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Chest Injury

Chest Injury

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Published by Rolando Reyna

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Categories:Types, School Work
Published by: Rolando Reyna on Jan 03, 2009
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11/26/2012

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CHEST INJURYThis extends Section 51.3 on thecare of a severely injured patient.
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Figure 65.1
: A SEVERE CHEST INJURY. A, this patient has surgical emphysema—in spite of his alarming appearance, this part of his injury is benign. B, a brokenrib has punctured his lung, air has collected under pressure in his right pleuralcavity, compressed his right lung, and forced his mediastinum over to the left,impairing the ventilation of his left lung. Air has also escaped into his mediastinumand tracked up into his neck and face. Adapted from an original illustration byFrank H. Netter, M.D. from the CIBA collection of medical illustrations, copyright byCIBA Pharmaceutical Company, Division of CIBA–GEIGY Corporation.
THE RAPID ASSESSMENT OF A CHEST INJURY
If a patient’s airway is blocked, clear it as in Section 52.1.
If air is going in and out, but his breathing is distressed,
he may have multiple fracturedribs or severe abdominal pain.
If he is making great respiratory efforts, but is still hungry for air,
think of a flail chestor a pneumothorax.
If he is cyanosed in the presence of an adequate airway,
he may have a badly damagedlung, a flail chest, or a pneumothorax. Give him oxygen.Many patients with chest injuries breathe much more easily as soon as they are intubated.
THE HISTORY OF A CHEST INJURY
Assess the force of the patient’s injury carefully. The greater the force, the greater thechances that he has a severe injury.
THE EXAMINATION OF A CHEST INJURY
If a patient is conscious, and is now breathing easily, strip him to the waist, and ask him todescribe the pain and show you exactly where it is. if unconscious, remove his clothes andexamine his chest carefully.INSPECTION Assess the rate and depth of the patient’s breathing, while he is breathingnormally. Ask him to take a deep breath. If his ribs are broken, his attempts to do so willsoon be stopped by sharp pain.
Mediastinal shift
Is his apex beat in its normal place? Feel in his suprasternal notch to find out if his tracheais displaced.Do both sides of his chest expand equally?2
 
Look carefully for any areas of diminished chest movement. This may be in one area only,or involve the whole of one side. Look at him from the sides and from the top and bottomof the trolley.CAUTION! Look carefully for paradoxical movement. Look at the movement of a normalarea, then compare this with the possibily abnormal one. Paradoxical movement may bedifficult to see when a patient is shocked and his respiratory movements are small; it mayonly come on later, when he is resuscitated. Don’t be confused by the indrawing of hislower costal margin that is common in mild respiratory obstruction, especially in children.Are his intercostal spaces distended on one side compared with the other? (tension pneumothorax).Is he cyanosed? Look at his mucous membranes and his finger nails.CAUTION! Anaemic patients do not become cyanosed, and may die of anoxia withoutshowing it. There must be 5 g/dl of reduced haemoglobin in a patient’s circulation beforeyou can observe cyanosis.Look carefully for any bruises on his chest caused by a steering wheel or a safety belt, or bythe imprint of his clothes.Are the patient’s jugular veins abnormally distended? (anything which impedes the venousreturn to the heart, a tension pneumothorax, mediastinal shift, and especially cardiactamponade).PALPATION If a patient is conscious, start by feeling a pain–free area, and then movetowards the injured one. Feel for: (1) Tenderness. (2) Crepitus when fractured ribs movewith respiration. (3) The crackly feeling of surgical emphysema.Feel his abdomen for rigidity, tenderness, and distension.PERCUSSION Do this gently. Don’t fail to turn him or sit him up so that you can examinehis back. Dullness may indicate blood or the collapse of a lung, and hyper–resonance may be caused by a tension pneumothorax.ASCULTATION Can you hear the patient’s breath sounds all over his chest, or are theydiminished? Note especially: (1) Clicking sounds from fractured ribs. (2) The coarsecrepitations of surgical emphysema. (3) Reduced or absent breath sounds on one sideindicating fluid, or air in a pleural cavity, or the collapse of a lung. Listen for this sign whilehe is supine, as in Fig. 65-7. (4) High pitched breath sounds suggesting a tension pneumothorax.
The two coin test
Place a coin on the patient’s chest and tap it with another coin. A bell– like note (combined with other signs) suggests a tension pneumothorax.
OTHER SIGNS OF A CHEST INJURY
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