EMT: Chapter 29 [chest injuries]
lung tissue
- right side: 3 lobes - left side: 2 lobes (space for heart -- cardiac notch) covered by the visceral pleura (thin membrane) lungs situated against parietal pleural (covers chest wall) - pleural fluid between linings allows lungs to move freely as person breathes
signs/symptoms of chest injury
- pain at the site of the injury -> tachypnea (deep breaths hurt) - pain localized at the site of the injury that is aggravated by breathing (pleuritic pain) - bruising to the chest wall - crepitus with palpation of the chest (air bubbles under skin) - any penetrating injury to the chest - dyspnea - hemoptysis (coughing up blood) - failure of chest to expand normally w inspiration - rapid/weak pulse w low BP - cyanosis
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 11. myocardial contusion 12. pulmonary contusion
Distended jugular veins, narrowing pulse pressure, and muffled heart tones are collectively known as _______.
Beck's triad
paradoxical motion
abnormality associated with multiple rib fractures in which one segment ("flail") of chest wall moves opposite the remainder of the chest during inspiration/expiration
tension pneumothorax
can occur when significant ongoing air accumulates in the pleural space first causes complete collapse of affected lung and then pushes mediastinum (central chest) into opposite pleural cavity - prevents blood from returning through venae cavae to the heart -> shock -> death signs: - chest pain - tachycardia - respiratory distress - absent lung sounds on affected side - signs of shock relief comes from inserting needle through rib cage into pleural space via ALS
distended jugular veins, a narrowing pulse pressure, and muffled heart sounds are seen in which of the following conditions?
cardiac tamponade
spinal cord injury at C3 and above
complete loss of breathing ability
intercostal muscles
contract upon inhalation, expanding and elevating rib cage innervated by C6 and C7 cervical spinal cord injury to C6/C7 may cause person to breathe entirely with diaphragm ("belly breathing")
The pliability of the pediatric rib cage _______.
increases the risk of internal injury
risks of BVM
overinflation: increased thoracic pressure, reduced cardiac output, worsening of chest injuries (i.e. pneumothorax) acid-base imbalance
Irritation or damage to the pleural surfaces that causes sharp chest pain during inhalation is called:
pleurisy
Following blunt trauma to the chest, an 18-year-old female presents with respiratory distress, shallow breathing, and cyanosis. Her blood pressure is 80/50 mm Hg and her pulse is 130 beats/min and thready. You should:
provide ventilation assistance with a BVM
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 saturation is 78%. His breath sounds are equal bilaterally and his jugular veins are normal. You should suspect:
pulmonary contusion
A patient with a chest injury has a blood pressure of 100/60 mm Hg and a pulse rate of 120 beats/min. Which of the following additional findings should make you suspect a pericardial tamponade?
repeat BP of 90/68 mm Hg
on inhalation, which of the following does NOT occur?
the pressure inside the chest increases
Children are often "belly breathers" because _______.
their intercostal muscles are not developed
The body's ability to move air in and out of the lungs is called _______.
ventilation
hemothorax
when blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel signs: - signs of shock without external bleeding - decreased breath sounds on affected side hemopneumothorax: air + blood (often result of penetrating trauma)
The phrenic nerves control the diaphragm and exit the spinal cord at:
C3, C4, C5
A flail chest occurs when:
a segment of the chest wall is detached from the thoracic cage
Pneumothorax is defined as:
accumulation of air in the pleural space
While jogging, a 19-year-old male experienced an acute onset of shortness 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:
administer O2 and transport to the hospital
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:
aggressively manage his airway
An open pneumothorax occurs when:
air enters the pleural space from outside the body (as opposed to from the lungs themselves)
pneumothorax
air enters through a hole in the chest wall as the patient attempts to breathe, causing the lung on that side to collapse if collapse is > 30-40%, you may hear diminished breath sounds (this will develop into a tension pneumothorax) can be caused by trauma, lung disease, spontaneously or by scuba-diving
Subcutaneous emphysema is an indication that:
air is escaping into the chest wall from a damaged lung
open pneumothorax (sucking chest wound)
an open or penetrating chest wall sound through which air passes during inspiration and expiration, creating a sucking sound purpose of occlusive dressing (commercial vented or improvised) is to seal wound and prevent air from being sucked in
simple pneumothorax
any pneumothorax that is free from significant physiologic changes and does not cause drastic changes in the vital signs of the patient signs: - dyspnea, increased breathing work - tachypnea, accessory muscle use - decreasing O2 saturation on pulse oximeter - sub emph late findings: - decrease breath sounds on injured side - lethargy - cyanosis adding positive- pressure ventilation will cause pneumothorax to advance rapidly; do not withhold if necessary
Which of the following blood vessels can be lacerated by a fractured rib?
aorta
commotio cordis
blunt chest injury caused by a sudden direct blow to the chest during a critical portion of a person's heartbeat, often leading to v-fib more commonly related to sports injuries with 35-40 mph speeds often results in cardiac arrest
Closed chest injuries are typically caused by _______.
blunt trauma
Patients with rib fractures will commonly:
breathe rapidly and shallowly
myocardial contusion
bruising of the heart muscle makes maintenance of adequate BP impossible note any pulse irregularities or changes in BP signs/symptoms often mimic a heart attack (chest pain that is cardiac in nature)
pulmonary contusion
bruising of the lungs should be suspected in patients with a flail chest; develops over a period of hours
scene size up
chest injuries most common in MVCs, falls, industrial incidents, accidents
Signs and symptoms of a tension pneumothorax include all of the following, EXCEPT:
collapsed jugular veins
You are transporting a stable patient with a possible pneumothorax. The patient is receiving high-flow oxygen and has an oxygen saturation of 95%. During your reassessment, you find that the patient is now confused, hypotensive, and profusely diaphoretic. What is MOST likely causing this patient's deterioration?
compression of the aorta and vena cava
flail chest
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 is effectively detached from the rest of the cage suggests forceful MOI that could have caused other serious internal damage major sign: paradoxical motion treatment: - maintaining the airway - providing respiratory support - giving supplemental O2 - performing ongoing assessments
________ in a patient with a chest injury is a sign that the blood is not being oxygenated sufficiently.
cyanosis
The thoracic cavity is separated from the abdominal cavity by the:
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?
engorged jugular veins
reassessment
every 5 minutes; chest wounds often worsen en route to hospital major points to recheck: - ABCs - effectiveness of interventions - comparison of vital signs - spinal immobilization
laceration of the great vessels
ex. superior/inferior vena cava, pulmonary arteries, pulmonary veins, aorta may be accompanied by signs of shock and rapid hemorrhage emergency treatment: - CPR - ventilatory support - supplementary O2 - immediate transport
A spontaneous pneumothorax would MOST likely occur as the result of:
exertion of a person with a congenital lung defect
rib fractures
extremely common especially in older people can present with pneumothorax if fracture penetrates into pleural space symptom: localized tenderness and pain when breathing signs: - pts will hold this area - pts will avoid taking deep breaths
In which condition is it recommended you use positive-pressure ventilation?
flail chest
Paradoxical motion is a sign of a _______.
flail chest
Common signs and symptoms of a chest injury include all of the following, EXCEPT:
hematemesis
You are assessing a patient and notice he has a collapsed jugular vein. What does this indicate?
hemothorax
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?
hemothorax
common signs and symptoms of tension pneumothorax include all of the following EXCEPT:
high BP
history taking
identify pertinent negatives, ex. - no SOB - no rapid breathing - no absent/abnormal breath sounds - no areas of abnormal movement (confirms nerve conduction to chest) asks questions about incident: - speed of vehicle, height of fall - use of safety equipment - type of weapon used - number of penetrating wounds
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 breathing. Further assessment reveals a large bruise to the left anterior chest, jugular venous distention, and unilaterally absent breath sounds. As your partner is supporting her ventilations, you should:
immediately request ALS support
primary assessment
in rapid physical, look for: - obvious injuries - blood - difficulty breathing - cyanosis - irregular breathing - chest rise/fall on one side - accessory muscle use - extended/engorged external jugular veins (sign of tension pneumothorax OR cardiac tamponade) - paradoxical motion open wounds: - use gloved hand to occlude - apply occlusive dressing if ventilation stops working, watch for signs of a tension pneumothorax
The treatment for relieving a tension pneumothorax involves:
inserting a needle through the rib cage into the pleural space
A simple pneumothorax:
is commonly caused by blunt chest trauma
which of the following statements regarding hemothorax is correct?
it can only be treated by a surgeon
You arrive at the scene of a major motor vehicle crash. The patient, a 50-year-old female, was removed from 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:
laceration of the aorta
When a patient sustains a spinal cord injury above the C3 region, which of the following is likely to happen?
loss of the ability to breathe due to loss of ability of phrenic nerves to function
Hemoptysis indicates damage to the _______.
lungs
Which of the following organs or structures does NOT reside within the mediastinum?
lungs
minute volume
mL of air moved through lungs in 1 minute
tidal volume
mL of air that is move in/out of lungs in a single breath
improvised occlusive dressing
may be taped to the patient on three sides (flutter valve-type) or on all four sides depending on protocol make sure dressing is not sucked into chest cavity
spinal cord injury at C5
may lose power to move intercostal muscles but diaphragm still should be able to contract ("belly breathing")
When a person is lying supine at the end of exhalation, the diaphragm:
may rise as high as the nipple line
diaphragm
may rise as high as the nipple line in supine patients penetrating injury to chest may penetrate it, along with the lung
The esophagus, trachea, and great vessels reside in the _______.
mediastinum
If a person's tidal volume decreases, but his or her respiratory rate remains unchanged:
minute volume will decrease
cardiac tamponade
more common with penetrating chest trauma occurs when pericardial sac fills with blood or fluid from a ruptured coronary vein - heart cannot pump adequate amount of blood signs: - distended jugular veins - narrowing pulse pressure - muffled heart sounds - decrease in mental status provide positive pressure and rapidly transport
If a patient with a chest injury is only able to inhale small amounts of air per breath, he or she:
must increase his/her respiratory rate to maintain adequate minute volume
A rapid, irregular pulse following blunt trauma to the chest is MOST suggestive of a:
myocardial contusion
a ________________ is the result of blunt chest trauma and is association with an irregular pulse and sometimes dangerous cardiac rhythms.
myocardial contusion
flutter valve (vented occlusive dressing)
one-way valve on vented occlusive dressing that allow air to leave the chest cavity but not return open on one side to allow air release if tension pneumothorax develops
What are the two most common injuries caused by penetrating chest trauma?
open pneumothorax, cardiac tamponade
you respond to a MVC and find a 29-year-old woman complaining of chest pain. her chest struck the steering wheel. her airway is open, she is breathing at 24 breaths/min, and she is coughing up blood. her pulse is 130 beats/min, rapid and weak, and her BP is 90/58 mm Hg. you notice cyanosis around the lips and note that her fingers are also blue. when you expose the chest, she tells you it hurts and points to a bruised spot. which of the following is a symptom?
pain at the site of the injury
Which of the following are you likely to see in flail chest?
paradoxical motion
A spinal cord injury at the level of C7 would MOST likely result in:
paralysis of the intercostal muscles
You have sealed the open chest wound of a 40-year-old male who was stabbed in the anterior chest. Your reassessment reveals that he is experiencing increasing respiratory distress and tachycardia, and is developing cyanosis. You should:
partially remove the dressing
The ________ nerves control the diaphragm.
phrenic
In order to avoid exacerbating a patient's injury, it is especially important to use extreme caution when providing positive-pressure ventilation to patients with a:
pneumothorax
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.
pneumothorax
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:
prepare for immediate transport
Immediately life-threatening chest injuries must be found and managed during the _______.
primary assessment
A patient who presents with profound cyanosis following a chest injury:
requires prompt ventilation and oxygenation
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?
rib fractures
When assessing a patient with a hemothorax, you will MOST likely find:
signs and symptoms of shock
What is the best position in which to place a patient when you want to assess for jugular vein distention?
sitting at a 45-degree angle
open chest injury
skin broken - caused by penetrating trauma do not attempt to move/remove impaled objects from the patient
closed chest injury
skin is not broken - caused by blunt trauma contusions in cardiac muscle and lung tissues - may lead to cardiogenic shock or hypoxia/hypercarbia can damage aorta -> rupture (1/3 of immediate MVC deaths) rib fractures can lacerate lung tissue and cause vessel damage -> hypovolemic shock
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:
stabilize the chest wall with a bulky dressing
secondary assessment
start with DCAP-BTLS to assess nature of thoracic injury; look for... - deformities (asymmetrical sides of chest/shoulder girdle) - specific points of contusion/abrasion - presence of puncture wounds/penetrating injuries - burns - tenderness - lacerations note initial presence of accelerated pulse or respiratory rates and later presence (preceding CP arrest) of slowing pulse and respiratory rates
other fractures
sternal: suggests forceful MOI clavicle: overlies and protects a large neurovascular bundle that can be damaged significantly -> severe pain
traumatic asphyxia
sudden severe compression of the chest which produces a rapid increase in pressure within the chest results in characteristic appearance: - distended neck veins - cyanosis in face/neck - hemorrhage into sclera of the eye
Patients with chest injuries will often present with _______.
tachypnea
What is ventilation?
the body's ability to move air in and out of the chest and lung tissue
Immediate death from blunt chest trauma following a motor vehicle crash is MOST often the result of:
traumatic aortic rupture
A 19-year-old male is unresponsive, apneic, and pulseless after being struck in the center of the chest with a softball. Based on the mechanism of injury, what MOST likely occurred?
ventricular fibrillation when the impact occurred during a critical portion of the cardiac cycle
Pleural fluid is contained between the:
visceral and parietal pleurae
