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Emt thoracic trauma

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Emt thoracic trauma

  1. 1. Thoracic Trauma Temple College EMS Professions
  2. 2. Chest Trauma <ul><li>Second leading cause of trauma deaths after head injury </li></ul><ul><li>About 20% of all trauma deaths </li></ul>
  3. 3. Chest Trauma <ul><li>Initial exam directed toward: </li></ul><ul><ul><li>Open pneumothorax </li></ul></ul><ul><ul><li>Flail chest </li></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Massive hemothorax </li></ul></ul><ul><ul><li>Cardiac tamponade </li></ul></ul>
  4. 4. Rib Fracture <ul><li>Most common chest injury </li></ul><ul><li>More common in adults than children </li></ul><ul><li>Especially common in elderly </li></ul><ul><li>Ribs form rings </li></ul><ul><ul><li>Consider possibility of break in two places </li></ul></ul>
  5. 5. Rib Fracture <ul><li>Most commonly 5th to 9th ribs </li></ul><ul><li>Poor protection </li></ul>
  6. 6. Rib Fracture <ul><li>Fractures of 1st, 2nd ribs require high force </li></ul><ul><li>Frequently have injury to aorta or bronchi </li></ul><ul><li>30% will die </li></ul>
  7. 7. Rib Fracture <ul><li>Fractures of 8th to 12th ribs can damage underlying abdominal solid organs: </li></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Spleen </li></ul></ul><ul><ul><li>Kidneys </li></ul></ul>
  8. 8. Rib Fracture <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Localized pain, tenderness </li></ul></ul><ul><ul><li>Increases when patient: </li></ul></ul><ul><ul><ul><li>Coughs </li></ul></ul></ul><ul><ul><ul><li>Moves </li></ul></ul></ul><ul><ul><ul><li>Breathes deeply </li></ul></ul></ul><ul><ul><li>Chest wall instability </li></ul></ul><ul><ul><li>Deformity, discoloration </li></ul></ul><ul><ul><li>Associated pneumo or hemothorax </li></ul></ul>
  9. 9. Rib Fracture <ul><li>Management </li></ul><ul><ul><li>High concentration O 2 </li></ul></ul><ul><ul><li>Splint using pillow, swathes </li></ul></ul><ul><ul><li>Encourage patient to breath deeply </li></ul></ul>
  10. 10. Rib Fracture <ul><li>Management </li></ul><ul><ul><li>Monitor elderly and COPD patients carefully </li></ul></ul><ul><ul><ul><li>Broken ribs can cause decompensation </li></ul></ul></ul><ul><ul><ul><li>Patients will fail to breath deeply and cough, resulting in poor clearance of secretions </li></ul></ul></ul>
  11. 11. Flail Chest <ul><li>Two or more adjacent ribs broken in two or more places </li></ul><ul><li>Produces free-floating chest wall segment </li></ul><ul><li>Usually secondary to blunt trauma </li></ul><ul><li>More common in older patients </li></ul>
  12. 12. Flail Chest <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Paradoxical movement </li></ul></ul><ul><ul><ul><li>May NOT be present initially due to intercostal muscle spasms </li></ul></ul></ul><ul><ul><ul><li>Be suspicious in any patient with chest wall: </li></ul></ul></ul><ul><ul><ul><ul><li>Tenderness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Crepitus </li></ul></ul></ul></ul>
  13. 13. Flail Chest <ul><li>Consequences </li></ul><ul><ul><li>Pain, leading to decreased ventilation </li></ul></ul><ul><ul><li>Increased work of breathing </li></ul></ul><ul><ul><li>Contusion of lung </li></ul></ul>
  14. 14. Flail Chest <ul><li>Management </li></ul><ul><ul><li>Establish airway </li></ul></ul><ul><ul><li>Suspect spinal injuries </li></ul></ul><ul><ul><li>Assist ventilation with BVM and oxygen </li></ul></ul><ul><ul><li>Stabilize chest wall </li></ul></ul>
  15. 15. Simple Pneumothorax <ul><li>Air in pleural space </li></ul><ul><li>Partial or complete lung collapse occurs </li></ul>
  16. 16. Simple Pneumothorax <ul><li>Causes </li></ul><ul><ul><li>Chest wall penetration </li></ul></ul><ul><ul><li>Fractured rib lacerating lung </li></ul></ul><ul><ul><li>Paper bag effect </li></ul></ul><ul><ul><li>May occur spontaneously following: </li></ul></ul><ul><ul><ul><li>Exertion </li></ul></ul></ul><ul><ul><ul><li>Coughing </li></ul></ul></ul><ul><ul><ul><li>Air Travel </li></ul></ul></ul>
  17. 17. Simple Pneumothorax <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Pain on inhalation </li></ul></ul><ul><ul><li>Difficulty breathing </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Decreased or absent breath sounds </li></ul></ul>Severity of symptoms depends on size of pneumothorax, speed of lung collapse, and patient’s health status
  18. 18. Simple Pneumothorax <ul><li>Management </li></ul><ul><ul><li>Establish airway </li></ul></ul><ul><ul><li>Suspect spinal injury based on mechanism </li></ul></ul><ul><ul><li>High concentration O 2 with NRB </li></ul></ul><ul><ul><li>Assist decreased or rapid respirations with BVM </li></ul></ul><ul><ul><li>Monitor for tension pneumothorax </li></ul></ul>
  19. 19. Open Pneumothorax <ul><li>Hole in chest wall </li></ul><ul><li>Allows air to enter pleural space </li></ul><ul><li>Larger hole = Greater chance air will enter there than through trachea </li></ul>“ Sucking Chest Wound”
  20. 20. Open Pneumothorax <ul><li>Management </li></ul><ul><ul><li>Close hole with occlusive dressing </li></ul></ul><ul><ul><li>High concentration O 2 </li></ul></ul><ul><ul><li>Assist ventilations </li></ul></ul><ul><ul><li>Consider transport on injured side </li></ul></ul><ul><ul><li>Monitor for tension pneumothorax </li></ul></ul>
  21. 21. Tension Pneumothorax <ul><li>One-way valve forms in lung or chest wall </li></ul><ul><li>Air enters pleural space; cannot leave </li></ul><ul><li>Air is trapped in pleural space </li></ul><ul><li>Pressure rises </li></ul><ul><li>Pressure collapses lung </li></ul>
  22. 22. Tension Pneumothorax <ul><li>Trapped air pushes heart, lungs away from injured side </li></ul><ul><li>Vena cavae become kinked </li></ul><ul><li>Blood cannot return to heart </li></ul><ul><li>Cardiac output falls </li></ul>
  23. 23. Tension Pneumothorax <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Extreme dyspnea </li></ul></ul><ul><ul><li>Restlessness, anxiety, agitation </li></ul></ul><ul><ul><li>Decreased breath sounds </li></ul></ul><ul><ul><li>Hyperresonance to percussion </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Subcutaneous emphysema </li></ul></ul>
  24. 24. Tension Pneumothorax <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Rapid, weak pulse </li></ul></ul><ul><ul><li>Decreased BP </li></ul></ul><ul><ul><li>Tracheal shift away from injured side </li></ul></ul><ul><ul><li>Jugular vein distension </li></ul></ul>Early dyspnea/hypoxia - Late shock
  25. 25. Tension Pneumothorax <ul><li>Management </li></ul><ul><ul><li>Secure airway </li></ul></ul><ul><ul><li>High concentration O 2 with NRB </li></ul></ul><ul><ul><li>If available, request ALS intercept for pleural decompression </li></ul></ul>
  26. 26. Hemothorax <ul><li>Blood in pleura space </li></ul><ul><li>Most common result of major chest wall trauma </li></ul><ul><li>Present in 70 to 80% of penetrating, major non-penetrating chest trauma </li></ul>
  27. 27. Hemothorax <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Rapid, weak pulse </li></ul></ul><ul><ul><li>Cool, clammy skin </li></ul></ul><ul><ul><li>Restlessness, anxiety </li></ul></ul><ul><ul><li>Thirst </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Collapsed neck veins </li></ul></ul>
  28. 28. Hemothorax <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Decreased breath sounds </li></ul></ul><ul><ul><li>Dullness to percussion </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Ventilatory failure </li></ul></ul>Shock precedes ventilatory failure
  29. 29. Hemothorax <ul><li>Management </li></ul><ul><ul><li>Secure airway </li></ul></ul><ul><ul><li>Assist breathing with high concentration O 2 </li></ul></ul><ul><ul><li>Rapid transport </li></ul></ul>
  30. 30. Traumatic Asphyxia <ul><li>Blunt force to chest causes </li></ul><ul><ul><li>Increased intrathoracic pressure </li></ul></ul><ul><ul><li>Backward flow of blood out of heart into vessels of upper chest, neck, head </li></ul></ul>
  31. 31. Traumatic Asphyxia <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Possible sternal fracture or central flail chest </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Purplish-red discoloration of: </li></ul></ul><ul><ul><ul><li>Head </li></ul></ul></ul><ul><ul><ul><li>Neck </li></ul></ul></ul><ul><ul><ul><li>Shoulders </li></ul></ul></ul><ul><ul><li>Blood shot, protruding eyes </li></ul></ul><ul><ul><li>Swollen, cyanotic lips </li></ul></ul>
  32. 32. Traumatic Asphyxia Name given because patients looked like they had been strangled or hanged
  33. 33. Traumatic Asphyxia <ul><li>Management </li></ul><ul><ul><li>Airway with C-spine control </li></ul></ul><ul><ul><li>Assist ventilations with high concentration O 2 </li></ul></ul><ul><ul><li>Spinal stabilization </li></ul></ul><ul><ul><li>Rapid transport </li></ul></ul>
  34. 34. Cardiovascular Trauma Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise
  35. 35. Myocardial Contusion <ul><li>Bruise of heart muscle </li></ul><ul><li>Most common blunt cardiac injury </li></ul><ul><li>Usually due to steering wheel impact </li></ul>
  36. 36. Myocardial Contusion <ul><li>Behaves like acute MI </li></ul><ul><ul><li>May produce arrhythmias </li></ul></ul><ul><ul><li>May cause cardiogenic shock, hypotension </li></ul></ul>
  37. 37. Myocardial Contusion <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Cardiac arrhythmias after blunt chest trauma </li></ul></ul><ul><ul><li>Angina-like pain unresponsive to nitroglycerin </li></ul></ul><ul><ul><li>Chest pain independent of respiratory movement </li></ul></ul>Suspect in all blunt chest trauma
  38. 38. Myocardial Contusion <ul><li>Management </li></ul><ul><ul><li>High concentration O 2 </li></ul></ul><ul><ul><li>Transport </li></ul></ul><ul><ul><li>Consider ALS intercept </li></ul></ul>
  39. 39. Cardiac Tamponade <ul><li>Rapid accumulation of blood in space between heart, pericardium </li></ul><ul><li>Heart compressed </li></ul><ul><li>Blood entering heart decreases </li></ul><ul><li>Cardiac output falls </li></ul>
  40. 40. Cardiac Tamponade <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Hypotension unresponsive to treatment </li></ul></ul><ul><ul><li>Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP) </li></ul></ul><ul><ul><li>Small quiet heart (decreased heart sounds) </li></ul></ul>Beck’s Triad
  41. 41. Cardiac Tamponade <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Narrowing pulse pressure </li></ul></ul><ul><ul><li>Pulsus paradoxicus </li></ul></ul><ul><ul><ul><li>Radial pulse becomes weak or disappears when patient inhales </li></ul></ul></ul>
  42. 42. Cardiac Tamponade <ul><li>Management </li></ul><ul><ul><li>Secure airway </li></ul></ul><ul><ul><li>High concentration O 2 </li></ul></ul><ul><ul><li>Rapid transport </li></ul></ul><ul><ul><li>Definitive treatment is pericardiocentesis followed by surgery </li></ul></ul>
  43. 43. Traumatic Aortic Aneurysm <ul><li>Caused by sudden decelerations, massive blunt force: </li></ul><ul><ul><li>Vehicle collisions </li></ul></ul><ul><ul><li>Falls from heights </li></ul></ul><ul><ul><li>Crushing chest trauma </li></ul></ul><ul><ul><li>Blunt chest trauma </li></ul></ul><ul><ul><li>Animal kicks </li></ul></ul>
  44. 44. Traumatic Aortic Aneurysm <ul><li>Rupture usually occurs just beyond left subclavian artery </li></ul><ul><li>Attachment of aorta to pulmonary artery at this point produces shearing force on aortic arch </li></ul>
  45. 45. Traumatic Aortic Aneurysm <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Increased BP in arms in absence of head injury </li></ul></ul><ul><ul><li>Decreased femoral pulses with full arm pulses </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Ache in chest, shoulders, lower back, abdomen. (Only 25% of patients) </li></ul></ul>Detection requires high index of suspicion
  46. 46. Traumatic Aortic Aneurysm <ul><li>Management </li></ul><ul><ul><li>High concentration oxygen </li></ul></ul><ul><ul><li>Assist ventilation </li></ul></ul><ul><ul><li>Suspect spinal injury </li></ul></ul><ul><ul><li>Rapid transport </li></ul></ul>
  47. 47. Associated Abdominal Trauma <ul><li>Diaphragm forms dome that extends up into rib cage </li></ul><ul><li>Trauma to chest below 4th rib = Abdominal injury until proven otherwise </li></ul>

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