1) Chest injuries can involve external trauma, damage to internal organs like the heart and lungs, and possible spinal injury. They account for 25% of trauma-related deaths. 2) The assessment and treatment of chest injuries follows the ABCDE approach - Airway, Breathing, Circulation, Disability, Exposure. This includes treating life-threatening conditions like tension pneumothorax immediately. 3) Specific injuries like rib fractures, pneumothorax, and open chest wounds require stabilization, positioning the patient for comfort, applying dressings, and providing supplemental oxygen while seeking urgent medical care.

1. Chest Injuries
First Aid and Treatment Options
Anas Bahnassi PhD
5

2. Anas Bahnassi PhD CDM CDE 2

3. • External trauma to the chest:
– Blunt
– Penetrating
• Possible damage to underlying organs:
– Heart
– Lungs
• Possible spinal injury.
• Chest injuries are responsible for 25% of
trauma related deaths.
Introduction

4. Tri-modal peak of Mortality
1st peak: Non-
survivable
severe CNS or
CVS injuries
Location of
death: Pre-
hospital
environment
2nd peak: First few
hours after injury,
most often due to
hypoxia and
hypovolemic shock
Usually can be
saved
3rd peak: Within 6
weeks of injury
Cause: Multisystem
failure and sepsis

5. The Golden Hour
• Treat the greatest threat to life first
• Treat despite lack of a definitive diagnosis
• Treat despite complete history

6. The Golden Hour
• A = Airway with c-spine protection
• B = Breathing
• C = Circulation, stop the bleeding
• D = Disability/Neurological
status
• E = Exposure and
Environment

7. Three Stage Approach
1. Primary Survey: ABCDE
– sequential yet actually simultaneous
– includes resuscitation efforts
– normalization of vital signs
2. Secondary Survey:
– AMPLE history
– head-to-toe and x-rays
3. Definitive Care: Specialist treatment of
identified injuries

8. Primary Assessment
ABCDE
Injury
Resuscitation
Re-evaluation Secondary Survey
Head-to-toe + X-Ray
Re-evaluation
Transfer
Definitive Care

9. Initial Assessment
Starting with the ABCDE
A.Airway
B.Breathing
C.Circulation
D.Disability
E.Exposure and Environment

10. Airway: Preventable Deaths
• Failure to recognize need
• Inability to establish
• Incorrectly placed airway
• Displacement
• Failure to ventilate
• Aspiration

11. Airway: Problem Recognition
• Objective Signs – Airway Obstruction:
– agitation, cyanosis = hypoxia
– obtundation = hypercarbia
– abnormal sounds
– tracheal location
– external trauma

12. Airway: Problem Recognition
• Altered Levels of Consciousness
– closed head injury
– intoxication
• Maxillofacial Trauma
– hemorrhage
– dislodged teeth
– mandible fracture

13. Airway: Problem Recognition
• Penetrating Neck
Trauma
– laceration of trachea
– hemorrhage with
tracheal deviation/
obstruction
– patient may initially maintain airway
– prophylactic intubation?

14. Airway: Problem Recognition
• Blunt Neck Trauma
– hemorrhage with
tracheal deviation/
obstruction
– disruption of the larynx
• hoarseness
• subcutaneous
emphysema
• palpable fracture
– prophylactic
intubation?

15. Airway: Management
Always Assume This…. So Do This….
C-Spine Stabilization

16. Airway: Management
• Airway Maintenance
Techniques:
• chin lift
• jaw thrust
• oral airway
• nasal trumpet
• Definitive Airway:
• orotracheal or nasotracheal intubation
• surgical airway

17. Airway: Cricothyroidotomy
Vertical skin incision – make it longer than you
think you need….

18. Circulation: Preventable Deaths
• Address:
– Immediately Life-Threatening Chest Injuries:
• Tension Pneumothorax
• Open Pneumothorax (sucking chest wound)
• Flail Chest
• Disruption of Tracheo-Brochial tree
– Potentially Life-Threatening Chest Injuries:
• Pulmonary contusion
• Diaphragmatic rupture
• esophageal rupture

19. Check:
1. Vital signs
2. ECG
3. Pulse oximetry
4. End-Tidal Carbon Dioxide
5. Arterial Blood Gas
6. Urinary output
7. Urethral Catheterization
8. Nasogastric tube
9. Chest X-Ray
10.Pelvic X-Ray

20. Breathing: Problem Recognition
Look
Listen
Feel
Assess:
Look
• Respiratory rate
• Shallow, gasping or labored breathing:
Respiratory failure?
• Cyanosis: Hypoxia
• Paradoxical Respiration: ‘Pendulum’ breathing
with asynchronisation of chest and abdomen:
Respiratory failure or Structural damage.
• Unequal chest inflation: Pneumothorax or Flail
chest
• Bruising or contusion: ‘Seat-Belt’ sign.
• Penetrating chest injury
• Distended neck veins: venous return-Tension
pneumothorax or cardiac tamponade

21. Breathing: Problem Recognition
Look
Listen
Feel
Assess:
LISTEN
• Absent breath sounds: Apnoea or tension
pneumothorax
• Noisy breathing/ Crepitations/ Stridor/ Wheeze:
Partially obstructed airway
• Reduced air entry: Pneumothorax, Haemothorax,
Heamo-pnemothorax, flail chest

22. Breathing: Problem Recognition
Look
Listen
Feel
Assess:
FEEL
• Tracheal deviation: Mediastinal shift
• Tenderness: Chest wall contusion and/ rib fracture
• Crepitus / Instabilty: Underlying rib fracture
• Surgical emphysema: ‘Bubble-wrap’ sign

23. Breathing: Management
The patient’s hemodynamic status dictates
imaging and management.
• Chest tube, chest tube,
chest tube
• Occlusive dressing
• Ventilatory support
• Thoracotomy?

24. Indications for thoracotomy
1. Internal cardiac massage
2. Control of haemorrhage from injury to the heart
3. Control of haemorrhage from injury to the
lungs/intrapleural haemorrhage
4. Cardiac tamponade
5. Ruptured oesophagus
6. Aortic transection
7. Control of massive air leak
8. Traumatic diaphragmatic tear

25. Circulation: Preventable Deaths
• Hypotension = Hemorrhage
• Assess:
– level of consciousness
– pulse / skin color
• Address:
– external bleeding
– massive hemothorax
– cardiac tamponade
– massive hemoperitoneum
– unstable pelvic fracture

26. Circulation: Classes of Shock

27. Circulation: Classes of Shock
Example:
• 1 year old falls off
the stairway (10 kg)
• “lost ¾ cup of blood”
• blood volume =
70cc/kg x 10kg
• EBL = ¾ cup=6
oz=180cc
• 180cc / 700cc =
25%blood loss
• Class II/III shock

28. Circulation: Causes of Shock
Hypovolemic = Hemorrhage:
5 spaces = chest, abdomen, pelvis, long-bones, street
• Fractures:
– rib = 100-200 cc
– tibia = 300-500 cc
– femur = 800-1200 cc
– pelvis = 1500 and up

29. Circulation: Causes of Shock
• Neurogenic: spinal cord injury
• Septic
• Cardiogenic:
• tension
Pnemothorax
• cardiac tamponade
or contusion
• air embolism
• primary cardiac
disease

30. 30
Fractured Ribs: Problem Recognition
• Pain at site which increases
with movement or touch
• Pain at site when breathing in
• Difficulty breathing, Rapid
shallow breathing
• Rapid pulse
• Bruising
• Deformity
• Bloody sputum
• ‘Guarding’ of the injury

31. Fractured Ribs: Management
• Primary survey - ABCDE
• Position of comfort (often sitting
position with the injured side
downwards).
• Stabilize the fracture site - Put
the arm on the injured side in a
‘collar and cuff’ or a sling.
• Seek medical aid
• Provide supplemental oxygen if
available
• Observe for respiratory
compromise
31

32. Fractured Ribs: Management
• Reduction of pain with 2 week follow
up
• Analgesics :
– Opiods
– NSAID’s
• Intercostal Blocks
• Strapping of chest: relieves pain by
immobilizing the ribs
• Breathing exercises

33. Pneumothorax (collapsed lung)
• Air enters the between the lungs and the inside of the chest wall
(pleural space).
• The air takes up space, causing a section of the lung to collapse.
• If air continues to enter - tension pneumothorax.
33

34. 34
Pneumothorax: Problem Recognition
• Severe chest pain
• Breathing distress (Rapid,
shallow breathing)
• Rapid pulse
• Bluish skin color (cyanosis)
• Possible altered conscious
state
• Possible deviated windpipe
(trachea)
• Distended neck veins

35. 35
Pneumothorax: Management
• Seek immediate medical aid,
• Primary Survey
• Oxygen provision
• Resuscitation
if required

36. 36
Flail Segment
• When ribs and/or the breastbone are fractured in a
number of places and result in a free-floating section
of bone.

37. 37
Flail Segment: Problem Recognition
• As for fractured rib but more severe
• Paradoxical breathing
• Mediastinal Flutter
• Pendular Movement of air
• Associated injuries:
Pulmonary Contusion!
• Hypoventilation

38. Flail Segment: Management
• Primary Survey
• Urgent medical assistance
• Position of comfort. (This is often a sitting
position with the injured side downwards).
• Stabilize the fracture site as for a fractured rib
• Provide supplemental oxygen
38

39. Open Chest Wound:
Problem Recognition
• Open wound to chest
• Severe breathing difficulty
• Rapid pulse
• Sound of air being sucked in through wound
39

40. Open Chest Wound: Management
• Urgent medical assistance
• Position the victim in a sitting position with
the injured side downwards
• Cover the wound site with some air tight
material (e.g. polythene).
• This dressing needs to be taped on three
sides with the bottom edge left free. This
will stop air being sucked in but will allow
trapped air to escape
• Provide supplemental oxygen if able
• Continuously monitor and reassure the
victim
• If the victim becomes unconscious, conduct
a Primary Survey and take appropriate
action
40

41. Clinical Pharmacy VI:
First Aid
abahnassi@gmail.com
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Anas Bahnassi PhD CDM CDE