Chapter 29 - Chest Injuries = NEED TO FINISH

Cyanosis around the lips or fingernails

- Cyanosis in a patient with a chest injury is a sign of inadequate respiration. - Patients with cyanosis are unable to provide a sufficient supply of oxygen to the blood through the lungs and require immediate ventilation and oxygenation.

Hemothorax Definiton

- A collection of blood in the pleural cavity. - In blunt and penetrating chest injuries, blood can collect in the pleural space from bleeding around the rib cage or from a lung or great vessel.

Flail Chest - Definition

- A condition in which three or more ribs are fractured in two or more places or in association with a fracture of the sternum so that a segment of the chest wall is effectively detached from the rest of the thoracic cage.

Crepitus

- A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.

Visceral Pleura

- A lining called the visceral pleura covers the lung

Flutter Valve

- A one-way valve that allows air to leave the chest cavity but not return; formed by taping three sides of an occlusive dressing to the chest wall, leaving the fourth side open as a valve; may also be part of a commercial vented occlusive dressing. - Vented occlusive dressings contain a one-way valve, called a flutter valve, that allows air to leave the chest cavity but not return. - Follow local protocol and manufacturer's guidelines.

Pneumothorax

- A partial or complete accumulation of air or gas in the pleural space. - In a pneumothorax, air enters through a hole in the chest wall or the surface of the lung as the patient attempts to breathe, causing the lung on that side to collapse.

Below C5 Injury

- A patient whose spinal cord is injured below the C5 level may lose the power to move the intercostal muscles, but the diaphragm still should be able to contract. - The patient still will be able to breathe because the phrenic nerves remain intact, but the injury may cause belly breathing.

Signs of Tension Pneumothorax

- A patient with a tension pneumothorax will have: - Chest pain - Tachycardia - Marked respiratory distress - Absent or severely decreased lung sounds on the affected side - Signs of shock such as hypotension or altered mental status - The patient may exhibit jugular vein distention (JVD), cyanosis, or tracheal deviation, but these signs are not always present.

A penetrating injury to the chest might penetrate...?

- A penetrating injury to the chest may penetrate the lung and diaphragm and injure the liver or stomach.

Spontaneous Pneumothorax

- A pneumothorax that occurs when a weak area on the lung ruptures in the absence of major injury, allowing air to leak into the pleural space. - While pneumothorax is often discussed in the context of trauma, there are other potential causes, such as lung disease, spontaneous pneumothorax, or scuba-diving injuries.

Rapid, weak pulse and low blood pressure

- A rapid, weak pulse and low blood pressure are the principal signs of hypovolemic shock, which can result from extensive bleeding from lacerated structures within the chest cavity, where the great vessels and heart are located. - Shock following a chest injury may also result from insufficient oxygenation of the blood by the poorly functioning lungs, from an increase in intrathoracic pressure from air or blood in the chest, or from direct injury to the heart itself.

Pleura

- A thin membrane called the pleura covers each of the lungs and the thoracic cavity. - The inner chest wall has a lining called the parietal pleura, and a lining called the visceral pleura covers the lung

Absent or Decreased Breath Sounds

- Absent or decreased breath sounds on one side usually indicate significant damage to a lung, preventing it from expanding properly.

Air Bags

- Air bags can hide signs, such as seat belt marks, that would suggest that a significant force or blow occurred to the chest. - Maintain a high degree of suspicion for severe injuries when an air bag has deployed.

Tension Pneumothorax Mechanism

- Air gradually increases the pressure in the chest, first causing the complete collapse of the affected lung and then pushing the mediastinum (the central part of the chest containing the heart and great vessels) into the opposite pleural cavity. - Prevents blood from returning through the venae cavae to the heart, decreasing cardiac output, causing shock, and ultimately leading to death

1/3 of People who Die in Car Crashes...

- Almost one-third of people who are killed immediately in car crashes die as a result of traumatic rupture of the aorta.

Damage to the Chest Wall

- Although the skin and chest wall are not penetrated in a closed injury, broken ribs may lacerate the contents of the chest. - Damage to the chest wall structures result in decreased ability of patients to ventilate on their own. - Vital organs can be torn from their attachment in the chest cavity without any break in the skin; this condition can cause serious and life-threatening bleeding that is unseen outside the body.

Tension Pneumothorax

- An accumulation of air or gas in the pleural space that progressively increases pressure in the chest that interferes with cardiac function with potentially fatal results.

Occlusive Dressing

- An airtight dressing that protects a wound from air and bacteria; a commercial vented version allows air to passively escape from the chest, while an unvented dressing may be made of petroleum jelly-based (Vaseline) gauze, aluminum foil, or plastic. - Depending on local protocol, the dressing may be taped on three sides to allow air to escape during exhalation.

Improvised Occlusive Dressing

- An improvised occlusive dressing may be taped to the patient on only three sides of the dressing to simulate a flutter valve, or taped on all four sides of the dressing, depending on your local protocol.

Open Chest Injury - Definition

- An injury to the chest in which the chest wall itself is penetrated by a fractured rib or, more frequently, by an external object such as a bullet or knife. - The damage is instant, but symptoms may take time to develop as the damaged vessels continue to bleed or the lung collapses from a puncture.

Closed Chest Injury - Definition

- An injury to the chest in which the skin is not broken, usually caused by blunt trauma.

Open Pneumothorax/Sucking Chest Wound

- An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound; also referred to as a sucking chest wound.

Blood Passing Through Collapsed Lung

- Any blood that passes through the collapsed portion of the lung is not oxygenated, and hypoxia can develop.

Simple Pneumothorax

- Any pneumothorax that is free from significant physiologic changes and does not cause drastic changes in the vital signs of the patient. - Be vigilant because the simple pneumothorax can often worsen or deteriorate into a tension pneumothorax or develop complications like bleeding or hemothorax.

Positive Pressure Ventilation and Pneumothorax

- As in all pneumothorax treatment, adding positive-pressure ventilation will cause the pathology to advance rapidly and possibly cause a tension pneumothorax to develop. - You should not withhold positive-pressure ventilation if the patient needs the support. - Be aware of the risk and plan on how to resolve complications. - Most patients with this problem require ALS intervention, so call for it early.

Things to be Aware of During Primary Assessment

- Be diligent with auscultation of breath sounds, and evaluate the effectiveness of your ventilatory support with signs of circulation to the skin. - Be aware of decreasing oxygen saturation (SpO2) values because they may indicate the development of hypoxia. - Watch for signs of an impending tension pneumothorax, such as increasingly poor compliance during ventilation.

Treatment of Cardiac Tamponade

- Because this injury is inaccessible, your role in treatment is supportive. - Provide positive-pressure ventilation to any patient who is hypoventilating or apneic. - Rapidly transport the patient to a facility that is capable of intervention.

Scene Size Up

- Begin the encounter with scene safety as the highest priority. - If you determine that the power company, fire department, or advanced life support (ALS) units are needed, call for them early. - Take standard precautions and put on a minimum of gloves and eye protection. - Because of the color of blood and the fact that it easily soaks through clothing, you can often identify patients with bleeding as you approach the scene. - Since darker clothing may mask signs of bleeding, remain vigilant when the MOI suggests the patient may be bleeding. - Look for indicators and significance of the mechanism of injury (MOI) to develop an early index of suspicion for underlying injuries. - Chest injuries are common in motor vehicle crashes, falls, industrial incidents, and assaults. - Determine the number of patients, and consider spinal stabilization.

Pleural Fluid

- Between these two linings is a small amount of pleural fluid that allows the lungs to move freely against the inner chest wall as a person breathes. - Pleural fluid also creates surface tension to allow the lungs to adhere to the rib cage, thus allowing the mechanics of ventilation to occur.

Address life-threatening bleeding immediately.

- Bleeding inside the chest can be significant and a quick cause of death. - Control external bleeding with direct pressure and a bulky trauma dressing.

When does cardiac tamponade occur?

- Cardiac tamponade (pericardial tamponade) occurs more commonly in the presence of penetrating chest trauma, although it may occur in blunt trauma.

Cardiac Tamponade Mechanism

- Cardiac tamponade occurs when the protective membrane around the heart (pericardium), the pericardial sac, fills with blood or fluid from a ruptured, torn, or lacerated coronary artery or vein. - The pericardial sac also can fill as a result of cancer or an autoimmune disease such as lupus. - As the fluid amount increases, the heart is less able to fill with blood during each relaxation phase, so it cannot pump an adequate amount of blood, and the patient experiences a decrease in systemic blood flow, or cardiac output.

Bruising to the chest wall

- Causes pain and tenderness

Cardiac Tamponade

- Compression of the heart as the result of buildup of blood or other fluid in the pericardial sac, leading to decreased cardiac output. - In a trauma situation, even a small amount of fluid in the pericardial sac is enough to cause fatal pericardial tamponade. - (Occasionally, fluid in surprisingly large amounts may collect in the pericardial sac as a result of chronic medical conditions like cancers and autoimmune diseases, or due to infection.)

Crepitus with palpation of the chest

- Crepitus is the sensation felt when broken bone ends grind together.

How fast for a lung to collapse?

- Depending on the size of the hole and the rate at which air fills the cavity, the lung may collapse in a few seconds or a few hours.

Where is the diaphragm?

- In a person who is lying down or who has just completed exhalation, the diaphragm may rise as high as the nipple line. - At the bottom of the chest, the diaphragm separates the thoracic cavity from the abdominal cavity.

Dyspnea

- Difficulty breathing, shortness of breath - Causes include: - Airway obstruction - Damage to the chest wall - Improper chest expansion because of the loss of normal control of breathing - Lung compression because of accumulated blood or air in the chest cavity - Dyspnea indicates potential compromise of lung function. - Prompt, vigorous support of oxygenation and ventilation with prompt transport are required.

Removing an Impaled Object?

- Do not attempt to move or remove an impaled object from the patient. - It may be occluding the hole in the vessel that has been punctured and if you remove the object, the patient may bleed heavily. - The object will likely cause damage on removal, resulting in further injury.

Secondary Assessment

- Do not focus only on a chest wound; Quickly assess the entire patient from head to toe. - If there is significant trauma likely affecting multiple systems, start with a rapid physical examination of the body, looking for DCAP-BTLS to determine the nature and extent of thoracic injury. - Obtain a baseline set of vital signs, including pulse, respirations, blood pressure, skin condition, and pupils. - Because patients with chest injury have so much potential for rapid deterioration, they should be reevaluated every 5 minutes or less. This will allow you to recognize changes quickly in the vital sign numbers or trends.

The more common findings are similar to other types of pneumothoraces:

- Dyspnea or increased work of breathing exhibited as increased rate - Tachypnea and accessory muscle use - Decreasing oxygen saturation on the pulse oximeter - Another sign of pneumothorax can be a crackling sensation felt on palpation of the skin (subcutaneous emphysema), which indicates that air escaping from a lacerated lung is leaking into the tissues of the chest wall.

Lungs and Lobes

- Each side of the chest (hemithorax) contains lung tissue that is separated into lobes. - The right lung has three lobes. - The left lung has two lobes. - The left-lobe formation allows space for the heart to reside; this is called the cardiac notch.

Initial Care of Open Chest Wound

- For quick, initial care, you can use your gloved hand to occlude an open chest wound. - When further dressings can be applied, apply an occlusive dressing to all penetrating injuries to the chest. - Apply oxygen with a nonrebreathing mask at 15 L/min; Provide positive-pressure ventilation with 100% oxygen if breathing is inadequate based on the patient's LOC and breathing rate and quality.

Problems with Chest Injuries - Overview

- Given the location of the heart, lungs, and great blood vessels within the chest cavity, potentially serious injuries may occur. - Any injury that interferes with normal breathing must be treated without delay to minimize or prevent permanent damage to tissues that depend on a continuous supply of oxygen. - Another major problem with chest injuries may be internal bleeding or when air collects in the chest and prevents the lungs from expanding.

Hemoptysis

- Hemoptysis, the spitting or coughing up of blood, usually indicates that the lung itself or the air passages have been damaged. - With a laceration of the lung tissue, blood can enter the bronchial passages and is coughed up as the patient tries to clear the airway.

Tension Pneumothorax and Occlusive Dressings

- If signs of a tension pneumothorax develop, vent the occlusive dressing by opening it on one side to allow air to be released from the chest. - If there is clotting present, it may be expelled with the force of the buildup of pressure. - This situation can develop even after a flutter valve has been applied.

30-40% Lung Collapse

- If the lung is collapsed past 30% to 40%, you may hear diminished breath sounds on that side of the chest. - Absent breath sounds are a significant finding in chest trauma and may indicate the development of a tension pneumothorax.

If the patient has shallow breaths, what happens to reach ensure an adequate minute volume?

- If the patient is only able to inhale small amounts of air (in the case of a chest injury or a reactive airway pathology), the patient will need to exceed the normal respiratory rate range of 12 to 20 breaths/min to make up the difference in the minute volume.

Assess the patient's pulse to determine whether it is present and adequate.

- If the pulse is too fast or too slow, or if the skin is pale, cool, or clammy, consider your patient to be in shock. - The body compensates for blood loss in the early stage of shock by increasing the heart rate. Be alert for this change, especially if tachycardia is still present beyond a few minutes after the initial adrenaline rush from the incident or injury.

If you find an accelerated pulse rate or respiratory rate...

- If you find an accelerated pulse rate or respiratory rate, the chest injury may be causing either a decrease in available oxygen (hypoxia) or blood loss that results in a decreased number of red blood cells that can carry oxygen (hypoxemia). - The increased respiratory rate is often associated with an obvious increase in work of breathing. - This can be identified by noting increased use of the accessory muscles in the face, neck, and chest to assist in the movement of air.

History Taking

- If you have not yet done so, determine and investigate the patient's chief complaint and further investigate the MOI. - Identify any associated signs and symptoms and pertinent negatives, including: No associated shortness of breath, No rapid breathing, No absent or abnormal breath sounds, No areas of deformity or abnormal movement - When a patient reacts to the pain, be certain to verify where the pain was located in relationship to the area being touched. - In a patient with a suspected spinal cord injury, equal expansion of the chest and movement of the rib cage and the diaphragm can confirm that there is nerve conduction to that region of the body. - Obtain a SAMPLE history to get a basic evaluation of signs and symptoms; allergies; medications; pertinent medical history, including respiratory or cardiovascular disease; and last oral intake. - Identify the events leading to the emergency. - Questions about the events surrounding the incident should focus on the MOI: - The speed of the vehicle or height of the fall - The use of safety equipment such as a helmet, air bag, seat belt, or life jacket - The type of weapon used - The number of penetrating wounds

Impairment of Lung Function Can Cause...

- Impairment can cause a decrease in oxygen (hypoxia) and an increase in carbon dioxide (hypercarbia) in the blood, leading to alterations of consciousness and possible death if not recognized and treated.

Blunt Trauma Fractures

- In blunt trauma, a blow to the chest may fracture the ribs, the sternum, or whole areas of the chest wall; bruise the lungs and the heart; and even damage the aorta.

Special Populations and Bone Density

- In older patients with reduced bone density or more fragile bones, even minor trauma to the chest wall can cause significant injury to the underlying tissues and organs. - Older patients may have also sustained a number of fractures to the rib cage. - Be alert for these injuries and for signs and symptoms of respiratory compromise, even in low-energy mechanisms of injury. - Older patients also have a decreased amount of physiologic reserve and are likely to decompensate quickly following an injury.

In the case of increasing pressure on the heart from the pleural space or the pericardial space...

- In the case of increasing pressure on the heart from the pleural space or the pericardial space, blood pressure may exhibit a narrowing pulse pressure as the systolic and diastolic pressures come closer together. - This is a result of the inability of the heart to fill with an adequate volume of blood and contract normally.

Hole in Chest Wall

- In the uncommon situation when the hole is in the chest wall, you can hear a sucking sound as the patient inhales and the sound of rushing air as he or she exhales. - An open or penetrating wound to the chest wall is often called an open pneumothorax or a sucking chest wound. - This type of injury is a true emergency requiring immediate emergency medical care and transport.

Young Children's Intercostal Muscles

- In very young children, the intercostal muscles are not yet developed. - Children therefore have a tendency to breathe with their diaphragms. - This is considered normal for this age group and does not typically indicate spinal cord injury.

Initial Emergency Care of Pneumothorax

- Initial emergency care, after clearing and maintaining the airway and then providing oxygen, is to rapidly seal the open wound with an occlusive dressing. - Careful observation is required after the placement of an occlusive dressing.

DCAPBTLS and Chest Injury Examination

- Inspection or visualization of the region looking for deformities, such as asymmetry of the left and right sides of the chest or shoulder girdle, may reveal the presence of multiple rib fractures, crush injuries, or significant chest wall injury. - Identification of discrete areas of contusion or abrasion may pinpoint a specific point of impact. The presence of puncture wounds or other penetrating injuries indicates a possible open chest injury that should be managed accordingly. - Be alert for associated burns, which may alter respiratory mechanics. - Palpate for tenderness to localize the injury and the presence of fractures. - Look for lacerations and local swelling.

Intercostal Muscles

- Intercostal muscles, innervated from the spinal nerves originating in the cervical region C6 and C7, allow for the active portion of ventilation to occur. - A patient who has sustained a spinal cord injury in that region may be unable to move the intercostal muscles and may breathe entirely with the diaphragm (belly breathing). - This is considered a clinical or positive diagnostic finding indicating cord damage at or above the level of C6 and C7.

Jugular Vein Distention Assessment

- Jugular vein distention is best assessed for with the patient sitting at a 45-degree angle. - Tracheal deviation, if seen, is a late and grave finding and is a sign that the patient requires immediate intervention.

Late Finding of Pneumothorax:

- Late findings can be: Decreased breath sounds on the injured side, Lethargy, Cyanosis

When should life threatening hemorrhaging be addressed?

- Life-threatening hemorrhage, when present, should be addressed immediately, even before airway concerns.

Neurovascular Bundle

- Lying close to each rib along the inferior and slightly posterior to the lowest margin of each rib is the neurovascular bundle, composed of a network of nerves, arteries, and veins. - Consider this structure when evaluating patients who have sustained rib fractures, because this may be a source of significant bleeding into the pleural space, creating a hemothorax.

Failure of the chest to expand normally with inspiration

- May occur on either one or both sides of the chest

Minute Volume

- Minute volume is the amount of air moved through the lungs in 1 minute.

Any penetrating injury to the chest

- Most frequently caused by an object such as a bullet or knife

Primary Assessment

- Note the patient's level of consciousness (LOC). - Perform a rapid physical examination, looking for: Obvious injuries, Blood, Difficulty breathing, Cyanosis, Irregular breathing, Chest rise and fall on only one side, Accessory muscle use in the neck while breathing, Extended or engorged external jugular veins - If no obvious problems are seen, focus on the ABCs. - Ensure that the patient has a clear and patent airway. - How you assess and manage the airway depends on whether you suspect a spinal injury. - Be suspicious, and protect the spine early in your care. - While considering immobilization of the cervical spine, note whether the jugular veins are distended. - Determine whether breathing is present and adequate. - Inspect for DCAP-BTLS, and look for equal expansion of the chest wall. - Listen with a stethoscope to each side of the chest. - Loss of muscle function may be the result of a direct injury to the chest wall, or it may be related to an injury of the nerves that control those muscles. - Check for paradoxical motion, an abnormality associated with multiple fractured ribs, in which one segment (often referred to as a flail segment) of the chest wall moves opposite the remainder of the chest—that is, out with expiration and in with inspiration. - Assess the patient's pulse to determine whether it is present and adequate. - Address life-threatening bleeding immediately. - Pay attention to subtle clues such as the appearance of the skin, level of consciousness, or a sense of impending doom in the patient. - When you find signs of poor perfusion or inadequate breathing, transport quickly and perform the remainder of the assessment en route to the emergency department (ED).

What is oxygenation?

- Oxygenation is the process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs. - Oxygen must be delivered to the cells, and carbon dioxide must be removed from the body for proper organ system function.

Signs/Symptoms of Chest Inury

- Pain at the site of injury -Pain localized at the site of injury that is aggravated by or increased with breathing - Bruising to the chest wall - Crepitus with palpation of the chest - Any penetrating injury to the chest - Dyspnea - Hemoptysis - Failure of the chest to expand normally with inspiration - Rapid, weak pulse and low blood pressure - Cyanosis around the lips or fingernails

Pain at the Site of Injury

- Patients with chest injuries often have tachypnea and shallow respirations because it hurts to take a deep breath. - Check the respiratory rate and see if there is actual air movement from the mouth and/or nose. - This is best accomplished through the use of auscultation of multiple locations on the chest wall for adequate breath sounds.

C3 or Above Injury

- Patients with spinal cord injuries at C3 or above can lose their ability to breathe entirely.

Pleuritic Pain

- Pleuritic pain, or pleurisy, is irritation of or damage to the pleural surfaces. It causes a characteristic sharp or sticking pain with each breath when these normally smooth surfaces slide on one another.

Positive Pressure Ventilation and Flail Chest vs. Pneumothorax

- Positive-pressure ventilation may be particularly important for the patient with a flail chest that compromises ventilation. - However, positive-pressure ventilation overcomes the normal physiologic functions and, if your patient has a pneumothorax (collapsed lung), you can quickly worsen the injury.

Priority Patients

- Priority patients are patients who have a problem with their airway, breathing, and/or circulation. - Sometimes the priority is obvious and the decision to transport quickly is easy; At other times, what's happening outside the body may not provide obvious clues to the seriousness of what's happening inside the body. - A delay on the scene to perform a lengthy assessment will reduce the chances of survival for your patient. - With chest injuries, when in doubt, transport rapidly to a hospital.

Relief of Pneumothorax

- Relieving a tension pneumothorax that is the result of blunt trauma is often done by inserting a needle through the rib cage into the pleural space. - This is typically performed by ALS personnel or ED staff, depending on local protocols. - Be prepared to support ventilation with high-flow oxygen, and request ALS support or transport immediately to the closest hospital.

Rib Fractures - In Depth

- Rib fractures are very common, particularly in older people, whose bones are brittle. - Because the upper four ribs are well protected by the bony girdle of the clavicle and scapula, a fracture of one of these upper ribs is a sign of a very substantial MOI. - Be aware that a fractured rib that penetrates into the pleural space may lacerate the surface of the lung, causing a pneumothorax, a tension pneumothorax, a hemothorax, or a hemopneumothorax. - Patients with one or more cracked ribs will report localized tenderness and pain when breathing. The pain is the result of broken ends of the fracture rubbing against each other with each inspiration and expiration. - Patients will: Avoid taking deep breaths (their breathing will be rapid and shallow instead); Hold the affected portion of the rib cage in an effort to minimize discomfort - Patients with rib fractures should receive supplemental oxygen during assessment and transport if they are experiencing any respiratory distress.

Rib Fractures

- Rib fractures create sharp broken bone ends that can lacerate lung tissue and cause further vessel damage with every movement of the chest wall. - This type of bleeding can be hidden from external view and rapidly lead to hypovolemic shock.

Suspect a hemothorax if the patient has:

- Signs and symptoms of shock without any obvious external bleeding or apparent reason for the shock state - Decreased breath sounds on the affected side, which is an indication that the lung is being compressed by the blood - Because bleeding is typically caused by severe damage within the chest cavity, there is virtually no way to control the bleeding in the prehospital setting.

Cardiac Output and a Functioning Heart

- The ability to pump blood depends on having a functional pump (the heart), an adequate volume of blood to be pumped, and an appropriate amount of resistance to the pumping mechanism. - Collectively, these properties help determine cardiac output. - Cardiac output is the volume of blood delivered to the body in 1 minute. - Any injury that limits the heart's pumping ability, the delivery of blood to the heart, the blood's ability to leave the heart, or the heart rate will affect cardiac output.

Hemopneumothorax Defintion

- The accumulation of blood and air in the pleural space of the chest.

BVM Volume

- The average bag-valve mask (BVM) consists of a self-inflating bag that contains 1,000 to 1,500 mL of air.

Average Tidal Volume

- The average tidal volume for a man is approximately 500 mL.

Where is the thoracic cage?

- The chest (thoracic cage) extends from the lower end of the neck to the diaphragm.

Esophagus

- The esophagus runs through the back of the chest, connecting the pharynx above with the stomach and the abdomen below.

Mediastinum

- The esophagus, trachea, and great vessels lie in the mediastinum, a cavity or space centrally located in the thorax. - This is where a thoracic aortic dissection can occur—a severing of the aorta that can occur when the body is exposed to traumatic forces.

Pericardium

- The fibrous sac that surrounds the heart.

Complication of Cardiac Contusion

- The heart may not be able to refill with blood or blood may not be pumped with enough force out of the heart, creating a form of inadequate tissue oxygenation (cardiogenic shock).

Parietal Pleura

- The inner chest wall lining

Cardiac Notch

- The left-lobe formation allows space for the heart to reside

Paradoxical Motion

- The motion of the portion of the chest wall that is detached in a flail chest; the motion—in during inhalation, out during exhalation—is exactly the opposite of normal chest wall motion during breathing.

Nerves Supplying the Diaphragm

- The nerves supplying the diaphragm (the phrenic nerves) exit the spinal cord at C3, C4, and C5. - A patient whose spinal cord is injured below the C5 level may lose the power to move the intercostal muscles, but the diaphragm still should be able to contract. - The patient still will be able to breathe because the phrenic nerves remain intact, but the injury may cause belly breathing. - Patients with spinal cord injuries at C3 or above can lose their ability to breathe entirely.

Breathing Attempts

- The patient may be making breathing attempts but may not actually be moving air. - Chest wall trauma may interfere with the ability to actually move air.

Air and Blood in Pleural Space

- The presence of air and blood in the pleural space is known as a hemopneumothorax. - Treatment involves providing rapid transport to the nearest facility capable of performing surgery.

In the later stages of injuries:

- The pulse rate slows as the myocardium becomes starved for oxygen. - The respiratory rate may drop as the brain becomes starved for oxygen and overloaded with carbon dioxide and other waste products. - These are usually signs of impending cardiopulmonary arrest.

Occlusive Dressing Purpose

- The purpose of an occlusive dressing is to seal the wound and prevent air from being sucked into the chest through the wound.

Reassessment

- The reassessment identifies how your patient's condition is changing. - It should focus on repeating the primary assessment, reassessing the chief complaint, and reassessing interventions performed. - Reevaluate the patient's airway, breathing, pulse, perfusion, and bleeding. - Reassess interventions to determine if they are effective. - Reassess vital signs and compare them to vital signs taken earlier. - Many chest injuries worsen during transport to the hospital. - Provide appropriate spinal immobilization of any patient who has blunt trauma with suspected spinal injuries. - Maintain an open airway, be prepared to suction the patient, and consider an oropharyngeal or nasopharyngeal airway. - Whenever you suspect significant bleeding, provide high-flow oxygen. - If needed, provide assisted ventilation using a bag-valve mask (BVM) with high-flow oxygen. If significant bleeding is visible, control it. - If you find penetrating trauma to the chest wall, place an occlusive dressing over the wound. - Use caution to avoid increasing the work of breathing and pain. - Be prepared to provide positive-pressure ventilation if the patient's efforts are not effective. - If the patient has signs of hypoperfusion, treat aggressively for shock and provide rapid transport to the appropriate hospital. - Do not delay transport of a seriously injured trauma patient to complete nonlifesaving treatments such as splinting extremity fractures; instead, complete these types of treatments en route to the hospital. - If a penetrating injury is present, describe it in your report to the hospital, along with what you have done to care for it. - Your documentation should be complete and thorough. - Describe all injuries and the treatment given. - Remember, your documentation is your legal record of what happened.

Rib Cage Function

- The ribs create a protective and functional cage around the vital organs. - The contents of the chest are partially protected by the ribs, which are connected in the back to the vertebrae and in the front, through the costal cartilages, to the sternum.

Beck's Triad

- The signs of this condition (referred to as Beck triad) are often subtle until the situation is dire; these include: 1. Distended or engorged jugular veins seen on both sides of the trachea 2. A narrowing pulse pressure (the difference between the systolic and diastolic blood pressure numbers) 3. Muffled heart sounds - An associated and more commonly noticed sign is a decrease in mental status as blood flow decreases to the brain.

Features That Allow for Ventilation

- The skin, muscle, and bones of the thoracic region have some unique features to allow for the ventilation process. - Just under the normal three layers of skin, the epidermis, dermis, and subcutaneous layers, lies striated or skeletal muscle. - This muscle extends between the ribs, forming the intercostal muscles.

What is in the thoracic cage?

- The thoracic cage also contains the heart and the great vessels: the aorta, the right and left subclavian arteries and their branches, the pulmonary arteries, and the superior and inferior venae cavae.

Trachea

- The trachea divides into the left and right mainstem bronchi, which supply air to the lungs.

Two Types of Chest Injuries

- There are two basic types of chest injuries: open and closed.

Simple Pneumothorax Causes

- These are commonly the result of blunt trauma that results in fractured ribs. - As in the spontaneous pneumothorax, the simple pneumothorax is often difficult to diagnose. - The lung has to collapse a significant amount before the effects will be heard as decreased breath sounds.

Closed Chest Injuries Often Cause

- These types of injuries often cause significant contusions in both the cardiac muscle (cardiac contusion) and the lung tissue (pulmonary contusion), impairing the function of those organs. - The heart may not be able to refill with blood or blood may not be pumped with enough force out of the heart, creating a form of inadequate tissue oxygenation (cardiogenic shock). - Any bruising of the lung tissue can result in exponential loss of the surface area where oxygen and carbon dioxide exchange occurs. - Rib fractures create sharp broken bone ends that can lacerate lung tissue and cause further vessel damage with every movement of the chest wall; This type of bleeding can be hidden from external view and rapidly lead to hypovolemic shock.

Jugular Vein Distention

- This can be the result of a tension pneumothorax (significant, ongoing air accumulation in the pleural space) or injury to the heart that allows bleeding into the pericardium, creating a cardiac tamponade (otherwise referred to as a pericardial tamponade).

Precautions/Complications w/ BVM

- This device can quickly overinflate the lungs, causing gastric distention, and impair the function of the lungs. - Overventilation can also increase intrathoracic pressure, reducing cardiac output and potentially worsening chest injuries such as pneumothorax. - There is also the risk of causing acid-base imbalance and blood gas imbalance by "blowing off" carbon dioxide faster than the body needs to get rid of it.

Tidal Volume

- Tidal volume is the amount of air in milliliters (mL) that is moved into or out of the lungs during a single breath.

Treatment of Simple Pneumothorax

- Treatment is much like any treatment for respiratory compromise: - Provide a high concentration of oxygen. - Monitor oximeter readings and breath sounds. - Treat underlying causes of the injury.

Occlusive Dressing Types

- Two types of occlusive dressings are available: - Commercial vented occlusive dressings - Improvised occlusive dressings that utilize petroleum jelly (Vaseline)-based gauze, aluminum foil, or plastic.

Occlusive Dressing Size

- Use a dressing that is large enough so that it is not pulled or sucked into the chest cavity.

What is ventilation?

- Ventilation is the body's ability to move air in and out of the chest and lung tissue.

Exhalation

- When you exhale, the intercostal muscles and diaphragm relax and the tissues move back to their normal positions, allowing air to be exhaled. - In a normal respiratory system, relaxation of the thoracic muscles and the diaphragm is a relatively passive function.

Inhalation

- When you inhale, the intercostal muscles between the ribs contract, elevating and expanding the rib cage, and the diaphragm contracts or flattens and pushes the contents of the abdomen down. - The intrathoracic pressure inside the chest decreases, creating a negative pressure differential. - Air then enters the lungs through the nose and mouth, which is the path of least resistance from the ambient air space to the upper and lower airway.

When using an occlusive dressing...

- When you use an occlusive dressing to seal an open chest wound, record the type of material used; whether three or four sides were sealed; and any changes noted afterward, such as skin color, vital signs, breath sounds, and particularly the patient's level of anxiety.

Pain localized at the site of injury that is aggravated by or increased with breathing

Pleuritic pain, or pleurisy, is irritation of or damage to the pleural surfaces. It causes a characteristic sharp or sticking pain with each breath when these normally smooth surfaces slide on one another.