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CHAPTER 23T H O R A C I C T R A U M A
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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
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OBJECTIVES
23.3 Describe the pathology of the following thoracic injuries:
a. flail chestb. pneumothoraxc. hemothoraxd. tension pneumothoraxe. sucking chest woundf. pericardial tamponade
continued
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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.
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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
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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
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CHEST INJURIES
Closed Blunt trauma Fall or collision
Open Penetration of chest Compression
Indirect
Inertia Deceleration
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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
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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
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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
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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
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PNEUMOTHORAX
Air in the pleural space Trauma (blunt or penetrating) Spontaneous Compressive forces
continued
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PNEUMOTHORAX
Penetrating wounds create differential pressure Sucking chest wound Collapsed lung possible
Blow to chest may cause lung to burst
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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
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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
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TENSION PNEUMOTHORAX
continued
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TENSION PNEUMOTHORAX
Subcutaneous emphysema Air under the skin – Rice Krispies® crackling
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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
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HEMOTHORAX
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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
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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
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PERICARDIAL TAMPONADE
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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
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AORTIC RUPTURE AND DISSECTION
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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
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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
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TRAUMATIC ASPHYXIA
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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
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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
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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
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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
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MANAGEMENT
continued
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MANAGEMENT
Match transport position to patient’s breathing needs
Treat/position for shock
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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
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CHAPTER SUMMARY
Treat sucking chest wounds with an occlusive dressing.
If the condition of a hypoxic patient with chest trauma worsens, consider a tension pneumothorax.