulse and respiratory rates may decrease in later stages of the chest injury you want to recess mint so you want to repeat the primary assessment reassess the chief complaint re-evaluate airway breathing pulse perfusion and bleeding and then your interventions so reassess vital signs and observe trends provide appropriate spinal mobilization for patients who have blunt trauma with suspected spinal injuries maintain an open airway roll significant visible bleeding and place a vented chest seal or semi-vented dressing over penetrating trauma to the chest wall provide aggressive treatment for shock and transport rapidly do not delay transport to complete non-life-saving treatments these can be performed and route to the hospital and then of course communicate all relevant information to the staff at the receiving facility complications and management of chest injuries so first we're going to talk about a pneumothorax okay so a pneumothorax is defined as accumulation of air in the pleural space air enters through a hole in the chest wall or surface of the lung the patient's attempts to breathe causes the lung in or on the side to collapse blood passing through the collapse portion of the lung is not oxygenated breath sounds on the affected side of the chest indicate different conditions okay so if the lung has collapsed past 30 to 40 percent you may hear diminished breath sounds absent breath sounds may indicate a tension pneumo and a sucking sound on inhalation and the sound of rushing air on exhalation indicate that the chest has been penetrated okay so the illustration on this slide shows how a pneumothorax occurs air leaks into the space between the pleural surface from an opening in the chest wall or the surface of the lung and then air in the pleural space causes the lung to collapse an open chest wound is often called an open pneumothorax or sucking chest wound after cleaning and make or clearing and maintaining the patient's airway and then providing oxygen these wounds must be rapidly sealed with an occlusive dressing a flutter valve is a one-way valve that allows air to leave the chest cavity but not to return follow local protocols and the manufacturer's guidelines an occlusive dressing without a flutter valve may be taped on the patient on three sides of the dressing allow air to leak from the foresight apply after applying the dressing carefully monitor the patient for the signs of the tension pneumo if it develops open the occlusive dressing on one side the illustration on this slide shows a sucking chest wound the air passes from the outside into the pleural space and back out with each breath creating a sucking sound and then you have a simple simple pneumothorax it does not result in major changes in the patient's cardiac physiology commonly the result of blood chest trauma that results in fractured ribs signs and symptoms include pleuratic pain dyspnea tachypnea accessory muscle use decreased oxygen set and a cracking sensation felt on palpation of the skin and this is subcutaneous emphysema late findings can be decreased breast sounds on the injured side as well as lethargy and cyanosis so pre-hospital treatment for this you want to provide high flow to and monitor oxygen readings and breath sounds then you have a tension pneumo so this results from ongoing air accumulation in the pleural space this rat this air gradually increases the pressure in the chest causing complete collapse of the uninfected lung mediastinum is pushed into the opposite pleural cavity more commonly caused by blunt trauma in which a fractured rib lacerates a lung or bronchus common signs and symptoms include chest pain tachycardia marked respiratory distress low or rapidly dropping oxygen sad and absent or severely decreased lung sounds on the affected side with lung sounds or with signs of shock the patient may also present with jvd cyanosis or tracheal deviation but these signs are not always present pre-hospital treatment includes support ventilation with high flow oxygen request advanced life support and transport immediately needle decompression may be performed by advanced life support personnel or emergency department staff depending on local protocols so the illustration on this slide shows a tension pneumothorax then we're going to talk about now we're going to talk about hemothorax so this is a condition in which blood collects in the pleural space from bleeding around the rib cage or from a lung or grave vessel and so what you see that on this slide is a hemothorax or a hemo-pneumothorax a hemothorax is a collection of blood in the plural space produced by bleeding into the chest wall or within the chest wall when both blood and air are present the condition is called a hemo pneumo suspect a hemothorax if the patient has signs and symptoms of shock without any obvious external bleeding or decreased breast sounds on the affected side pre-hospital treatment include bleeding cannot be controlled in the pre-hospital setting provide rapid transport to the nearest facility capable of performing surgery the presence of air and blood in the plot space is known as a hemo pneumothorax cardiac tamponades the next one we're going to talk about and this is car also known as pericardial tampon and it occurs when pericardial sac fills with blood or fluid now that results in the part not being able to pump an adequate amount of blood so this illustration shows cardiac tamponade and with cardiac tamponade fluid builds up in the pericardial sac causing compression of the heart's chambers and dramatically impairing its ability to pump blood to the body signs and symptoms are referred to as the bex triad and include distended or engorged jugular veins on both sides of the trachea and narrowing pulse pressures and muffled heart tones pre-hospital treatment and core includes supporting ventilations and rapidly transporting the patient to the facility capable of intervention and then you have rib fractures so they're common particularly in older patients whose bones are brittle a fracture of one of the upper four ribs is a sign of a substantial mechanism of injury a fractured rib may lacerate the surface of the lung causing a pneumothorax attention pneumothorax hemothorax or a hemopneumothorax patients with one or more cracked ribs will report localized tenderness and pain when breathing pre-hospital treatment includes supplemental oxygen then you have a flailed chest so this is caused by two or more adjacent fractures in two or more places causing a segment of the chest wall to detach from the rest of the thoracic cage the deta attached portion of the chest wall moves possible or normal which is called paradoxical motion paradoxical motion is a late sign of a flail segment pre-hospital treatment of a flailed chest includes maintaining the airway providing respiratory support if needed giving supplemental oxygen and perform ongoing assessments for possible pneumothorax or other respiratory complications treatment may also include positive pressure ventilation with a bag valve mask restricting chest wall movements such as splinting the flailed chest with a bulky dressing and is no longer recommended flail chest may indicate serious internal damage and possible spinal injury then we're gonna now we're gonna talk about other chest injuries so you could have a pulmonary contusion and this should be suspected in a patient with a flailed chest the pulmonary alveoli become filled with blood and the fluid accumulates in the injured area leaving the patient hypoxic okay pre-hospital treatment includes providing supplemental oxygen and positive pressure ventilations as needed to ensure adequate oxygenation and ventilation and then other fractures so you could have sternal fractures and this requires a significant amount of force it may involve the lungs great vessels and the heart you could also have clavicle fractures and also significant damage or disruption to the large neurovascular bundle that the clavicle protects is possible suspect upper rib fractures in the medial clavicle fractures be alert to possible signs of a hemothorax which could develop then there's traumatic asphyxia so this is a severe compression of the chest which produces a rapid increase in pressure within that chest it's characterized by distended neck veins cyanosis to the face and neck or hemorrhage into the sclera of the eyes this suggests underlying injury to the heart and possibly pulmonary contusions pre-hospital treatment includes providing ventilatory support with supplemental oxygen monitors the signs during immediate transport we're going to talk about kamado cortis and this is a blunt chest injury caused by a sudden direct blow to the chest that occurs only during the critical portion of the person's heartbeat and what this will do is it will result in immediate cardiac arrest the result is of ventricular fibrillation is often responsive to defibrillation and early initiation of cpr okay so more commonly associated with sports related injuries but should be suspected in all cases in which the person is unconscious and unresponsive after a blow to the chest and then there could be laceration of great vessels so this may be accompanied by a massive fatally a rapidly fatal hemorrhage pre-hospital treatment of includes cpr ventilate ventilatory support with supplemental oxygen immediate transport and remain alert to signs and symptoms of shock closely monitor patients in baseline vital signs okay so that concludes chapter 30 a chest injuries lecture let's go through these uh review questions let's see how much we've learned okay so when the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration the resulting injury that kills almost one-third of the patients usually within seconds is uh that's going to be an aortic shearing i don't think we talked much about that but um and aortic injuries or shearing are caused of the causes of death in nearly nearly one-third of patients the aorta is the largest artery in the body when it is sheared from its supporting structures um basically the patients bleed out within a matter of seconds signs and symptoms of a chest injury include all of the following except okay so that's going to be b hemoemesis okay so usually they're not vomiting blood okay during your assessment of the patient who has been stabbed you see an open wound to the left anterior chest your most immediate action should be cover the wound with an occlusive dressing so d cover that wound with an occlusive dressing when caring for a patient with a sign of a pneumothorax your most immediate concern should be okay we're going to worry about ventilatory inadequacy okay because that lung is involved so that is correct number five what purpose does a one-way flutter valve serve when the patient's when used on a patient with a pneumo so what it's going to do it's going to allow the release of air trapped in that pleural space okay so that's b won't let air in but it'll allow us to release it okay so signs of a cardiac tamponade include all of the following except so the bex triad which is muffled hard tones and narrowing pulse pressure and enlarged jugular veins not collapsed so we're going to say c is wrong and that is correct it is going to be distended check jugular veins okay so a patient experiencing a severe compression to the chest when trapped between a vehicle and a brick wall you suspect traumatic asphyxia due to a hemorrhage into the sclera of the eyes and which other sign which other sign i would think it would be cyanosis to the face and neck okay number eight a 14 year old baseball player was hit in the chest with a line drive he is in cardiac arrest well we know right away this is going to be kamado cortis kamato quartus paradoxical chest movement is typically seen in patients with and we know that that is going to be a flail chest paradoxical is flailed 40 year old man who was the unrestrained driver of a car that hit a tree at a high rate of speed struck the tree he start struck the steering wheel with his chest he has a large bruise over the sternum irregular pulse rate you should be most concerned with i would say an extensive bleeding into that pericardial sac oh and they're gonna say is that he injured his myocardium so i guess that's about the same thing but um a bruise to that myocardium okay all right so thank you very much for joining us tonight for chapter 30 chess injuries if you like this lecture go ahead and subscribe to the channel thanks