thoracic trauma

What happens when a chest wound is larger than the normal pathway for air through the nose and mouth?

- atmospheric pressure forces the air through the open wound and into the thoracic cavity during inspiration - as the air builds up in the pleural space, the lung on the injured side collapses - lung begins to shift to the uninjured side - very little air enters the tracheobronchial tree to be exchanged with the intrapulmonary air on the affected side - this results in a decreased alveolar ventilation and decreased perfusion

How is a hemothorax caused?

- bleeding from the lung parenchyma or damaged vessels

Why is pulmonary contusions life-threatening?

- bleeding into the alveolar air spaces - prevents gas exchange because no air enters these alveoli from terminal airways

What is a pulmonary contusion?

- bruising of the lung tissue that results in rupture of the alveoli and interstitial edema

What are the signs and symptoms of rib fractures?

- chest pain - dyspnea - labored respirations - chest wall tenderness - crepitus

Who is the most common to get a clavicle fracture?

- children who fall on their shoulders or outstretched arms - it is also common in athletes involved in contact sports

What is the most commonly fractured bone?

- clavicle

Based on mechanism of injury what should the paramedic consider?

- closed pneumothorax - internal bleeding

What are pulmonary injuries?

- closed pneumothorax - open pneumothorax - tension pneumothorax - hemothorax - pulmonary contusion - traumatic asphyxia

What should the paramedic encourage the patient with a rib fracture to do?

- cough - breathe deeply - helps to prevent the collapse of the alveoli (atelectasis) and the potential for pneumonia and other complications

With flail chest what happens during inspiration?

- diaphragm descends (lowes the intrapleural pressure) - unstable chest wall is pushed inward by the negative intrathoracic pressure as the rest of the chest wall expands

With flail chest what happens during expiration?

- diaphragm rises - the intrapleural pressue exceeds atmospheric pressure - this causes the chest wall to move outward

What do sternal fractures usually result from?

- direct blow to the chest - striking a steering column or dashboard - massive crush injury

What is the pre-hospital care for traumatic asphyxia?

- ensuring a patent airway - providing adequate ventilations - caring for associated injuries - being prepared to manage hypovolemia and shock when the compressive force is released

In an open pneumothorax, why is the normal side adversely affected?

- expired air may enter the lung on the collapsed side - it then is rebreated into the functioning lung with the next ventilation - this may result in severe ventilatory dysfunction, hypoxemia, and death

Under what condition is pulmonary contusion is almost always present?

- flail segment

What are the causes of closed pneumothorax?

- fractured rib that penetrates the underlying rib - excessive pressure on the chest wall against a closed glottis - rupture or tearing of the lung parenchyma and visceral pleura from no demonstrable clause

What is the pre-hospital care for a hemothorax?

- high-concentration oxygen should be administered - ventilation support if necessary with bag-mask or endotracheal intubation - iv access - appropriate fluid therapy provided with a goal of maintaining adequate perfusion without large volume indiscriminately administered. - rapid transport to an appropriate facility capable of immediate surgical intervention

What are the signs and symptoms of a sternal fracture?

- history of significant anterior chest trauma - tenderness - abnormal motion or crepitation over the sternum - ECG changes

What can happen if blood fills the pleural space?

- lung collapse on affected side - mediastinum may shift away from the hemothorax, which would compromise the unaffected lung

Why do patient's with chest wall often develop hypoxia?

- lung contusion usually related to this injury - bleeding from the alveoli and the lung tissue causes the contusion - decreased vital capacity - vascular shunting of deoxygenated blood

What is the prehospital care for a sternal fracture?

- maintain a high degree of suspicion for associated injuries - airway management - ventilatory support - ECG monitoring - rapid transport to an appropriate medical facility

How is a pulmonary contusion caused?

- most often by rapid deceleration forces - forces push the lung against the chest wall - more than 50% of patients with blunt chest trauma have pulmonary contusion

Why is this flail chest usually not detected prehospital?

- muscle spasms that accompany the injury - within two hours the muscle spasms subside

If the second and first ribs are fractured, what injuries might you suspect?

- myocardial contusion - bronchial tears - vascular unjury

What is the pre-hospital care for a tension pneumothorax?

- needle decompression - brief removal of occlusive dressing if it has been applied - positive pressure ventilations should only be used if the patient is hypoxic and fails to respond to supplemental oxygen, as this may rapidly worsen the tension pneumothorax.

What is the prehospital care for an open pneumothorax?

- occlusive dressing - administer supplemental oxygen - watch for a tension pneumothorax (air is still entering the pleural space from the lung) - endotracheal intubation and positive-pressure ventilations may be necessary if above measures fail to support the patient adequately - if increasing respiratory distress develops, the dressing over the wound should be removed to aloow for decompression of any accumulated tension. - if removing occlusive dressing is ineffective consider needle decompression and positive-pressure ventilations if not already employed - treat shock if applicable

What are the signs and symptoms of a clavicle injury?

- pain - point tenderness - deformity

How do you confirm rib fractures?

- palpation - sometimes movement or grating of the bone ends (crepitus) can be felt

What will you see after muscles spasms with the patient who has a flail chest?

- paradoxical motion with inspiration and expiration

What does morbidity or mortality depend on with rib fractures?

- patient's age - the number and location of the fractures

What are the signs and symptoms of closed pneumothorax?

- pleuritic chest pain - dyspnea - tachypnea - breath sounds may be diminished or absent on the affected side - tympanic percussion note

What are associated injuries that often contribute to serious disability or death?

- pulmonary and myocardial contusion - flail chest - vascular disruption of thoracic vessels (rare) - intrabdominal injuries - head injury

Are rib fractures life-threatening?

- rarely

What is the pre-hospital management of rib fractures?

- reassurance - positioning of the patient's arm using a sling and swath - iv access - administration of oxygen and assisting ventilations may be necessary - administration of small doses of IV narcotic analgesics

What are the signs and symptoms of traumatic asphyxia?

- reddish purple discoloration of the face and neck (the skin below the area remains pink) - jugular vein distention - swelling or hemorrhage of the conjuctiva (subconjunctival petechiae may appear)

With a tension pneumothorax, what is emergency care directed at?

- reducing the pressure in the pleural space - returning the intrapleural pressure to atmospheric or subatmospheric levels

What is the goal of treatment for rib fractures?

- relieve the pain

Which ribs are most often broken?

- ribs 3 to 8 on lateral side - least protected

What are the signs and symptoms of an open pneumothorax?

- shortness of breath - pain - sucking or gurgling sounds as air moves in and out of the pleural space through the open chest wound - obvious respiratory distress - anxious - tachypneic - pulse tachycardic and thready

In an open pneumothorax, the severity of the injury is directly proportional to what?

- size of the wound

What does the treatment involve for a clavicle injury

- sling and swathe

Fractures to the lower ribs, may be associated with injuries to what?

- spleen - kidneys -liver

What are the complications of rib fractures?

- splinting which leads to actelectasis - ventilation-perfusion mismatch (ventilated alveioli that are not perfused or perfused alveoli that are not ventilated)

Why is their purple discoloration in traumatic asphyxia?

- subcutaneous venules and small capillaries rupture

What is the pre-hospital care for flail chest?

- supplemental oxygen - pulse oximetry - iv access if time allows - support of ventilations with bag-mask assistance, CPAP, or endotracheal intubation and positive-pressure ventilations

What are the signs and symptoms of a hemothorax?

- tachypnea - dyspnea - cyanosis (often not evident in hemorrhagic shock) - diminished or decreased breath sounds (dullness on percussion) - hypovolemic shock - narrow pulse pressure - tracheal deviation to the unaffected side (rare) - chest pain - confusion - pallor - percussion note is dull

What are the signs and symptoms of flail chest?

- tachypnea - shallow breathing - cyanosis - tenderness and bony crepitus on palpation - paradoxical motion (late sign) - floating segment moving opposite of chest

What are the signs and symptoms of pulmonary contusion?

- tachypnea - tachycardia - cough - hemoptysis - apprehension - respiratory distress - dyspnea - evidence of blunt chest trauma - cyanosis

what is a hemothorax?

- the accumulation of blood in the pleural space

What are sternal fractures associated with?

- unstable chest wall - myocardial injury - cardiac tamponade

What are causes of flail chest?

- vehicle crashes - falls - industrial accidents - assault - birth trauma

What is the pre-hospital care for pulmonary contusion?

- ventilatory support - supplemental oxygen with a goal of maintaining oxygen saturation in the normal range - CPAP when supplemental O2 proves to be inadequate for maintaing acceptable O2 saturation levels - support of ventilation with bag-mask or endotracheal intubation may be necessary - fluids should be administered only to maintain normal pulse and blood pressure

What are the signs and symptoms of a tension pneumothorax?

- anxiety, restlessness - cyanosis - increasing dyspnea - tracheal deviation (late sign) - tachycardia - hypotension or unexplained signs of shock - diminished or absent breath sounds on the injured side - distended neck veins (unless the patient is hypovolemic) - unequal expansion of the chest (tension does not fall with respiration - subcutaneous emphysema - apprehension - chest pain - agitation - tympanic percussion note - chest wall crepitus - tachypnea

How much blood can the thorax hold?

- 30% to 40% of the patient's blood volume - 2000 to 3000 mL

How much can a severed intercostal artery bleed?

- 50 mL per minute

What is a flail chest?

- a chest wall injury in which three or more adjacent ribs are fractured in two or more places

What is an open pneumothorax?

- a chest wall injury that exposes the pleural spce to atmospheric pressure

What is a closed pneumothorax

- a collection of air or gas in the pleural space that causes the lung to collapse without exposing the pleural space to atmospheric pressure - this air causes the lung to partly or totally collapse

what is a traumatic asphyxia?

- a severe crushing injury to the chest and abdomen that causes an increase in the intrathoracic pressure. - the increased pressure forces blood from the right side of the heart into the veins of the upper thorax, neck, and face.

What is the prehospital care for closed pneumothorax?

- administer supplemental oxygen - obtain iv access - prepare to treat for shock - monitor spo2 and capnography - if spinal immobilization is not necessary the patient may be more comfortable in a semi-recumbent position. - rapid transport is essential - watch for a tension pneumothorax

Ribs fractures are most likely to occur in adults or children?

- adults - younger patients have more resilient cartilage

When does the mortality rate increase with flail chest?

- advanced age - seven or more rib fractures - three or more associated injuries - shock - head injury

What happens when someone has a tension pneumothorax?

- air is allowed to leak into the pleural space during inspiration and becomes trapped during expiration - the pleural pressure increases - this increase in pressure produces a shift in the mediastinum - it further compresses the lung on the uninjured side - compression of the vena cava reduces venous return to the heart - decrease in cardiac output

What is the percentage of closed pneumothorax in a patient who has a penetrating trauma?

- almost 100%

What is a tension pneumothorax?

- an accumulation of air or gas in the pleural cavity that can lead to collapse of the lung