Chapter 29 Chest Injuries

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

C3

a spinal injury to this cervical region or above can lose the ability to breath entirely

great vessels

superior and inferior vena cava, right and left subclavian arteries, pulmonary arteries, 4 main pulmonary arteries, the aorta and it's major branches

hemopneumothorax

the accumulation of blood and air in the pleural space of the chest

mediastium

the esophagus, trachea, heart and great vessels. Also know as the death box

pericardium

the fibrous sac that surrounds the heart

C5

A patient with a spinal cord injury to this cervical region might loose the power to move the intercostal muscles. however the diaphragm should still contract. and the patient is still able to breath due to the phrenic nerves being intact.

these type of fractures are more common in older people whose bones are brittle (osteoporosis) they may also lacerate the surface of the lung.

Rib fractures

C3, C4 and C5

This cervical region helps keep the breathing alive

hemothorax

a collection of blood in the pleural cavity from bleeding around the rib cage or from a lung or great vessel.

flail chest

a condition in which three or more ribs 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; paradoxical motion

crepitus or subcutaneous emphysema

a grating or grinding sensation caused by fractured bone ends or joints rubbing together.

flutter valve

a one-way valve that allows air to leave the chest cavity but not return; formed by taping three sides of an sterile dressing to the chest wall leaving the fourth side open as a valve; may also be part of a commercial vented occlusive dressing

life threatening injuries that must be detected and managed during the primary assessment

airway obstruction - bronchial disruption - diaphragmatic tear - esophageal injury - open pneumothorax - tension pneumothorax - massive hemothorax - flail chest - cardiac tamponade

traumatic rupture of the aorta

almost 1/3 of people who are killed immediately in a car crash die of this

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

tension pneumothorax

an accumulation of air or gas in the pleural cavity that progressively increases pressure in the chest, causes complete collapse of the unaffected lung, the mediastinum is pushed to the opposite side of the pleural cavity and interferes with cardiac function with potentially fatal results

pneumothorax

an accumulation of air or gas in the pleural cavity. this is commonly called a collapsed lung. air enters through a hole in the chest wall or surface of the lung. the patients attempt to breath cause the lung on that side to collapse. if the lung is collapsed past 30 - 40% you may hear diminished breath sounds. sucking sound on inhalation, rushing air on exhalation indicates the wall has been penetrated.

occlusive dressing

an airtight dressing that protects a wound from air or bacteria being sucked into the chest through the wound. 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

closed chest injury

an injury to the chest in which the skin is not broken, usually caused by blunt trauma. they often cause significant contusions in cardiac muscle (cardiac contusion) and lung tissue (pulmonary contusion)

sucking chest wounds

an open or penetrating chest wall wound through which air passes during inspiration and expiration creating a sucking sound

open pneumothorax

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

open chest injury

any injury to the chest wall itself and enters the lungs. do not attempt to remove an object as it may be occluding a hole in the punctured vessel and removal would cause heavy bleeding

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 (fractured ribs)

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 (SA nose) , may result is immediate cardiac arrest

myocardial contusion

bruise of the heart muscle after traumatic injury, may have the same signs and symptoms of a heart attack

cardiac tamponade (pericardial tamponade)

compression of the heart as the result of buildup of blood or other fluid in the pericardial sac leading to decreased cardiac output (Becks Triad, JVD, narrowing pulse pressure, muffled heart sounds)

signs and symptoms of a simple pneumothorax

dyspnea, increased work of breathing, increased respirator rate, tachypnea and accessory muscle use, decreased oxygen saturation and a crackling sensation felt on palpation of the skin (crepitus or subcutaneous emphysema) late findings include decreased breath sounds on injured side and cyanosis

all patients with chest injuries should receive

high flow oxygen or ventilation with a bag-mask device

pulmonary contusion

injury or bruising of lung tissue that results in hemorrhage. this should always be suspected in a patient with a flail chest. the pulmonary alveoli becomes filled with blood and fluid accumulates in the injured area leaving the patient hypoxic

general impression of a chest injury

look for obvious injuries, blood and difficulty breathing. cyanosis, chest fall and rise on only one side, accessory muscle use and jugular vein distention

symptoms of spontaneous pneumothorax

sudden chest pain and shortness of breath without known cause, and increase the respiratory rate

hemoptysis

spitting or coughing up blood. this indicates damage to the lung or air passage

mechanics of ventilation

the intercostal muscles between the ribs contract during inhalation, elevating and expanding the rib cage. the diaphragm contracts or flattens at the same time. the pressure inside the chest decreases creating a negative pressure differential. air then enters the lungs through the nose and mouth.

If tidal volume decreases

the respiration rate must increase to make up the difference in minute volume

thoracic aortic dissection - myocardial contusion - pulmonary contusion

these are lethal chest injuries that may be identified during the secondary assessment

traumatic asphyxia

these patterns of injuries are seen after a severe force is applied to the chest forcing blood from the great vessels back into the head and neck. this is characterized by JVD, cyanosis in the face and neck, hemorrhage into the sclera of the eye. it also suggests underlying injury to the heart and possible pulmonary contusion

sternal fractures

these types of fractures require a significant amount of force and creates an increased index of suspicion for injuries to underlying organs (lungs, great vessels, heart)

cardiogenic shock

this can be caused if the heart is damaged as it may not be able to refill with blood or blood may not be pumped with enough force out of the heart

over-ventilation

this can cause an increase in intra-thoracic pressure, reduce cardiac output and potentially worsen chest injuries such as a pneumothorax. additionally rapid respirations can cause acid-base imbalance and blood-gas imbalance

rib fractures

this can lacerate lung tissues and cause further vessel damage with every chest wall movement and can rapidly lead to hypovolemic shock

lung tissue bruising

this can result in exponential loss of surface area and leads to decreased oxygen and carbon dioxide exchange. it can also cause hypoxic (decrease in available oxygen) and hypercarbia (increase in carbon dioxide)

C6 and C7

this cervical region allows the chest to expand on contraction and allow for the active portion of ventilation to occur. a patient who has sustained an injury to this region may be unable to move the intercostal muscles and breath entirely with the diaphragm often called belly breathing.

parietal pleura

this covers the inner chest wall lining

visceral pleura

this covers the lungs

thoracic cage

this extends from the lower end of the neck to the diaphragm.

pleural fluid

this fluid between the parietal and visceral pleura allows the lungs to move freely against the inner chest wall as a person breaths.

neurovascular bundle

this is a network of nerves, arteries and veins lying closely along the inferior and slightly posterior to the lowest margin of each rib. it can be a significant source of bleeding into the pleural space

cyanosis

this is a sign of inadequate respiration. it is the classic blue or ashen gray appearance around the lips and fingernails indicating that blood is not being oxygenated sufficiently

jugular vein distention (JVD)

this is an indication of cardiac tamponade

pleuritic pain (pleurisy)

this is caused by irritation or damage to the pleural surfaces and causes a characteristic sharp or sticking pain with each breath when these normally smooth surfaces slide on one another.

tachypnea

this is known as rapid respirations

ventilation

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

oxygenation

this 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 (a waste product of cell function) must be removed from the body for proper organ system function

thoracic skin, muscle and bones

this lies underneath the normal three layers of skin; the epidermis, dermis and subcutaneous layers and lies striated or skeletal muscle. this muscle extends between the ribs forming the intercostal muscles.

phrenic nerve

this nerve controls the diaphragm, originates at C3, C4 and C5

blunt chest trauma

this type of trauma may fracture the ribs, sternum and chest walls; bruise the lungs, heart and even damage the aorta resulting in death or life threatening internal bleeding