Chapter 23

Chapter 23Chest and Abdominal Trauma

2

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved

Overview

Anatomy Review Chest Trauma Chest Injuries Abdominal Trauma Abdominal Injuries

3


Anatomy Review

Thoracic cavity and abdominal cavity: two spaces in the trunk of the body

They contain some of the body’s most important organs

4


Chest Trauma

Chest injuries result in a significant number of deaths each year

The chest contains organs vital to life Damage to vital organs threatens life Most common consequence is hypoxia

5


Chest Trauma

Mechanism of injury (MOI): Blunt chest trauma– Most common cause of serious chest injuries– Motor vehicle collisions (MVCs), falls, direct

blows, and crushing injuries– Many injuries are not immediately apparent

in physical exam

6


Chest Trauma

Mechanism of injury (MOI): Blunt chest trauma– Injuries linked to size of object applying force

and most important, to speed– Speed kills

7


Chest Trauma

MOI: Blunt chest trauma– Evaluating MOI at a motor vehicle collision

• Significant damage to vehicle’s exterior?• Damage to interior of vehicle?• Broken or bent steering wheel means significant

force was applied to the driver’s chest• The higher the forces, the higher the suspicion for

serious injury to patient

8


Chest Trauma

MOI: Penetrating trauma– Increasingly common in today’s society– Immediate result can be severe bleeding

or impaired breathing

9


Chest Trauma

MOI: Penetrating trauma– Any chest wound can involve underlying

organ injury • No matter how superficial it looks

– Injuries to the heart, lungs, and great vessels can quickly lead to shock and cardiac arrest

10


Chest Trauma

Signs and symptoms– Most common symptoms: pain and difficulty

breathing– Signs are obvious injury to the chest wall

• Use DCAP-BTLS, looking at both the front and back of the chest

– Note any subcutaneous emphysema, or air present under the skin

11


Chest Trauma

Assessment– Follow all steps in the assessment of

the trauma patient

12


Chest Trauma

Management– Ensure patient has adequate

oxygenation and perfusion– Provide high-flow oxygen, ventilating

when necessary– Halt any obvious bleeding

13


Chest Trauma

Management– Support circulation when needed– Rapidly transport patient to definitive care

14


Chest Trauma

Transport– Transport patient to a hospital with the

capability to diagnose and treat serious traumatic injuries

– Arrange for ALS intercept as guided by local protocols

– Notify receiving hospital so staff can prepare

15


Chest Injuries

Open chest wounds– A sharp object penetrates the skin on the

chest wall– Laceration of vessels such as the vena cava

or aorta will likely cause bleeding between the lung and the chest wall • The accumulation of blood in the pleural space is

called a hemothorax

16


Chest Injuries

Open chest wounds– If penetrating object has pierced pleura,

outside air can enter the thoracic cavity– As the volume of air in the thoracic cavity

expands, the lung starts to collapse – Air within the pleural space is called a

pneumothorax

17


Chest Injuries

When air enters between the lung and the chest wall, pneumothorax is created

18


Chest Injuries

Open chest wounds– As air passes in and out of an open wound,

it can create a sucking-type sound – Sucking chest wound means possibility of

pneumothorax– Signs of pneumothorax: difficulty breathing,

cyanosis, diminished breath sounds on the affected side

19


Chest Injuries

Open chest wounds: Management– Cover open chest wounds with

occlusive dressing– Gloved hand is an effective temporary

occlusive dressing– Secure dressing on three sides

20


Chest Injuries

Open chest wounds: Management– High-flow oxygen– Transport with unaffected side slightly elevated– Arrange for ALS intercept

21


Open Chest Wound

Watch this animation illustrating management of an open chest wound.

22


Stop and Review

Name three signs of a simple pneumothorax.

23


Chest Injuries

Tension pneumothorax– Buildup of pressure in pleural space resulting in

decrease in blood pressure– Potentially life-threatening condition that must be

treated immediately– Can occur in blunt or penetrating chest trauma

24


Chest Injuries

Increasing pressure in the lung pushes the heart and the great vessels to the opposite side of the chest.

25


Chest Injuries

Tension pneumothorax: Signs– Include all those of a pneumothorax– Jugular venous distension (JVD)– If ventilating becomes more difficult, significant

lung compression is indicated

26


Chest Injuries

Tension pneumothorax: Signs– Tracheal deviation is a late sign– If patient is hypotensive, immediately lift

a corner of the occlusive dressing• Transport this patient rapidly • Consider ALS intercept

27


Chest Injuries

Rib fractures– Local swelling and tenderness may be

the only sign of a broken rib– Can be very painful– Patients often present with guarding

and shallow breathing

28


Chest Injuries

Rib fractures: Management– Move the patient carefully to prevent

the bone ends from puncturing a lung– Administer oxygen

29


Chest Injuries

Rib fractures: Management– Allow patient to self-splint by assuming

the most comfortable position possible– Encourage patient to limit movement

30


Chest Injuries

Flail segment– When three or more ribs are broken in two or

more places, a rib-cage segment may detach from the rest

– Flail segment is free floating

31


Chest Injuries

Flail segment– Paradoxical movement: movement of flail segment

in opposite direction of the rest of the chest wall – Paradoxical movement can significantly impair

breathing and cause injury to the underlying lung

32


33


Flail Chest Segment

Watch this animation of a flail chest segment.

34


Chest Injuries

Flail segment: Management– Quickly stabilize flail segment by placing gloved

hand over injured area– After manual stabilization, place folded universal

dressing over segment and tape securely

35


Chest Injuries

Flail segment: Management– Consider assisting patient’s

breathing if tachypnea increases– Transport on side with unaffected

lung on top

36


Chest Injuries

Pulmonary contusion– Bleeding into the lung itself is a

pulmonary contusion– Bleeding and edema can impair

gas exchange, causing hypoxia– Soft crackles may be heard over

injury site– Chest pain, point tenderness, and

localized swelling over area of impact

37


Chest Injuries

Pulmonary contusion: Management– Support ventilation as needed – Supply high-flow supplemental oxygen– Transport to hospital

38


Chest Injuries

Cardiac contusion– Can impair heart’s ability to pump– Bleeding into heart tissue can cause heart to

beat irregularly– Irregular pulse should alert EMT to possibility

of a cardiac contusion

39


Chest Injuries

Cardiac contusion: Management– High-flow oxygen– Ventilation support as needed– Support of circulation if appropriate– Prompt transport– Request ALS backup

40


Chest Injuries

Pericardial tamponade– Bleeding around heart and into pericardial

sac that encloses the heart can cause pericardial tamponade

– Usually results from a penetrating chest trauma with laceration to the heart itself

41


Chest Injuries

Pericardial tamponade – Blood filling the pericardial sac compresses heart,

causing blood to back up– JVD is a telltale sign of pericardial tamponade– Narrowed pulse pressures

42


Chest Injuries

Pericardial tamponade: Management– High-flow oxygen– Treat patient for shock– Transport rapidly to ED– Request ALS intercept– Notify hospital so staff can properly prepare

43


Chest Injuries

Aortic injury– In sudden decelerations such as high-speed head-

on MVCs, body organs are thrown forcefully against the front of the body

– Most significant tear: aorta– If tear is complete, patient will die in minutes

• Incomplete tears bleed severely

44


Chest Injuries

Aortic injury: Management– High-flow oxygen– Treat patient for shock– Transport rapidly to ED– Notify hospital so staff can properly prepare

45


Chest Injuries

Traumatic asphyxia– Rapid ejection of blood and air out of chest– Rapid compression of chest increases internal

pressure dramatically• Blood is immediately forced out of the chest and into the

vessels in the neck, head, and face

46


Chest Injuries

Traumatic asphyxia– Neck veins immediately become distended– Cyanosis is apparent in face– Bleeding in the eyes’ sclera may occur

47


Chest Injuries

Traumatic asphyxia: Management– High-flow oxygen– Treat patient for shock– Transport rapidly to ED– Notify hospital so staff can properly prepare

48


Abdominal Trauma

MOI: Penetrating abdominal trauma– Stab or gunshot wound to abdomen, no

matter how superficial, can seriously injure internal organs

49


MOI: Penetrating abdominal trauma– Inquire

• Kind of knife and length?• Caliber of gun? • How many shots were fired?• Trajectory?

Abdominal Trauma

50


Abdominal Trauma

MOI: Blunt abdominal trauma– External signs of injury may not be readily

apparent– Injury potential is as great as that of a

penetrating trauma – Most vehicle air bags don’t protect against

abdominal injury from lateral impacts in an MVC

– Improper use of seat belts may cause abdominal injury in a collision

51


Abdominal Trauma

Signs and symptoms– Look for DCAP-BTLS– Look for signs of penetrating trauma– Pain– Guarding, rigidity, distension, masses– Rebound tenderness

52


Assessment– Follow all of the steps in patient assessment

Abdominal Trauma

53


Management– Ensure patient has adequate

oxygenation and perfusion– Provide high-flow oxygen, ventilating

when necessary

Abdominal Trauma

54


Management– Halt any obvious bleeding – Support circulation when needed– Rapidly transport patient to definitive care,

usually a trauma center

Abdominal Trauma

55


Transport– Transport patient to a hospital with the capability

to diagnose and treat serious traumatic injuries– EMT should arrange for ALS intercept as guided

by local protocols– Notify hospital so staff can prepare

Abdominal Trauma

56


Abdominal Injuries

Liver and spleen injury– Most commonly injured abdominal organs– Both are very vascular– Potential signs of liver or spleen injury: contusions

and abrasions over the lower rib cage with upper abdominal tenderness

57


Abdominal Injuries

Liver and spleen injury: Management– High-flow oxygen– Ventilation support as needed– Support of circulation if appropriate– Prompt transport

58


Abdominal Injuries

Evisceration– Large abdominal wound may allow abdominal

contents such as the small intestine to eviscerate through wound opening

– The EMT can recognize evisceration easily but should not let it distract him from addressing other potentially life-threatening issues

59


Abdominal Injuries

Evisceration: Management– Do not replace abdominal contents into abdomen– Cover protruding contents with dry nonadherent

sterile dressing– Cover dressings with a sheet of aluminum foil to

retain heat and protect organs from further injury

60


Abdominal Injuries

Evisceration: Management– High-flow oxygen– Ventilation support as needed– Support of circulation if appropriate– Prompt transport

61


Abdominal Injuries

Pelvic fracture– Fractures of the bony pelvis can result in injury to

the underlying organs and vessels– Internal bleeding can result in hemorrhagic shock

62


Abdominal Injuries

Pelvic fracture: Management– Consider use of MAST for stabilization– High-flow oxygen– Ventilation support as needed– Support of circulation if appropriate– Prompt transport

63


Stop and Review

What is the management for traumatic asphyxia?

Name two significant signs of pericardial tamponade.

What is a late sign of tension pneumothorax?

Chapter 23

Documents

Transcript of Chapter 23