TCAD Chest Trauma course

1. CHEST
TRAUMA
-CHALLENGES WITH
VENTILATIONS/RESPIRATIONS
- Chris Strobach, NREMT-P

2. • 187,000 deaths
per year in the US
due to trauma
• That’s
approximately 1
person every 3
minutes
• Blunt/penetrating
chest trauma is one
of the leading
causes of trauma
death (25+%)

3. Leading causes of chest trauma include:
▪ MVAs: (70 – 80% of trauma deaths)
▪ Falls from excessive heights (usually >15’ vertically)
▪ Blast injuries (both primary and secondary)
▪ Significant blows to the chest
▪ Chest compression injuries
▪ Gunshot wounds (GSW)
▪ Stab/impalement wounds

4. Leading Pulmonary Injuries:
• Rib fractures / flail
segment
• Pulmonary contusion
• Simple open/closed
pneumothorax
• Tension pneumothorax
• Hemothorax

5. • Rib Fractures:
• Most common type of
chest injury
• While painful, the
fracture itself is
typically not the
pathology of concern
• The potential for
serious internal injury is
what demands your
attention.

6. • Rib Fractures:
• 1 – 2 fx. ribs = 5% mortality
rate
• 7+ fx ribs = 29% mortality
• Elderly population mortality
rate doubles
• Fx of the 1st or 2nd rib
requires significant force
• Ribs are thick and dense
• Often will injure the aorta
or bronchi
• 30% mortality rate
• May result in
pneumothorax or
subclavian artery/vein
injuries

7. • Rib Fractures:
• Fractures of the 8th to 12th
ribs can damage underlying
abdominal solid organs:
• Liver
• Spleen
• Kidneys
• Laceration of these organs
will likely require aggressive
volume replacement.

8. • Rib Fracture’s
Best Friend:
• Analgesics can often be the
key to improving pulmonary
function if painful
respirations are the key
contributor to poor tidal
volumes.

9. • Flail Chest
• A flail chest occurs
when 2 or more ribs
are fractured at two
or more places,
creating a free
moving segment of
chest wall moving
paradoxically to the
rest of the chest.
• Paradoxical movement may not be
seen early on due to the splinting
effect of chest muscle spasms.

10. • Flail Chest
effects:
• Work of Breathing
• Increased by the loss of
integrity of the chest
wall
• Tidal Volume
• Decreases due to the
paradoxical movement
• Pulmonary Contusions
• Create atelectasis and
poor gas exchange

11. • Flail Chest
Treatment:
“Management should
include ventilatory
support, pain
management and
monitoring for
deterioration. Do not
attempt to stabilize flail
section.” – TCAD protocol

12. • Pulmonary
Contusion
• Bruising of the lung
parenchyma from a
high velocity impact
• 20 – 40% of pts with
rib fractures will have
a PC

13. • Pulmonary
Contusion S/S:
• Chest pain
• Adventitious lung
sounds
• Lung stiffness
• Hemoptysis or non-
productive cough
• Respiratory
insufficiency
• Ecchymosis

14. • Pulmonary
Contusion Tx:
• High flow O2
• Assist ventilations with
BVM as necessary
• Pts will need analgesics
to enable them to
breathe adequately
• Assess need for
advanced airway.
• Pt’s with dyspnea or lung
disease should be
monitored and managed
aggressively
• Emergent transport

15. • Pneumothorax:
• Air in the pleural
space decreases or
eliminates the
normal negative
pressure which is
necessary for proper
lung expansion.
• Can cause the lung
to collapse.
• Can be caused by fx
rib(s) which puncture
the actual lung tissue
(parenchyma).

16. • Pneumothorax:
• Various degrees of
pneumothoracies
• Partial vs. complete
• Respiratory distress
typically not seen
until 30 – 40% lung
involvement.
• Can vary
depending on
patient’s age and
overall health.

17. • Pneumo S/S:
• Decreased/absent
breath sounds.
• Pain with
inspiration
• Pain with
palpation.
• Dyspnea
• Tachypnea

18. • Pneumo Tx:
• Establish airway
• High flow on NRB or
BVM
• Be suspicious of
other injuries
• Continuous
assessment of
ventilations
• Monitor and
capnography
• Watch for
development of
tension pneumo.

19. • Open Pneumo:
• The “sucking chest wound”
• Visible hole in the chest wall
(or look for bubbles)
• Small vs. large wound have
different pathologies
• Small wounds will likely
create a tension pneumo
• Act as a 1-way valve.
• Large wounds will cause air
to enter through hole rather
than through trachea.
• Decreased tidal volume and
gas exchange.
• PPV essential
• Subcutaneous air will likely
be seen/felt in chest, neck
and axilla.

20. • Open Pneumo
Tx:
• Regardless of hole size,
apply an occlusive
dressing taped on 3
sides.
• The Medics should
consider cutting a
square patch from the
dorsal aspect of a clean
glove to act as the
dressing.
• Clean the area around
the wound prior to
applying 2” tape.

21. • Open Pneumo
Tx cont’d:
• High flow oxygen with
BVM assist as needed
• Monitor closely for
development of tension
pneumothorax
• IV and EKG
• Rapid transport to
trauma center

22. • Tension
Pneumo:
• Air enters the pleural space on
inspiration and becomes
trapped.
• Intrapleural pressure rises
collapsing the lung on the
affected side.
• Increasing pressure push creates a
mediastinal shift
• Applies pressure to the heart,
superior and inferior vena cava
• Bottoms out pre-load
• Cardiac output falls along with
blood pressure.
• Shock will develop rapidly
• True life-threatening emergency!

23. • Tension
Pneumo S/S:
• Severe dyspnea / respiratory
distress
• Restlessness, anxiety, agitation
• Decreased/absent breath
sounds
• Percussive hyperresonance
• SubQ air
• Assymetrical chest rise
• Cyanosis/late
• JVD (unless hypovolemic as well)
• Rapid/weak pulse
• Hypotension

24. • Tension
Pneumo Tx:
• This is obstructive shock!
• Needle Decompression
(Thoracostomy)
• Secure airway
• High flow O2
• Capnometry
• Heart monitor
• Rapid transport

25. • ARS (Air Release System):
• Connect to a 10ml saline
flush (make room for air to
purge)
• 2nd or 3rd intercostal space,
midclavicular (5th intercostal
space, mid-axillary as
alternate site)
• Prep with aseptic technique
• Insert OVER the top of rib at a
90 angle to chest wall.
• When air escapes (bubbles)
stop and advance catheter
only until flush with skin.
• Re-assess and repeat as
necessary.
• If blood flows continuously,
withdraw catheter.

26. • Hemothorax
• Blood in the pleural
space
• Each lung can hold
up to 3 liters of
blood.
• High incidence with
penetrating trauma
(knife and gun club)
• Can have
hemopneumothorax
concurrently

27. • Hemothorax S/S:
• Decreased chest rise
and breath sounds
• Dyspnea
• Trachea midline
• No JVD
• AMS
• Hypotension
• Pleuritic chest pain
• Narrow pulse
pressure

28. • Hemothorax Tx:
• High flow O2
• 2 large bore IVs with
fluid replacement.
• Permissive
hypotension
• Rapid Transport
• They need chest
tube(s)!

29. In Summary:
▪ Blunt chest trauma is a leading cause of trauma death (25%)
▪ Simple but aggressive management can truly be the difference between
life and death.
▪ Rib Fx’s are not critical, but the damage they can inflict could be.
▪ Good assessment of the physical signs can provide the best clue of
what’s going on inside your patient.
▪ Capnometry is an invaluable tool to identify your patient’s current status
as well as their response to treatment “real-time”.
▪ Needle decompression is a simple but life-saving procedure
▪ Whether by ground or by air, ensure the patient gets to a Trauma Facility
as rapidly as possible.

30. References:
▪ Center for Disease Control; Injury
Prevention and Control; 2011
[Online]
http://www.cdc.gov/injury/overvi
ew/leading_cod.html.
▪ Casey Thompson RN, CFRN,
CCRN, CEN, NREMT; (AirMed)
University of Utah Health Care;
Trauma Grand Rounds;
http://youtu.be/iT5Y2B2zZ1c
▪ Simple Thoracostomy: Moving
Beyond Needle Decompression in
Traumatic Cardiac Arrest. Andrew
Karrer, LP | Brett J. Monroe, MD
| Guy R. Gleisberg, MBA, BSEE,
NREMT-B, EMS-I | Jared Cosper,
BS, LP | Kasia Kimmel, MD |
Mark E.A. Escott, MD, MPH,
FACEP. s.l. : JEMS, March 2014.