27: Chest Injuries

Cognitive Objectives (1 of 2)

1. Differentiate between a pneumothorax, a

hemothorax, a tension pneumothorax, and a
sucking chest wound.
2. Describe the emergency medical care of a patient
with a flail chest.
3. Describe the emergency medical care of a patient
with a sucking chest wound.
 Cognitive Objectives (2 of 2)

4. Describe the consequences of blunt injury to

the heart.
5. List the signs of pericardial tamponade.
6. Discuss complications that can accompany
chest injuries.
• There are no affective objectives for this
chapter.
 Psychomotor Objectives
7. Demonstrate the steps in the emergency medical
care of a sucking chest wound.
Organs of the Chest
Structures of the Chest
 Mechanics of Ventilation (1 of 2)
• Inspiration
– Intercostal muscles contract and diaphragm
flattens.
• Expiration
– Intercostal muscles and diaphragm relax;
tissues move back to normal position.
 Mechanics of Ventilation (2 of 2)
• Phrenic nerves exit the spinal cord at C3, C4, and
C5.
• Spinal cord injury below C5
– Loss of ability to move intercostal muscles
– Diaphragm can still contract; patient can still
breathe.
• Spinal cord injury at C3 or higher
– No ability to breathe
Spinal Cord Injury Below C5
 Injuries to the Chest
• Closed chest injuries
– Caused by blunt
trauma
• Open chest injuries
– Caused by
penetrating trauma
 Signs and Symptoms
• Pain at site of injury • Dyspnea
• Pain aggravated by • Hemoptysis
increased breathing
• Failure of chest to
• Bruising to chest wall expand normally
• Crepitus with palpation • Rapid, weak pulse and
of chest low blood pressure
• Penetrating injury to • Cyanosis around lips
chest or fingernails
• You and your EMT-B partner are dispatched to a
construction site where a worker fell on a piece of
metal and has an open chest wound.
• You arrive and see no scene hazard or need for
other resources.
You are the Provider
• What is the mechanism of injury?
• What precautions should you take? You are the provider continued
 Scene Size-up

• Observe for hazards.

• Do not disturb potential evidence.
• Put several pairs of gloves in your pocket.
• Consider spinal immobilization.
• Ensure that police are on scene if incident involved
violence.
• Your partner provides spinal immobilization.
• The patient is responsive with an open airway. He
says, “I can’t catch my breath. It hurts.”
• You find a penetrating injury on the right anterior
portion of the chest.
• You see a small amount of bleeding. The blood
You are the provider
continued (1 of 2)

bubbles as your patient breathes.

• What are the steps of the initial assessment?
• What life-saving treatments would you provide?
• What treatment do you provide?
• Describe the rest of your assessment process after
the initial assessment. You are the provider
continued (2 of 2)
 Initial
Assessment

• General impression
– Quickly evaluate ABCs.
– Difficulty speaking may indicate several
problems.
– Patients with significant chest injuries will look
sick.
• Airway and breathing
– Ensure that patient has a clear, patent airway.
– Protect the spine.
– Inspect for DCAP-BTLS.
 Inspection
• Decreased breath sounds usually indicate
significant damage to a lung.
• If both sides of chest do not have equal rise and
fall, chest muscles have lost ability to work
properly.
• If one section of chest moves in opposite direction
from the rest of the chest (paradoxical motion), this
is a life threat.
 Immediate Interventions
• Apply an occlusive dressing to any penetrating chest
injury.
• Stabilize paradoxical motion with a large bulky
dressing and 2'' tape.
• Apply oxygen via nonrebreathing mask at 15 L/min.
• Provide positive pressure ventilations if breathing is
inadequate.
 Circulation
• Assess patient’s pulse.
• Consider aggressive treatment for shock.
• Internal bleeding can quickly cause death.
 Transport Decision
• Rapidly transport if patient has problems with
ABCs.
• Pay attention to subtle clues.
– Skin signs
– Level of consciousness
– Sense of impending doom
• You ensure that his airway is open. You are the provider
continued

• Breathing is labored; you start oxygen via nonrebreathing

mask at 15 L/min.
• You quickly assess for DCAP-BTLS; seal sucking chest
wound with an occlusive dressing.
• You check distal pulse. Skin is clammy. Bleeding is noted
and controlled.
• High-priority transport
 Focused History and
Physical Exam

• Focused physical exam

– For a patient with isolated chest injury and
limited MOI
• Rapid physical exam
– For a patient with a significant MOI
– Use DCAP-BTLS.
– Do not focus just on the chest wound.
• Obtain baseline vital signs.
• Obtain SAMPLE history quickly.
 Interventions
• Provide complete spinal immobilization.
• Maintain open airway; be prepared to suction.
• Provide assisted ventilations if needed.
• Control bleeding.
• Place occlusive dressing over penetrating chest
wound.
• Stabilize flail segment with a bulky dressing.
• Treat aggressively for shock.
• Do not delay transport.
 Detailed Physical Exam

• Perform en route to the hospital if time allows.

 Ongoing Assessment

• Assess effectiveness of interventions.

• Reassess vital signs.
• Communication and documentation
– Communicate with hospital early if patient has
significant MOI.
– Describe injuries and treatment given.
• Patient has a significant MOI; do a rapid physical
exam.
• Obtain baseline vital signs and SAMPLE history.
• Take c-spine precautions and transport continuing
oxygen therapy.
• Perform detailed physical exam and ongoing
assessment en route.

You are the provider continued

 Complications of Chest Injuries

A pneumothorax occurs when air leaks into the space

between the pleural surfaces.
 Pneumothorax
• Air accumulates in the
pleural space.
• Air enters through a
hole in the chest wall.
– The lung may
collapse in a few
seconds or a few
minutes.
• An open or
penetrating wound to
the chest is called a
sucking chest wound.
 Care for Open Pneumothorax
• Clear and manage
the airway.
• Provide oxygen.
• Seal an open wound with
an occlusive dressing.
• Depending on local
protocol, tape down all
four sides or create a
flutter valve.
 Spontaneous Pneumothorax
• Some people are born with or develop weak areas
on the surface of the lungs.
• Occasionally, the area will rupture spontaneously,
allowing air into the pleural space.
• Patient experiences sudden chest pain and trouble
breathing.
• Consider a spontaneous pneumothorax for a
patient with chest pain without cause.
Tension Pneumothorax (1 of 2)
• Can occur from sealing all four sides
of the dressing on a sucking chest
wound
• Can also occur from a fractured rib
puncturing the lung or bronchus
• Can also result from a spontaneous
pneumothorax
Tension Pneumothorax (2 of 2)
Signs and Symptoms of
Tension Pneumothorax
• Respiratory distress
• Distended neck veins
• Tracheal deviation
• Tachycardia
• Low blood pressure
• Cyanosis
• Decreased lung sounds
Care for Tension Pneumothorax
• If a tension pneumothorax develops from
sealing an open chest wound, partly
remove the dressing to let the air escape.

• If there is no open wound, follow local

protocol.
 Hemothorax (1 of 2)
• Collection of blood in the pleural space
• Suspect if the following are seen:
– Signs and symptoms of shock
– Decreased breath sounds on affected side
• If both air and blood are present in the pleural
space, it is a hemopneumothorax.
Hemothorax (2 of 2)
 Rib Fractures
• They are very common in the older people.
• A fractured rib may lacerate the surface of the lung.
• Patients will avoid taking deep breaths and
breathing will be rapid and shallow.
• The patient often holds the affected side to minimize
discomfort.
• Administer oxygen.
 Flail Chest (1 of 2)
• Segment of chest wall detached from rest of
thoracic cage
• Occurs when:
– Three or more ribs are fractured in two or
more places.
– Sternum is fractured along with several ribs.
• Creates paradoxical motion
Flail Chest (2 of 2)
 Care for Flail Chest
• Maintain airway.
• Provide respiratory
support with BVM if
needed.
• Perform ongoing
assessments for
pneumothorax and
other respiratory
complications.
• Immobilize flail
segment.
 Pulmonary Contusions
• Bruising of the lung
• Develops over hours
• Alveoli fill with blood, and edema
accumulates in the lung, causing hypoxia.
• Provide oxygen and ventilatory support.
 Traumatic Asphyxia
• Sudden, severe compression of chest
• Produces rapid increase in pressure within chest
• Results in neck vein distention, cyanosis, and
bleeding into the eyes
• Provide supplemental oxygen and monitor vital
signs.
• Transport immediately.
 Blunt Myocardial Injury
• Bruising of heart muscle
• Pulse is often irregular.
• There is no prehospital treatment for
this condition.
• Check patient’s pulse and note
irregularities.
• Provide supplemental oxygen and
transport immediately.
 Pericardial Tamponade (1 of 2)

• Blood or other fluids collect in the pericardium.

 Pericardial Tamponade (2 of 2)
• Signs and symptoms:
– Very soft and faint heart tones
– Weak pulse
– Low blood pressure
– Decrease in difference between systolic and
diastolic blood pressure
– Jugular vein distention (JVD)
• Provide oxygen and transport quickly.
 Laceration of the Great Vessels
• The superior vena cava, inferior vena cava,
pulmonary arteries and veins, and aorta are
contained in the chest.
• Injury to these vessels can cause fatal hemorrhage.
• Treatment includes:
– CPR
– Ventilatory support
– Supplemental oxygen
– Transport immediately.