Pulmonary Disease Management

Chapter 27: Chest Injuries (Final Term)

I. Chest Injuries • The intercostal muscles and the diaphragm relax

1. Anatomy and Physiology during exhalation.
2. Mechanics of Ventilation
3. Injuries of the Chest
4. Patient Assessment • The body should not have to work to breathe when in
• Scene Size-up a resting state.
• Primary Assessment
• History taking
• Secondary Assessment
• Reassessment
5. Pneumothorax
6. Hemothorax
7. Cardiac Tamponade
8. Rib Fractures
9. Flail Chest
10. Other Chest Injuries

Anatomy and Physiology

• Ventilation is the body’s ability to move air in and out of

the chest and lung tissue.
• Respiration is the exchange of gases in the alveoli of
the lung tissue.
• The chest (thoracic cage) extends from the lower end
of the neck to the diaphragm.
• Thoracic skin, muscle, and bones
⎯ Similarities to other regions
⎯ Also, unique features to allow for ventilation,
such as skeletal muscle
• The neurovascular bundle lies closely along the lowest
margin of each rib.
• The pleura covers each lung and the thoracic cavity.
⎯ Surfactant allows the lungs to move freely
against the inner chest wall during respiration.
• Vital organs, such as the heart, are protected by the
ribs.
⎯ Connected in the back to the vertebrae
⎯ Connected in the front to the sternum
• The mediastinum contains the heart, great vessels,
esophagus, and trachea.
⎯ A thoracic aortic aneurysm can develop in this
area of the chest.
• The diaphragm is a muscle that separates the thoracic
cavity from the abdominal cavity.
• Patients with a spinal injury below
C5 can still breathe from the
diaphragm.
• Patients with a spinal injury above
C3 may lose the ability to breathe.
• Minute ventilation (minute volume)
– Amount of air moved through the lungs in 1
minute
– Normal tidal volume × respiratory rate
– Patients with a decreased tidal volume will
have an increased respiratory rate.
Injuries of the Chest
Two types: open and closed
• In a closed chest injury, the skin
is not broken.
– Generally caused by
blunt trauma
Closed chest injury
– Can cause significant cardiac and pulmonary
contusion
– If the heart is damaged, it may not be able to refill with
or receive blood.
– Lung tissue bruising can result in exponential loss of
surface area.
– Rib fractures may cause further damage.

• In an open chest injury, an object penetrates the

chest wall itself.
– Knife, bullet, piece of
metal, or broken end of
fractured rib
– Do not attempt to move
or remove object.

• Blunt trauma to the chest may cause:

– Rib, sternum, and chest wall fractures
– Bruising of the lungs and heart
– Damage to the aorta
– Vital organs to be torn from their attachment
in the chest cavity
• Signs and symptoms:
Mechanics of Ventilation
– Pain at the site of injury
• The intercostal muscles (between the ribs) contract – Localized pain aggravated or increased with
during inhalation. breathing
– The diaphragm contracts at the same time. – Bruising to the chest wall
– Crepitus with palpation of the chest
 – Penetrating injury to the chest – Address life-threatening bleeding
– Dyspnea immediately, using direct pressure and a
– Hemoptysis bulky dressing.
– Failure of one or both sides of the chest to • Transport decision
expand normally with inspiration – Priority patients are those with a problem with
– Rapid, weak pulse their ABCs.
– Low blood pressure – Pay attention to subtle clues, such as:
– Cyanosis around the lips or fingernails ▪ The appearance of the skin
• Chest injury patients often have rapid and shallow ▪ Level of consciousness
respirations. ▪ A sense of impending doom in the
– Hurts to take a deep breath patient
– The patient may not be moving air. ▪ Table 27-1 lists the “deadly dozen”
– Auscultate multiple locations to assess for chest injuries.
adequate breath sounds.
Patient Assessment

• Patient assessment steps:

1. Scene size-up
2. Primary assessment
3. History taking
4. Secondary assessment
5. Reassessment
Scene Size-up

• Scene safety
– Ensure the scene is safe for you, your partner,
your patient, and bystanders.
– If the area is a crime scene, do not disturb
evidence.
– Request law enforcement for scenes
involving violence.
– Use gloves and eye protection.
• Mechanism of injury/nature of illness
– Chest injuries are common in motor vehicle
crashes, falls, and assaults.
– Determine the number of patients.
– Consider spinal immobilization.
Primary Assessment
• Form a general impression.
– Note the patient’s level of consciousness.
– Perform a rapid scan.
▪ Obvious injuries
▪ Appearance of blood
▪ Difficulty breathing
▪ Cyanosis
▪ Irregular breathing Primary Asses
▪ Chest rise and fall on only one side
▪ Accessory muscle use
▪ Extended or engorged jugular veins
▪ Assess the ABCs.
▪ Assess overall appearance.
• Airway and breathing
– Ensure that the patient has a clear and patent
airway.
– Consider early cervical spine stabilization.
– Are jugular veins distended?
– Is breathing present and adequate?
– Inspect for DCAP-BTLS
– Look for equal expansion of the chest wall.
– Check for paradoxical motion.
– Apply occlusive dressing to all penetrating
injuries.
– Support ventilations.
– Reassess the effectiveness of ventilatory
support.
– Be alert for decreasing oxygen saturation.
– Be alert for impending pneumothorax.
• Circulation
– Pulse rate and quality
– Skin color and temperature
History Taking
• Investigate the chief complaint.
– Further investigate the MOI.
– Identify signs, symptoms, and pertinent
negatives.
• SAMPLE history
– Focus on the MOI.
– A basic evaluation should be completed:
• Signs and symptoms
• Allergies
• Medications
• Pertinent medical problems
• Last oral intake
• Events leading to the emergency
Secondary Assessment
Physical examinations
– Perform a full-body scan.
– For an isolated injury, focus on:
• Isolated injury
• Patient’s complaint
• Body region affected
• Location and extent of injury
• Anterior and posterior aspects of the chest
wall
• Changes in respirations
– For significant trauma, use DCAP-BTLS to determine
the nature and extent of the thoracic injury.
– Quickly assess the entire patient from head to toe.
Vital signs
– Assess pulse, respirations, blood pressure, skin
condition, and pupils.
– Reevaluate every 5 minutes or less.
– Pulse and respiratory rates may decrease in later
stages of the chest injury.
– Use a pulse oximeter to recognize any downward
trends in the patient’s condition.
Reassessment Tension pneumothorax

• Repeat the primary assessment. – Results from significant air accumulation in the pleural
• Reassess the chief complaint. space
– Airway – Increased pressure in the chest causes:
– Breathing • Complete collapse of the unaffected lung
– Pulse • Mediastinum to be pushed into the opposite
– Perfusion pleural cavity
– Bleeding – Commonly caused by a blunt injury in which a fractured
• Interventions rib lacerates the lung or bronchus
– Provide complete spinal immobilization for
patients with suspected spinal injuries.
– Maintain an open airway.
– Control significant, visible bleeding.
– Place an occlusive dressing over penetrating
trauma to the chest wall.
– Manually stabilize a flail segment using a
bulky dressing.
– Provide aggressive treatment for shock and
transport patients with signs of hypoperfusion.
– Do not delay transport to complete nonlife
saving treatments.
• Communication and documentation
– Communicate all relevant information to the
staff at the receiving hospital.
– Describe all injuries and the treatment given.
Hemothorax
Pneumothorax
Blood collects in the pleural space from bleeding around the rib
• Commonly called a collapsed lung cage or from a lung or great vessel.
• Accumulation of air in the pleural space
- Blood passing through the collapsed portion
of the lung is not oxygenated.
- You may hear diminished, absent, or
abnormal breath sounds.

• Signs and symptoms

Open chest wound – Shock
– Often called an open – Decreased breath sounds on the affected
pneumothorax or a sucking side
chest wound • Prehospital treatment:
– Wounds must be rapidly – Rapid transport
sealed with a sterile • The presence of air and blood in the pleural space is a
occlusive dressing. hemopneumothorax.
– A flutter valve is taped on
Cardiac Tamponade]
only three sides.
– Carefully monitor the patients for tension Protective membrane
pneumothorax. (pericardium) around
the heart fills with
Spontaneous pneumothorax
blood or fluid
– Caused by structural weakness rather than trauma
The heart cannot
– Weak area (“bleb”) can rupture spontaneously, letting
adequately pump the
air into the pleural space.
blood.
– Suspect it in patients with sudden, unexplained chest
pain and shortness of breath.
Simple pneumothorax • Signs and symptoms
– Beck’s triad
– Does not result in major changes in the patient’s
– Altered mental status
physiology
• Prehospital treatment
– Commonly due to blunt trauma that results in fractured
– Support ventilations.
ribs
– Rapidly transport.
– Can often worsen, deteriorate into tension
– pneumothorax, or develop complications Rib Fractures

• Common, particularly in older people

 • A fracture of one of the upper four ribs is a sign of a – Monitor vital signs during immediate
very substantial MOI. transport.
• A fractured rib may cause a pneumothorax or a
hemothorax.
• Signs and symptoms
– Localized tenderness and pain when
breathing
– Rapid, shallow respirations
– Patient holding the affected portion of the rib
cage
• Prehospital treatment includes Blunt myocardial injury
- supplemental oxygen
• Bruising of the heart muscle
• The heart may be unable to maintain adequate blood
pressure.
Flail Chest
– Signs and symptoms
• Caused by compound • Irregular pulse rate
rib fractures that detach • Chest pain or discomfort
a segment of the chest • Suspect it in all cases of severe blunt injury to the
wall chest.
• Detached portion • Prehospital treatment
moves opposite of – Carefully monitor the pulse.
normal – Note changes in blood pressure.
• Prehospital treatment
- Maintain the airway. Commotio cordis
- Provide respiratory support, if needed. • Injury caused by a sudden, direct blow to the chest
- Give supplemental oxygen. during a critical portion of the heartbeat.
- Reassess for complications. • May result in immediate cardiac arrest.
• To immobilize a flail segment: • Ventricular fibrillation responds to defibrillation within
– Tape a bulky dressing or pad against that the first 2 minutes of the injury.
segment of the chest.
– Have the patient hold a pillow against the Laceration of the great vessels
chest wall. • May result in rapidly fatal hemorrhage
• Flail chest may indicate serious internal damage or • Prehospital treatment
spinal injury. – Ventilatory support, if needed
– Immediate transport
– Be alert for shock.
Other Chest Injuries
– Monitor for changes in baseline vital signs.
Pulmonary Contusion
– Should always be suspected in a patient with
a flail chest
– Pulmonary alveoli become filled with blood,
leading to hypoxia
– Prehospital treatment
• Respiratory support and
supplemental oxygen
• Rapid transport
Other fractures
– Sternal fractures
• Increased index of suspicion for
organ injury
– Clavicle fractures
• Possible damage to neurovascular
bundle
• Suspect upper rib fractures in medial
clavicle fractures.
• Be alert to pneumothorax
development.
Traumatic Asphyxia

• Characterized by distended neck veins, cyanosis in the

face and neck, and hemorrhage in the sclera of the eye
• Sudden, severe compression of the chest, producing a
rapid increase in pressure.
• Suggests an underlying injury to the heart and possibly
a pulmonary contusion
• Prehospital treatment:
– Ventilatory support and supplemental oxygen