Ch.30 Chestinjuries Flashcards
___ is the body’s ability to move air in and out of the chest and lung tissue.
Ventilation
____ is the process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs.
Oxygenation
The ___ (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
Chest
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___. 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.
skeletal muscle
In very young children, the ___are not yet developed. Children therefore tend to breathe with their diaphragm, referred to as belly breathing, which is normal for their age group.
intercostal muscles
Lying on the inferior and slightly posterior part of each rib is the___, composed of a network of nerves,
arteries, and veins. When punctured by fractured ribs, bleeding from these vessels can cause a hemothorax.
neurovascular bundle
Each side of the chest (hemithorax) 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___. 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.
cardiac notch
___ also creates ates surface tension to allow the lungs to adhere to the rib cage, thus allowing the mechanics of ventilation to occur
Pleural fluid
The inner chest wall has a lining called the ___, and a lining called the __ covers the lungs
Parietal pleura
Visceral pleura
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
___, in the middle of the neck, divides into the left and right mainstem bronchi, which supply air to the lungs.
The trachea
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__.
venae 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___, a cavity or space centrally located in the thorax.
mediastinum
At the bottom of the chest, the___ is a muscle that separates the thoracic cavity from the abdominal cavity.
diaphragm
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____, 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 air space to the upper and lower airway.
decreases
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 (FIGURE 30-3). In a normal respiratory system, relaxation of the thoracic muscles and the diaphragm is a relatively___ 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.
passive
Note that the nerves supplying the diaphragm (the phrenic nerves) exit the spinal cord at __, ___, and __.
C3, C4, C5
A patient whose spinal cord us injured below the __ level may lose the power to move the intercostal muscles, but the diaphragm should still be able to contract. The patient wil still be able to breathe because the phrenic nerves remain intact, but the injury may cause belly breathing.
C5
Patients with spinal cord injuries at _ or above can lose their ability to breathe entirely
C3
A patient who sustains a spinal cord injury below the level of___ and is paralyzed can still breathe spontaneously because the phrenic nerves, which cause the diaphragm to contract, originate at the C3, C4, and C5 levels.
C5
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 mL at the normal rate of 12 breaths/min, then the minute volume is 6,000 mL (6 L). If you increase the ventilation rate by four extra breaths per minute, then the minute volume increases to 8,000 mL (8 L). 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/min to make up the difference in the minute volume. Remember that the average bag-mask device consists of a self-inflating bag that contains 1,000 to 1,500 mL of air. This device can quickly overinflate the lungs, causing gastric distention, and impair the function of the lungs. Overventilation can also increase intrathoracic pressure (pressure inside the chest), reducing venous return to the chest and secondarily reducing___. 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.
cardiac output
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____ 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 (FIGURE 30-5). 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.
closed chest injury
Injury or bruising of lung tissue that results in hemorrhage
Pulmonary contusion
A bruise from an injury that causes bleeding beneath the skin without breaking the skin; also see ecchymosis
Contusion
Closed chest injuries usually result from__, such as when a patient strikes the steering wheel or an airbag in a motor vehicle crash, or is struck by a falling object. A closed chest injury can occur even when a seat belt is worn.
blunt trauma
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
An_____ 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 (FIGURE 30-6). 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____ 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.
open chest injury
In blunt 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 ____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 patients’ ability to ventilate on their own.
traumatic rupture of the aorta
If the patient’s oxygen saturation was normal initially and begins to drop rapidly, suspect tension pneumothorax and immediately communicate your suspicions to the team. This life threat must be treated rapidly by a paramedic or physician. Rapid transport or intercept with an advanced life support (ALS) unit is essential.
Street smarts :)
A grating or grinding sensation or sound caused by fractured bone ends or joints rubbing together
Crepitus
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/min without difficulty and without pain. The chest should rise and fall in a symmetric pattern with each breath. Respirations of fewer than 10 breaths/min or of more than 20 breaths/min may indicate inadequate breathing. Patients with chest injuries often have___ (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.
tachypnea
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___ and is typical of chest injuries.
pleuritic pain
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.
_____, 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
Hemoptysis
A rapid, weak pulse and low blood pressure are the principal signs of___, 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 ashen 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.
hypovolemic shock
Be sure to assess the neck before applying the cervical collar.___ cannot be observed after the collar is applied. The presence of____ may indicate tension pneumothorax (significant ongoing air accumulation in the pleural space) or pericardial tamponade, an injury to the heart that results in blood accumulating in the pericardial sac.
Jugular vein distention
Once you have determined the patient has a patent airway, determine whether breathing is present and adequate. With chest injuries, begin by inspecting for DCAP-BTLS, and look for equal expansion of the chest wall. Listen with a stethoscope to each side of the chest. Absent or decreased 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
the nerves that continue nucle hay a the out or a rot in an a th
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 control those muscles. Check for____, 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.
paradoxical motion
If you determine the patient has___, 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 occlude 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 a nonrebreathing mask at 15 L/min. 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 (Spoz) 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 a tension 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
penetrating trauma
An occlusive dressing designed to allow air to escape through the dressing but not be drawn back in
Vented chest seal
An airtight dressing that protects a wound from air and bacteria; a commercial-vented version allows air to passively escape from the chest, while an invented dressing may be made of petroleum jelly-based (Vaseline) gauze, aluminum foil, or plastic
Occlusive dressing
The deadly dozen chest injuries
- Airway obstruction
- Bronchial disruption
- Diaphragmatic tear
- Esophageal injury
- Open pneumothorax
- Tension pneumothorax
- Massive hemothorax
- Flail chest
- Cardiac tamponade
- Thoracic aortic dissection (leakage from a traumatic aneurysm of the portion of the aorta that lies within the chest)
- Myocardial contusion
- Pulmonary contusion
A condition in which two or more adjacent ribs are fractured in two or more places or in association with a fracture of the sternum so that a segment of the chest wall is effectively detached from the rest of the thoracic cage
Flail chest
Compression of the heart as the result of buildup of blood or other fluid in the pericardial sac, leading to decreased cardiac output
Cardiac tamponade
An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound; also referred to as a sucking chest wound
Open pneumothorax
An accumulation of air or gas in the pleural cavity that progressively increases pressure in the chest and that interferes with cardiac function, with potentially fatal results
Tension pneumothorax
Bruising of the heart muscle
Myocardial contusion
Injury or bruising of lung tissue that results in hemorrhage
Pulmonary contusion
In older patients with reduced bone density or more fragile bones, even minor trauma to the chest wall can cause significant injury to the underlying tissues and organs. Older patients may have also sustained several fractures to the rib cage. Be alert for these injuries and for signs and symptoms of respiratory compromise, even in lower-energy MOls. Older patients also have a decreased amount of physiologic reserve and are likely to decompensate more quickly following an injury.
Special populations :)
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 pleural space or blood in the pericardial space, the blood pressure may exhibit a_____ 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.
narrowing pulse pressure
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 __ precautions are needed
PPE
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 ___ (commonly called a collapsed lung). In this condition, air enters through a hole in the chest wall or surface of the lung as the patient attempts to breathe, causing the lung in 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.
Pneumothorax
___ dressings contain a one-way valve, called a flutter valve, that allows air to leave the chest cavity but not return
Vented chest seal dressings
Careful observation is required after placing an___. The occlusive seal or a clot in the injury may allow a tension pneumothorax to develop. If signs of a tension pneumothorax develop, it is suggested that the occlusive dressing be partially removed to allow air to escape and to then be resecured. 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.
occlusive dressing
When a vented chest seal is not available, plastic wrap, foil, or petrolatum gauze can be used for the semiocclusive dressing. If the wound is very large and no suitable material is available, a defibrillation pad sealed on three sides can work as an occlusive dressing. When you use an occlusive dressing to seal an open chest wound, record the type of material used and any changes noted afterward: skin color, vital signs, breath sounds, and particularly the patients level of anxiety.
Words of wisdom :)
Any pneumothorax that does not result in major changes in the patient’s cardiac physiology is referred to as a___. 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; tachypnea 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 a tension 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 a tension 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 ALS 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.
simple pneumothorax
A potential complication that may develop following chest injuries with pneumothorax is a __. This can occur when there is significant ongoing air accumulation in the pleural 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 pleural cavity. This prevents blood from returning through the venae cavae to the heart, decreasing cardiac output, causing shock, and ultimately leading to death
Tension pneumothorax
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 distention, cyanosis, or tracheal deviation, but these signs are not always present. Jugular vein distention is best assessed for with the patient sitting at a 45° angle. Tracheal deviation, if seen, is a late and grave finding and is a sign that the patient requires immediate intervention.
Relieving a tension 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 thoracotomy; however, this procedure typically is performed by ALS personnel or ED staff, depending on local protocols. A tension pneumothorax is a life-threatening condition. Be prepared to support ventilation with high-flow oxygen, and request ALS support or transport immediately to the closest hospital.
Tension pneumothorax
In blunt and penetrating chest injuries, blood can collect in the pleural space from bleeding around the rib cage or from a lung or great vessel. This condition is called a____ (FIGURE 30-13). Suspect a hemothorax 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 prehospital 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 hemopneumothorax. 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.
Hemothorax
The accumulation of blood AND air in the pleural space of the chest
Hemopneumothorax
_____(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 (FIGURE 30-14). 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 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 Beck 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.
Cardiac tamponade
The signs and symptoms, referred to as the__, 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.
Beck triad
___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 MOl.
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 hemopneumothorax.
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 are experiencing any respiratory distress.
Rib fractures
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 (FIGURE 30-15). This condition, known as__, 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, and 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 fläil segment.
flail chest
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 ___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.
pulmonary contusion
Any suspected fracture of the sternum should increase your___ 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.
index of suspicion
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.
Clavicle fractures
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 intrathoracic 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 (FIGURE 30-16). This is called___. 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.
traumatic asphyxia
A pattern of injuries seen after a severe force is applied to the chest, forcing blood from the great vessels back into the head and neck
Traumatic asphyxia
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 prehospital setting, and there is no prehospital 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. Provide supplemental oxygen, and transport immediately.
Blunt myocardial injury
___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 CPR. Commotio cordis is more commonly associated with sports-related injuries, although it 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.
Commotio cordis
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 CPR, 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.
Laceration of the great vessels
