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National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Chapter 23
Thoracic Trauma
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Objectives
23.1 List the major anatomical structures of the thoracic cavity.
23.2 Describe the basic physiology of thoracic structures.
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Objectives
23.3 Describe the pathology of the following thoracic injuries:
a. flail chest
b. pneumothorax
c. hemothorax
d. tension pneumothorax
e. sucking chest wound
f. pericardial tamponade
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Objectives
23.4 List the signs and symptoms of various thoracic injuries.
23.5 Describe and demonstrate how to assess the chest for trauma, using the L.A.P. method.
23.6 Describe and demonstrate the emergency management of a sucking chest wound.
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Topics
Anatomy and Physiology of the Chest Chest Injuries Assessment Management Chapter Summary
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Case Presentation
A snowboarder enters the half pipe and slams into the rail on the top deck and slides down the wall. When you arrive the patient is sitting up, complaining of difficulty breathing, but resisting attempts to maintain manual spinal stabilization.
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Anatomy and Physiologyof the Chest
Thorax: Protected by bony structures Two major organs:
◦ Lungs (trachea, and esophagus)• Aveoli, capillary nets• Pleuras: visceral and parietal
◦Heart and great vessels• Pericardium
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Anatomy and Physiologyof the Chest
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Anatomy and Physiologyof the Chest
Diaphragm is the primary muscle of respiration◦Controlled by two phrenic nerves located
at C3, C4, and C5◦ Assisted by intercostals
Breathing process ◦ Lungs fill and empty due to pressure
changes within the chest as muscles contract and relax
◦Gas exchanges in aveoli
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Chest Injuries
Closed◦ Blunt trauma◦ Fall or collision
Open◦ Penetration of chest◦ Compression
Indirect Inertia
◦ Deceleration
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Types of Chest Injuries
Contusions Fractures and dislocations Flail chest Pnuemothorax/ Hemothorax Pericardial tamponade Aortic tear or rupture Commotio cordis Traumatic asphyxia
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Contusions
External from minor blunt trauma Pulmonary = lung tissue bruise
◦ Fluid/blood in alveoli compromise gas exchange, leads to hypoxia
◦Occurs often with rib fractures Myocardial = heart bruise
◦ Less effective contractions◦ Arrhythmia◦Cardiogenic shock
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Contusions
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Fractures and Dislocations
Suspect internal damage Painful – self splinted often Rib
◦May lacerate lung tissues Flail chest
◦ Two or more ribs/fractures◦ Paradoxical motion◦Hypoxia continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Fractures and Dislocations
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Fractures and Dislocations
Scapula◦ Severe trauma◦ Serious internal injury
Sternum◦ Severe underlying organ damage◦ Severe trauma – entire flail segment
Sternoclavicular joint◦ Posterior dislocation puts pressure on
the great vessels to the heart
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Pneumothorax
Air in the pleural space◦ Trauma (blunt or penetrating)◦ Spontaneous◦Compressive forces
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Pneumothorax
Penetrating wounds create differential pressure◦ Sucking chest wound◦Collapsed lung possible
Blow to chest may cause lung to burst
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Tension Pneumothorax
Pressurized air in pleural space◦ From burst or punctured lung
Organs are compressed, lungs may collapse
Vena cava may collapse Life threatening Rescue breathing (BVM) may cause
or make worse continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Tension Pneumothorax
May occur spontaneously – no trauma
Signs and Symptoms◦ Shortness of breath◦ Jugular vein distention (JVD)◦ Low BP◦Cyanosis ◦Decreased lung sounds◦ Tracheal deviation (late sign)
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Tension Pneumothorax
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Tension Pneumothorax
Subcutaneous emphysema◦ Air under the skin – Rice Krispies®
crackling
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Hemothorax
Blood in pleural space ◦ Blunt or penetrating injury
Arterial bleeding leads to hypovolemic shock
Hemopneumothorax = blood and air in pleural space◦Multi-system trauma◦ Life threatening
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Hemothorax
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Pericardial Tamponade
Bleeding/fluid inside the pericardial sac◦ Blunt or penetrating trauma◦Rupture of a cardiac vessel◦ Bacterial sepsis, viral infection
Pressure on heart impairs function
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Pericardial Tamponade
Pain, shortness of breath, neck vein distention are early signs and symptoms
Muffled heart sounds, drop in pulse pressure come later
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Pericardial Tamponade
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Aortic Rupture and Dissection
Often lethal Deceleration/inertia injury Massive bleeding/hypovolemic
shock and death Partial thickness tear may lead to
aneurysm, later rupture Signs and symptoms are acute
chest or back pain, signs of profound shock
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Aortic Rupture and Dissection
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Commotio Cordis
Sudden cardiac death due to blunt thoracic trauma that interrupts the electrical activity of the heart, usually following a direct blow to the chest
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Traumatic Asphyxia
Pressure on chest wall prevents expansion
Compressive injury as from avalanche
Massive rib cage fractures where chest is unable to expand
Ruptured blood vessels in face, neck, and eyes causing discolorations
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Traumatic Asphyxia
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Environmental Factors
Altitude can complicate thoracic injuries
Descent in elevation is necessary Helicopter evacuation may be contra-
indicated with thoracic injuries
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Case Update
You maintain cervical spine stabilization while you assess the patient. The airway is open, there is no external bleeding, circulation to all extremities is normal, and his mental status is normal He has moderate difficulty breathing and pain at the rib cage. He has shallow respirations at 28 per minute even after receiving oxygen. His pulse is 102 BPM.
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Assessment
Standard assessment procedures to start – ABCDs and vitals
Observe skin color and neck veins Look for self-splinting If breathing is a major concern,
suspend secondary exam and transport
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Assessment
Use L. A. P. method Monitor through ongoing assessment
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Management
Sever symptoms - “Load and go” Do CPR, use AED Open airway of avalanche victim ASAP High flow oxygen, assist ventilations
◦Worsening condition here = tension pneumothorax
• L —Look• A —Auscultate• P —Palpate continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Management
Use occlusive dressing with sucking chest wound
Spinal involvement needs backboard Control bleeding in usual manner Splint flail segments Consider patient comfort with O2,
BVM Leave impaled objects in place
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Management
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Management
Match transport position to patient’s breathing needs
Treat/position for shock
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Case Disposition
You immobilize the patient’s spine on a long spine board, load him into a toboggan transport him to the first-aid room. His pulse has increased to 114, the blood pressure is 100/70, and the respiratory rate is 28 on high-flow oxygen. You show the paramedics a large bruise on the upper chest wall that extends beneath the patient’s armpit. The patient is transported by air.
National Ski Patrol, Outdoor Emergency Care, 5th Ed.©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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Chapter Summary
Both blunt and penetrating chest injuries can be life threatening.
Maintain a high index of suspicion for chest injury based on the mechanism of injury.
Assess the entire chest, including the upper back and armpits. Provide oxygen to any patient with a suspected chest injury.
continued