EMT Basic Chapter 29 Chest Injuries

In open chest injuries

, an object (eg, knife, bullet, piece of metal, broken end of a fractured rib) penetrates the chest wall itself. 1. Causes instant damage, but symptoms develop over time 2. An impaled object remains in place. a. Do not attempt to move or remove the object. i. May be occluding the hole in the punctured vessel; removal would cause heavy bleeding ii. May cause damage during its removal

Commotio cordis

. Blunt chest injury caused by a sudden, direct blow to the chest that occurs only during the critical portion of a person's heartbeat 2. The result may be immediate cardiac arrest. 3. The resulting ventricular fibrillation responds positively to defibrillation within the first 2 minutes after the injury. 4. More commonly associated with sports-related injuries, but should be suspected in all cases in which the person is unconscious and unresponsive after a blow to the chest

Rib fractures

1. Common, particularly in older people whose bones are brittle 2. A fracture of one of the upper four ribs is a sign of a very substantial MOI. 3. A fractured rib may lacerate the surface of the lung, causing a pneumothorax, a tension pneumothorax, a hemothorax, or a hemopneumothorax. 4. Signs and symptoms 5. Prehospital treatment: a. Supplemental oxygen

Pneumothorax

1. Commonly called a collapsed lung 2. Defined as an accumulation of air in the pleural space a. Air enters through a hole in the chest wall or surface of the lung. b. The patient's attempts to breathe cause the lung on that side to collapse. 3. Blood passing through the collapsed portion of the lung is not oxygenated.

Hemothorax

A condition in which blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel 2. Common signs and symptoms 3. Prehospital treatment: a. Bleeding cannot be controlled in the prehospital setting. b. Provide rapid transport to the nearest facility capable of performing surgery. 4. The presence of air and blood in the pleural space is known as a hemopneumothorax.

Which of the following blood vessels can be lacerated by a fractured rib? A) Aorta B) Brachial artery C) Iliac veins D) Jugular vein

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

You are assessing a patient who sustained a blunt force chest injury during a motorcycle accident. There are no obvious signs of external bleeding, but the patient is hypovolemic and there are decreased breath sounds on the left side. Which of the following should you suspect? A) Hemothorax B) Hemopneumothorax C) Pneumothorax D) Traumatic asphyxia

A) Hemothorax

Which of the following is NOT a sign or symptom of a chest injury? A) clear and equal breath sounds B) bruising of the chest wall C) crepitus with palpation of the chest D) unequal expansion of the chest wall

A) clear and equal breath sounds

A simple pneumothorax: A) is commonly caused by blunt chest trauma B) heals on its own without any treatment C) often has a nontraumatic cause D) is caused by penetrating chest trauma

A) is commonly caused by blunt chest trauma

Which of the following is NOT a pertinent negative to note during your assessment of a patient with chest trauma? A) no heart murmurs B) no rapid breathing C) no associated shortness of breath D) no areas of deformity

A) no heart murmurs

In order to avoid exacerbating a patients injury, it is especially important to use extreme caution when providing positive-pressure ventilation to patients with a: A) pneumothorax B) myocardial contusion C) flail chest D) cardiac tamponade

A) pneumothorax

A man called EMS 12 hours after injuring his chest. Your assessment reveals a flail segment to the right side of the chest. The patient is experiencing respiratory distress and his oxygen saturations is 78%. His breath sounds are equal bilaterally and his jugular veins are normal. You should suspect: A) pulmonary contusion B) massive hemothorax C) traumatic asphyxia D) tension pneumothorax

A) pulmonary contusion

Patients with chest injuries will often present with _______? A) tachypnea B) cheyne-stokes respirations C) agonal respirations D) kussmaul respirations

A) tachypnea

What is Ventilation? A) the bodys ability to move air in and out of the chest and lung tissue B) the process of removing carbon dioxide and waste products from the body C) The process of delivering oxygen to the cells D) The exchange of gases across the alveoli of the lungs

A) the bodys ability to move air in and out of the chest and lung tissue

Elevation of the rib cage during inhalation occurs when: A) the intercostal muscles contract B) the diaphragm descends C) abdominal contents descend D) intrathoracic pressure decreases

A) the intercostal muscles contract

Simple pneumothorax

Any pneumothorax that is free from significant physiologic changes and does not cause drastic changes in the vital signs of the patient. Commonly the result of blunt trauma that results in fractured ribs Decreased breath sounds associated with significant lung collapse Signs and symptoms d. Late findings e. Be vigilant, because a simple pneumothorax can often worsen or deteriorate into a tension pneumothorax or develop complications like bleeding or hemothorax. f. Prehospital treatment: i. Provide high-flow oxygen. ii. Monitor oximeter readings and breath sounds. iii. Treat the underlying causes of the injury. iv. Do not withhold positive-pressure ventilation if the patient needs support. (a) May cause tension pneumothorax (b) Have a plan to resolve complications.

The phrenic nerves control the diaphragm and exit the spinal cord at: A) C1, C2, and C3 B) C3, C4, and C5 C) C3 and C4 D) C1 and C2

B) C3, C4, and C5

________ in a patient with a chest injury is a sign that the blood is not being oxygenated sufficiently. A) Crepitus B) Cyanosis C) Pleurisy D) Tachypnea

B) Cyanosis

In which condition is it recommended you use positive-pressure ventilation? A) Pneumothorax B) Flail chest C) Traumatic asphyxia D) Tension pneumothorax

B) Flail chest

You are assessing a patient and notice he has a collapsed jugular vein. What does this indicate? A) Cardiac tamponade B) Hemothorax C) Tension pneumothorax D) Commotio cordis

B) Hemothorax Collapsed jugular veins suggest a hemothorax or shock.

You are treating a patient who fell hard on her right side when she fell off a bike. Exposure of the patient's chest reveals a large bruise on the lateral aspect of the right side of the chest. When you palpate the area, the patient yells out in extreme pain and states that she cannot take a deep breath. What condition should you suspect? A) Cardiac tamponade B) Rib fractures C) Spontaneous pneumothorax D) Open pneumothorax

B) Rib fractures Rib fractures are common in this type of injury. The pain is the result of broken ends of the fracture rubbing against each other with each inspiration and expiration.

While jogging, a 19 year old male experienced an acute onset of breath and pleuritic chest pain. He is conscious and alert with stable vital signs. Your assessment reveals that he has diminished breath sounds over the left side of the chest. You should: A) recognize that he needs a needle decompression B) administer oxygen and transport to the hospital C) immediately perform a rapid head-to-toe exam D) circumferentially tape a dressing around his chest

B) administer oxygen and transport to the hospital

An open pneumothorax occurs when: A) extreme pleural pressure causes the lung to rupture B) air enters the pleural space from outside the body C) a fractured rib perforates the tissue of the lung D) air enters the pleaural space from a perforated lung

B) air enters the pleural space from outside the body.

Which of the following is most likely to cause immediate death? A) pulmonary contusion B) aortic rupture C) aortic dissection D) Myocardial contusion

B) aortic rupture

Closed chest injuries are typically caused by ________? A) flying debris B) blunt trauma C) penetraiting trauma D) high-velocity weapons

B) blunt trauma

The thoracic cavity is separated from the abdominal cavity by the: A) anterior rib cage B) diaphragm C) intercoastal margin D) costovertebral angle

B) diaphragm

Following a stab wound to the left anterior chest, a 25 year old male presents with a decreased level of consciousness and signs of shock. Which of the following additional assessment findings should increase your index of suspicion for a cardiac tamponade? A) widening pulse pressure B) engorged jugular veins C) diminished breath sounds D) a rapid, irregular pulse

B) engorged jugular veins

When a person is lying supine at the end of exhalation, the diaphragm: A) is less prone to penetrating trauma B) may rise as high as the nipple line C) contracts and flattens inferiorly D) descends below the level of the navel

B) may rise as high as the nipple line

If a patient with a chest injury is only able to inhale small amounts of air per breath, he or she: A) will maintain adequate minute volume if his or her respiratory rate stays the same B) must increase his or her respiratory rate to maintain adequate minute volume C) will eliminate more carbon dioxide than if he or she were breathing deeply D) often breaths at a slower rate because of the lung damage caused by the injury

B) must increase his or her respiratory rate to maintain adequate minute volume

A _____ results when an injury allows air to enter 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. A) hemothorax B) pneumothorax C) hemopneumothorax D) tension pneumothorax

B) pneumothorax

Children are often "belly breathers" because _________? A) they are routinely hypoxic B) their intrercoastal muscles are not developed C) their diaphragm is not functional D) they are consciously controlling ventilations

B) their intrercoastal muscles are not developed

Blunt myocardial injury

Blunt trauma may injure the heart itself, making it unable to maintain adequate blood pressure. 2. Signs and symptoms 3. Suspect myocardial contusion in all cases of severe blunt injury to the chest. 4. Prehospital treatment: a. Monitor the patient's pulse carefully. b. Note any change in blood pressure. c. Provide supplemental oxygen and transport immediately.

When a patient sustains a spinal injury above the C3 region, which of the following is likely to happen? A) Belly breathing due to the loss of power to move the intercostal muscles B) cardiogenic shock C) loss of the ability to breathe due to loss of ability of phrenis nervies to function D) Severe pain radiating from C3 down to L1

C) Loss of the ability to breath due to loss of ability of phrenic nerves to function

Which of the following organs or structures does NOT reside within the mediastinum? A) Esophagus B) Trachea C) Lungs D) Vena Cavae

C) Lungs

Which of the following are you likely to see in flail chest? A) Belly breathing B) Myocardial contusion C) Paradoxical motion D) Ventricular fibrillation

C) Paradoxical motion Paradoxical motion is a sign of flail chest. The detached portion of the chest wall moves opposite of normal: It moves in instead of out during inhalation and out instead of in during exhalation.

A 37-year-old male was pinned between a flatbed truck and a loading dock. On exam, you find bruising to the chest, distended neck veins, bilaterally diminished breath sounds, and bilateral scleral hemorrhaging. You should: A) request a paramdeic ambulance B) suspect a severe hemopneumothorax C) aggressively manage his airway D) perform a secondary assessment

C) aggressively manage his airway

You respond to a residence for a 40 year old female who was assaulted by her husband, the scene has been secured by law enforcement. Upon your arrival, you find the patient lying supine on the floor in the kitchen. She is semiconscious with severely labored breath sounds. As your partner is supporting her ventilations, you should: A) insert an oropharyngeal airway B) obtain a set of baseline vital signs C) immediately request ALS support D) perform a focused secondary exam

C) immediately request ALS support

A spinal cord injury at the level of C7 would MOST likely result in: A) paralysis of all the respiratory muscles B) immediate cardiac arrest C) paralysis of the intercoastal Muscles D) paralysis of the diaphragm

C) paralysis of the intercoastal Muscles

A 28 year old male was struck in the chest with a baseball bat during an altercation. He is conscious and alert and complains of severe chest pain. Your assessment reveals a large area of ecchymosis over the sternum and a rapid, irregular pulse. In addition to providing supplemental oxygen, you should: A) apply an AED and assess his BP B) determine if he has cardiac problems C) prepare for immediate transport D) apply bulky dressings to the sternum

C) prepare for immediate transport

A patient with blunt trauma who is holding the lateral side of his chest and has rapid and shallow respirations is most likely suffering from: A) a sternal fracture B) a pneumothorax C) rib fractures D) a pulmonary contusion

C) rib fractures

On inhalation, which of the following does NOT occur? A) air enters through the nose and mouth B) the diaphragm contratcs C) the pressure inside the chest increases D) the intercoastal muscles contract, elevating the rib cage

C) the pressure inside the chest increases

Cardiac tamponade

Cardiac tamponade (pericardial tamponade) occurs more commonly with penetrating chest trauma, although it may occur in blunt trauma. 2. The protective membrane around the heart (pericardium) fills with blood or fluid. 3. The heart then cannot pump an adequate amount of blood. 4. Signs and symptoms 5. Prehospital treatment: a. Support ventilations. i. Provide positive-pressure ventilation to any patient who is hypoventilating or apneic. b. Rapidly transport the patient to a facility capable of intervention.

Flail chest

Caused by compound rib fractures that detach a segment of the chest wall from the rest of the thoracic cage 2. The detached portion of the chest wall moves opposite of normal (paradoxical motion). a. Paradoxical motion is a late sign of flail segment. 3. Prehospital treatment: a. Maintain the airway. b. Provide respiratory support, if needed. c. Give supplemental oxygen. d. Perform ongoing assessments for possible pneumothorax or other respiratory complications. e. Treatment may also include positive-pressure ventilation with a bag-valve mask. f. Restricting chest wall movement (splinting of the flail segment with bulky dressing) is no longer recommended. 4. Flail chest may indicate serious internal damage and possible spinal injury.

________ in a patient with a chest injury is a sign that the blood is not being oxygenated sufficiently

Cyanosis

What are the two most common injuries caused by penetrating chest trauma? A) Flail chest and simple pneumothorax B) Commotio cordis and hemopneumothorax C) Pulmonary and myocardial contusion D) Open pneumothorax and cardiac tamponade

D) Open pneumothorax and cardiac tamponade

What is the best position in which to place a patient when you want to assess for jugular vein distention? A) Supine B) Modified Fowler C) Prone D) Sitting at a 45-degree angle

D) Sitting at a 45-degree angle Jugular vein distention is best assessed with the patient sitting at a 45-degree angle. Next

A flail chest occurs when: A) more than three ribs are fractured on the same side of the chest B) multiple ribs are fractured on both sides of the thoracic cage C) a segment of fractured ribs bulges during the inhalation phase D) a segment of the chest wall is detached from the thoracic cage

D) a segment of the chest wall is detached from the thoracic cage.

During your assessment of a patient with blunt chest trauma, you note that the patient has shallow breathing and paradoxical movement of the left chest wall. You should: A) make note of it and continue your assessment B) apply high-flow oxygen via nonrebreathing mask C) request a paramedic to decompress the chest D) assist ventilations with a bag-valve-mask

D) assist ventilations with a bag-valve-mask

You respond to an 18-year-old man who has been assaulted with a baseball bat. He was hit in the chest. He is unresponsive, apneic, and pulseless. This condition is most likely related to: A) pneumothorax B) cardiac tamponade C) traumatic asphyxia D) commotio cordis

D) commotio cordis

You arrive at the scene of a major motor vehicle crash. The patient, a 50 year old female, was removed form her vehicle prior to your arrival. Bystanders who removed her state that she was not wearing a seatbelt. The patient is unresponsive, tachycardic, and diaphoretic. Your assessment reveals bilaterally clear and equal breath sounds, a midline trachea, and collapsed jugular veins. You should be MOST suspicious that this patient has experienced a: A) massive hemothorax B) tension pneumothorax C) pericardial tamponade D) laceration of the aorta

D) laceration of the aorta

You have sealed the open chest wound of a 40 year old male who was stabbed in the anterior chest. Your assessment reveals that he is experiencing increasing respiratory distress and tachycardia, and is developing cyanosis. You should: A) call for a paramedic ambulance B) begin ventilatory assistance C) begin rapid transport at once D) partially remove the dressing

D) partially remove the dressing

The ________ nerves control the diaphragm. A) intercostal B) vagus C) costal D) phrenic

D) phrenic

Immediately life-threatening chest injuries must be found and managed during the _________? A) patient history B) secondary assessment C) scene size-up D) primary assessment

D) primary assessment

A patient who presents with profound cyanosis following a chest injury: A) is most likely experiencing severe blood loss B) should be placed in Trendelenburg position C) has most likely experienced a ruptured aorta D) requires prompt ventilation and oxygenation

D) requires prompt ventilation and oxygenation

Pleural fluid is contained between the: A) visceral pleaura and the lung B) parietal pleura and the chest wall C) parietal pleura and the heart D) visceral and parietal pleurae

D) visceral and parietal pleurae

Laceration of the great vessels

May be accompanied by massive, rapidly fatal hemorrhage 3. Prehospital treatment: a. Cardiopulmonary resuscitation b. Ventilatory support and supplemental oxygen, if appropriate b. Immediate transport c. Remain alert to signs and symptoms of shock. d. Closely monitor changes in baseline vital signs (eg, tachycardia and hypotension).

Signs and symptoms of chest injury

Pain at the site of injury 2. Pain localized at the site of injury that is aggravated by or increased with breathing a. Irritation of or damage to the pleural surfaces causes sharp or sticking pain with each breath (pleuritic pain or pleurisy). 3. Bruising to the chest wall 4. Crepitus with palpation of the chest 5. Any penetrating injury to the chest 6. Dyspnea (difficult breathing, shortness of breath) a. Can be caused by airway obstruction, damage to the chest wall, improper chest expansion, or lung compression 7. Hemoptysis (spitting or coughing up blood) a. Indicates damage to the lung or air passage 8. Failure of one or both sides of the chest to expand normally with inspiration 9. Rapid, weak pulse and low blood pressure a. Principal signs of hypovolemic shock b. Can result from extensive bleeding of lacerated structures within the chest cavity 10. Cyanosis around the lips or fingernails a. Sign of inadequate respiration

Pulmonary contusion

Should always be suspected in a patient with a flail chest 2. The pulmonary alveoli become filled with blood, and fluid accumulates in the injured area, leaving the patient hypoxic. 3. Prehospital treatment: a. Provide supplemental oxygen and positive-pressure ventilation as needed to ensure adequate oxygenation and ventilation.

Traumatic asphyxia

Sudden, severe compression of the chest, which produces a rapid increase in pressure within the chest. 2. Characterized by: a. Distended neck veins b. Cyanosis in the face and neck c. Hemorrhage into the sclera of the eye 3. Suggests an underlying injury to the heart and possibly a pulmonary contusion 4. Prehospital treatment: a. Provide ventilatory support with supplemental oxygen. b. Monitor vital signs during immediate transport.

A patient whose spinal cord is injured below the C5 level may lose the power to move the intercostal muscles.

The diaphragm should still contract. The patient will still be able to breathe because the phrenic nerves remain intact.

Oxygenation

The process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs.

Tension pneumothorax

a type of pneumothorax in which air that enters the chest cavity is prevented from escaping Results from ongoing air accumulation in the pleural space b. This air gradually increases the pressure in the chest, causing: i. Complete collapse of the unaffected lung ii. Mediastinum to be pushed into the opposite pleural cavity, which decreases cardiac output and results in death c. More commonly caused by blunt injury in which a fractured rib lacerates a lung or bronchus d. Common signs and symptoms e. Prehospital treatment: i. Support ventilation with high-flow oxygen. ii. Request ALS support and provide immediate transport. iii. Needle decompression may be performed by ALS personnel or the emergency department staff depending on local protocols.

The minute ventilation, or minute volume, is the

amount of air moved through the lungs in 1 minute.

An open chest wound is often called

an open pneumothorax or a sucking chest wound. a. After clearing and maintaining a patient's airway and then providing oxygen, rapidly seal these wounds with occlusive dressings. i. The dressing prevents air from being sucked into the chest through the wound. ii. Two types of occlusive dressings: (a) Commercial vented occlusive dressings (b) Improvised occlusive dressings utilizing petroleum jelly (Vaseline)-based gauze, aluminum foil, or plastic 6. A flutter valve is a one-way valve that allows air to leave the chest cavity but not return. Follow local protocols and the manufacturer's guidelines. 7. After applying the dressing, carefully monitor the patient for signs of a tension pneumothorax. a. If it develops, open the occlusive dressing on one side. i. Consult local protocols and the manufacturer's guidelines.

major artery in the chest exhalation thoracic cage pericardium inhalation aorta mediastinum

aorta

The trachea divides into the right and left main stem ____________

bronchi

The mediastinum is the

central part of the chest containing the heart, great vessels, esophagus, and trachea. This location is where a thoracic aortic dissection—a severing of the aorta—can occur when the body is exposed to traumatic forces.

Visceral pleura

covers the lung

During inhalation, the pressure in the chest____________

decreases

chest falls exhalation thoracic cage pericardium inhalation aorta mediastinum

exhalation

The intercostal muscles and diaphragm relax during

exhalation, allowing air to be exhaled.

Overventilation can

increase intrathoracic pressure, reducing cardiac output and potentially worsening chest injuries, such as pneumothorax.

The intercostal muscles (between the ribs) contract during

inhalation

chest rises exhalation thoracic cage pericardium inhalation aorta mediastinum

inhalation

Blunt trauma to the chest may

may fracture the ribs, sternum, and chest wall; bruise the lungs and heart; and even damage the aorta. 1. Almost one third of people killed immediately in car crashes die as a result of traumatic rupture of the aorta. 2. Vital organs can be torn from their attachment in the chest cavity, causing internal, life-threatening bleeding.

center cavity of the thorax exhalation thoracic cage pericardium inhalation aorta mediastinum

mediastinum

Ventilation

movement of air in and out of the lungs

The diaphragm is a

muscle that separates the thoracic cavity from the abdominal cavity.

The___________lines the inner chest wall

parietal pleura

sac around the heart exhalation thoracic cage pericardium inhalation aorta mediastinum

pericardium

Patients with decreased tidal volume will have an increased _____________ rate.

respiratory

Patients with chest injuries often have

tachypnea (rapid respirations) and shallow respirations because it hurts to take a deep breath.

The thoracic cage 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.

Parietal pleura

the inner chest wall lining

A small amount of pleural fluid between the parietal and visceral pleura allows..........

the lungs to move freely against the inner chest wall as a person breathes.

In closed chest injuries

the skin is not broken. 1. Generally caused by blunt trauma 2. Often cause significant contusions in cardiac muscle (cardiac contusion) and lung tissue (pulmonary contusion) 3. If the heart is damaged, it may not be able to refill with blood or blood may not be pumped with enough force out of the heart. a. Results in cardiogenic shock 4. Lung tissue bruising can result in exponential loss of surface area. a. Decreased oxygen and carbon dioxide exchange b. Can cause hypoxic and hypercarbic states 5. Rib fractures can lacerate lung tissues and cause further vessel damage with every chest wall movement. a. Can rapidly lead to hypovolemic shock

chest exhalation thoracic cage pericardium inhalation aorta mediastinum

thoracic cage

The trachea divides into the left and right main stem bronchi, which

which supply air to the lungs.