2. Statistics
Chest injuries are the second leading cause of
trauma deaths each year.
Most thoracic injuries (90% of blunt trauma and
70% to 85% of penetrating trauma) can be
managed without surgery.
3. Main Causes of Chest Trauma
Blunt Trauma- Blunt force to chest.
Penetrating Trauma- Projectile that enters
chest causing small or large hole.
Compression Injury- Chest is caught
between two objects and chest is
compressed.
7. Rib Fractures
Pathophysiology
Most often caused by blunt trauma
Ribs 3 to 8 are fractured most often (they are thin
and poorly protected)
Respiratory restriction as a result of pain and
splinting
Intercostal vessel injury
Associated complications
– First and second ribs are injured by severe
trauma
– Tracheobronchial tree injury
– Vascular injury
8. Rib Fractures
Assessment findings
– Localized pain
– Pain that worsens with movement, deep
breathing, coughing
– Point tenderness
Most patients can localize the fracture by pointing
to the area (confirmed by palpation).
– Crepitus or audible crunch
9. Rib Fractures
Management
Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation
– Encourage coughing and deep breathing
Pharmacological
– Analgesics
– Intercostal block
– Epidural block
11. Flail Chest
Pathophysiology
Two or more adjacent ribs fractured in two
or more places producing a free-floating
segment of chest wall
Flail chest usually results from direct impact.
14. Flail Chest
Pathophysiology (2 of 2)
Respiratory failure due to:
– Underlying pulmonary contusion
The blunt force of the injury typically
produces an underlying pulmonary
contusion.
– Associated intrathoracic injury
– Inadequate bellows action of the chest
15.
16. S/S of Flail Chest
Chest wall contusion
Respiratory distress
Paradoxical chest wall movement
Pleuritic chest pain
Crepitus
Pain and splinting of affected side
Tachypnea
Tachycardia
18. Flail Chest
Management
Airway and ventilation
– High-concentration oxygen.
– Positive-pressure ventilation may be needed.
» Reverses the mechanism of paradoxical
chest wall movement
» Restores the tidal volume
» Reduces the pain of chest wall movement
» Assess for the development of a
pneumothorax
– Evaluate the need for endotracheal intubation.
– Stabilize the flail segment (controversial).
19. Bulky Dressing for splint of Flail
Chest
Use Trauma bandage
and Triangular
Bandages to splint
ribs.
20. Flail Chest
Morbidity/Mortality
Significant chest trauma
Mortality rates 20% to 40% due to
associated injuries
Mortality increased with
–
–
–
–
–
Advanced age
Seven or more rib fractures
Three or more associated injuries
Shock
Head injuries
23. Closed (Simple) Pneumothorax
Pathophysiology
May occur in the absence of rib fractures from:
– A sudden increase in intrathoracic pressure
generated when the chest wall is compressed
against a closed glottis (the paper-bag effect)
» Results in an increase in airway pressure and
ruptured alveoli, which lead to a
pneumothorax
Small tears self-seal; larger ones may progress.
Ventilation/perfusion mismatch.
26. Closed Pneumothorax
Management
Airway and ventilation
– High-concentration oxygen.
– Positive-pressure ventilation if necessary.
– If respiration rate is <12 or >28 per minute,
ventilatory assistance with a
bag-valve mask may be indicated.
28. Open Pneumothorax
Opening in chest cavity that allows air to enter
pleural cavity
Causes the lung to collapse due to increased
pressure in pleural cavity
Can be life threatening and can deteriorate
rapidly
29.
30. Open Pneumothorax
Pathophysiology (1 of 2)
An open defect in the chest wall (>3 cm)
– If the chest wound opening is greater than twothirds the diameter of the trachea, air follows the
path of least resistance through the chest wall
with each inspiration.
– As the air accumulates in the pleural space, the
lung on the injured side collapses and begins to
shift toward the uninjured side.
38. S/S of Open Pneumothorax
Dyspnea
Sudden sharp pain
Subcutaneous Emphysema
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound
( Sucking chest wound)
39. Open Pneumothorax
Management (1 of 2)
Airway and ventilation:
– High-concentration oxygen.
– Positive-pressure ventilation if necessary.
– Assist ventilations with a bag-valve device and
intubation as necessary.
– Monitor for the development of a tension
pneumothorax.
Circulation—treat for shock with crystalloid
infusion.
40. Open Pneumothorax
Management (2 of 2)
Nonpharmacological
– Occlude the open
wound—apply an
occlusive petroleum
gauze dressing (covered
with sterile dressings)
and secure it with tape.
42. Plus Care
Monitor Heart Rhythm
Establish IV Access and Draw Blood
Samples
Airway Control that may include Intubation
Monitor for Tension Pneumothorax
43. Tension Pneumothorax
Air builds in pleural space with no where
for the air to escape
Results in collapse of lung on affected side
that results in pressure on mediastium,the
other lung, and great vessels
44. Tension Pneumothorax
Pathophysiology
Occurs when air enters the pleural space from a
lung injury or through the chest wall without a
means of exit.
Results in death if it is not immediately recognized
and treated.
When air is allowed to leak into the pleural space
during inspiration and becomes trapped during
exhalation, an increase in the pleural pressure
results.
45. Tension Pneumothorax Pathophysiology
(2 of 2)
Increased pleural pressure produces
mediastinal shift.
Mediastinal shift results in:
– Compression of the uninjured lung
– Kinking of the superior and inferior vena cava,
decreasing venous return to the heart, and
subsequently decreasing cardiac output
49. Tension Pneumothorax Assessment
Findings (1 of 3)
Extreme anxiety
Cyanosis
Increasing dyspnea
Difficult ventilations while being assisted
Tracheal deviation (a late sign)
Hypotension
50. Tension Pneumothorax Assessment
Findings (3 of 3)
Bulging of the intercostal muscles
Subcutaneous emphysema
Jugular venous distention (unless
hypovolemic)
Unequal expansion of the chest (tension
does not fall with respiration)
Hyperresonnace to percussion
52. Tension Pneumothorax Management
Emergency care is directed at reducing the
pressure in the pleural space.
Airway and ventilation:
– High-concentration oxygen
– Positive pressure ventilation if necessary
Circulation—relieve the tension
pneumothorax to improve cardiac output.
53. Tension Pneumothorax Management (2 of 5)
Nonpharmacological
– Occlude open wound
– Needle thoracostomy
– Tube thoracostomy—in-hospital management
55. Tension Pneumothorax Management (4 of 5)
Tension pneumothorax associated with penetrating
trauma
– May occur when an open pneumothorax has been
sealed with an occlusive dressing.
– Pressure may be relieved by momentarily
removing the dressing (air escapes with an audible
release of air).
56. Tension Pneumothorax Management (5 of 5)
Tension pneumothorax associated with closed
trauma
– If the patient demonstrates significant dyspnea and
distinct signs and symptoms of tension pneumothorax:
» Provide thoracic decompression with either a large-bore needle
or commercially available thoracic decompression kit.
» Insert a 2-inch 14- or 16-gauge hollow needle or catheter into
the affected pleural space.
Usually the second intercostal space in the midclavicular line
Insert the needle just above the third rib to avoid the nerve, artery, and
vein that lie just beneath each rib.
57. Needle Decompression
Locate 2-3 Intercostal space midclavicular line
Cleanse area using aseptic technique
Insert catheter ( 14g or larger) over the top of the
3rd rib( nerve, artery, vein lie along bottom of rib)
Place Flutter valve over catheter
Reassess for Improvement
60. Pulmonary Contusion
A pulmonary contusion is the most common
potentially lethal chest injury.
» Incidence
Blunt trauma to the chest
– The most common injury from blunt thoracic
trauma.
– 30% to 75% of patients with blunt trauma
have pulmonary contusion.
Commonly associated with rib fracture
High-energy shock waves from explosion
High-velocity missile wounds
Rapid deceleration
64. Hemothorax (2 of 2)
Incidence
– Associated with pneumothorax.
– Blunt or penetrating trauma.
– Rib fractures are frequent cause.
65. Hemothorax
Occurs when pleural space fills with blood
As blood increases, it puts pressure on heart
and other vessels in chest cavity
Each Lung can hold 1.5 liters of blood
74. Hemothorax
Assessment Findings (1 of 2)
Tachypnea
Dyspnea
Cyanosis
– Often not evident in hemorrhagic shock
Diminished or decreased breath sounds on
the affected side
75. Hemothorax
Assessment Findings (2 of 2)
Hyporesonance (dullness on percussion) on
the affected side
Hypotension
Narrowed pulse pressure
Tracheal deviation to the unaffected side
(rare)
Pale, cool, moist skin
76. S/S of Hemothorax
Anxiety/Restlessness
Tachypnea
Signs of Shock
Frothy, Bloody Sputum
Diminished Breath Sounds on Affected Side
Tachycardia
Flat Neck Veins
78. Hemothorax
Management
Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation if necessary
– Ventilatory support with bag-valve mask, intubation, or
both
Circulation
– Administer volume-expanding fluids to correct
hypovolemia
– Nonpharmacological—tube thoracostomy (in-hospital
management)
– Transport considerations
» Appropriate mode
» Appropriate facility
79. Treatment for Hemothorax
ABC’s with c-spine control as indicated
Secure Airway assist ventilation if necessary
General Shock Care due to Blood loss
RAPID TRANSPORT
80. Hemothorax
Morbidity/Mortality
A life-threatening injury that frequently requires
urgent chest tube placement and/or surgery
Associated with great vessel or cardiac injury
– 50% of these patients will die immediately.
– 25% of these patients live 5 to 10 minutes.
– 25% of these patients may live 30 minutes or longer.
81. Traumatic Asphyxia
Incidence
– A severe crushing injury to the chest and
abdomen
» Steering wheel injury
» Conveyor belt injury
» Compression of the chest under a heavy object
82. Traumatic Asphyxia
Pathophysiology
A sudden compressional force squeezes the
chest.
An increase in intrathoracic pressure forces
blood from the right side of the heart into
the veins of the upper thorax, neck, and
face.
Jugular veins engorge and capillaries
rupture.
83. S/S of Traumatic Asphyxia
Severe Dyspnea
Distended Neck Veins
Bulging, Blood shot eyes
Swollen Tounge with cyanotic lips
Reddish-purple discoloration of face and
neck
Petechiae
84. Traumatic Asphyxia
Assessment
Reddish-purple discoloration of the face and neck
(the skin below the face and neck remains pink).
Jugular vein distention.
Swelling of the lips and tongue.
Swelling of the head and neck.
Swelling or hemorrhage of the conjunctiva
(subconjunctival petechiae may appear).
Hypotension results once the pressure is released.
85. Traumatic Asphyxia
Management
Airway and ventilation
– Ensure an open airway.
– Provide adequate ventilation.
Circulation
– IV access.
– Expect hypotension and shock once the compression is
released.
86. Diaphragmatic Rupture
Incidence
Penetrating trauma
– Blunt trauma
– Injuries to the diaphragm account for 1% to 8%
of all blunt injuries.
» 90% of injuries to the diaphragm are associated with
high-speed motor vehicle crashes.
88. Diaphragmatic Rupture
Rupture can allow intra-abdominal organs
to enter the thoracic cavity, which may
cause the following:
– Compression of the lung with reduced
ventilation
– Decreased venous return
– Decreased cardiac output
– Shock
89. Diaphragmatic Rupture
Pathophysiology
Can produce very subtle signs and
symptoms
Bowel obstruction and strangulation
Restriction of lung expansion
– Hypoventilation
– Hypoxia
Mediastinal shift
– Cardiac compromise
– Respiratory compromise
90. Diaphragmatic Rupture Assessment
Findings
Tachypnea
Tachycardia
Respiratory distress
Dullness to percussion
Scaphoid abdomen (hollow or empty appearance)
– If a large quantity of the abdominal contents are displaced into the
chest
Bowel sounds in the affected hemithorax
Decreased breath sounds on the affected side
Possible chest or abdominal pain
91. S/S of Diaphragmatic Rupture
Abdominal Pain
Shortness of Air
Decreased Breath Sounds on side of rupture
Bowel Sounds heard in chest cavity
92. Diaphragmatic Rupture Management
Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation if necessary
– Caution: positive pressure may worsen the injury
Circulation—IV access
Nonpharmacological—do not place patient in
Trendelenburg position
Transport considerations
– Appropriate mode
– Appropriate facility
93. Plus Care
Cardiac Monitor
Establish IV access and draw blood samples
Airway management including Intubation
Observe for Pneumothorax due to compression on
lung by abdominal contents
Possible insertion of NG tube to help decompress
the stomach to relieve pressure
Rapid transport
94. Summary
Chest Injuries are common and often life threatening
in trauma patients. So, Rapid identification and
treatment of these patients is paramount to patient
survival. Airway management is very important and
aggressive management is sometimes needed for
proper management of most chest injuries.