Chapter 30. Chest Injuries. Introduction. Emergency medical technicians commonly encounter chest injuries.
According to the Centers for Disease Control and Prevention, chest trauma causes more than 1.2 million emergency department visits in the United States annually. Given the location of the heart, lungs, and great blood vessels within the chest cavity, potentially serious injuries may occur. Chest injuries may be the result of blunt trauma, penetrating trauma, or both.
Blunt trauma may occur from motor vehicle crashes or falls. Penetrating trauma may be due to shootings, stabbings, or other mechanisms, such as industrial or construction incidents. Any injury that interferes with breathing must be treated without delay to minimize or prevent permanent damage to tissues that depend on a continuous supply of oxygen. Another major problem with chest injuries may be internal bleeding. Blood from lacerations of the thoracic organs or major blood vessels can collect in the chest cavity, compressing the lungs or heart.
This may also occur when air collects in the chest and prevents the lungs from expanding. Your ability to act quickly to care for patients with these injuries can make the difference between a successful outcome and death. This chapter begins with a review of the anatomy of the chest.
and the physiology of respiration. It then describes the common signs and symptoms of chest injuries, and the proper emergency medical treatment for specific injuries. Anatomy and Physiology. To understand and evaluate chest injuries in the pre-hospital setting, you must first understand the anatomy of the chest, and the mechanism by which gases are exchanged during breathing.
A quick review will help you understand the logic in the emergency treatment of chest injuries. and the potential complications of that treatment. A key point to remember is the difference between ventilation and oxygenation. Ventilation is the body's ability to move air in and out of the chest and lung tissue. This is described in the section on mechanics of ventilation.
Any injury that affects the patient's ability to move air in and out of the chest is serious and may be life-threatening. oxygenation is the process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs oxygen must be delivered to the cells and carbon dioxide a waste product of cell function must be removed from the body for proper organ system function the chest thoracic cage extends from where the neck and chest meet to the diaphragm in a person who is lying supine or who has just completed exhalation the diaphragm may rise as high as the nipple line thus a penetrating injury to the chest such as a gunshot or stab wound may also penetrate the lung and diaphragm and injure the liver spleen or stomach the skin muscle and bones of the thoracic region have some unique features to allow for the ventilation process just under the normal three layers of skin the epidermis dermis and subcutaneous layers lies striated or skeletal muscle this muscle extends between the ribs forming the intercostal muscles these muscles innervated from the spinal nerves originating in the lower cervical or upper thoracic region contract to expand the rib cage during inhalation in very young children the intercostal muscles are not yet developed children therefore tend to breathe with their diaphragm referred to as belly breathing which is normal for their age group Lying on the inferior and slightly posterior part of each rib is the neurovascular bundle, composed of a network of nerves, arteries, and veins. When punctured by fractured ribs, bleeding from these vessels can cause a hemothorax.
The ribs themselves create a protective and functional cage around the vital organs. Each side of the chest, hemothorax, contains lung tissue that is separated into lobes. The right lung has three lobes, and the left lung has two lobes the left lobe formation allows space for the heart to reside this is called the cardiac notch a thin membrane called the pleura covers each of the lungs and the thoracic cavity the inner chest wall has a lining called the parietal pleura and a lining called the visceral pleura covers the lung between these two linings is a small amount of pleural fluid that allows the lungs to move freely against the inner chest wall as a person breathes pleural fluid also creates surface tension to allow the lungs to adhere to the rib cage thus allowing the mechanics of ventilation to occur the contents of the chest are partially protected by the ribs which are connected in the back to the vertebrae and in the front through the costal cartilages to the sternum The trachea, in the middle of the neck, divides into the left and right main stem bronchi, which supply air to the lungs.
The thoracic cage also 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 cavae. The esophagus runs through the back of the chest, connecting the pharynx above with the stomach, and the abdomen below. The esophagus. Trachea and great vessels lie in the mediastinum, a cavity or space centrally located in the thorax. At the bottom of the chest, the diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity.
Mechanics of ventilation When you inhale, the intercostal muscles between the ribs contract, elevating and expanding the rib cage. At the same time, the diaphragm contracts or flattens. increasing the inferior superior diameter of the chest. The intrathoracic pressure inside the chest decreases, creating a negative pressure differential. Air then enters the lungs through the nose and mouth, which is the path of least resistance from the ambient airspace to the upper and lower airway.
When you exhale, the intercostal muscles and diaphragm relax, and the tissues move back to their normal positions, forcing the air out, referred to as exhalation. In a normal respiratory system, relaxation of the thoracic muscles and the diaphragm is a relatively passive function. When you are assessing the patient, you should be able to recognize when there is an increase in the work of breathing and equate that with respiratory distress. Note that the nerves supplying the diaphragm, the phrenic nerves, exit the spinal cord at C3, C4, and C5. Refer to Chapter 6, The Human Body, for a review of the spinal column.
A patient whose spinal cord is injured below the C5 level may lose the power to move the intercostal muscles, but the diaphragm should still be able to contract. The patient will still be able to breathe because the phrenic nerves remain intact, but the injury may cause belly breathing. Patients with spinal cord injuries at C3 or above can lose their ability to breathe entirely.
Tidal volume is the amount of air moved into or out of the lungs during a single breath. Discussed further in Chapter 11, Airway Management. The average tidal volume is approximately 500 milliliters.
If you multiply this amount of air by the number of breaths per minute, the result is called the minute ventilation or minute volume. Changing either of these numbers, increasing or decreasing the rate or volume, affects the amount of air moving through the system. For example, if you ventilate a patient with 500 milliliters at the normal rate of 12 breaths per minute, per minute, then the minute volume is 6,000 milliliters, 6 liters.
If you increase the ventilation rate by 4 extra breaths per minute, then the minute volume increases to 8,000 milliliters, 8 liters. Conversely, if the amount of tidal volume decreases, then the minute volume will drop. This information is important because if the patient is only able to inhale small amounts of air in the case of a chest injury. the patient will need to exceed the normal respiratory rate of 12 to 20 breaths per minute to make up the difference in the minute volume remember that the average bag mask device consists of a self inflating bag that contains 1000 to 1500 milliliters of air this device can quickly over inflate the lungs causing gastric distension and impair the function of the lungs over ventilation can also increase intrathoracic pressure pressure inside the chest reducing venous return to the chest and secondarily reducing cardiac output it can also potentially worsen chest injuries such as pneumothorax in addition there is the risk of causing acid base imbalance by blowing off too much carbon dioxide if the rate of artificial ventilation is too high injuries of the chest recall the discussion of kinematics in chapter 25 trauma overview there are two basic types of chest injuries open and closed as the name implies a closed chest injury is one in which the skin is not broken this type of injury is generally caused by blunt trauma such as when a person strikes a steering wheel or an airbag in a motor vehicle crash is struck by a falling object or is struck in the chest by some object during a fight these types of injuries often cause significant contusions in both the cardiac muscle cardiac contusion and the lung tissue pulmonary contusion, thus impairing the function of those organs.
If the heart is damaged in this manner, it may not be able to refill with blood or blood may not be pumped with enough force out of the heart, creating a form of inadequate tissue oxygenation called cardiogenic shock. Any bruising of the lung tissue may result in the affected alveoli not functioning. This impairment can cause a decrease in available oxygen, hypoxia, and an increase in carbon dioxide in the blood, hypercarbia, rib.
fractures create sharp broken bone ends that can lacerate lung tissue and cause further vessel damage with every movement of the chest wall. This type of bleeding can be hidden from external view, and rapidly lead to hypovolemic shock. An open chest injury is generally caused by penetrating trauma. Some objects, such as a knife, a bullet, a piece of metal, or the broken end of a fractured rib, penetrate the chest wall itself. the damage occurring from this type of trauma typically is instant however the symptoms of these injuries may take time to develop as the damaged vessels continue to bleed or the lung collapses from a puncture that results in an expanding pneumothorax occasionally the object that penetrates and creates an open chest injury remains in place this is referred to as an impaled object when you have a patient with an impaled object Do not attempt to move or remove the object because it may be occluding the hole in the vessel that has been punctured.
Removing the object can lead to severe bleeding. Another reason not to remove the impaled object from the chest is that the objects that cause tissue damage on entry will likely cause damage on removal, resulting in further injury. The removal is best left for the surgeon.
Any alteration from this standard should come directly from online medical control. In blood trauma, a blow to the chest may fracture the ribs, the sternum, or whole areas of the chest wall, bruise the lungs, and the heart, and even damage the aorta. Almost one-third of people who are killed immediately in car crashes die as a result of traumatic rupture of the aorta when it is torn from its attachment to the chest cavity.
Although the skin and chest wall are not penetrated in a closed injury, broken ribs may lacerate the contents of the chest. Damage to the chest wall structures may impair patient's ability to ventilate on their own. Signs and symptoms of chest injury. Important signs and symptoms of chest injury include the following. Pain at the site of injury.
Pain localized at the site of injury that is aggravated by or increased with breathing. Bruising to the chest wall. Crepitus, the sensation felt when broken bone ends grind together, with palpation of the chest. any penetrating injury to the chest dyspnea difficulty breathing shortness of breath hemoptysis coughing up blood failure of one or both sides of the chest to expand normally with inspiration rapid weak pulse and low blood pressure cyanosis around the lips or fingernails diminished breath sounds on one side low oxygen saturation after a chest injury Any change in normal breathing is a particularly important sign. A healthy, uninjured adult usually breathes at a rate from 12 to 20 breaths per minute without difficulty, and without pain.
The chest should rise and fall in a symmetric pattern with each breath. Respirations of fewer than 10 breaths per minute or of more than 20 breaths per minute may indicate inadequate breathing. Patients with chest injuries often have tachypnea. Rapid respirations. and shallow respirations because it hurts to take a deep breath.
Shallow breathing or chest wall trauma may interfere with the actual ability to move air. Check the respiratory rate and see if there is actual air movement from the mouth and or nose. This is best accomplished through visualizing the chest wall for rise and fall.
As with any other injury, pain and tenderness are common at the point of impact as a result of a bruise or fracture. The normal process of breathing usually aggravates pain. Irritation or damage to the pleural surfaces causes a characteristic sharp or sticking pain with each breath when these normally smooth surfaces slide on one another. This sharp pain is called pleuritic pain, and is typical of chest injuries. In an injured patient, dyspnea, or difficulty breathing, has many causes, including airway obstruction, damage to the chest wall.
poor chest expansion because of the loss of normal control of breathing, or lung compression because of accumulated blood or air in the chest cavity. Hemoptysis, the spitting or coughing up of blood, usually indicates that the lung itself or the air passages have been damaged. With a laceration of the lung tissue, blood can enter the bronchial passages, and is coughed up as the patient tries to clear the airway.
A rapid, weak pulse and low blood pressure are the principal signs of hypovolemic shock, which can result from extensive bleeding from lacerated structures within the chest cavity. Shock following a chest injury may also result from insufficient oxygenation of the blood by the poorly functioning lungs, from an increase in intrathoracic pressure from air or blood in the chest. or from direct injury to the heart itself cyanosis in a patient with a chest injury is a sign of inadequate respiration the classic blue or ash and gray appearance around the lips and fingernails indicates that blood is not being oxygenated sufficiently patients with cyanosis are unable to provide a sufficient supply of oxygen to the blood through the lungs and require immediate ventilation and oxygenation many of these signs and symptoms occur simultaneously When any one of these develops as a result of a chest injury, the patient requires prompt hospital care. Patient Assessment Scene Size Up As you arrive on the scene, observe for hazards and threats to the safety of the crew, bystanders, and the patient.
Ensure that the police are on scene at incidents involving violence, such as assaults or gunshot wounds. Begin the encounter with scene safety as the highest priority. If you determine the power company, fire department, or advanced life support units are needed, call for them early. Ensure that you and your crew take standard precautions, at a minimum, put on gloves and eye protection. Because of the color of blood, and the fact that it easily soaks through clothing, you can often identify patients with bleeding as you approach the scene.
However, darker clothing may mask signs of bleeding. so you must remain vigilant when the mechanism of injury suggests the patient may be bleeding. As you observe the scene, look for indicators and significance of the mechanism of injury. This helps you develop an early index of suspicion for underlying injuries in a patient who has sustained a significant mechanism of injury. Chest injuries are common in motor vehicle crashes, falls, industrial incidents, and assaults.
Determine the number of patients. and consider spinal stabilization. Primary assessment. During your primary assessment, you must quickly identify and treat potential life threats, and determine priority of patient care, and transport.
Life-threatening hemorrhage, when present, should be addressed immediately, even before airway concerns. As you approach, note the patient's level of consciousness. Responsive patients may be able to tell you their chief complaint.
Note not only what they say, but also how they say it. Difficulty speaking may indicate several problems, and chest injury is an important one. Perform a rapid physical examination of the patient.
Look for obvious injuries, the appearance of blood, and difficulty breathing. Look for cyanosis, irregular breathing, and chest rise and fall on only one side. The initial general impression will help you develop an index of suspicion for serious injuries, and determine your sense of urgency for medical intervention. A good question to ask yourself is, how sick is this patient?
Patients with significant chest injuries will look sick and are often frightened or anxious. Keep in mind that you are rapidly searching for life threats, and you will repeat the physical examination in a more detailed manner later in the assessment if time and patient condition allow. Addressing life threats begins with the assessment of airway and breathing unless life-threatening uncontrolled bleeding is seen.
Ensure that the patient has a clear and patent airway. Normal breathing should be effortless, and any deviation from this pattern should be cause for concern. How you assess and manage the airway depends a great deal on whether you suspect a spinal injury.
Be suspicious, and protect the spine early in your care if indicated. Further measures to ensure spinal motion restriction can be performed after you have secured the X-airway, breathing, and circulations and completed your secondary assessment. Once you have determined the patient has a patent airway, determine whether breathing is present and adequate. With chest injuries, begin by inspecting for DCAB-BTLS, and look for equal expansion of the chest wall.
Listen with a stethoscope to each side of the chest. Absent or decreased. chest breath sounds on one side usually indicate significant damage to a lung, preventing it from expanding properly.
Be alert to the pattern of symmetric rise and fall of the patient's chest wall. If the chest wall does not expand on each side when the patient inhales, the chest muscles may have lost their ability to work appropriately. Loss of muscle function may be the result of a direct injury to the chest wall, or it may be related to an injury of the nerves that controlled those muscles. Check for paradoxical motion, an abnormality associated with multiple fractured ribs, in which one segment, often referred to as a flail segment. of the chest wall moves opposite the rest of the chest that is out with expiration and in with inspiration if you determine the patient has penetrating trauma address this life threat at once this condition may interfere with the normal mechanics of breathing and can cause the patient's condition to worsen quickly for quick initial care you can use your gloved hand to include an open chest wound when further dressings can be applied use a vented chest seal or an occlusive dressing for all penetrating injuries to the chest an occlusive dressing should be taped on three sides leaving one side open allows air to escape but not enter the chest apply oxygen with the non rebreathing mask at 15 liters per minute provide positive pressure ventilation with 100% oxygen if breathing is inadequate based on the patient's level of consciousness and breathing rate and quality Positive pressure ventilation is important for the patient with a flail chest that compromises ventilation.
Be diligent with auscultation of breath sounds, and evaluate the effectiveness of your ventilatory support with signs of circulation to the skin. Be aware of decreasing oxygen saturation values because they may indicate the development of hypoxia. Watch for signs of an impending tension pneumothorax, such as increasingly poor compliance during ventilation.
difficulty delivering breaths to the patient if you believe attention pneumothorax has developed in a patient with an open chest wound the occlusive dressing should be burped briefly removed to allow air to escape and then placed back over the wound assess the patient's pals 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 your patient to be in shock note that because skin paleness can be difficult to detect in patients with dark skin you may need to check for pale mucus membranes inside the inner lower eyelid or slow capillary refill you need to treat aggressively to reverse the cause of shock and support the patient's circulatory system in the early stage of shock the body compensates for blood loss by increasing the heart rate be alert for this change especially if If tachycardia is still present beyond a few minutes after the initial adrenaline rush from the incident or injury. External bleeding may or may not be significant, but if it is considered life-threatening, address this threat immediately. Bleeding inside the chest can be significant and, as discussed earlier, can be a quick cause of death. Control external bleeding with direct pressure, and a bulky trauma dressing. Priority patients are considered patients who have a problem with their ex-airway, breathing, and circulations.
Sometimes the priority is obvious, and the decision to transport quickly is also easy. At other times, what is happening outside the body may not provide obvious clues to the seriousness of what is happening inside the body. Pay attention to subtle clues such as the appearance of the skin, level of consciousness, or a sense of impending doom in the patient.
When you find signs of poor perfusion or inadequate breathing, transport quickly and perform the remainder of the assessment en route to the emergency department. A delay on the scene to perform a lengthy assessment will reduce your patient's chances of survival. With chest injuries, when in doubt, transport rapidly to a trauma center. Table 30-1 lists the deadly dozen chest injuries. History taking.
Once you have identified and treated life threats. you can gather the patient's history if you have not yet done so determine and investigate the patient's chief complaint and further investigate the mechanism of injury identify any associated signs and symptoms and pertinent negatives if the patient was assaulted with a blunt object such as a bat further evaluate the spinal region for injury because the force may have been transferred through the body from the point of impact if the patient fell from a great height and is reporting chest discomfort or dyspnea. This may distract the patient from recognizing that he or she has fractures or is bleeding from the extremities. Palpation of the chest will typically cause direct pain at the site of the fracture. When a patient reacts to the pain, be certain to verify where the pain was located relative to the area being touched.
Pertinent negatives when examining the chest include no associated shortness of breath, no rapid breathing, no absent or abnormal breath sounds, and no areas of deformity or abnormal movement. In a patient with a suspected spinal cord injury, equal expansion of the chest and movement of the rib cage, and the diaphragm can confirm that there is nerve conduction to that region of the body. A basic evaluation of signs and symptoms, allergies, medications, Pertinent medical history, including respiratory or cardiovascular disease, and last oral intake should be completed when time allows.
The events leading to the emergency should also be identified. Questions about the events surrounding the incident should focus on the mechanism of injury, the speed of the vehicle or height of the fall, the use of safety equipment such as a helmet, airbag, seatbelt, or life jacket, the type of weapon used, the number of penetrating wounds. and so on.
A sample history can be obtained quickly in most situations, and can certainly be obtained while accomplishing other tasks. However, if the patient has a loss of consciousness, it will no longer be possible to obtain the information directly. Interviewing witnesses briefly in these circumstances is important.
Secondary assessment. In a patient who has an isolated injury to the chest with a limited mechanism of injury, such as in a stabbing, you should focus your assessment on the isolated injury the patient's chief complaint and the body region affected ensure that wounds are identified and that any bleeding is controlled note the location and extent of the injury assess all underlying systems examine the anterior and posterior aspects of the chest wall and be alert to changes in the patient's ability to maintain adequate respirations It is important in patients with a chest injury not to focus only on a chest wound. With significant trauma, you should quickly assess the entire patient from head to toe. If there is significant trauma, such as a blunt trauma or gunshot wound, likely affecting multiple systems, start with a rapid physical examination of the body, looking for DCAPBTLS to determine the nature and extent of thoracic injury.
This examination will help to determine all injuries, and the extent of these injuries. Inspection or visualization of the region looking for deformities, such as asymmetry of the left and right sides of the chest or shoulder girdle, may reveal the presence of multiple rib fractures, crush injuries, or significant chest wall injury. Identification of discrete areas of contusion or abrasion may pinpoint a specific point of impact.
The presence of puncture wounds or other penetrating injuries indicates a possible open chest injury that should be managed accordingly. Be alert for burns that encircle the chest, which may alter respiratory mechanics. Palpate for tenderness to localize the injury, and the presence of fractures.
Look for lacerations, and local swelling. Application of this systematic approach to patient assessment minimizes the chance of missing a significant injury. Once you have stabilized X-airway, breathing, and circulations problems, and have checked the patient from head to toe to identify injuries, obtain a baseline set of vital signs.
This activity should include assessment of pulse, respirations, blood pressure, skin condition, oxygen saturation, and pupils. Each of these is considered a sign indicating how your patient is tolerating the injuries. Consider these signs as a window to the functioning of the vital organs.
This baseline set of vital signs will be used to evaluate changes in the patient's condition. Because patients with chest injury have so much potential for rapid deterioration, they should be re-evaluated every 5 minutes. This will allow you to quickly recognize changes in the vital sign numbers or trends.
If you find an accelerated pulse rate or respiratory rate, The chest injury may be causing either a decrease in available oxygen, hypoxia, or blood loss that results in a decreased number of red blood cells that can carry oxygen, hypoxemia. The increased respiratory rate is often associated with an obvious increase in work of breathing. This can be identified by noting increased use of the accessory muscles in the face, neck, and chest to assist in the movement of air. In the later stages of injuries, The pulse rate can slow as the myocardium becomes starved for oxygen, and the body is no longer able to keep up with the demands.
The respiratory rate may drop as the brain becomes starved for oxygen, and overloaded with carbon dioxide, and other waste products. these are usually signs of impending cardiopulmonary arrest in the case of increasing pressure on the heart from air in the chloral space or blood in the pericardial space the blood pressure may exhibit a narrowing pulse pressure as the systolic and diastolic pressures come closer together this is a result of the inability of the heart to fill with an adequate volume of blood and contract normally reassessment the reassessment identifies how your patient's condition is changing It should focus on repeating the primary assessment, reassessing the chief complaint, and reassessing interventions performed. Re-evaluate the patient's airway, breathing, pulse, perfusion, and bleeding. Has breathing improved now that the wound is sealed, or has it become more difficult? If assisting ventilations with a bag-masked device, is it becoming increasingly difficult to deliver breaths to the patient?
Other interventions should also be assessed to determine if they're effective. For example, are pulse oximeter values rising now that the patient is receiving oxygen? Reassess vital signs, and compare them to vital signs taken earlier.
Vital signs are a snapshot in time. Reassessing them frequently allows you to trend the patient's status, and determine if the patient is compensating versus decompensating. many chest injuries will worsen during transport to the hospital because of the seriousness of the injuries an astute reassessment will help identify worsening conditions in a timely manner so that they can be addressed provide appropriate spinal motion restriction at any patient who has blunt trauma with suspected spinal injuries if the patient's shortness of breath is worsened in the supine position place the patient in a position of comfort by elevating the head if necessary while still maintaining spina spinal motion restriction. Maintain an open airway, be prepared to suction the patient, and consider an oropharyngeal or nasopharyngeal airway. Whenever you suspect significant bleeding, provide high flow oxygen.
If needed, provide assisted ventilation using a bag mask device with high flow oxygen. If significant bleeding is visible, you must control the bleeding. If you find penetrating trauma to the chest wall, place a vented chest seal or semi-occlusive dressing over the wound be prepared to provide positive pressure ventilation if the patient's efforts are not effective if the patient has signs of hypoperfusion treat aggressively for shock and provide rapid transport to the appropriate hospital do not delay transport of a seriously injured trauma patient to complete non life-saving treatments such as splinting extremity fractures instead Complete these types of treatments en route to the hospital.
Communicating with hospital staff early when your patient has a significant mechanism of injury to the chest can help them be prepared with appropriate equipment and personnel when you arrive. If a penetrating injury is present, describe it in your report, along with what you have done to care for it. Your documentation should be complete and thorough.
Describe all injuries, and the treatment given. Remember. Your documentation is your legal record of what happened, complications and management of chest injuries, personal protective equipment in chest injuries, movement of air out of an open chest wound can aerosolize droplets from the lung.
If the patient is at risk for a communicable respiratory virus, extra personal protective equipment precautions are needed. When treating these patients, providers should wear an N95 mask. eye protection including goggles or face shield, a gown, and gloves.
The unit needs to be thoroughly decontaminated after these calls if there is any ongoing suspicion of COVID-19 or other respiratory virus in the community. Pneumothorax. In any chest injury, damage to the heart, lungs, great vessels, and other organs in the chest can be complicated by the accumulation of air in the pleural space.
This is a dangerous condition called a pneumothorax commonly called a collapsed lung. In this condition, air enters through a hole in the chest wall or the surface of the lung as the patient attempts to breathe, causing the lung on that side to collapse. As a result, any blood that passes through the collapsed portion of the lung is not oxygenated, and hypoxia can develop. If the lung is collapsed past 30% to 40%, you may hear diminished breath sounds on that side of the chest.
Absent breath sounds are a significant finding in chest trauma, and may indicate the development of a tension pneumothorax, discussed later. Depending on the size of the hole, and the rate at which air fills the cavity, the lung may collapse in a few seconds or a few hours. In the uncommon situation when the hole is in the chest wall, you may hear a sucking sound as the patient inhales, and the sound of rushing air as he or she exhales.
For this reason, an open or penetrating wound to the chest wall is often called an open pneumothorax or a sucking chest wound. This type of injury is a true emergency requiring immediate emergency medical care, and transport. Initial emergency care, after clearing and maintaining the airway.
and then providing oxygen, is to rapidly seal the open wound with a vented chest seal or semi-occlusive dressing. The purpose of the dressing is to seal the wound and prevent air from being sucked into the pleural space through the wound. Vented chest seals are designed to allow air to escape through the dressing but not be sucked back in, thus preventing the development of a pneumothorax. If a vented chest seal is not available, an occlusive dressing can be used.
Vented chest seal dressings contain a one-way valve, called a flutter valve, that allows air to leave the chest cavity but not return. Follow local protocol and the manufacturer's guidelines if you use such a dressing. An occlusive dressing without a flutter valve may be taped to the patient on three sides of the dressing, allowing air to leak from the fourth side.
Regardless of which type of dressing you carry, use a dressing that is large enough so that it is not pulled or sucked into the chest cavity. Careful observation is required after placing an occlusive dressing. The occlusive seal or a clot in the injury may allow attention pneumothorax to develop. If signs of attention pneumothorax develop, it is suggested that the occlusive dressing be partially removed to allow air to escape, and to then be re-secured. You may hear a sudden release of air pressure when you remove one side of the dressing.
This situation can develop even after a flutter valve has been applied. Simple pneumothorax. Any pneumothorax that does not result in major changes in the patient's cardiac physiology is referred to as a simple pneumothorax.
These are commonly the result of blunt trauma that results in fractured ribs. As in the spontaneous pneumothorax, the simple pneumothorax is often difficult to diagnose. The lung has to collapse significantly before the effects will be heard as decreased breath sounds.
The more common findings are similar to those of other types of pneumothoraces, pleuritic chest pain, dyspnea or increased work of breathing exhibited as increased rate, pachypnea and accessory muscle use, and decreasing oxygen saturation on the pulse oximeter. Another sign of pneumothorax can be a crackling sensation felt on palpation of the skin, called subcutaneous emphysema, which indicates that air escaping from a lacerated lung is leaking into the tissues of the chest wall. late findings can be decreased breath sounds on the injured side as well as lethargy and cyanosis be vigilant because the simple pneumothorax can often worsen or deteriorate into attention pneumothorax or develop complications such as bleeding or hemothorax the treatment for a simple pneumothorax is much like any treatment for respiratory compromise provide a high concentration of oxygen monitor oximeter readings and breath sounds and treat underlying causes of the injury as in all pneumothorax treatment adding positive pressure ventilation may cause the pathology to advance rapidly and possibly cause attention pneumothorax to develop however you should not withhold positive pressure ventilation if the patient needs the support simply be aware of the risk and plan on how to resolve complications most patients with this problem require advanced life support intervention so call for it early or transport rapidly to the nearest hospital or trauma center depending on which is the fastest way to get your patient to a higher level of care tension pneumothorax a potential complication that may develop following chest injuries with pneumothorax is attention pneumothorax this can occur when there is significant ongoing air accumulation in the plural space this air gradually increases the pressure in the chest first causing the complete collapse of the affected lung and then pushing the mediastinum the central part of the chest containing the heart and great vessels into the opposite plural cavity this prevents blood from returning through the vena cava to the heart decreasing cardiac output causing shock and ultimately leading to death tension pneumothorax occurs more commonly as a result of closed blunt injury to the chest in which a fractured rib lacerates along or bronchus Only rarely does attention pneumothorax arise spontaneously.
A patient with a tension pneumothorax will have chest pain, tachycardia, marked respiratory distress, low or rapidly dropping oxygen saturation, and absent or severely decreased lung sounds on the affected side, with signs of shock such as hypotension or altered mental status. The patient may also exhibit jugular vein distension, cyanosis, or tracheal deviation, but these signs are not always present. Jugular vein distension is best assessed for with the patient sitting at a 45 degree angle. Tracheal deviation, if seen, is a late and grave finding and is a sign that the patient requires immediate intervention.
Relieving attention pneumothorax that is the result of blunt trauma is often done by inserting a needle through the rib cage into the pleural space, called a needle foracotomy, however, this This procedure typically is performed by advanced life support personnel or emergency department staff, depending on local protocols. Attention Pneumothorax is a life-threatening condition. Be prepared to support ventilation with high flow oxygen, and request advanced life support or transport immediately to the closest hospital. In blunt and penetrating chest injuries. blood can collect in the pleural space from leading around the rib cage or from a lung or great vessel this condition is called a hemo thorax suspect a hemo thorax if the patient has signs and symptoms of shock without any obvious external bleeding or apparent reason for the shock state or decreased breath sounds on the affected side an indication that the lung is being compressed by the blood in the cavity because the bleeding is typically caused by severe damage within the chest cavity there is virtually no way to control the bleeding in the pre-hospital setting the only person who can treat this condition is often a surgeon the presence of air and blood in the pleural space is known as a hemo pneumothorax again because the injury has occurred within the walls of the chest the treatment involves providing rapid transport to the nearest facility capable of inserting a chest tube and potentially performing surgery cardiac tamponade cardiac tamponade pericardial tamponade occurs when the pericardial sac the space between the protective membrane around the heart pericardium and the heart fills with blood or fluid perhaps from a ruptured torn or lacerated coronary artery or vein the pericardial sac can also fill with fluid as a result of cancer or an autoimmune disease such as lupus as the amount of blood or fluid increases the heart is less able to fill with blood blood during each relaxation phase.
As a result, the heart cannot pump an adequate amount of blood, and the patient experiences a decrease in systemic blood flow, or cardiac output. The signs of this condition are often subtle until the situation is dire. The signs and symptoms, referred to as the back triad, include distended or engorged jugular veins seen on both sides of the trachea, a narrowing pulse pressure.
The difference between the systolic and diastolic blood pressure numbers, and muffled heart sounds. Because the heart cannot pump sufficiently, the jugular veins fill with blood and, thus, blood backs up. The narrowing pulse pressure occurs as the diastolic pressure increases but the systolic pressure cannot, because the heart cannot stretch to contract harder. An associated and more commonly noticed sign is a decrease in mental status as blood. flow decreases to the brain.
The heart muscle is unique in that it needs to be stretched to create a good contraction to pump blood out of the ventricles. This mechanism can fail because of tamponade and can be directly related to a decrease in blood returning to the heart. Treatment for this condition involves recognition and supportive care.
Oxygen should never be withheld from a patient who needs it. Provide positive pressure ventilation to any patient who is hypoventilating or apneic. rapidly transport the patient to a facility that is capable of intervention.
Rib fractures. Rib fractures are very common, particularly in older people, whose bones can be more brittle. Because the upper four ribs are well protected by the bony girdle of the clavicle and scapula, a fracture of one of these upper ribs is a sign of a substantial mechanism of injury.
Be aware that a fractured rib that penetrates into the pleural space may lacerate the surface of the lung. causing a pneumothorax, a tension pneumothorax, a hemothorax, or a hemo-pneumothorax. Patients with one or more cracked ribs will report localized tenderness and pain when breathing. The pain is the result of broken ends of the fracture rubbing against each other with each inspiration and expiration.
Patients will tend to avoid taking deep breaths, and their breathing will be rapid and shallow instead. They will often hold the affected portion of the rib cage to minimize the discomfort. Patients with rib fractures should receive supplemental oxygen during assessment, and transport if they're experiencing any respiratory distress. Flail chest.
Ribs may be fractured in more than one place. If two or more adjacent ribs are fractured in two or more places, A segment of chest wall may be detached from the rest of the thoracic cage. This condition, known as flail chest, can also occur if the sternum is fractured along with several ribs.
In what is called paradoxical motion, the detached portion of the chest wall moves opposite of normal. It moves in instead of out during inhalation, and out instead of in during exhalation. Breathing with a flail chest can be painful and ineffective. hypoxemia easily results as air is circulated between the lungs due to the flail segment a flail segment seriously interferes with the body's normal mechanics of ventilation and must be treated quickly paradoxical motion is a late sign of flail segment therefore an absence of paradoxical motion does not mean the patient does not have a flail segment treatment of a patient with a flail chest should include maintaining the airway providing respiratory support if necessary, giving supplemental oxygen, and performing ongoing assessments for possible pneumothorax or other respiratory complications.
Treatment may also require positive pressure ventilation with a bag mask device. Historically, other treatments have been recommended, including splinting the flail segment. However, these treatments are not evidence-based and should not be used to treat a patient.
keep in mind that although flail chest itself is a serious condition it also suggests an injury that was forceful enough to cause other serious internal damage and possible spinal injury other chest injuries pulmonary contusion in addition to fracturing ribs any severe blunt trauma to the chest can injure or bruise the lung the pulmonary alveoli become filled with blood and fluid accumulates in the injured area leaving the patient hypoxic Severe pulmonary contusion should always be suspected in patients with a flail chest, and usually develops over a period of hours following the injury. If you believe that a patient may have a pulmonary contusion, provide supplemental oxygen, and positive pressure ventilation as needed to ensure adequate oxygenation and ventilation. Other fractures.
In addition to the rib fractures you have already learned about, there are other types of fractures that should be discussed. sternal fractures any suspected fracture of the sternum should increase your index of suspicion for injuries to the underlying organs because the amount of force required to break the sternum is significant there may be involvement of the lungs great vessels and the heart clavicle fractures whereas this fracture is also covered under skeletal injuries it is important to mention here that the clavicle overlies the first rib and protects a large neurovascular bundle nerve artery and vein that can be significantly damaged or disrupted should injury to the clavicle occur the pain deformity and swelling that accompany a clavicle fracture can also detract from assessment of the first and second ribs in proximity to the fracture suspect upper rib fractures in medial clavicle fractures and be alert to possible signs of pneumothorax development traumatic asphyxia Sometimes a patient will experience a sudden severe compression of the chest which produces a rapid increase in pressure within the chest this may occur in a pedestrian who is compressed between a vehicle and a wall or a patient who is pinned under a vehicle the sudden increase in intra thoracic pressure results in a characteristic appearance including distended neck veins cyanosis in the face and neck and hemorrhage into the sclera of the eye signaling the bursting of small blood vessels this is called traumatic asphyxia These findings suggest an underlying injury to the heart, and possibly a pulmonary contusion. Provide ventilatory support with supplemental oxygen, and monitor the patient's vital signs as you provide immediate transport.
Blunt myocardial injury. Blunt trauma to the chest may injure the heart itself, making it unable to maintain adequate blood pressure. There is much debate in the medical literature about how to assess myocardial contusion, or bruising of the heart muscle.
Often the pulse is irregular, but dangerous rhythms such as ventricular tachycardia and ventricular fibrillation are uncommon. Currently, there is no specific diagnostic test in the pre-hospital setting, and there is no pre-hospital treatment for the condition. Still, you should suspect myocardial contusion in all cases of severe blunt injury to the chest. Carefully check the patient's pulse and note any irregularities. Also note any change in blood pressure because this can be a direct result of the injury to the myocardium.
Often the patient's signs and symptoms can mimic a heart attack in which the patient may report chest pain or discomfort that is similar in nature to cardiac symptoms, provides supplemental oxygen, and transport immediately. Commotio Cordis Commotio Cordis is a blunt chest injury caused by a sudden, direct blow to the chest, over the heart, that occurs during a critical portion of a person's heartbeat. The result may be immediate cardiac arrest.
This phenomenon has occurred after patients were struck with softballs, baseballs, bats, snowballs, fists, and even kicks during kickboxing. The force of the blow to the chest is commonly at speeds of 35 to 40 miles per hour. The blunt force, at a single specific point in the cardiac cycle, causes a lethal abnormal heart rhythm called ventricular fibrillation. The ventricular fibrillation is often responsive to defibrillation.
and early initiation of cardiopulmonary resuscitation. Comotional cortis is more commonly associated with sports-related injuries, although should be suspected in all cases in which the person is unconscious and unresponsive after a blow to the chest. These patients present in cardiac arrest, and should be managed as any other cardiac arrest, understanding that they may be particularly responsive to early defibrillation.
Laceration of the Great Vessels The chest contains several large blood vessels, the superior vena cava, the inferior vena cava, the pulmonary arteries, four main pulmonary veins, and the aorta, with its major branches distributing blood throughout the body. Injury to any of these vessels may be accompanied by massive, rapidly fatal hemorrhage. Any patient with a chest wound who shows signs of shock may have an injury to one or more of these vessels.
Frequently Significant blood loss is unseen because it remains within the chest cavity. Remain alert to signs and symptoms of shock and to changes in the baseline vital signs, such as tachycardia and hypotension. Emergency treatment in these cases includes cardiopulmonary resuscitation, if appropriate, ventilatory support, and supplemental oxygen.
Immediate transport to the trauma center may be critical. Occasionally, some of these patients can be treated. The overwhelming majority of injuries to the great vessels in the chest are rapidly fatal.