EMT Chapter 29 - Chest Injuries

Mechanisms of Ventiation

- *Inhalation:* intercostal muscles between the ribs contract, elevating and expanding the rib cage. > At the same time, the diaphragm contracts or flattens and pushes contents of the abdomen down. > Intrathoracic pressure inside chest decreases, creating a negative pressure differential. > Air enters lungs through nose and mouth (path to least resistance) - *Exhalation:* intercostal muscles and diaphragm relax, and the tissues move back to their normal positions, allowing air to be exhaled.

*Right lung has 3 lobes and left lung has 2 lobes*

- left lobe formation allows space for the heart to reside; this is called the cardiac notch.

*When you use an occlusive dressing to seal an open chest wound, record the type of material used, whether 3 or 4 sides were sealed, and any changes noted afterward: skin color, vital signs, breath sounds, and particularly the patient's level of anxiety.*

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Deadly Dozen Chest Injuries

1. Airway obstruction 2. Bronchial disruption 3. Diaphragmatic tear 4. Esophageal injury 5. Open pneumothorax 6. Tension pneumothorax 7. Massive hemothorax 8. Flail chest 9. Cardiac tamponade 10. Thoracic aortic dissection (leakage from a traumatic aneurysm of the portion of the aorta that lies within the chest) 11. Myocardial contusion 12. Pulmonary contusion

Commotio Cordis

A blunt chest injury caused by a sudden, direct blow to the chest that occurs only during the critical portion of a person's heartbeat.

hemothorax

A collection of blood in the pleural cavity.

flail chest

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.

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

*The skeletal muscle, innervated from spinal nerves originate in C6 and C7 (cervical region). Allows chest to expand on contraction and allow for 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*

traumatic asphyxia

A pattern of injuries seen after a severe force is applied to the chest, forcing blood from the great vessels back into the head and neck. - These findings suggest an underlying injury to the heart and possibly a pulmonary contusion

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.

tension pneumothorax

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

pneumothorax

An accumulation of air or gas in the pleural cavity.

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.

open chest injury

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.

closed chest injury

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

sucking chest wound

An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound. See also open pneumothorax.

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.*

simple pneumothorax

Any pneumothorax that is free from significant physiologic changes and does not cause drastic changes in the vital signs of the patient.

myocardial contusion

Bruising of the heart muscle.

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.

Ventilation

The body's ability to move air in and out of the chest and lung tissue - Any injury that affects the patient's ability to move air in and out of the chest is serious and may be life threatening.

pulmonary contusion

Injury or bruising of lung tissue that results in hemorrhage.

*Anatomy and Physiology of the Chest*

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

Hemopneumothorax

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

pericardium

The fibrous sac that surrounds the heart.

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.

Oxygenation

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.

*Rib Fractures*

Very common, particularly in older people - 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. - Patients with one or more cracked ribs will report localized tenderness and pain when breathing - pain is result of broken ends of fracture rubbing against each other during ventilation

Irritation or damage to the pleural surfaces that causes sharp chest pain during inhalation is called: a) pleurisy. b) dyspnea. c) pneumonitis. d) pneumothorax.

a) pleurisy.

An open pneumothorax occurs when: a) a fractured rib perforates the tissue of the lung. b) air enters the pleural space from outside the body. c) extreme pleural pressure causes the lung to rupture. d) air enters the pleural space from a perforated lung.

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

During your assessment of a patient with blunt chest trauma, you note paradoxical movement of the left chest wall. As your partner is administering oxygen to the patient, you should: a) request a paramedic to decompress the chest. b) document it, reassess lung sounds often, and continue your assessment. c) stabilize the chest wall with a bulky dressing. d) reassess the adequacy of the patient's breathing.

b) document it, reassess lung sounds often, and continue your assessment. OR, d) reassess the adequacy of the patient's breathing.

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

b) may rise as high as the nipple line.

Immediate death from blunt chest trauma following a motor vehicle crash is MOST often the result of: a) a tension pneumothorax. b) traumatic aortic rupture. c) penetrating lung injuries. d) a massive cardiac contusion.

b) traumatic aortic rupture.

Pneumothorax is defined as: a) accumulation of air between the lungs. b) blood collection within the lung tissue. c) accumulation of air in the pleural space. d) blood collection within the pleural space.

c) accumulation of air in the pleural space.

Laceration of the Great Vessels

chest contains several large blood vessels: the superior vena cava, the inferior vena cava, the pulmonary arteries, four main pulmonary veins, and the aorta - Any patient with a chest wound who shows signs of shock may have an injury to one or more of these vessels.

The tough, fibrous outer meningeal layer is called the: a) pia mater. b) arachnoid. c) gray mater. d) dura mater.

d) dura mater.

When assessing a patient with a hemothorax, you will MOST likely find: a) jugular venous engorgement. b) ipsilateral tracheal deviation. c) distant or muffled heart tones. d) signs and symptoms of shock.

d) signs and symptoms of shock.

*▶ Signs and Symptoms of Chest Injury*

▪ 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