9) Chest Flashcards
% of MVC deaths due to thoracic trauma:
Thoracic Cavity (chest) contains:
= 25% of all motor vehicle deaths due to thoracic trauma
= Heart, great vessels , esophagus, tracheobronchial tree, lungs
completes bony thorax structure/base:
Thorax base structure bone easiest to break:
= Sternum
= Xiphoid process (easiest to break)
Thoracic Skeleton:
1st rib usually:
Angle lewie:
Indirectly vs directly:
= 12 pairs ribs 7-12 false & 1-7 true
= usually under clavicle
= Manubrium’s hump meets sternum usually 2nd rib
= directly 1-1 connects to manubrium
1 Esophagus:
2 Lower esophageal sphincter divides
3 Enters & Exits through:
4 Moves food & liquid toward stomach Via
5 Acid reflex:
1 = GI & very vascular peristalsis
2 = esophagus & 20-30 cm water pressure to overcome
3 = Smooth muscular tube
Enters through thoracic inlet & Exits through esophageal hiatus of diaphragm
4 = Moves food & liquid toward stomach through peristalsis
5 = gastroesophageal reflux disease GERD, Acid pH 1
ICS: given by number of rib directly above it
Thorax divided by anatomical imaginary lines:
= given by number of rib directly above it
= Posterior, Mid, & anterior auxiliary, axillary fossa (armpit)
Midclavicular, Mid scapular, posterior median line
Lung Anatomy:
lung Lobes:
Lung Lobes Fn:
divisions of bronchi till alveoli:
= both same size/Vol, Bronchi further divide into bronchioles & terminate in the alveoli
= RL 3Upper, mid, lower/ LL 2: Upper & lower (cardiac notch)
= “covid containment rooms to stop spread”
= 22 divisions of bronchi till alveoli
pleura:
Viscera & Parietal:
Flail chest can only:
Usually when vent a conscious PT:
= reduce friction 5-10mL w/ surface tension pleura fluid (teaspoon5mL), Major reason for negative pressure
= Viscera outer lung tissue Parietal has nerves
= only ventilate not respirate (Usually only time PPV conscious PT) Paradoxical only w/ flail segments
1 Mediastinum:
2 Houses:
3 Heart Base & apex:
4 highleighm: = where everything important is in&out
5 Diaphragm is connects to
6 Sinus arrhythmia most common: using diag too much
Liver & spleen
7 Backdelect: is weakest part of diaphragm at point of L ventricle
8 Diaphragm rupture auscultation:
1= medium/middle of thoracic/middle of body/chest
2= Heart, Great vessels, Trachea, Esophagus, Vagus nerve, Phrenic nerve, Thoracic duct
3= Base 2nd ICS & apex 5th ICS
4= where everything important is in&out
5=thorax, Liver & spleen
6= using diaphragm too much
7= weakest part of diaphragm at point of L ventricle
8= L side “blop blop blop” abdominal-thorax ruptured diaphragm
Cardiac contusion lacks pump
Heart Anatomy:
Coronary arteries fill during:
% of Pericardial tamp/s:
= in mediastinum} receives blood supply via coronary arteries
= diastole} blood drains fron aorta & coronary art valve open
= 97% from penetrating trauma but can be from blunt
Great/Large arteries & vein that enter and leave heart:
Aorta
Pulmonary arteries
Pulmonary veins
= Aorta & Pulmonic veins & arteries
=Superior and inferior vena cava
=Pulmonary arteries
=Pulmonary veins
1 Chest Wall Injuries:
2 Rib Fractures Occur at:
3 Rib fracture S/S:
4 Ribs most & least commonly fractured:
1= Rib fractures, Sternal fracture/dislocation, flail chest
2= weakest rib flexion from impact point or border
3= Not breathing, hypovent +chance of pneumonia
4= 4-8 most common & Most inferior least common 11&12
Diaphragm:
Chest wall muscles:
= Domelike, M. sheet inhale down inflating, exhale relaxes up
Separates abdominal cavity from thoracic cavity
= ICM} Scalene(neck M) 1-2 rib verta Sternocleidomastoid M.s (SCM)
A. Blast Injuries:
B. Causes tissue disruption by:
C. Particularly damaging to:
D. 1st Phase (Primary):
E. 2nd Phase (Secondary):
F. 3rd Phase (Tertiary):
G. 4th Phase (Quaternary):
A= Explosive chem reaction; creates P-wave traveling outward from explosion’s epicenter.
B= compression & decompression thus inflate then pop
C= hollow, air-filled structures LUNGS
D= Pressure wave hits PT & Hollow organs LUNGS
E= Flying debris can become missiles that produce injuries
F= Victim becomes a missile & can be thrown into other object or the ground
G= other injuries that PT recieves EX tree falls, radiation
1 Blunt Trauma “deadly dozen” Injuries:
2 Crush injuries:
3 Traumatic asphyxia:
4 Deceleration injuries:
= Injury resulting from kinetic energy transmitted through tissues} Blast, Crush, Deceleration, Traumatic asphyxia
= Direct injury or disruption of the chest wall, diaphragm, heart, or tracheobronchial tree.
= Trauma “kinks” heart & blood goes to head
= myocardium Rupture , great vessels, lungs, trachea, and bronchi.
Paper bag syndrome
Chest Trauma “Deadly Injuries”:
Airway Obstruction
Flail Chest
Open Pneumothorax (gas exchange)
Massive Hemothorax (blood loss)
Tension Pneumothorax (air prob
Cardiac Tamponade
Myocardial Contusion
Aortic Dissection
Trachea or Bronchial Tree Injury
Diaphragmatic tears ( ABDMN up into L thorax)
Pulmonary Contusion
Blast injuries
Sternal Fracture or Dislocation:
Pneumomediastinum:
= Blunt anterior chest trauma, Sternal fracture = severe impact thus +Mortality due to underlying blunt cardiac injury
= air around heart impedes heart
1 Flail Chest:
2 Chest segment relation w/ vent/ & RR:
3 Initial assessment:
4 S/S
1= 3 or > adjacent ribs fractured in 2 or > places (can be more) Severe underlying pulmonary injury Paradoxical breathing
2= Chest segment becomes free to move w/ - respiratory pressure change, Not +P. breathers so vent/ing not resp/s
3= M. spasms & moving chest norm/ but when run out of ATP then M. give up w/ paradoxical swing then non-perfusable
4= Tachypneic, Paradoxical chest Mnt, hypoxia,
Flail Chest Book Treatment book tape chest
Best Rx
Akers Treatmeant:
= tape pad over chest…
= PPV} -pressure now + so vent for PT
= Assist ventilations if needed, Consider CPAP (monitor), Load-and-go, Monitor for: Pulmonary contusion, Hemothorax, Pneumothorax (bad compliance: = bagging is easy w/o back force/ resistance)
1 Open Pneumothorax:
2 S/S:
3 What causes sucking chest sound:
4 Chest hole minimum to become sucking:
5 Sucking chest wound Rx:
6 Treatment:
1= Penetrating chest injury Leads to free air passage between atmosphere & pleural space, Air compresses lung tissue
2= chest trauma, Chest pain w/ inhale, Dyspnea, Dim/ lung sounds ipsilaterally, Sucking chest wound, Hemoptysis
3= Air Mnt into & out of hole causes “sucking” sound
4= Hole ¾ inch minimal to suck Sucking chest wound
5= Exit wound bigger 4 sided in back 3 anterior
6= GLOVE 1st, Oxygen therapy, 3-Sided Occlusive Dressing, Standard ALS care
Simple Pneumothorax:
Etiology:
Air amount w/ symptomology:
Cause:
S/S:
= Air inbetween lungs pleuras} AKA closed pneumothorax
= Marfran syndrome increased chance & w/ bleps
= 20-50% usually symptom]usually fixes self & unnoticed
= Lung tissue injured, air leaks into pleural space.
= Trauma to chest, Chest pain on inspiration, Dyspnea, Diminished breath sounds on the affected side
1 Tension Pneumothorax:
2 S/S:
3 Decompressing:
4 Treatment:
1= Open/simple pneumo/ that gen/s & keeps P. > than atmospheric P., Pushes against unaffected side, (R-atria compression)
2= Severe dyspnea, >preload, Absent lung sounds on ipsilaterally, Cyanosis, +JVD at 45degree angle, HypoBP, TachyC, Subcutaneous emphysema, Hyperresonance or dull ipsilaterally, tracheal deviation
3= Anterior 2nd ICS best, 5th ICS lateral mid axillary
3way stop-cock, finger of glove, hamleick valve,
4= PT needs an immediate needle decompression or digital thoracostomy, Assist vent/s as needed with a BVM
Hemothorax:
Associated w/ & Often accompanies:
Decompress if:
S/S:
Percussion & Lung sound
Treatment:
= Accumulation of blood in pleural space from internal hemorrhage, Blood loss problem
= rib fractures, blunt or penetrating MOI & pneumothorax
= ABSOLUTE needed or blood is hanging
= Dyspnea, Diminished lungs sounds on ipsilateral side, S/Sx of shock, No JVD!!!!!, Dull “thud” percussive sounds over site of collecting blood
= Dull “thud” percussion & dim/absent sounds w/ site of collecting blood
= Shock Rx, permissive IV therapy, Monitor for: Tension Hemopneumothorax (blood go down & can disperse)
Pulmonary Contusion:
Spalding Effect:
= Soft tissue contusion or bruise to the lung
= Small, flame-shaped disruption areas throughout membrane leading to microhemorrhage & edema.
Pneumomediastinum:
S/S:
= abnormal air in mediastinum, air escaping & surrounding pericardium pushing R-Atrium
= Chest pain, dyspnea, subcutaneous emphysema
Cardiac Contusion:
Pain progression degrades:
Can through into:
= Contusion affects R-atrium & ventricle, Disrupts muscle cells, May reduce cardiac contractile strength & CO
= Preload, SV, CO, perfusion
= dysrhythmia (amio, lid, pro) EKG: can show as MI
Commotio Cordis:
Treatment:
= Cardiac arrest by direct blow to chest, Induces V-Fib, Occurs during relative refractory period
= High quality CPR & quick defib/ 200J adults (kids 2J/kg, 4J/kg)
Pericardial Tamponade:
Pericardial sac starts impeding majorly:
S/S:
Treatment:
= pericardial sac filling causes pump failing, w/ 90%
= 120/5-150mL for major impeding
= Beck’s Triad, Kussmaul’s Sign, Pulsus Paradoxus, Electrical & Pulsus alternans:
= shock Rx, Permissive IV therapy, Monitor & fix dysrhythmias, Monitor for: HT, PT, Transport ASAP for pericardiocentesis
Myocardial Aneurysm:
After injury:
= “heart explodes” Extreme blunt thoracic trauma, Can affect heart’s chambers, septums, valves & support structures.
= Necrosis dev/s 2 weeks after injury, weakens myocardium
Aortic Dissection:
Survivability:
Fixation points:
S/S:
= A fixation point (Ligamentum) dissects a aorta
= Extremely life threatening w/ <min
= Ligamentum Arteriosum, Pericardial Ligaments (Aorta roots), Median Arcuate Ligament (Diaphragmatic)
=Pulsus deficit (R-hand pink/left cold blue), Severe tearing chest pain w/ ripping pain radiating to back, HypoBP, TachyC
Traumatic Asphyxia:
MOI/ caused by:
S/Sx :
= Reverse blood flow from right heart into superior vena cava into venous vessels of upper extremities
= Severe compressive force applied to chest
= Petechiae, Subconjunctival hemorrhages, Stagnating blood above compression point, purplish color face, eye protrusion or anterior chamber blood rupture
Dislocated Clavicle:
Anterior vs Posterior
Anterior dislocation:
Posterior dislocation:
Posterior Dislocation Rx:
= Dislocated medial head
= P. can kill you, A. is fine usually
= creates noticeable deformity
= displaces head pressing trachea (uncommon)
= (pain>sedate) 1. Lay PT down (Rq sig/ force)2. Rotate out 3. pull arm out
Diaphragmatic Rupture:
S/S:
Rx:
= Perforation & herniation most frequently on left side
= Scaphoid abdomen, similar to TPt: dyspnea, hypoxia, hypotension, JVD
= Rapid detection, elevate postion/PT’s torso, Try to decrease the use of a BVM, Early ET intubation! Put incline position
Traumatic rupture or perforation of diaphragm:
Most frequently occurs on what side:
S/S:
= High-energy blunt & penetrating trauma to diaphragm
= left side
= Scaphoid abdomen & similar to TPt: dyspnea, hypoxia, hypotension, JVD
Tracheobronchial Injury:
Approaching Intubating:
Mortality of the injury:
S/S:
= Blunt/penetrating injury Trachea going into bronchi gap
= drop ET right there! if trouble go into a bronchis
= 50% die w/in hour or so of injury
= Resp distress w/ cyanosis, hemoptysis, massive subcutaneous emphysema, PneumoT & possible TP
Traumatic Esophageal Rupture might need:
Traumatic Esophageal Rupture Mortality
= 3-4 younkers (Rare blunt trauma complication)
= greater if not diagnosed and treated promptly
PT Chest Assessment) 3 phases of chest exam:
= Chest wall, Pulmonary, Cardiovascular assessment
Partial pluera=
Visceral pluera=
Many nerve ending
No nerve endings
chemoreceptors=
in the carotid bodies and in the arch of the aorta. These chemoreceptors are stimulated by decreased PaO2, increased PaCO2, and decreased pH
Inspiratory reserve volume (IRV)=
maximum amount of air that can be inhaled after a normal inspiration.
Expiratory reserve volume (ERV)=
maximum amount of air that can be exhaled after a normal expiration.
Residual Volume (RV)=
amount of air remaining in the lungs at the end of maximal expiration
Functional residual capacity (FRC)=
volume of gas that remains in the lungs at the end of normal expiration
Tension pneumo only crushes
Right atrium
Erb’s point @:
&means:
= 3rd ICS L-sternal border.
= heart murmurs can be heard more distinctly.
Percussion sounds:
Tympany sound:
Hyperresonance sound:
Resonance sound:
Dull sound:
Flat sound:
= tone’s resonance/lack of indicates if region is filled w/ air, air under pressure, fluid, or normal tissue
= “drumlike” , loud intensity, High pitched, Medium duration, located in stomach “teeter-totter”
= “Booming” ,loud intensity, Low pitched, long duration, located in Hyperinflated-Lung “Hums of mongolian”
= “Hallow” , loud intensity, low pitched, long duration, located in a normal lung “Ringing tornado”
= “thud” , Medium intensity, medium pitched, medium duration, in solid organs “Dumb down-syndrome”
= “Extremely dull” , Soft intensity, High pitched, short duration, in muscle & atelectasis “fly flying by”
What does Boyle’s Law state?
When/how does Boyle’s law apply in EMS?
What does Henry’s Law state?
When/how does Henry’s law apply in EMS?
= Vol/ of gas is inversely proportional to pressure of it (more pressure less volume)
= BVM Ventilations to PT
= amount of a dissolved gas in given amount of fluid is directly proportional to amount of pressure on top of that gas
=supplemental oxygen therapy
What does Charles’s Law state?
When/how does Charle’s law apply in EMS?
What is Gay-Lussac’s Law?
When/how does it apply in EMS?
=At a constant temp/, the volume of a gas is directly proportional to gas temp
= Ensuring oxy/ cylinders & other gas containers are stored at appropriate temp/s to maintain consistent gas delivery.
=As you heat gas, the pressure is going to go up.
=Gas Storage: gas containers stored @ stable temp/s to avoid pressure changes & PT Care: Recognize PT hyper/hypothermic conditions might altered resp/circulatory from changes in gas pressures w/in body
What is Dalton’s Law?
When/how does it apply in EMS?
=Total pressure of a mixture of gases = the sum of the partial pressure of the individual gases.
=Resp/ Gas Exchange: how partial pressures of oxygen & CO2 affect diffusion across the alveolar-capillary membrane.
& Hyperbaric Oxygen Therapy: Utilizing increased partial pressure of oxy/ to treat conditions like carbon monoxide poisoning by displacing CO from hemoglobin.
Site for pneumo decompression:
needs:
Never go under a rib b/c:
Locating decompression site:
Digital thoracostomy:
= Anterior 2nd ICS midclavicular/3rd rib & b/c air is always up/rising
= At least 3in catheter, attach 1way valve: Could use 3way valve, glove,
= vascular; have major thoracic arteries & nerves
= palp/ then slide over 3rd rib
= 1-2in incision between 4th & 5th ICS, ( “cut finger tube” )
Breakdown of muscle fibers & the release of muscle fiber contents into circulation is called:
Rhabdomyolysis
The mediastinum is a:
Union between xiphoid process & sternum body:
Organs w/in & not thoracic cavity:
Pulmonary arteries enter & pulmonary veins exit is:
= area of vital organs & vessels
= Xiphisternal joint
= great vessels, esophagus, lungs / Diaphragm
= Pulmonary hilum
The fibrous 2 layered sac surrounding heart:
The pericardial space typically contains:
= Pericardium
= 25 to 50 mL’s of straw colored fluid
Most commonly fractured ribs:
11th & 12th ribs often termed what & why:
= 4th through 8th
= “floating ribs” b/c they have no anterior attachment
Percussion sound w/ a Hemothorax:
S/S of a hemothorax include:
A sign not seen with Hemothorax’s:
= Dull percussive sounds (Indirect ICS)
= hypotension, muffled/absent lung sounds, Dull percussion
= JVD
Quicker S/S of a tension pneumothorax are:
Late S/S of a tension pneumothorax are:
Primary dif/ between a simple & tension pneumothorax:
= hypotension, muffled/absent lung sounds
= Tracheal deviation & JVD
= TP gen/s & keeps a pressure > than atmospheric pressure w/in the thorax
Cardiac tamponade most commonly occurs:
Blood or other fluid in pericardial sac is called:
> than 10SBP drop during inspiration is:
= as a result of penetrating trauma
= Pericardial tamponade
= Pulsus paradoxus
The only initial evidence of a chest injury may be:
Vol of air entering or leaving the lungs w/ each breath is:
Management of the chest injury patient focuses on:
During rapid trauma assess/ of thoracic injury, you should:
= An area of erythema
= Tidal volume
= Ensuring a patent airway & adequate oxygenation
= Auscultate lung sounds
PPV of a tension pneumo can do what:
Positive-pressure ventilation may increase a tension pneumo
Occlusive dressing secured on 3 sides is for:
Paradoxical chest wall motion is seen w/:
PTs w/ Paradoxical chest vent/ vs rr
= A sucking chest
= Flail chest
= cant ventilate myself but isn’t perfusing
Thoracic trauma 2 major categories by mechanisms that are:
Deceleration injuries occur when:
Most obvious indicator of a chest injury is:
= Blunt and penetrating
= the body is in motion & Impacts a fixed object
= the mechanism of injury
Traumatic asphyxia is typically caused by:
A PT w/ Traumatic asphyxia would present w/:
= a crush injury
= deep red, purple, or blue skin; petechiae; & subconjunctival hemorrhage
Sternal bone structures:
Manubrium, Sternal body, Xiphoid process
Do you need to RSI/med conscious PT for intubation
NO! don’t need to medicate to save airway
Kussmaul’s sign
inhale +inthoracic Pressure pushes & JVD on inhale, Exhale decreases pressure reliefing JVD
Pulsus Paradoxus
drop SBP 10 or more in inhale (Manual BP Heart beat sounds inhale goes away)
Electrical alternans: amplitude alternating goes w/ Pulsus alternans
!Pulsus alternans:
pericardiocentesis (sub xiphoid)
Hammond’s Crunch Crunch or rasping sound heard over the precordium
Crunch crack over erb’s point w/ each heart beat (4ICS midclavicular) rapid ascending dividers (every 33ft 2000 sea lvl,
Boyles law: +Pressure= -Vol
Benz: henry’s law}
Severe dyspnea gauged by
words speaking “1-2word tachypneia”
