Vol.4-Ch.7 "Chest Trauma"

Question 1

How many total pairs of ribs are there?

Which ribs are the floating ribs?

Which ribs do not have direct cartilage connections (indirect), and what ribs cartilage do they join into?

Answer 1

12 total pairs

11&12 are floating (no cartilage connection)

8-10 have indirect cartilage connections because their cartilage connects to 7’s cartilage

Question 2

What are the 3 sections of the sternum? (top to bottom)

Answer 2

• manubrium (only 1st rib attaches)
• body
• xiphoid process

Question 3

What is the angle of louis and why is it important?

Answer 3

it is the joint between the manubrium and body parts of the sternum meet and has a palpable bony projection that indicates where the 2nd rib connects, so it is an important land mark for pleural decompressions

Question 4

What intercostals can the diaphragm extend to on max expiration?

Answer 4

from the 4th intercostal space anteriorly and the 6th posteriorly (it lays at an angle)

Question 5

What are the 3 main muscle groups of respiration and how do they play their part?

Answer 5

• Sternocleidomastoid muscle: pulls on first rib which effectively makes the following 9 ribs pull up
• Intercostal muscles: contract to further elevate the ribs to increase the anterior-posterior dimensions
• Diaphragm: contracts and flattens to increase overall thoracic volume

Question 6

Exhalation is mostly _____ and is aided by ____ ____ of the lungs musculature.

Answer 6

passive ; elastic recoil

*gravity also plays a role

Question 7

What is the bellows effect?

Answer 7

changing of volume to move air in and out

Question 8

What is the cough reflex?

Answer 8

a respiratory reflex that induces a cough to help keep the airways clear and the alveioli expanded

Question 9

How does increased or decreased intrathoracic volume effect blood flow to the heart and thorax?

How does it effect blood pressure and pulse?

Answer 9

In inspiration (so high volume and low pressure) it decreases (pulls) blood going to the thorax and heart; it also makes blood pressure and pulse strength fall slightly

In expiration (so low volume and high pressure) it increases (pushes) blood to the thorax and heart; it also makes BP and pulse strength raise slightly

Question 10

What is the name of the region where the trachea splits into 2 mainstem bronchi?

Answer 10

The Carina

Question 11

What is the importance of the Pulmonary Hilum? (4)

Answer 11

• it is where the mainstem bronchi enter the lungs
• it is the sole point of fixation for the lungs to the thoracic cage
• it is where the pulmonary arteries and veins enter and exit the lungs
• it is where the visceral pleura folds over on itself and becomes the parietal pleura

Question 12

What is the thin layer of membrane surrounding the lungs and what is the layer on the thoracic cavity?

What is the fluid that separates the two?

Answer 12

The visceral pleura is on the lungs, it then folds over on itself at the pulmonary Hilum to become the parietal pleura.

The serous (pleural) fluid separates the two

Question 13

What is the thin layer of membrane surrounding and protecting the heart?

What are the 2 levels of this layer called?

Answer 13

Overall it is called the PERICARDIUM; but similar to the lungs it has a lining on the surface of the heart called the VISCERAL PERICARIUM or EPICARDIUM which folds back on itself at the root of the great vessels and then becomes the PARIETAL PERICARDIUM. And between these two layers is the SERIOUS PERICARDIUM

Question 14

What is the fibrous pericardium and if blood spilled under this layer what does it create?

Answer 14

It is a tough fibrous sac that surrounds the pericardium and resists distention. It function is to hold the heart in place and prevent the great vessels from kinking but if blood spills below it, it resists distention (unlike the pericardium) and can cause pericardial tamponade

Question 15

What vessels create the Great Vessels?

Answer 15

• Aorta
• Superior/Inferior Vena Cava
• Pulmonary arteries/veins

Question 16

What is particularly harmful to the kidneys that gets released in things like a crush injury or rhabdomyolysis?

Answer 16

Myoglobin (which stores O2 for usage in muscles)

Question 17

What are the 3 places where the aorta is fixed to the thoracic cavity and therefore subject to rupture from shearing forces (commonly caused by rapid deceleration)?

Answer 17

• the Annulus (where it leaves the heart)
• the Ligamentum Arteriosum (near the bifuraction of the pulmonary artery
• the Aortic Hiatus (where is passes through the diaphragm and goes into the abdomen)

Question 18

How can a persons health or age effect their response to chest trauma?

Answer 18

Pediatrics have more limber cartilage and tend to have less rib fractures, but this causes more energy to be transferred to the organs beneath causing increased likelihood of internal trauma

Geriatrics have a more calcified and brittle skeleton which causes an increase likelihood of rib fracture but decreased chance of internal injury

Question 19

What are the 3 different classes of penetrating chest trauma?

Answer 19

• Low Energy (knives, arrows, small handguns; do mostly direct trauma, i.e. don’t cause cavitation)
• High Energy (military, hunting rifles, etc; cause direct and indirect trauma through cavitation wounds)
• Shotgun damage (have 3 types)

Question 20

What are the 3 types of shotgun wounds?

Answer 20

Type 1: Pt is more that 7 meters from gun shot; pellets usually only make it up to the subcutaneous tissue layer, with the exception of buck shot rounds

Type 2: Pt is 3-7 meters from gun shot; causes deep tissue penetration with chance of organ damage

Type 3: Pt is less than 3 meters from gun shot; causes massive tissue damage and is life threatening

Question 21

How do the lungs vs great vessels/heart handle penetrating wounds differently? (in regards to high energy)

Answer 21

The lungs may handle a high energy impact well because they are spongy and can absorb and diffuse any cavitating energy

The heart and vessels (especially when filled with blood) may take more damage because the blood (a fluid) disperses energy more rapidly causing increased likelihood of rupturing

Question 22

What is a chest wall contusion?

What are your likely signs and symptoms, as well as things to watch out for?

How may different age groups react differently?

Answer 22

• It is injury to the soft tissue covering the thoracic cage.
• It will most likely result in ERYTHEMA or ECCHYMOSIS, sometimes in the shape of the trauma object. It may cause PAIN ON INSPIRATION because the damaged tissue is trapped between the ribs and the surface (exacerbated if the ribs are also damaged), and this pain on inspiration may lead to HYPOVENTILATION
• ADULTS usually have higher respiratory reserves and can adapt the the hypoventilation well. PEDIATRICS have more limber cartilage and bones and may not have much pain. However, GERIATRICS are most at risk because of they lower respiratory reserves and pre-existing conditions making them more at risk if hypoventilation occurs

Question 23

Ribs can fracture at the point of impact, along the objects borders, but mostly at their weakest point which is what?

Answer 23

At their posterior angle (along the posterior axillary line)

Question 24

What changes with impact to the rib sections:
+ 1-3
+4-8
+9-12

Answer 24

+ 1-3: are hard to fracture b/c they are protected by shoulder, scapula, and heavy musculature of upper chest. Therefore, if these are fractured, it usually means that there is going to be severe intrathoracic injuries as well

+4-8: most commonly fractured b/c they are less protected and firmly fixed at both end to the spine and sternum

+9-12: are not firmly attached to the sternum and therefore can move more making them less likely to fracture; however, this also means they transmit more energy to the organs beneath and are commonly related to splenic or hepatic injuries

Question 25

What is atelectasis?

What are 2 common sign/symptoms?

Answer 25

Alveoli collapse
Often the alveoli have collapsed or filled with fluid (fluid in the alveoli can also increase chances of infection of the lung called pneumonia); and often results in hypoventilation and hypoxia from reduced surface area for gas exchange.

Adults and geriatrics may use the Sigh Reflex or geriatrics may grunt; both are an attempt to increase positive end-expiratory pressure (PEEP) to limit atelectasis by keeping the alveoli open

Question 26

The clavicle can dislocated what 2 ways from the sternum?

Which is more dangerous?

Answer 26

Anteriorly (causing a noticeable deformity) or posteriorly (causing a deep void)

Posterior is worse b/c it can damage the great vessels or compress/injure the trachea (compression of the trachea will be noticeable through stridor or voice change)

Question 27

What is a flail chest?

What can help a flail chest pt tremendously; adversely what will this aid increase the risk of?

Answer 27

A flail chest is when tremendous energy manages to break a segment of 3 or more consecutive ribs in 2 or more places

Positive Pressure Ventilation can reverse paradoxical chest movement, restore tidal volume, and reduce chest wall pain while breathing. It does this by creating constant increased pressure in the lungs that keeps the flail segment moving with the chest wall.

HOWEVER, this positive pressure ventilation can be dangerous if other injuries exist and can cause a pneumothorax as well as decrease blood return to the vena cava b/c the vena cava usually gets increase flow in bursts when the pressure of the thoracic cavity decreases during expiration (PPV maintains a high pressure thoracic cavity)

Question 28

Why might paradoxical movement of a flail chest be hidden and then increase over time?

Answer 28

The intercostal muscles may spasm and effective make a natural splint for the flail segment, but over time the muscles will fatigue and the movement will become more pronounced

Question 29

What is a closed pneumothorax (simple pneumothorax)?

Other than the obvious dyspnea, pain on inspiration, and diminished breath sounds, what other signs/symptoms might you see?

Answer 29

It is when trauma has caused a hole in the lungs to leak air into the pleural cavity, and as it increases it causes the associated lung to collapse under the increased pleural cavity pressure

Other than dyspnea, pain on inspiration, and diminished breath sounds this can also cause ACIDOSIS (b/c the blood is being shunted passed the collapsed alveoli, skipping gas exchange; also called VENTILATION/PERFUSION MISMATCH) and HYPERINFLATION (this is done via the medulla that responds to the increased CO2 by sending signals to increase resp rate and volume)

Question 30

What is considered a small vs large pneumothorax?

Answer 30

small = less than 15%; may be hard to distinguish and may even heal itself with minimal assistance

large = 15% or more and usually involves aggressive O2 therapy and chest tube placement (or pleural decompression)

Question 31

What is an open pneumothorax?

Answer 31

When there is a hole in the chest wall, that allows air to be sucked into the pleural space, from the atmosphere, on inspiration

This is called a SUCKING CHEST wound b/c it sucks air into the pleural space on inspiration and pushes it out on expiration

Question 32

How big must the chest wound size be in order for air to be sucked in?

Answer 32

The unimpeded size of the chest wall opening must be at least 2/3rds the size of the trachea; and the trachea is typically the size of the pts little finger

Question 33

What is a tension pneumothorax?

Answer 33

It is caused by and open or closed (simple) pneumothorax that has created a one way valve. This one way valve allows for air to enter on respiration (low pressure) but on expiration (increased pressure) it closes the wound, blocking the air from escaping

Question 34

What is the relative order of effects of a tension pneumothorax?

Answer 34

• trauma causes one way valve (increasing pressure over time)
• increased intrapleural pressure collapses lung, causes intercostal & suprasternal bulging, hyperresonant to percussion, limited to absent lung sounds, ventilation/perfusion mismatch
• mediastinum shifts to uninjured side causing atelectasis of uninjured lung and vena cava crimping; causes dull percussion and decreased breath sounds on uninjured lung
• vena cava crimping causes JVD and narrowing pulse pressure; atelectasis of uninjured lung causes increased dyspnea, ventilation/perfusion mismatch, and systematic hypoxia

** Tracheal deviation can sometimes occur more often in young pts with a more mobile mediastinum

• The resulting severe hypoxia will cause cyanosis, diaphoresis, and AMS

Question 35

How must a tension pneumothorax be treated?

Answer 35

It must be converted into an open pneumothorax via pleural decompression with a “burping mechanism”

Question 36

What is a hemothorax?

Answer 36

It is bleeding into the pleural space. It can be minor but if a bigger vessel is involved it usually results in a hemopneumothorax (pneumothorax created from blood in the pleural space)

***this often results in the signs and symptoms of a tension pneumothorax, shock, and dull percussive sounds over site of collecting blood

Question 37

What is a pulmonary contusion?

Answer 37

It is soft tissue damage or bruising of a lung; in order for trauma to reach a lunch it must go through the chest wall so there is often chest wall injuries or fractured ribs

Question 38

What are the 2 specific types of injuries that can cause energy transfer to pulmonary tissue and result in pulmonary contusions?

Answer 38

• deceleration

- pressure wave from high velocity bullet or explosion

Question 39

What might cause edema in the chest when talking about pulmonary contusion?

Answer 39

If blood is leaked onto the pulmonary tissue due to traumatic damage of the soft tissue, it may irritate the tissue and initiate an inflammatory response.

The increased permeability and shift of fluids to the interstitial space (out of intercellular) caused by the inflammatory response can lead to increased fluid in the lungs

Question 40

Edema of the lungs will cause what 3 things?

Answer 40

• decreases the rate at which respiratory gases can exchange across the alveoli/capillary membranes
• the fluid stiffens the membrane, making the lungs less compliant and increasing respiratory effort
• increases the needed pressure to push blood across the pulmonary capillary bed, increasing the work of the right side of the heart

Question 41

What is a blunt cardiac injury, what is most commonly injured?

Answer 41

It is commonly when there is severe blunt anterior chest trauma and the heart gets thrown against the anterior chest wall and then gets compressed by the sternum and thoracic spine causing a contusion.
This may cause muscle cell/muscle fiber damage, hemorrhaging, edema, effect conductivity and lead to a wide array of larger issues

This will most likely affect the right atrium and ventricle as they sit the most anterior

Question 42

What is one thing to check quickly for blunt cardiac trauma?

Answer 42

Check for any heart arrhythmias, the symptoms of blunt cardiac trauma may be similar to a myocardial infarction

Question 43

What is Commotio Cordis?

Answer 43

It is the rare instant where a seemingly modest direct chest blow can actually cause the heart to go into immediate ventricular fibrillation (most common in young athletes)

Question 44

What is pericardial tamponade? What is most often the cause?

Answer 44

It is a restriction of cardiac filling do to blood pooling in the pericardial sac

Most often caused by low velocity wounds such as stabbings and low energy weapons

Question 45

What are the steps of progression for pericadial tamponade?

Answer 45

• it begins with a tearing in a superficial coronary artery or penetration of the myocardium by an object
• blood then fills the pericardial space, and starts to squeeze the heart inward b/c the surrounding fibrous pericardium does not stretch
• it first effects the right ventricle, decreasing flow through the pulmonary arteries, this in turn slows blood return to the heart causing JVD
• over time, the end result is systemic hypotension and a narrowing pulse pressure
• the pressure exerted on the heart also restricts blood flow of the coronary arteries to the myocardium, eventually resulting in ischemia and myocardial infarction

Question 46

Where is the precordium?

Answer 46

central lower chest

Question 47

What are some different signs and symptom groupings that indicate pericardial tamponade?4

Answer 47

• Beck’s triad: JVD, distant heart tones, hypotension
• Kussmaul’s sign: decrease or absent JVD on inspiration (on inspiration it decreases intrathoracic pressure, allowing for more venous blood return in the thoracic cavity)
• Pulsus Paradoxus: an abnormaly large decrease in systolic blood pressure during inspiration (more than 10mmHg in drop)
• Electrical Alternans: rarely seen but in very severe cases it is a cardiac rhythm strip that decreases the p, QRS, & T wave with every cardiac cycle (even more severe is if it gives a rhythm without a pule [pulseless electrical activity or PEA])

Question 48

What is a myocardial aneurysm?

Answer 48

It is a rupture of the myocardium anywhere in the heart, and is the result of almost exclusively severe blunt thoracic trauma.
The signs and symptoms often differ based on location of rupture (can be in any of the heart chambers, interatrial septum, interventricular septum, or the valves and their supporting structures)

Question 49

Where are the three most likely points where the aorta would rupture or dissect?

Which aorta is more likely to be affected?

What layers of the aorta are typically torn apart?

Answer 49

1) where the aorta joins the heart (aortic annulus)
2) where the aorta joins the ligamentum arteriosum (aortic isthmus)
3) where it exits the chest (diaphragm)
- Most commonly affects the descending aorta
- Typically the interior surface (tunica intima) is torn from the muscular layer (tunica media)

Question 50

Which is faster and more severe, an aortic rupture or an aortic dissection?

Answer 50

An aortic rupture is much faster and more severe, although a dissection is always very close to becoming a rupture

Question 51

What side of the diaphragm is usually perforated or herniation occurance?

Answer 51

the left side; the liver protects the right side and its large size makes it hard to herniate unless the tear is large

Question 52

What are typical signs and symptoms of a diaphragmatic rupture?

Other than bowel strangulation or necrosis, ipsilateral lung restriction, what else can occur from this?

Answer 52

they are similar to a tension pneumothorax; dyspnea, hypoxia, hypotension, and JVD

Mediastinum displacement (causing the similar symptoms to a tension pneumothorax); this happens when the displaced abdominal contents push pressure on the lung and mediastinum moving them to the contralateral side

Question 53

What is the main concern with a rupture of the esophagus?

Answer 53

the spilling of its contents into the mediastinum, causing infection or chemical irritation

Question 54

What is traumatic asphyxia?

Answer 54

It is actually a cardiovascular problem where a crushing weight pushes blood from the right heart to go backwards through the vena cava and the rest of the system, engorging the veins of the head and neck

This will cause a severe discoloration of the head and neck, swelling of the face, subconjunctival hemorrhaging, possible small strokes, accumulation of toxins and acids in blood, and ultimately result in hypovolemia, hypotension, and shock

Question 55

What are 5 important things should you do during you rapid trauma assessment (secondary assessment) especially for chest injuries?

Answer 55

• observe
• question
• palpate
• auscultate
• percuss

Question 56

If the pts systolic BP drops below _____ start giving 250-500ml fluid boluses

Answer 56

80mmHg; once you start giving fluids though, do so slowly and intermittently as giving too much can increase fluid loss and edema. Try to keep BP at or below 80, and auscultate for lungs sounds, discontinuing fluids immediately if you hear crackles or dyspnea increases

Question 57

For rib fracturs, what can be done for pain management?

Answer 57

Pain management can be given via morphine sulfate, fentanyl, or meperidine so long as the Pt is hemodynamically stable, no associated head or abdominal injury, and the Pt is fully conscious and oriented

Question 58

What drug should NOT be used if a pneumothorax or tension pneumothorax is suspected because they can make them worse

Answer 58

Nitrous oxide

Question 59

What is one way you can help a pt with a sternoclavicular dislocation, specifically a posterior one? (supportive therapy is usually all that is needed, unless other injury is indicated)

Answer 59

you can lay the pt supine and put a sand bag between their shoulder blades to help push the clavicle anteriorly and off the trachea

Question 60

What are treatment options for a flail chest?

Answer 60

• place pt on unijured side
• place bulky dressing and bandaging over flail segment
• Positive pressure ventilations w/ high flow O2

Question 61

Treatment options for a open pneumothorax?

Answer 61

• high flow O2
• three sided occlusive dressing, such as an Asherman Chest seal or sterile plastic wrap

**complications can still arise even after the Pt may do better and then get worse; if pt dyspnea increases, hypoventilation and hypoxia, decreased breath sounds, increased JVD then remove the dressing and if this does not help then prepare to treat as a tension pneumothorax with pleural decompresion

Question 62

What are your main signs and symptoms that confirm a tension pneumothorax?
What is going to be your treatment?

Answer 62

Look for one by auscultating the lung sounds for diminished breath sounds, percussing for hyperresonance, severe dyspnea, chest hyperinflation, and JVD

Give O2 with bag or intubation, then give pleural decompression in 2 intercostal space(just over the third rib or you may hit the arteries or nerves that pass under the ribs) midaxillary, (more than one may need ot be placed and you can put another in the 3rd or 4th intercostal spaces)

**Avoid fluid therapy as this can worsen effects of edema in the lungs, only give if the pt remains hypotensive and indicates internal bleeding, but even still give slowly

Question 63

What might you consider giving a PT who has been entrapped for more than 20 minutes with pressure applied to his chest?

Answer 63

Sodium Bicabonate at 1mEq/kg to combat the acidotic fluid that may rush to the heart and kidneys after the pressure is lifted. Consider giving before or as pressure is lifted