Chest Injuries
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Transcript of Chest Injuries
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Chest Injuries
Chapter 27
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Organs of the Chest
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Structures of the Chest
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Mechanics of Ventilation• Inspiration
– Intercostal muscles contract and diaphragm flattens.• Expiration
– Intercostal muscles and diaphragm relax; tissues move back to normal position.
• Phrenic nerves exit the spinal cord at C3, C4, and C5.• Spinal cord injury below C5
– Loss of ability to move intercostal muscles– Diaphragm can still contract; patient can still breathe.
• Spinal cord injury at C3 or higher– No ability to breathe
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Spinal Cord Injury Below C5
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Injuries to the Chest
• Closed chest injuries– Caused by blunt
trauma• Open chest injuries– Caused by
penetrating trauma
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Signs and Symptoms• Pain at site of injury• Pain aggravated by
increased breathing• Bruising to chest wall• Crepitus with palpation
of chest• Penetrating injury to
chest
• Dyspnea• Hemoptysis• Failure of chest to
expand normally• Rapid, weak pulse and
low blood pressure• Cyanosis around lips or
fingernails
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Scene Size Up
• Observe for hazards• Do not disturb potential evidence• Put several pairs of gloves in your pocket.• Consider spinal immobilization• Ensure that police are on scene if incident
involved violence
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Initial Assessment
• General impression– Quickly evaluate ABCs– Difficulty speaking may indicate several problems– Patients with significant chest injuries will look sick
• Airway and breathing– Ensure that patient has a clear, patent airway– Protect the spine– Inspect for DCAP-BTLS
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Inspection (AB)
• Decreased breath sounds usually indicate significant damage to a lung
• If both sides of chest do not have equal rise and fall, chest muscles have lost ability to work properly
• If one section of chest moves in opposite direction from the rest of the chest (paradoxical motion), this is a life threat
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Immediate Interventions
• Apply an occlusive dressing to any penetrating chest injury
• Stabilize paradoxical motion with a large bulky dressing and 2'' tape
• Apply oxygen via nonrebreathing mask at 15 L/min
• Provide positive pressure ventilations if breathing is inadequate
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Circulation (C)
• Assess patient’s pulse• Consider aggressive treatment for shock• Internal bleeding can quickly cause death
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Transport Decision
• Rapidly transport if patient has problems with ABCs.
• Pay attention to subtle clues.– Skin signs– Level of consciousness– Sense of impending doom
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Focused History and Physical Exam
• Focused physical exam– For a patient with isolated chest injury and limited
MOI• Rapid physical exam– For a patient with a significant MOI – Use DCAP-BTLS– Do not focus just on the chest wound
• Obtain baseline vital signs• Obtain SAMPLE history quickly
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Interventions
• Provide complete spinal immobilization• Maintain open airway; be prepared to suction• Provide assisted ventilations if needed• Control bleeding• Place occlusive dressing over penetrating chest
wound• Stabilize flail segment with a bulky dressing• Treat aggressively for shock• Do not delay transport
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Detailed Physical Exam
• Perform enroute to the Hospital if time allows
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Ongoing Assessment
• Assess effectiveness of interventions• Reassess vital signs• Communication and documentation– Communicate with hospital early if patient has
significant MOI– Describe injuries and treatment given
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Complications of Chest Injuries• A pneumothorax occurs when air leaks into the space
between the pleural surfaces.
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Pneumothorax• Air accumulates in the
pleural space• Air enters through a
hole in the chest wall– The lung may collapse in
a few seconds or a few minutes
• An open or penetrating wound to the chest is called a sucking chest wound
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Care for Open Pneumothorax
• Flutter valve dressing
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Spontaneous Pneumothorax
• Some people are born with or develop weak areas on the surface of the lungs
• Occasionally, the area will rupture spontaneously, allowing air into the pleural space
• Patient experiences sudden chest pain and trouble breathing
• Consider a spontaneous pneumothorax for a patient with chest pain without cause
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Tension Pneumothorax
• Can occur from sealing all four sides of the dressing on a sucking chest wound
• Can also occur from a fractured rib puncturing the lung or bronchus
• Can also result from a spontaneous pneumothorax
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• Signs and Symptoms– Respiratory distress– Distended neck veins– Tracheal deviation– Tachycardia– Low blood pressure– Cyanosis– Decreased lung sounds
• Treatment
– If a tension pneumothorax develops from sealing an open chest wound, partly remove the dressing to let the air escape.
– If there is no open wound, follow local protocol
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Hemothorax• Collection of blood in the
pleural space• Suspect if the following are
seen:– Signs and symptoms of shock– Decreased breath sounds on
affected side• If both air and blood are
present in the pleural space, it is a hemopneumothorax
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Rib Fractures
• They are very common in the older people.• A fractured rib may lacerate the surface of the
lung• Patients will avoid taking deep breaths and
breathing will be rapid and shallow• The patient often holds the affected side to
minimize discomfort• Administer oxygen
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Flail Chest
• Segment of chest wall detached from rest of thoracic cage
• Occurs when:– Three or more ribs are fractured in two or more
places.– Sternum is fractured along with several ribs.
• Creates paradoxical motion
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Care for Flail Chest• Maintain airway• Provide respiratory
support with BVM if needed
• Perform ongoing assessments for pneumothorax and other respiratory complications
• Immobilize flail segment
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Pulmonary Contusions
• Bruising of the lung• Develops over hours• Alveoli fill with blood, and edema accumulates
in the lung, causing hypoxia• Provide oxygen and ventilatory support
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Traumatic Asphyxia
• Sudden, severe compression of chest• Produces rapid increase in pressure within
chest• Results in neck vein distention, cyanosis, and
bleeding into the eyes• Provide supplemental oxygen and monitor
vital signs• Transport immediately
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Blunt Myocardial Injury
• Bruising of heart muscle• Pulse is often irregular• There is no prehospital treatment for this
condition• Check patient’s pulse and note irregularities• Provide supplemental oxygen and transport
immediately
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Pericardial Tamponade
• Blood or other fluids collect in the pericardium
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Pericardial Tamponade
• Signs and symptoms:– Very soft and faint heart tones– Weak pulse– Low blood pressure– Decrease in difference between systolic and
diastolic blood pressure– Jugular vein distention (JVD)
• Provide oxygen and transport quickly
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Laceration of the Great Vessels
• The superior vena cava, inferior vena cava, pulmonary arteries and veins, and aorta are contained in the chest
• Injury to these vessels can cause fatal hemorrhage
• Treatment includes:– CPR– Ventilatory support– Supplemental oxygen– Transport immediately