Chapter 29 - Chest Injuries PDF

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Ch. 29 Chest Injuries 1. Thoracic Cavity a. Extends from the lower part of the neck to the diaphragm. b. Surrounded by ribs c. Protects vital organs for breathing/circulation i. Heart ii. Lungs 2. Mediastinum a. Middle of the chest cavity b. Contains: i. Trachea ii. Heart iii. Great Vessels (Vena Cava, Aorta) iv. Esophagus v. Major Bronchi 3. Types of injuries a. Closed chest injury i. Injury in which the skin is not broken; generally caused by blunt trauma. ii. Often cause significant contusions in the cardiac muscle (cardiac contusion) and lung muscle (pulmonary contusion), thus impairing their functions. b. Open chest injury i. Injury in which the skin IS broken; generally caused by penetrating trauma. ii. Damage is typically instant; however, symptoms may take time to develop. 4. Signs/Symptoms of Chest Injury a. Pain at the site of injury b. Pain localized at the site of injury that is aggravated by or increased with breathing c. Bruising to the chest wall d. Crepitus e. Any penetrating injury to the chest f. Dyspnea/tachypnea g. Hemoptysis (coughing up blood) h. Failure of one or both sides of the chest to expand norm. with inspiration. i. Rapid, weak pulse, and low blood pressure j. Cyanosis around lips/fingernails 5. Complications and Management of Chest Injuries a. Pneumothorax i. Aka. Collapsed lung ii. The accumulation or air in the pleural space iii. Causes 1. Blunt Trauma 2. Penetrating Trauma

3. Lung ruptures if during impact, patient’s epiglottis is closed over the trachea (paper bag effect). iv. Signs/symptoms: 1. Chest pain worsening w/inspiration 2. Dyspnea 3. Tachypnea 4. Decreased or absent breath sounds on the affected side. b. Sucking Chest Wound i. Aka. Open pneumothorax ii. Air that is pulled into the chest cavity from an open wound sometimes causing a sucking sound. TRUE EMERGENCY iii. Complications 1. Air sucked in 2. Air trapped inside iv. Emergency Care 1. Positive pressure Ventilation 2. Seal open wound w/ gloved hand 3. Apply occlusive dressing – tape 3 sides 4. Position the patient v. Complications associated w/sealed wound 1. Difficulty breathing 2. Tachypnea 3. Decreased or absent breath sounds 4. Tachycardia 5. Decrease BP w/ narrowing pulse pressure 6. Un equal chest 7. Extreme anxiety 8. Increase resistance to positive pressure vent. 9. JVD (Jugular Vein Distention) – LATE SIGN 10. Tracheal deviation – LATE SIGN c. Simple Pneumothorax i. Aka. Spontaneous pneumothorax ii. Any pneumothorax that does not result in major changes in the patient’s cardiac physiology. iii. Commonly the result of blunt trauma that results in fractured ribs. iv. Also common among smokers, emphysema patients, and tall skinny people. v. Signs/Symptoms: 1. Dyspnea 2. Tachypnea 3. Accessory muscle use 4. Decreasing oxygen saturation on pulse oximeter. 5. Subcutaneous emphysema 6. Decreased breath sounds on injured side, lethargy, and cyanosis – LATE SIGN

d. Tension Pneumothorax i. Immediate life-threatening condition ii. Results from Simple/Spontaneous Pneumothorax iii. Trapped air begins to build pressure in the chest, collapsing the lung of the injured side and pushing the mediastinum into the uninjured side. (Mediastinum Shift) – The killer iv. The shift prevents blood from returning through the vena cava to the heart, decreasing cardiac output, causing shock, and ultimately leading to death! v. Signs/Symptoms: 1. Rapid deterioration 2. Severe respiratory distress 3. Shock (hypoperfusion) 4. Absent breath sounds 5. Cyanosis 6. Unequal movement of chest 7. Distended neck veins 8. Diminished breath sounds on uninjured side 9. Tracheal deviation – LATE SIGN (pt. required immediate intervention) vi. Emergency Care 1. Support Ventilation with high- flow O2 & request ALS support or Transport immediately. 2. If caused by occlusive dressing, lift corners to allow air to escape e. Hemothorax i. Blood filling the chest cavity. ii. Caused by blunt force of penetrating trauma iii. Signs/Symptoms: 1. Suspect hemothorax if Pt. has s/s of shock without an obvious external bleeding or apparent reason for the shock state. 2. Decreased breathing sounds on the affected side 3. Also, may have pink or red sputum when patient coughs iv. No way to control the bleeding, needs RAPID transport to a surgeon v. Hemopneumothorax: the presence of AIR and BLOOD in the pleural space. f. Cardiac Tamponade i. Aka. Pericardial tamponade ii. Bleeding into the pericardium (sac around the heart) iii. More common in penetrating trauma; may occur blunt trauma iv. Could also result from cancer or autoimmune disease such as lupus. v. Causes compression of the heart and reduces cardiac output vi. Signs/Symptoms: (often subtle until situation is dire) 1. Beck’s Triad a. Distended or engorged jugular vein on both sides b. Narrowing pulse pressure c. Muffled heart sounds 2. Commonly noticed decrease in mental status

3. Rapid deterioration 4. Severe respiratory distress 5. Shock (hypoperfusion) 6. Absent breath sounds 7. Cyanosis 8. Unequal movement of chest 9. Distended neck veins 10. Diminished breath sounds on uninjured side 11. Tracheal deviation vii. Requires Prompt recognition and transport. g. Rib Factures i. Very common (3rd – 8th rib fracture) ii. Can easily cause internal bleeding iii. Also be aware: fractured rib can penetrate the plural space causing any pneumothorax, hemothorax, or hemopneumothorax. iv. Signs/Symptoms: 1. Pain while breathing 2. Crepitation 3. Tenderness upon palpation 4. Deformity of chest wall 5. Rapid & Shallow respirations 6. Coughing 7. Tachypnea v. Provide supplemental O2 and transport if they are experiencing respiratory distress vi. Place patient’s arm over injury site and apply sling/swathe vii. Give patient pillow to hold for added support viii. DO NOT completely wrap or tape the chest. h. Flail Chest i. 3 or more consecutive rib fractured in 2 or more places or the sternum is fractured along several ribs ii. Causes movable segment to be sucked in during inhalation. iii. Causes segment to move outward during exhalation iv. Creates paradoxical motion or opposite of norm. function. – LATE SIGN v. Palpate crepitus and subcutaneous air vi. Breathing can be painful and ineffective, and hypoxemia easily results; address quickly. vii. Treatment 1. Placed gloved hand over the failed segment 2. Initiate positive pressure ventilation w/ BVM 3. Stabilize with bulky dressing, pillow, or towel 4. If possible, secure patient’s arm to body to help stabilize the area. i. Cardiac Contusion i. Bruise on the heart wall

ii. Disturbances in the electrical conduction system may occur iii. Signs/symptoms 1. Chest pain 2. Signs of blunt trauma 3. Tachycardia/irregular pulse iv. Prompt transport is required. j. Pulmonary contusion i. Caused by severe blunt trauma ii. Alveoli become filled with blood, and fluid accumulates in the injured area, leaving the patient hypoxic. iii. Should always be suspected in Flail chest injury and can develop over a period of hours. iv. Provide supplemental O2 and positive pressure vent. k. Other Fractures i. Sternal fractures 1. Fracture of the sternum may involve the lungs, great vessels, and the heart itself. ii. Clavicle Fractures 1. Suspect upper rib fractures in medial clavicle fractures and be alert to possible signs of pneumothorax development. l. Traumatic Asphyxia i. The severe and sudden compression of the chest that produces rapid increase in pressure within the chest ii. Pressure on the heart and lungs causes backflow of blood out of the left ventricle and into the veins of the head, shoulders, and upper chest. iii. Patients looks like they were strangled iv. Signs/Symptoms: 1. Bluish/purple discoloration of face, neck, head, shoulders, upper chest 2. JVD 3. Bloodshot or bulging eyes 4. Cyanotic & swollen tongue, lips v. Provide emergency care for wounds and treat for shock. m. Blunt Myocardial Injury i. Blunt trauma to the chest that injures the heart itself ii. Unable to maintain adequate blood pressure iii. Often pulse is irregular, but no specific diagnostic test available iv. Suspect in all cases of severe blunt injury to the chest v. Patients signs/symptoms can mimic a heart attack vi. Provide supplemental O2 & transport immediately n. Commotio Cordis i. Phenomenon ii. May result in immediate cardiac arrest. iii. Cause by direct blunt chest injury to the chest during the critical portion of a person’s heartbeat.

iv. Causes lethal abnormal heart rhythm called ventricular fibrillation; responds well to defibrillation without the first two minutes after the injury. v. Commonly associated with sport-related injuries. o. Laceration of the great Vessels i. Injury to any of the great vessels can be accompanied by massive, rapidly fatal hemorrhage. ii. Significant blood loss can go unseen because blood remains in the chest. iii. Be alert to signs/symptoms of shock and to changes in baseline vitals, such as tachycardia and hypotension. iv. Emergency Treatment 1. Includes Cardiopulmonary resuscitation 2. Ventilation support/ supplemental O2 (if appropriate) 3. Immediate transport...