Chest Injuries

Question 1

Chest injuries

Answer 1

Any injury to the chest can impair breathing and cause hypoxia.

If left untreated chest injuries can cause one or both lungs to collapse, putting pressure on the heart and ultimately leading to cardiac arrest.

If lung collapses, now have a space between the two pleura. Things can then fill this space (e.g air or blood). The more air that gets into the cavity, the more the pressure increases inside the cavity. This squeezes other organs over.

Question 2

Two main categories of chest injuries…

Answer 2

Closed and open chest injuries

Question 3

Closed v open chest injuries

Answer 3

Closed: skin is not broken, but there may be damage to internal organs.
E.g. can happen in a RTC.
Air does not have access through the chest wall (so no hole on the outside)

Open:
Foreign objects can penetrate the chest wall from outside the body
Broken ribs can penetrate the chest wall from inside the body
Air can enter the chest cavity

Question 4

What are the mechanisms for chest injuries

Answer 4

Blunt trauma:
a blow to the chest can fracture ribs
Damage to underlying organs can occur with or without fractured ribs.

Penetrating trauma:
Bullets, knives, pieces of metal, wood or glass can penetrate the wall.

Compression
Is a rapid action
Rapid compression of the chest can occur during a RTC.

Question 5

Impaled objects

Answer 5

Do not remove (could be acting as a plug, stemming the blood)
Handle carefully
Secure the object with a dressing
If pulsating, do not completely immobilise the object, allow it to pulsate.
dont let patient remove it

Question 6

Signs and symptoms of a fracture

Answer 6

Bruising
Swelling
Loss of motor function
Irregularities
Pain
Deformity
Unnatural movement
Crepitus
Tenderness

All these things can be personal and may not show straight away

Question 7

Fractured rib

Answer 7

Exhibit usual sign of a fracture
Identify Mechanism that caused injury and what are likely results of this/ potential injuries.

Pain usually made worse by deep inspiration and coughing
Be aware that the end of a broken rib could pierce and puncture a lung, causing a pneumothorax.

Multiple rib fractures interfere with mechanism of breathing and can create life threatening situations.

Question 8

What is a flail segment

Answer 8

Two or more rib fractures in two or more places.
So we end up with a section that isn’t attached to the rib cage anymore. This is going to get sucked in when we breathe in as diaphragm moves up and out.

Don’t immobilise segment
Efforts to maintain ventilation are important (12-20BPM). Probably breathing faster than normal, so need oxygen as respiration not effective.
Traditionally, the patient has been turned onto the effected side for transport. (If you put on their good side the chest on the good side can’t expand properly)
Consider analgesia
Time critical transport

Question 9

What is a pneumothorax

Answer 9

Air in the potential space between the two pleura. The pocket of air puts pressure on the lung, causing it to collapse.

Tension pneumothorax - more air than space so increase in pressure.

Question 10

Spontaneous pneumothorax

Answer 10

Build up of air in pleural cavity
Small spontaneous rupture in the lung
More common on young men
No trauma that caused this, just spontaneous.

Question 11

Open pneumothorax

Answer 11

Sucking chest wound
To be class as this it needs to have an open wound associated with it.
Draws air into a lung during inspiration and draws air into pleural cavity. So air coming in through two holes.
Forces air out a lung during expiration and pleural cavity. But not all air will be able to come back out the wound.

Question 12

How to help open pneumothorax

Answer 12

Russel chest seal. Cover penetrating chest wound allowing air to escape from pleural cavity without being drawn back in.

Nightingale dressing - para only application for chest injury

Question 13

What is a tension pneumothorax

Answer 13

Life threatening and time critical
Any pneumothorax can lead to a tension pneumothorax
It occurs when air gets into the pleural cavity but cannot escape.

Question 14

How to fix a tension pneumothorax

Answer 14

Needle thoracocentesis (chest decompression paramedic only skill)

Don’t really expect it to work

Question 15

Signs and symptoms of a tension pneumothorax

Answer 15

Hyperinflation on the one side (looks bigger than the other)
Reduced or no movement on that side
Pale
Clammy skin
This might not be an injury in isolation
Struggling to breathe/ respiratory distress
Tachycardia and tachypnoea.
Reducing SPO2.
Hyper resonance on affected side (higher sound) and reduced air sounds.
Distended neck veins
Tracheal deviation (air pressure is now so great it is pushing everything over)t

Question 16

Closely monitor patients with …

To prevent tension pneumothorax

Answer 16

Surgical emphysema
History of blunt or penetrative chest trauma
Use of BVM/ventilation

Question 17

What is a haemothorax

Answer 17

Similar signs and symptoms to a pneumothorax
Blood is chest cavity rather than air.
Affected side is dull on percussion.

Question 18

Difference in sound when listening to chest

Answer 18

Hyporessonance with haemothorax instead of hyper resonance with pneumothorax.

Question 19

What is cardiac tamponade

Answer 19

Usually blood inside potential space between two pericardial layers.
Usually caused by trauma
Can’t do anything about it as paramedics.

Question 20

Trauma breathing assessment

Answer 20

Twelve flaps

T.W.E.L.V.E:
tracheal deviation
wounds - open or sucking and manage them
Emphysema - surgical (bubbling underneath skin can be anywhere)
Laryngeal crepitus ( if you were to touch your larynx, you would hear crepitus (grinding noise)).
Veins - distended neck. (Congestion because of build up in pressure)
Reassess

F.L.A.P.S
Feel - feel across chest to feel for fractures, surgical emphysema
Look - movement in chest, any wounds etc.
Auscultate - listen
Percuss
Check sides and back

Question 21

Trauma assessment auscultation

Answer 21

Three main sides on front chest

4 places on the back

Question 22

General signs and symptoms of chest injuries

Answer 22

Dyspnoea - difficulty breathing 
Panic and anxiety 
Cyanosis 
Haemoptysis - coughing up blood. Would be really red and frothy.
pain
Tachycardia and pnoea 
Assymmetry of chest wall
Extreme respiratory distress
Subcutaneous/ surgical emphysema

Question 23

Management of chest injuries

Answer 23

SMART - safe, mechanism of injury, additional resources you might need, regulations, triage (how many patients have you got)
CAcBCDE - catastrophic bleed, airway, c spine, Breathing, Circulation, Disability, exposure (consent)

Trauma breathing assessment - twelve flaps
High flow oxygen via a trauma mask.

Seal any chest wounds with a chest seal

Analgesia

Look for signs of tension pneumothorax

Request paramedic assistance

Consider trauma tool

Question 24

Consider assisted ventilations if …

Answer 24

Consider assisted ventilations at 12-20BMP if any of the following are Present…

SP02 <90% on high flow 02
Resp rate of <10
Inadequate chest expansion

Question 25

Transporting a conscious patient

Answer 25

Can be transported on a semi recumbent and inclined to the injured side.

Can be transported upright upright and included to injured side.

Question 26

Unconscious patient transport

Answer 26

Transport in recovery position

Injured side lower