Alexander ch38 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 38
Thoracic Trauma

• The Advanced EMT applies fundamental
knowledge to provide basic and selected
advanced emergency care and transportation
based on assessment findings for an acutely
injured patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Explain the relationship between an intact thoracic cavity
and lungs, and ventilation, oxygenation, and respiration.
3. Relate mechanism of injury to the potential for specific
types of chest trauma.
4. Relate assessment findings to suspicion for specific
types of chest injuries.
Objectives (1 of 2)

5. Explain the pathophysiology and management of the
following types of chest injuries: blunt cardiac injury,
commotio cordis, flail chest, hemothorax, myocardial
contusion, open pneumothorax, penetrating cardiac
injury, pericardial tamponade, pulmonary contusion, rib
fractures, simple pneumothorax, tension pneumothorax,
and traumatic asphyxia.
Objectives (2 of 2)

Introduction (1 of 2)
• Organs of thoracic cavity are responsible for
ventilation, respiration, circulation.
• Injury to them can quickly lead to death from
hypoxia, hypercarbia, blood loss.
• Injury can occur on anterior, lateral, posterior
thorax surface.
• Impact or penetration can result in injury to vital
organs.

Introduction (2 of 2)
• Blunt trauma
– Motor vehicle collisions, falls, assaults, crush injuries
– 20% to 25% of all trauma deaths
• Penetrating trauma
– Shootings, stabbings, flying debris from explosions
• Recognize and treat thoracic injuries promptly and
properly; address problems with breathing and
circulation.

Think About It
• What injuries might the patient have sustained as
a result of the gunshot wound?
• What additional information do Byron and Angela
need at this point?
• How does the mechanism of injury play a part in
Bryon and Angela’s transport destination
decision?

Figure 38-1
The thoracic cavity.

Anatomy and Physiology Review (1 of 7)
• Thoracic cavity (chest) is within upper torso.
• Separated from abdominal cavity by diaphragm
• Mediastinum immediately behind sternum.
– Contains portions of esophagus, trachea, great
vessels, heart
• Lungs on either side of mediastinum

• Organs within thoracic cavity are protected on
anterior surface by sternum, clavicles, ribs,
pectoral muscles of chest.
• Lateral walls of thorax are protected by ribs.
• Posterior wall of thorax are protected by spine,
scapula, posterior ribs.

• The lungs and ventilation
– Providing oxygen for cellular metabolism and
eliminating carbon dioxide requires:
 Ventilation
 Respiration
– External
– Internal

• The lungs and ventilation (continued)
– Ventilation requires:
 Intact brainstem, nerve pathways, intact chest wall, pleura,
lungs
– External respiration requires:
 Adequate perfusion and ventilation
 Alveoli and capillaries must be in close contact with each other
– Internal respiration requires:
 Adequate onloading and offloading of oxygen
 Adequate circulation

• The lungs and ventilation (continued)
– Thoracic cavity lined with pleura
 Visceral and parietal pleura
– Inspiration
– Expiration

• The heart
– Located at the center of chest below sternum.
– Responsible for:
 Perfusing the body with nutrients,chemical messengers, and
oxygen-rich blood
– Bringing carbon dioxide back to lungs for elimination
– Pericardium
 Tough membrane that surrounds heart
 Visceral
 Parietal

• The heart (continued)
– Vena cava carries deoxygenated venous blood from
circulation back to right side of heart.
– Blood from right ventricle is circulated to lungs by way
of pulmonary arteries.
– Once blood circulates through lungs for gas exchange,
it returns to left side of heart via pulmonary veins.
– Blood leaves left side of heart to be circulated through
systemic circulation through aorta.
– Coronary arteries
 Supply blood to the myocardium during diastole

General Assessment and Management
of Thoracic Trauma (1 of 11)
• Injuries to thorax classified as blunt or penetrating
– May cause injury to internal organs of thorax
• During assessment
– Inspect, palpate, assess thorax on all sides.
– Do not overlook additional wounds.

• Ensure open airway.
– Assist ventilations as needed
– Provide O2 to maintain minimum SpO2 of 95%.
• Monitor ECG, SpO2, and EtCO2.
• Treat for shock when indicated.
• Consider need for immediate surgical intervention.
• Transport patient to appropriate facility.

• Scene size-up
– Ensure scene is safe.
– Identify number of patients.
– Call for additional resources as needed.
– Ensure Standard Precautions selected are adequate.
– Consider mechanism of injury (MOI).
– Consider need for manual stabilization of spine.
– Form general impression.

• Primary assessment
– If unresponsive, immediately check for pulse.
– If pulse not present, begin CPR.
– Ensure patent airway.
– Assess breathing; assist with bag-valve-mask device
and supplemental oxygen if needed.
– Check pulse.

• Primary assessment (continued)
– Control significant bleeding with direct pressure.
– Administer oxygen if needed.
– Maintain patient’s SpO2 at 95% or above.
– High priority transport
– Rapidly extricate critical trauma patients in vehicles.
– Make decisions about need and feasibility for ALS
response and air medical transportation early.

• Secondary assessment: rapid trauma assessment
– Expose patient.
 Check head, neck, chest, abdomen, pelvis, extremities for
potentially life-threatening injuries.
– Quickly palpate and auscultate chest to check for injury
and equality of breath sounds.
– Immediately cover open injury of neck or chest.
– Do not forget that the back is part of the chest.

• Signs of chest trauma
– Cyanosis
– Tachypnea
– Dyspnea
– Soft-tissue injury to thorax
– Penetrating trauma to thorax with or without presence
of sucking chest wound
– Decreased or absent breath sounds in lung field

• Signs of chest trauma (continued)
– Paradoxical movement of chest
– Hemoptysis, or bloody sputum
– Subcutaneous emphysema
– Jugular venous distention (JVD)
– Tracheal deviation (late sign)
– Shock

• Secondary assessment: vital signs, monitoring
devices, history, and physical exam
– Obtain baseline vital signs.
– Perform head-to-toe or focused assessment.
– Treat life-threatening injuries when found.
– Critical patients: medical history en route
– Unconscious: look for medical identification jewelry and
medications

• Communication and documentation
– Serious thoracic injuries require immediate physician
evaluation and intervention.
– Notify hospital.
– Request specific orders from medical direction.
– Include what is pertinent so that preparations can be
made.
– Record details in PCR.

• Reassessment
– Anticipate potential for developing problems with
ventilation and perfusion.
– Perform reassessment every 5 minutes for critical
patients, every 15 minutes for noncritical patients.
– Pay close attention to vital signs and signs of patient
deterioration.

Think About It
• What further assessments or treatments should
Byron and Angela perform en route?
• What additional information is important for Byron
and Angela to know?

Figure 38-2
Penetrating trauma to the anterior chest. (© Edward T. Dickinson, MD)

Types of Thoracic Injuries (1 of 3)
• Open chest injury
– Penetrating or blunt trauma to thorax in which integrity
of thoracic wall is broken
– Identify MOI
 Look for entrance and exit wounds.
 Identify the weapon’s length and width.
– Injury to trachea, esophagus, diaphragm, heart, great
vessels
 Can result in very rapid deterioration of patient
 Results in death from hypoxia, massive blood loss

• Open chest injury (continued)
– Pneumothorax
 Air accumulates in pleural space in presence of open
chest wound.
– Sucking chest wounds
 Patient breathes in, outside air is drawn into thoracic cavity,
making sucking sound.
 You may see bubbling of blood as air escapes through
wound.

• Closed chest injury
– Caused by blunt trauma
– Evaluate MOI.
– Broken bones may lacerate or penetrate internal
organs.
 Can cause massive internal hemorrhage

Specific Thoracic Injuries (1 of 13)
• Rib fracture
– Results from blunt or penetrating trauma
– Can cause internal bleeding, severe pain, hypoxia,
lung injury
– Suspect underlying injury if one or more ribs injured
– Assess during primary assessment.
 Ensure adequate ventilation and oxygenation.

• Signs and symptoms of rib fractures
– Pain or tenderness at injury site
– Contusions
– Open wounds
– Crepitus
– Guarding
– Pain on inspiration
– Hypoventilation
– Hypoxia
– Hypercarbia

• Rib fracture
– No definitive treatment in prehospital environment.
– Maintain adequate airway, breathing, circulation.
– Allow patient to sit in position of comfort.
– Monitor ECG, SpO2, and EtCO2.
– Apply sling and swathe to reduce pain.

Figure 38-3
Paradoxical movement of a flail segment.

• Flail chest
– Two or more ribs are broken in two or more places;
segment detached from rib cage.
– Segment floats during inspiration and expiration,
causing paradoxical movement of chest.
– Life-threatening injury
 Interferes with ventilation
– Flail segments penetrate into the lungs, resulting in
pulmonary contusion or laceration

Figure 38-4
Pulmonary contusion results in bleeding into and around the alveoli, reducing the ability of
gas exchange to take place.

• Flail chest—pulmonary contusion
– Injury to lung tissue that decreases ability of gas
exchange to take place, leading to hypoxemia
– Swelling and bleeding in lung increase the distance
between alveoli and capillaries.

• Flail chest—signs and symptoms
– Pain or tenderness at injury site
– Dyspnea
– Contusions
– Crepitus
– Paradoxical movement
– Guarding
– Pain on inspiration
– Hypoxia/hypercarbia

• Flail chest—treatment
– Immediately ensure adequacy of ABCs.
– Consider CPAP or assisted ventilation if hypoxia or
hypoventilation are present.

• Pneumothorax
– Simple
 Air within closed pleural space
– Open
 Open chest injury allows air to be sucked into pleural space
during ventilation.
– Tension
 Uncommon; immediate threat to life; air accumulates within
pleural space and cannot escape

• Pneumothorax (continued)
– Tracheal deviation
 Mediastinal shift associated with tension pneumothorax
 Late sign; not always evident
– Do not rely on presence of tracheal deviation to
suspect tension pneumothorax.
– Tension pneumothorax can occur with both open and
closed thoracic injuries.

• Pneumothorax
– Signs and symptoms
 Tachypnea
 Diminished or absent
breath sounds
 Tachycardia
 Hypoxia
 JVD
 Cyanosis
 Subcutaneous emphysema
 Unequal chest expansion
 Extreme anxiety
 Increased resistance
 Tracheal deviation
 Shock
 Worsening condition

Figure 38-6
Securing the occlusive dressing on three sides assists with preventing the development of
tension pneumothorax.

• Pneumothorax (continued)
– Prevent condition from progressing to tension
pneumothorax
– Sucking chest wound
 Immediately cover with gloved hand to prevent air from
entering into wound.
 Cover with occlusive dressing; secure on three sides.

• Hemothorax
– Accumulation of blood in pleural space
– Result of blunt or penetrating trauma
– Same emergency management as pneumothorax
– Tension hemothorax may develop; use same treatment
as tension pneumothorax.

• Traumatic asphyxia
– Sudden massive compression forces applied to chest
– Patient appears to be asphyxiated.
– Signs and symptoms
 Bluish-purple discoloration of upper chest, neck, head; jugular
venous distention (JVD); conjunctival hemorrhage; edema of
tongue and lips

Blunt Cardiac Injury (1 of 4)
• When blunt trauma to chest occurs with enough
force, heart can be injured by:
– Impact with sternum
– Being compressed between sternum and spine
• Heart can sustain contusion; can lead to
decreased cardiac output and shock.

• Myocardial contusion
– Bruising of heart muscle
– Result of a force causing vessels within myocardium to
rupture
– Chest pain
– Signs of heart failure or cardiogenic shock
– Cardiac arrhythmias

• Commotio cordis
– Sudden cardiac arrest resulting from sudden blow to
center of chest
– Impacts of certain velocity during particularly
vulnerable phase in cardiac electrical cycle
– Has occurred in martial arts, baseball, other sports

• Pericardial tamponade
– Pressure increases inside pericardial sac as result of
accumulation of blood, leading to decrease in cardiac
output
– Low-velocity penetrating trauma to chest.
– Life-threatening condition
– If impaled object, do not remove it.
– Signs and symptoms: Beck’s Triad
 Hypotension
 Distended neck veins
 Muffled heart sounds

Chapter Summary (1 of 2)
• When thoracic trauma present, pay close attention
to MOI and patient’s clinical signs and symptoms.
• Because organs and vessels contained within
thoracic cavity are vital to sustaining life, maintain
high index of suspicion that underlying injury
present.

Chapter Summary (2 of 2)
• When life-threatening injury to thorax exists, act
immediately to prevent deterioration of patient’s
condition.
• Assessment skills and knowledge of appropriate
treatment will reduce morbidity and mortality.

Alexander ch38 lecture

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