EMS Care and Transport

8/11/2019 EMS Care and Transport

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27: Chest Injuries


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1. Differentiate between a pneumothorax, ahemothorax, a tension pneumothorax, and asucking chest wound.

2. Describe the emergency medical care of a patientwith a flail chest.3. Describe the emergency medical care of a patient

with a sucking chest wound.

Cognitive Objectives (1 of 2)


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4. Describe the consequences of blunt injury tothe heart.

5. List the signs of pericardial tamponade.6. Discuss complications that can accompany

chest injuries. There are no affective objectives for this

chapter.

Cognitive Objectives (2 of 2)


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Organs of the Chest


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Structures of the Chest


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Mechanics of Ventilation (2 of 2) 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 blunttrauma

Open chest injuries Caused by

penetrating trauma


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Signs and Symptoms Pain at site of injury

Pain aggravated byincreased breathing

Bruising to chest wall Crepitus with palpation

of chest

Penetrating injury tochest

Dyspnea

Hemoptysis

Failure of chest toexpand normally

Rapid, weak pulse andlow blood pressure

Cyanosis around lipsor fingernails


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Y o u a r e t h e P r o v i d e r

You and your EMT-B partner are dispatched to aconstruction site where a worker fell on a piece ofmetal and has an open chest wound.

You arrive and see no scene hazard or need forother resources.


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You are the provider continued

What is the mechanism of injury? What precautions should you take?


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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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InitialAssessment

General impression Quickly evaluate ABCs.

Difficulty speaking may indicate severalproblems. 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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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

Assess patients 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 andPhysical 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 en route 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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You are the provider continued

Patient has a significant MOI; do a rapid physicalexam.

Obtain baseline vital signs and SAMPLE history. Take c-spine precautions and transport continuing

oxygen therapy. Perform detailed physical exam and ongoing

assessment en route.


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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 fewseconds or a fewminutes.

An open orpenetrating wound tothe chest is called asucking chest wound.


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Care for Open Pneumothorax Clear and manage

the airway. Provide oxygen. Seal an open wound with

an occlusive dressing. Depending on local

protocol, tape down allfour sides or create a

flutter valve.


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Spontaneous Pneumothorax

Some people are born with or develop weak areason the surface of the lungs.

Occasionally, the area will rupture spontaneously,allowing air into the pleural space.

Patient experiences sudden chest pain and troublebreathing.

Consider a spontaneous pneumothorax for apatient with chest pain without cause.


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Tension Pneumothorax (1 of 2) Can occur from sealing all four sides

of the dressing on a sucking chestwound

Can also occur from a fractured ribpuncturing the lung or bronchus

Can also result from a spontaneouspneumothorax


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Signs and Symptoms of

Tension Pneumothorax Respiratory distress Distended neck veins

Tracheal deviation Tachycardia Low blood pressure Cyanosis Decreased lung sounds


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Hemothorax (1 of 2)

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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Hemothorax (2 of 2)


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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 (2 of 2)


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Care for Flail Chest Maintain airway. Provide respiratory

support with BVM ifneeded.

Perform ongoingassessments forpneumothorax andother respiratorycomplications.

Immobilize flailsegment.


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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 patients pulse and note

irregularities. Provide supplemental oxygen and

transport immediately.


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Pericardial Tamponade (2 of 2)

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 arecontained in the chest.

Injury to these vessels can cause fatal hemorrhage. Treatment includes:

CPR Ventilatory support Supplemental oxygen

Transport immediately.

EMS Care and Transport

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