Chapter 23 Thoracic Injuries

Introduction

• Thoracic trauma accounts for a significant amount of injuries and fatalities annually– Approximately 700,000 emergency department visits– Over 18,000 deaths

• You are dispatched to a call involving a gunshot victim. You are told he was trying to rob the liquor store and the clerk shot him with a .32-caliber handgun.

• When you arrive, things are very quiet and still around the store. You see no obvious dangers, and the scene seems safe. However, police are still on the scene, two inside the store and two walking around the parking lot and front of the store.

– Since you were dispatched to that scene, should you assume that it is safe to enter?

Anatomy (1 of 2)

• Thorax: a bony cage consisting of the following structures:– 12 pairs of ribs– Scapula– Clavicle– Sternum– Thoracic vertebrae

Anatomy (2 of 2)

Sternum

• Sternum: composed of three sections called the manubrium, body, and xyphoid process

• Suprasternal notch: just superior to the manubrium• Angle of Louis: junction of the manubrium

and sternal body

Rib Anatomy

• Each of the 12 ribs attach posteriorly to the 12 vertebrae

• Intercostal space: area located between the ribs• Neurovascular bundle: artery, vein, and nerve

located in the intercostal space

Mediastinum

• Located within the central region of the thorax• Contains heart, great vessels, esophagus, trachea,

mainstem bronchi, and vagus and phrenic nerves

Pericardium

• The heart is located within the pericardial sac.• The pericardial sac consists of two layers: visceral

and parietal.• There is a potential for blood or fluid to become

trapped between these layers.

Aorta

• The largest artery in the human body• It exits the left ventricle, and attaches at three

points: anulus, ligamentum arteriosum, and aortic hiatus.

• These points represent sites of potential injury.

Lungs

• Occupy most of the space in the thoracic cavity• Lined with two pleural membranes• Small amount of fluid found between parietal

and visceral membranes

Respirations (1 of 2)

• The diaphragm is the principle muscle of respiration.• Intercostal muscles work in conjunction with the

diaphragm.• The thoracic cavity increases in size when the

muscles contract.

Respirations (2 of 2)

Physiology

• The process of breathing includes delivery of oxygen and removal of carbon dioxide.

• Gas exchange occurs at alveoli.

Respiratory Stimulus

• Stimulation to breathe occurs via chemoreceptors located in the carotid sinus and aortic arch.

• When CO2 level increases, the brain is stimulated to increase respiratory rate and depth and “blow off” CO2.

Inspiration

• The diaphragm contracts and moves downward while the intercostals contract and move outward.

• Intrathoracic pressure decreases resulting in air entering the thoracic cavity.

Expiration

• The diaphragm relaxes and moves upward while the chest wall relaxes.

• Intrathoracic pressure increases above atmospheric pressure.

• Air leaves the body.

Oxygenation and Ventilation

• Oxygenation is the delivery of oxygen from the air to the blood.

• Oxygen binds with hemoglobin.• Ventilation is the removal of carbon dioxide from the

body to the atmosphere.

Cardiac Output

• Proper cardiac output is required to ensure adequate tissue perfusion.

• Cardiac output is the volume of blood delivered in one minute.

• Cardiac output is equal to heart rate times stroke volume.

• When the scene is declared safe, you go in to find a man lying on the floor. He is bleeding heavily. Upon closer inspection, you can see that he has been shot twice—once in the upper chest, about an inch below his right clavicle, and once in the abdomen, slightly up and to the left of his belly button.

• You note that the patient is pale; has cool, clammy skin; and is breathing rapidly but shallowly. The majority of the bleeding is coming from the wound in his abdomen. The one in his chest is bleeding only slightly. He tries to be combative and uncooperative, but he is weak and seems to be very confused.

– When assessing the patient’s injuries, what possible

(or probable) life-threatening problems are you facing?– How would you quickly and efficiently find out if any

life-threatening conditions do exist for this patient?

(continued)

Thoracic Injuries

• Thoracic injuries risk serious airway, respiratory, and circulatory compromise for your patient.

• Aggressive identification and management of injuries is required.

Flail Chest (1 of 2)

• Major chest wall injury from blunt force trauma• Two or more adjacent ribs fractured in two or more

places• Creates a “free-floating” segment that impairs chest

wall motion

Flail Chest (2 of 2)

Rib Fractures

• Most common thoracic injury• Patient often “self-splints,” leading to inadequate

ventilation and atelectasis• Consider underlying injuries

Sternal Fractures

• 1 out of 4 patients with this injury will die.• Patient will complain of anterior chest pain.• Look for deformity, flail sternum, and ECG changes.

Simple Pneumothorax (1 of 2)

• Presentation depends upon size of pneumothorax.• Small pneumothorax may cause only mild dyspnea

and pleuritic chest pain.• Breath sounds may be diminished.

Simple Pneumothorax (2 of 2)

• Large pneumothorax will produce increased respiratory compromise:– Absent breath sounds– Hypoxia– AMS– Tachycardia– Cyanosis

Open Pneumothorax (1 of 2)

• Occurs when a defect in the chest wall allows air to enter the thoracic space

• Results from penetrating chest trauma• Air is drawn into the pleural space.• Collapse of lung results in mismatch between

ventilation and perfusion.

Open Pneumothorax (2 of 2)

Tension Pneumothorax (1 of 3)

• Life-threatening condition that results from continued air accumulation within the intrapleural space

• May occur from open thoracic injury, blunt trauma, barotrauma, or shearing forces

Tension Pneumothorax (2 of 3)

• Injury to the lung can cause a one-way valve to develop.

• Air enters pleural space.

• Air exerts increasing pressure.

Tension Pneumothorax (3 of 3)

• Classic signs include:– Increased dyspnea– Absent breath sounds on affected side– Tachycardia– JVD (late sign)– Tracheal deviation (late sign)

Massive Hemothorax (1 of 2)

• Occurs when blood begins to fill the potential space between the parietal and visceral pleura

• Occurs in approximately 25% of chest trauma patients

• Each lung can hold up to 3,000 mL of blood.

Massive Hemothorax (2 of 2)

• Condition will result in both ventilatory compromise and circulatory collapse.

• There are several physical findings that help differentiate between tension pneumothorax and hemothorax.

Pulmonary Contusion (1 of 2)

• Caused by compression of lung tissue against chest wall

• Alveolar and capillary damage results• Results in reduced delivery of oxygen across

the alveolar-capillary membrane

Pulmonary Contusion (2 of 2)

• Patient may have hemoptysis.

• Look for signs of overlying injury, such as crepitus, tenderness, or contusions.

Pericardial Tamponade (1 of 3)

• Excessive fluid in the pericardial sac causing compression of the heart

• May be caused by blunt or penetrating injury

Pericardial Tamponade (2 of 3)

• In medical conditions, inflammation leads to fluid collection.

• As the pericardium fills, the atria and vena cavae become compressed.

• Preload is therefore reduced, which reduces stroke volume.

Pericardial Tamponade (3 of 3)

• Beck’s triad is a classic combination:– Muffled heart tones– Hypotension– JVD

• Patient appears in shock with signs and symptoms similar to tension pneumothorax.

Myocardial Contusion (1 of 2)

• Blunt cardiac injury caused by the heart colliding with the sternum

• Leads to local tissue contusion, hemorrhage, edema, and cellular damage

• May lead to dysrhythmias

Myocardial Contusion (2 of 2)

• Patient complains of sharp, retrosternal chest pain.• Soft-tissue injury may be present.• Lung sounds may reveal crackles.• ECG changes may occur.

Myocardial Rupture

• Acute perforation of the ventricles, atria, septum, chordae, muscles, or valves

• Caused by severe blunt force compression• Life-threatening condition that accounts for 15%

of fatal chest injuries

Commotio Cordis

• Immediate cardiac arrest caused by blunt trauma during the heart’s repolarization period

• Patient appears in ventricular fibrillation, which responds well to defibrillation if performed quickly.

Vascular Injuries (1 of 2)

• Injury to the thoracic aorta accounts for one in every five blunt trauma deaths.

• Caused by transection or dissection • Aorta is sheared at its fixed points.• Most patients die before EMS arrives.

Vascular Injuries (2 of 2)

• Patient may complain of pain behind sternum.• Patient may also show signs and symptoms

of hypoperfusion.

Diaphragmatic Injuries (1 of 2)

• May be due to blunt or penetrating trauma• The most serious injury is diaphragmatic herniation.• Abdominal organs enter the thoracic cavity, causing

a tension gastrothorax.

Diaphragmatic Injuries (2 of 2)

• May be identified by bowel sounds in the chest cavity

• Absence of breath sounds on affected side

Esophageal Injuries

• Rapidly fatal injury• Associated with other significant injuries especially

tracheal injuries• Patient may have subcutaneous emphysema.• There is no prehospital treatment.

Tracheobronchial Injuries

• Rare injuries normally caused by penetrating trauma• Have a high mortality rate• May lead to a tension pneumothorax• Be prepared to decompress the patient as needed.

Traumatic Asphyxia (1 of 2)

• Caused by the sudden and forceful compression of the thoracic cavity

• Causes pressure to be translated into the veins of the head, neck, and kidneys

• Pressure in capillary beds results in their rupture.

Traumatic Asphyxia (2 of 2)

• Dramatic findings on patient– Cyanosis of head and upper extremities– Subconjunctival hematoma– Exophthalmos– Tongue and lips may be swollen

• You do not find exit wounds from either bullet upon examination. The patient’s blood pressure is 104/62. Heart rate is 24 bpm and irregular. O2 saturation is 87% on room air. He has diminished breath sounds on the upper right section of his lungs, where a bullet penetrated. Radial pulses are palpable, but not strong.

• You and your partner work quickly to address the life-threatening injuries that are most likely in this case. You take vitals a second time before going out to the ambulance: there is no radial pulse, his heart rate is very irregular and fast (tachycardia), and he is taking short, shallow breaths at a rate of 28 breaths per minute. His blood pressure is now 78/46. Instead of being confused, the patient is close to losing consciousness.

– Given the second set of vitals and the injury sustained, what

is most likely happening inside your patient’s body?– What should you be prepared to do quickly if your findings

suggest a life-threatening condition such as tension pneumothorax?

(continued)

Scene Size-up

• Is the scene safe to enter?• Do you have the proper BSI?• How many patients are there?• Has triage been performed?• Do you need additional resources?

Initial Assessment

• Mental status: Assess the patient’s LOC while maintaining C-spine.

• Airway: Consider the MOI when determining the possibility of airway compromise.

• Airway obstruction may be due to the tongue, blood, or broken teeth.

Signs of Airway Compromise

• Stridor• Hoarseness• Gurgling• Snoring• Signs of hypoxia• AMS• Tachypnea• Coughing• Hemoptysis• Accessory muscle usage• Retractions

Airway Management

• If a patient has signs of airway compromise, it must be controlled immediately.

• Use jaw-thrust in all trauma patients.• Suction, use airway adjuncts, or use advanced

airway management skills as necessary.

Breathing (1 of 2)

• Identify and manage any impairment of the patient’s oxygenation and ventilation.

• Expose the thoracic cavity.• Palpate, percuss, inspect, and auscultate.• Note the rate and quality of respirations.

Breathing (2 of 2)

Circulation (1 of 2)

• AMS is the first sign of hypoperfusion.• Assess pulses to determine rate, quality,

and rhythm.• Tachycardia may be caused by shock or other

causes.• The absence of tachycardia does not exclude

hypovolemia.

Circulation (2 of 2)

• “Weak and thready” suggests hypovolemia.• Irregular pulse suggests hypoxia of the myocardium.• Blood pressure is only a clinical guide in managing

a shock patient.

Jugular Venous Distension

• Must be measured

at a 45º angle• Cannot be

determined when the patient is immobilized

• Lack suggests hypovolemia

Heart Auscultation

• Listening for heart sounds is difficult, but crucial.• Muffled heart sounds may indicate tension

pneumothorax or pericardial tamponade.

Focused History and Physical Exam

• Due to patient’s condition, this may need to be done en route to the hospital.

• Obtain a complete set of vital signs.• Obtain a SAMPLE history.• Question the events surrounding the incident

and the MOI.

Detailed Physical Exam

• Complete a head to toe exam on your patient.• Identify any missed injuries and reassess injuries

already noted.• Pay particular attention to injuries affecting the

ABCs.

Ongoing Assessment

• Any patient with suspected chest trauma should be considered unstable and reassessed every five minutes.

• Check vital signs, ABCs, oxygenation, and lung sounds.

• Maintain a high degree of suspicion for the “deadly dozen.”

General Management

• Focus on the maintaining an airway, ensuring oxygenation and ventilation, providing circulatory support, and rapid transport.

• Use jaw thrust to maintain airway.

Airway Management

• If you suspect a possible tracheal injury, reconsider intubation unless absolutely necessary.

• Intubation may worsen the injury and lead to a completely unmanageable airway.

Ventilation

• When ventilating patients with possible lung trauma, ventilate gently.

• Watch closely for patient’s chest rise.• If too much force is used, a simple pneumothorax

may be converted into a tension pneumothorax.

Circulatory Support

• If a patient is showing signs of circulatory compromise, provide supportive care.

• Establish IV access and administer fluids as needed.

Golden Hour

• Remember that surgery is the definitive care required for a patient who has suffered a thoracic injury.

• Scene times should be kept to 10 minutes.• Rapidly transport patient to a trauma center.

• Your patient is confused, weak, and worsening rather quickly.

– When you try to get a patient history in this particular case, is it important to doggedly push to find out what medications he is on, what he may be allergic to, when he ate last, and other questions normally asked during the SAMPLE history?

– If time does not permit given the severity of the patient’s injuries, what other way might you be able to get important information regarding your patient? What must you be careful to do if the information comes from a source other than the patient himself?

(continued)

Flail Chest Management (1 of 2)

• Signs and symptoms– Paradoxical motion– Dyspnea– Chest pain

• Underlying pulmonary contusion common with flail segment

Flail Chest Management (2 of 2)

• Life-threatening emergency• Stabilize immediately with bulky dressing during

exhalation.• Control airway and assist ventilations as needed.

Rib Fracture Management

• Assessment is key.• Signs and symptoms

– Hypoxia, hypercarbia, and pain• Threat to breathing• External stabilization is no longer recommended.• Supportive care

Sternal Fracture Management

• Pain in anterior chest• Risk of myocardial contusion• Supportive treatment only

Simple Pneumothorax

• Treatment begins with ABCs.• Deliver high-concentration oxygen.• The most critical intervention is repeat assessments

to ensure tension pneumothorax is not developing.

Open Pneumothorax Management (1 of 2)

• Determine if a “sucking chest wound” exists.

• Sucking chest wounds must be treated immediately.

Open Pneumothorax Management (2 of 2)

• Cover open pneumothorax with occlusive dressing secured on three sides.

• Place patient on high-flow oxygen.• Intubation may be required if ventilation is

inadequate.

Tension Pneumothorax

• Patient complains of pleuritic chest pain

and dyspnea.• High-flow supplemental oxygen

Skill Drill 23-1 Needle Decompression (1 of 2)

Step 2

Step 4Step 3

Step 1

Skill Drill 23-1 Needle Decompression (2 of 2)

Step 6

Step 8Step 7

Step 5

Massive Hemothorax Management (1 of 2)

• Significant findings– Lack of JVD– Lack of tracheal deviation– Hemoptysis– Dull to percussion

Massive Hemothorax Management (2 of 2)

• Management is supportive care of ABCs• High-flow oxygen• Two large-bore IVs• Treat for shock.

Pulmonary Contusion Management

• Hemoptysis• Airway management• Edema may exacerbate the injury.• Supportive care

Pericardial Tamponade Management

• Beck’s triad• Treatment consists of

– Ensuring adequate oxygenation– Giving IV fluids– Transporting rapidly to trauma center

• Surgery is definitive care.

Myocardial Contusion Management

• Abnormal ECG• Coronary artery injury• Care consists of ABCs and frequent reassessment

of vital signs.• Monitor cardiac rhythm and establish IV.• Consult with medical direction.

Myocardial Rupture Management

• Patient may present with acute pulmonary edema or signs of cardiac tamponade.

• Give patient supportive care. • Rapid transport to a trauma center

Vascular Injury Management

• Maintain a high index of suspicion based

upon the mechanism of injury.• Provide supportive care.• Establish two large-bore IVs.• Do not use PASG.• Transport to trauma center.

Diaphragmatic Injury Management

• Diagnosis improbable in the field• Acute phase• Obstructive phase• Maintain adequate oxygenation• Rapid transport

Esophageal Injury Management

• Pleuritic chest pain may be present.• Subcutaneous emphysema• No prehospital therapy

Tracheobronchial Injuries Management

• Physical findings may include– Respiratory distress– Hoarseness– Hemoptysis

• Do not intubate unless it is absolutely necessary.• Be sure to bag gently and slowly.

Traumatic Asphyxia Management

• Implies a fatal outcome• Maintain C-spine on all patients.• Intubate as necessary.• Provide high-flow oxygen.• Two large-bore IVs• Transport to a trauma center.

• Once the life threats to your patient have been addressed and treated, you should concentrate on packaging the patient and getting him to a trauma center as quickly as possible. When you arrive at the emergency department, having radioed in the condition of the patient before arrival, they are ready to begin immediate work on your patient.

• A chest tube is put in almost immediately. Emergency surgery is performed to fix the internal injuries to his lung, liver, and small intestine. After 4 days in ICU, he is moved to a room to recover from his injuries. Your quick thinking and efficient response saved his life. Criminal charges will be pressed by officials when he is recovered enough.

Summary

Summary

• Anatomy and physiology• Pathophysiology• General assessment and management• Managing specific injuries