LO4 Thoracic Trauma (Chapter 8) Flashcards
Chest wall is composed of
skin, subcutaneous tissue, muscle, ribs and the neurovascular bundle
The neurovascular bundle
runs around the lower border of the rib this is an important anatomical feature for needle decompression
The structures within the chest above the diaphragm include
the lungs, lower trachea and mainstem bronchi, the heart and great vessels, and the esophagus
The adult thoracic cavity can hold up to – of blood on each side
3L
The visceral pleura vs parietal pleura
The visceral pleura overlies the lungs directly whereas the parietal pleura makes up the inner lining of the chest wall
The mediastinum includes
the heart, the owner and the pulmonary artery, superior and inferior vena cava, trachea, major bronchi in the esophagus
Diaphragm
thin sheet of muscle has its origin on the lower six ribs and the xiphoid process of the sternum its main function is respiration and is innervated by the phrenic nerve which begins at the cervical level C3 to C5
Spinal cord injury below the fifth cervical vertebrae
spinal cord injury above the third cervical vertebrae
Spinal cord injury below the fifth cervical vertebrae Will cause paralysis from the neck down yet allow the victim to continue to breathe using the diaphragm only
spinal cord injury above the third cervical vertebrae will not allow patient to breathe
Blunt trauma
is the result of rapid deceleration, shearing forces and crush injuries
Penetrating trauma
injuries are unpredictable
Injuries to the organs within the thoracic cavity may result in
decreased oxygenation and massive haemorrhage both of which can lead to tissue hypoxia and death
Tissue hypoxia can result from the following chest injuries:
In adequate oxygen delivery to the tissues secondary to airway obstruction
Hypovolaemia from blood loss
Ventilation/perfusion mismatch from lung injury
Compromise of ventilation and or circulation from a tension pneumothorax
Pump failure from severe myocardial injury or pericardial Tampaonade
The signs of chest injury found upon inspection include:
chest wall contusion open wounds subcutaneous emphysema hemoptysis distened neck veins tracheal deviation asymmetrical chest movement cyanosis shock TIC
Life threatening thoracic injuries found on Primary Survey
Airway obstruction Flail chest Open pneumothorax Massive hemothorax Tension pneumothorax Cardiac tamponade
Thoracic injuries found during secondary survey or in hospital
Myocardial contusion Traumatic aortic rupture Tracheal or bronchial tree injury Diaphragmatic tears Pulmonary contusion Blast injuries
Airway obstruction
Hypoxia secondary to airway obstruction is a common cause of preventable trauma death
Flail chest
Occurs with the fracture of two or more adjacent ribs in two or more places causing instability of the chest wall and paradoxical movement of the flail segment in spontaneously breathing patient
The unstable section of the ribs will suck in when the patient breathes in and will push out when the patient breaths out
Positive pressure ventilation reverses the movement of the flail segment
Flail chest patients usually develop a pulmonary contusion
Signs and symptoms of flail chest
LOC: Often unconscious
Airway: Possible snoring or gurgling
Breathing: Apneic or shallow and guarded, often no tidal volume
Circulation: rapid/thready
Skin: cool, clammy, cyanotic
Neck veins flat
Trachea: midline
Chest: asymmetrical with paradoxical motion
Breath sounds: usually decreased on affected side
Abdomen: pain of broken ribs may mask tenderness
Flail Chest Treatment/Management
Analgesia is an important component
Large flails are best treated with endotracheal intubation and assisted ventilation with PEEP
Be alert for development of tension pneumothorax if CPAP is used
- Ensure open airway
- Assist ventilation if inadequate
- Administer highflow oxygen
- Load and go
- Notify medical direction early
- Consider intubation early to provide PEEP
- Pain relief
- If shock present use care to prevent fluid overload
Open pneumothorax
An open pneumothorax or a sucking chest wound remains open to the atmosphere
The open wound equalizers intrathoracic pressure and atmospheric pressure is resulting in a partial or complete lung collapse
Normal ventilation involves the creation of negative intrathoracic pressure by diaphragmatic contraction to draw air into the airways and lungs
Open pneumothorax Signs and symptoms
LOC: possible decreased
Airway: Possible gurgling
Breathing: rapid and shallow possibly labored , often poor or no tidal volume
Circulation: rapid/thready
Skin: cool, clammy, cyanotic
Neck veins flat
Trachea: midline
Chest: asymmetrical with penetration(s)
Breath sounds: decreased on affected side
Abdomen: where did the penetrating object go
Open pneumothorax Management/Treatment
- Insure an open airway
- Administer high flow oxygen assist ventilation as necessary
- Initially seal the wound with your gloved hand then place a commercial chest seal over the defect
- Load and go
- Insert a large bore IV on route to the hospital
- Monitor the heart and the heart tones for comparison later
- Monitor oxygen saturation with a pulse oximeter and CO2
- Notify medical direction early
Massive hemothorax
Massive haemothorax occurs as a result of at least 1000 mL of blood loss into the plural space within the thoracic cavity
More common after penetrating trauma than to blood trauma but either injury may distract a major pulmonary or systemic vessel
The patient may be hypotensive from blood loss
Massive hemothorax Signs and symptoms
LOC: decreased
Breathing: rapid shallow labored
Circulation: weak/thready, absent radials
Skin: cool, clammy, diaphoretic; pale/ashen
Neck veins flat
Trachea: midline
Breath sounds: decreased or absent on affected side
Treatment/Management of Massive Hemothorax
- Secure and open airway
- High flow o2
- Load and go
- Notify medical direction eaely
- Treat for shock
a) Replace volume carefully
b) Try to keep blood pressure high enough for perfusion target 80-90 systolic
c) Elevating blood pressure will increase bleeding into chest consider TXA - Observe for tension hemopneumothorax
Tension pneumothorax
Tension pneumothorax Air continues to accumulate without means of exit resulting in an increase in intrathoracic pressure on the affected side displacing the heart and trachea to the opposite side and collapsing the superior and inferior vena cava occluding venous return to the heart
The development of decreased lung compliance in the intubated patient should always alert you to the possibility of a tension pneumothorax
Tension pneumothorax Signs and symptoms
LOC: decreased
Airway: open?
Breathing: rapid shallow labored
Circulation: weak/thready, absent radials
Skin: cool, clammy, cyanotic
Neck vein distention
Trachea: possible deviation
Breath sounds: absent or decreased on affected side
Treatment/management of tension pneumothorax
- Establish an open airway
- Minister high flow oxygen
- Decompress the affected side if indicated:
- -Expiratory distress with or without cyanosis
- -Loss of the radial pulse
- -Decreasing level of consciousness - Load and go
- Rapidly transport to appropriate hospital
- Notify medical direction early
Pericardial tamponade
the rapid collection of blood between the heart and pericardium from a cardiac injury
Accumulating blood compresses the ventricles of the heart preventing the ventricles from filling between contractions and causing cardiac output to fall
The major differential diagnosis in the field is tension pneumothorax
Cardiac tamponade: Patient will be in shock with equal breath sounds and a midline trachea
Pulsus paradoxus
radial pulse is not felt during inspiration
Cardiac tamponade s/s
LOC: decreased
Breathing: rapid shallow l
Circulation: weak/thready, absent radials- possible paradoxical pulses
Skin: cool, clammy, diaphoretic
Neck veins distended
Trachea: midline
Chest: sternal contusion or fracture?
Penetrating chest wound?
Breath sounds: usually present and equal
Heart sounds: muffled
Treatment/management of cardiac tamponade
- Ensure open airway
- Administer high flow 02
- Load and go
- Monitor heat early
- Treat for shock: IV en route but only give enough fluid to maintain perfusion
- 12 lead
- Treat dysrhythmias as they present
- Watch for hemothorax and pneumothorax
- Pericardiocentesis
Myocardial contusion
A potentially lethal lesion that is the result of a blunt chest injury
This bruising of the heart is similar injury to the heart as an acute myocardial infarction and presents with chest pain, dysrhythmias
May develop overtime
Should be suspected if the patient complains of chest pain has an otherwise unexplained irregular pulse and exhibits JVD especially in the presence of blunt force trauma to the anterior chest
Myocardial contusion Signs and symptoms
LOC: decreased
Breathing: rapid shallow l
Circulation: weak/thready, absent radials- possible paradoxical pulses
Skin: cool, clammy, diaphoretic
Neck veins distended
Trachea: midline
Chest: sternal contusion or fracture?
Penetrating chest wound?
Breath sounds: usually present and equal
Heart sounds: muffled
Treatment/management of cardiac contusion
- Ensure open airway
- Administer high flow 02
- Load and go
- Apply cardiac monitor
- 12 lead
- Treat for shock: IV en route but only give enough fluid to maintain perfusion
- Treat dysrhythmias as they present
- Watch for hemothorax and pneumothorax
Traumatic aortic rupture
Traumatic aortic rupture is a tear in the wall of the aorta
80% die at scene
Should be suspected in patients with a blunt mechanism associated with rapid deceleration such as falls and high speed MVC
There may be no symptoms or the patient may complain of chest pain or scapular pain
Be suspicious if the patient has asymmetrical blood pressures in upper extremities or upper extremity hypertension, widen pulse pressure and diminished lower extremity pulses
Treatment/management of Aortic tear
- Ensure open airway
- Administer high flow 02
- Rapidly transport to hospital
- Control external hemorrhage
- IV fluid but limited
- Monitor heart
- 12 lead
- Notify medical direction early
Diaphragmatic tears
Tears in the diaphragm may result from a severe blow to the abdomen a sudden increase in entropy abdominal pressure may tear the diaphragm
Herniation of the abdominal organs into the thoracic cavity occurs more commonly on the left then the right because the liver protects the right
Bowel sounds may be heard when the chest is auscultated
The abdomen may appear sunken if quantity of abdominal contents are in the chest
Treatment/ management of diaphragmic tear
- Ensure open airway
- Assist ventilation
- Administer o2
- Treat for shock IV fluid
MOI by explosion is due to five factors
primary secondary tertiary quarternary quinary
Primary
initial air blast is caused solely by the direct effect of blast over pressure on tissue
Almost always affects air filled structures such as the lungs, ears and gastrointestinal tract
There may be pulmonary contusions, pneumothorax, tension pneumothorax or arterial gas embolus
Secondary
the patient is struck by material propelled by the blast force these are penetrating injuries
Tertiary
patient’s body is thrown by the pressure and impacts the ground or another object this is classic blunt force trauma these injuries include crush injury
Quarternary
can be thermal burns from explosion, radiation radiological material or respiratory injuries from inhalation of toxic dust or fumes
Quinary
reported as hyper inflammatory state caused by chemicals used in making a bomb
Treatment/management of blast injuries
- Safety
- Triage
- Ensure open airway
- High flow 02
a) Positive pressure may worsen or lead to pneumothorax/tension - Load and go
- Manage other injuries
- IV
Impaled objects
Penetrating objects may remain impaled in the chest with the exception of the face/cheek
- Stabilize impaled object
- ensure airway
- insert IV
- transport the patient
- perform 12 lead
traumatic asphyxia
Results from a severe compression injury to the chest
The patient appear similar to those who have been strangulated with sinuses and swelling of the head and neck the tongue and lips are swollen and conjunctival hemorrhage is evident
Indicates the patient has suffered a severe blunt thoracic injury and major thoracic injuries are likely to be present
- Airway maintenance
- IV access
- Treat other injuries
- Rapid transport
Simple pneumothorax
May result from blunt or penetrating trauma is caused by accumulation of air within the potential space between the visceral and parietal the lung may be totally or partially collapsed as Air continues to accrue in the thoracic cavity
Clinical findings include pleuritic chest pain, dyspnea, decreased breath sounds on the affected side
