ChestandAbdominalTraumaCaseStudies
Case#1
Scenario:EMSisdispatchedtoa2-carMVCwithheadoncollision.Thepostedspeedlimitismarkedat40MPH.
UponEMSarrivaltothesceneanunrestrainedadultdriverisfoundinsidethevehiclewithnoted+steeringwheel
deformity.ThepatientisA&OX3butappearsrestlessandagitated.
Onassessmentthefollowingisnoted:
Airway: Patent
Breathing:
RR:fast;laboredwithasymmetricchestexpansionanduseofaccessorymusclesbutnoparadoxical
movement; left side appears hyperinflated and does not move. Breath sounds absent on left,
diminishedonright;noadventitioussounds.Noopenwounds;tracheamidline.SpO286%,EtCO2
27.
Circulation:
JVD present; radial pulses absent; carotid pulses fast, weak and thready; equal bilaterally. C / O
severechestpain&difficultybreathing
Disability/LOC:
Eyesopenspontaneously,ptisawake,alert&orientedtovoice&isabletomoveallextremitiesto
command;PERL,EMSnotesanabrasiontoLanteriorchest;theptisA&Obutrestless&agitated.
Pain:
9/10
VS:
BP84/60,P116,R24
Questions
Answers
1.
Whattwoimmediatelife-threatsshouldbe
suspectedbasedonthispresentation?
2.
Whichoneismostlikelybasedonthe
mechanismofinjury?Whatisthe
pathophysiologyandtheclassicclinical
findingsofthisinjury?
3.
Whatisthemechanismofdeathinthis
injury?
4.
Whattemporizinglife-savingproceduremust
beperformedimmediately?
5.
Whatequipmentwillyouneed?
6.
Whatlandmarksmustyoufind?
7.
Atwhatangleisinsertionperformed?
Ifyouhitbone,shouldyougooverorunder?
Why?
8.
Whatshouldhappenafterpenetrationinto
thepleuralspace?
9.
Willthisprocedurere-expandthecollapsed
lung?Whyorwhynot?
Whatisthedifferencebetweenasimple
pneumothoraxandatensionpneumothorax?
10.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 2
Case#2
Scenario:EMSisdispatchedforanadultwhofell.Uponarrivaltothescene,aneighborgreetsyouandstatesthat
theysawthepersoncleaningguttersearlier.EMSseesanadultpt(50M)lyingoncementdrivewaysupineoutside
home.Uponscenesizeupaladderisfoundonthegroundoutsidea2story(~20ft.)familyhome;bushesinfront
appeardamaged.Uponarrivaltothept,EMSfindsapersonasstatedwithbleedingfromleftforehead;10”diamof
bloodongroundandappearsindistressmoaningandlocalizespain.
Onprimaryassessmentyounotethefollowing:
Airway: Gurglingsoundsnotedinairwayw/bloodysecretions
Breathing:
Breathingfasterthannormal,shallowandlaboredeffort(diminishedBSonLside).
Circulation:
Pulseisfastandregular;butradialsareweak.Capillaryrefillis3seconds.Neckveinsareflatand
skinisdusky,coolandmoisttothetouch.
Disability/LOC:
Eyesareopentopain,incomprehensiblesoundsmade&localizestopainfulstimuli.PupilsPERL;
bloodglucoselevelis86.
Pain:
8/10
Secondaryassessment:
VS:
BP94/64,P116,R24
Head: airwayclearw/suctioning;nobruisingtoface.
Pupils: PERL
Neck: JVD,tracheamidline
Chest: abrasion&tendernessLlatarea;+distress;+crepitustopalpw/paradoxicalmovement
Abdomen:
abrasionnotedtotheLUQ/Lflankarea;ptmoanstopalpation
Pelvis: unremarkable
Ext:
LLEw/deformity;otherwise+movementx4
Questions
Answers
1.
What3chestinjuriesshouldbesuspected
basedonthispresentationandmechanismof
injury?
2.
Whatisthemostlikelychestinjurybasedon
themechanismofinjuryandptpresentation?
3.
Whatisthedefinitionforthatinjury?
4.
Whataretheotherinjuryconcernsbasedon
ptpresentation?
Whatcriteriaisneededforthepttobe
placedonCPAP?
6.
OncetreatmentincludesCPAP,whatareaof
re-assessmentifkey?
7.
Whereshouldthisptbetransportedbasedon
presentationandinjury?
5.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 3
Case#3
Scenario:. EMSiscalledtoahouseforanadultwithchestpainfromapenetratinginjury.PDisonscenestatingthat
thesceneissafeandthattherewasanattemptedhomeburglaryinwhichtheburglarstabbedthehomeownerinan
attempttoescapescene.Uponenteringthehouse,theptissittingonthesofaholdinghischestindistress.ThetshirtisnotedtohaveaminoramountofbrightredbloodinacircularfashiontotheslightLoflateralpositionmid
chest.Hestatesthathischestfeelslikethereisaburningsensationandisinrespiratorydistress.Nopenetrating
objectsremain.
Onprimaryassessmentyounotethefollowing:
Airway: Breathing:
Circulation:
LOC:
Patent
Dyspneic;RRrapid,shallowandlaboredwithnomovementofLlateralchestwall;breathsounds
absentbilaterally.RASpO289%;EtCO230
Radialpulsesbecomingnon-palpw/inspiration,carotidsfast,weakandthready.Skinisdusky,cool
&clammy.Nouncontrolledhemorrhagebut+bubblingtochestwound,+JVD
eyesopenspontaneously;voiceisorientedandmovesextremitiestocommands.PupilsarePERL.
Secondaryassessment
VS:
BP:96/72;P:136;RR:32shallowandlabored.Ptstates“Ican’tcatchmybreath.”
HEENT: airwayremainsopen;noDCAP-BTLS-TICPMStoheadorneck
Neck: Tracheaismidline;jugularveinsflat
Chest: 1½”openingoverleftmedialchestwall;painonpalpationwithbloodbubblyw/resps.
Heartsoundsmuffled.
Abdomen:
Softandnon-tender.
Skin:
Duskynailbeds;circumoralcyanosis.Cool,pale,diaphoretic.
Neuro: GCS15;PERL;SMVintactX4
Pain: 10/10
Questions
Answers
1.
What2chestinjuriesshouldbesuspectedbased
onthispresentationandmechanismofinjury?
2.
Whataretheclassicclinicalfindingsofthese
injuries?
3.
Identifythelifethreat?
4.
Howshouldthispatientbetreated?Whatlife
savingtreatmentshouldbedoneforthese
injuries?
5.
Whatequipmentisneededtoperformthis
treatment?
6.
Whatistheongoingdangertotheptfromthis
injury?Whatisthemechanismofdeath?
7.
WhatshouldbedoneifaftertreatmentwithBP
rising,thentheptagainbecomeshypotensive?
8.
Whereshouldthisptbetransportedbasedon
presentationandinjury?
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 4
Case#4
Scenario:YouarecalledtoarestraineddriverinaMVConexpressway.Thereis15-20inchesofmetalintrusioninat
the dashboard due to a frontal impact. The windshield is broken and the steering wheel is bent. The patient is
complainingofseveresubsternalchestpain.Heisholdinghisarmagainsthischesttosplintwhenhebreathes.
Onprimaryassessmentyounotethefollowing:
Airway: Breathing:
Patent
Dyspneic; RR rapid, shallow and labored with redness and abrasions to the chest wall; no
paradoxicalmovement,SpO290%;Breathsoundspresentbutdiminishedbilaterally.
Radialpulsesequal;rapid,weakandthready.Skinpale,cool,clammy.
Awake;respondstoverbalstimuli
Circulation:
LOC:
Secondaryassessment:
VS:
HEENT: Neck: Chest: Abdomen:
Skin:
Neuro: Pain: BP:92/50;P:116;RR:26andshallow
AllWNL
Tracheaismidline;jugularveinsflat
Contusionoversternumonchestwall;painnotedonpalpation.
ECG:STwithmulti-focalPVCs
Softandnon-tender.
Cool,pale,diaphoretic.
GCS14;PERL;SMVintactX4
9/10
Questions
1.
Answers
Whatchestinjuriesshouldbesuspectedbasedon
thismechanismofinjury?
2.
Whichonewouldbemostlikely?Why?
3.
Howshouldthisptbemonitored?
4.
Howshouldyoutreatthispatient?
5.
What2treatmentmodalitiesareindicatedifthept
becomes/remainshypotensive?
Whereshouldthisptbetransportedbasedon
presentationandinjury?
6.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 5
Case#5
Scenario:A50y/orestraineddriverofasinglevehiclecrashwhodroveofftheroadandlaterallyhitintoatreeat40
mph on the drivers side. Upon arrival, assessment reveals the car to be a vintage model with only the lap belt
available.Thereforethepatientisslumpedsidewaysintothecenterofthevehicle,moaning.
Onprimaryassessmentyounotethefollowing:
Airway: Breathing:
Circulation:
LOC:
patent
labored;rapidrate.Breathsoundsnormalandequalbilaterally.
Radialpulsesrapidandweak;skinpaleandcooltotouch.
Eyesclosed;respondstoverbalstimulibymoaning;notmovingextremitiestocommand.Pupils
PERL,sluggishtorespond.
Secondaryassessment:
VS:
HEENT: Neck: Chest: Abdomen:
Extremities:
BP:88/54;P:110;RR:24.
Multipleabrasionstothelateralaspectsofthept’sheadwithlactoLforeheadandbleeding.Pupils
asnotedabove;bleedingcomingfrommouthwithlooseteeth.
Tracheamidline;jugularveinsflat.
No injury noted to chest with equal chest expansion; no paradoxical movements. EKG: ST with
PVCs.
abdominal exam with point tenderness to palpation to R and LLQ with positive guarding and
tendernesstopalpation(moansandlocalizespain).
multipleabrasionsbutnoentrapmentorextricationneeded.
Questions
Answers
1.
Whatabdominalinjuriesshouldbesuspected
basedonthispresentationandmechanismof
injury?
2.
Whichabdominalinjuryisthepatientat
greatestrisk?
3.
Why?Doesthisinjurytotheabdomencreate
animmediatelife-threat?
4.
Howshouldyoutreatthispatient?
5.
Whatistheongoingdangertothepatient
fromthisinjury?
6.
Identify3internalorgansintheLQsthatcould
beinjuredfromalowlyinglapbelt?
7.
8.
Identify3internalorgansintheUQsthatcould beinjuredfromahighlyinglapbelt?
Whereshouldthisptbetransportedbasedon
presentationandinjury?
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 6
ThoracicTraumaaswrittenforthe
NWCEMSSParamedicEducationProgram
ConnieJ.Mattera,M.S.,R.N.,EMT-P
I.
Epidemiologyofchesttrauma
A.
Incidence
1.
Chestinjuriesarecommonoccurrencesfollowingbluntandpenetratingtrauma.
2.
Isolated chest trauma is uncommon; the majority of these patients will have additional
injuries.
3.
Preventioneffortsamajorkey
4.
Thoracictraumaaccountsfor⅓alltraumaadmits
5.
Thoracicinjurymayinvolve:
a.
Chestwall
b.
Thoracicgreatvessels
c.
Heart,lungs,pleura
d.
Diaphragm,esophagus
e.
Tracheaandbronchus
6.
Bluntchesttrauma
a.
Occursinbothruralandurbansettings
b.
Motorvehiclecrashesareresponsiblefor70-80%ofbluntthoracictraumaplus
falls,sportsandcrushinjuries
7.
Penetratingchesttrauma
a.
Usuallyassociatedwithanurbansetting
b.
Commonlyduetogunshotwoundsandknifewounds
(1)
Low velocity gunshot wounds: Hand guns - 12-25% mortality. Sterile,
woundonlyalongtrackofmissile.
(2)
High velocity gunshot wounds: Military and hunting rifles. Cavitation
maycreatetissuedamage15timesthediameterofthebullet.Allthese
woundswillrequireoperativedebridementatthehospital.
(3)
Shot gun wounds: Result in varying wound types depending on pellet
size,choke,anddistancefromthevictim.
(4)
Stab wounds: 75% of penetrating chest wounds resulting from knives,
icepicks,sticks,arrows,portionsofautomobilesorotherprojectiles.
(5)
Impalementinjuries
8.
Isolated chest trauma is uncommon (16%); 84% of these patients will have additional
injuries
B.
Morbidityandmortality
1.
Thoracicinjuriesarethesecondleadingcauseoftraumamortalityoccurringin15-25%of
alltrauma-relateddeaths(about12,000peryearintheU.S.).Mostdeathsaresecondary
to heart and great vessel trauma causing exsanguinating hemorrhage and respiratory
failure.
2.
Thoracicinjuriesaresecondonlytoheadtraumainmortalityrates.Overallmortalityrate
is3%to18%.
3.
Chest injuries are often associated with abdominal injuries and are a significant
contributor to fatal outcomes in an additional 25%-50% of cases. They are the leading
causeofpreventabletraumadeath.
4.
Mechanismsofinjurycausingdeathfromthoracictrauma
a.
MVC
(1)
Accountforlargestnumberoftraumadeaths
(2)
Over50%haveoneormoredriverslegallyintoxicated
(3)
Motorcycledeathratemorethan15timesgreaterthenautocrash
b.
Falls:Morethan½inelderly
c.
Penetratinginjuries;seenmorefrequentlyinurbanareasduetoviolentcrime
d.
Crushinjuries
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Mechanisms of injury: Deceleration, shearing, acceleration, acceleration-deceleration,
compression
1.
Acceleration-deceleration: Skeletal body starts or stops moving more quickly than the
internal organs. This type of motion frequently causes more damage to relatively fixed
structures,(aorta),thantonon-fixedorgans,suchastheheartandlungs.
2.
Compression:Occurswhentheexternalforceappliedisgreaterthantheresistanceofthe
skeletalbody.
D.
Basicapproachtomajorthoracictraumaremainsunchanged,butthetreatmentofseveralinjuries
haveundergoneanevolutionintherecentpast:
1.
Pericardialtamponade
2.
Aortictransection
3.
Bluntcardiacinjury
4.
Pulmonarycontusionandflailchest
E.
Preventioneffortshavethepotentialtoreducetheincidenceofthoracicinjuries:
1.
Firearmsafety
2.
Sportstraining
3.
Seatbeltuse,passiverestraintsystems
4.
Decreasedspeedlimits
5.
Community/legalactivityregardingdrunkdriving,etc.
6.
Violencepreventioneducationi.e.,conflictresolutionskills
ReviewthoracicanatomyfromRespiratoryA&PandCardiacA&Plectures
Generalpathophysiologyofchestinjuries
A.
Impairmentsinventilatoryefficiency
1.
Painrestrictingchestexcursion
2.
Airorbloodenteringthepleuralspace
3.
Chestwallfailstomoveinunison
4.
Ineffectivediaphragmaticcontraction
B.
Impairmentsingasexchange
1.
Hypoxia:ResultsfrominadequateO2deliverytotissues
2.
Pulmonaryventilation/perfusionmismatch:i.e.-contusion,hematoma,alveolarcollapse
3.
Changes in intrathoracic pressure relationships: tension/open pneumothorax or severe
hemothorax
4.
Atelectasis
5.
Contusedlungtissue
6.
Respiratoryacidosis,hypercarbia:mostoftenresultsfrominadequateventilationcaused
bychangesinintra-thoracicpressurerelationshipsanddepressedlevelofconsciousness
C.
Disruptionofrespiratorytract
D.
Impairmentsincardiacoutput
1.
Hypovolemia:Inadequateintravascularvolumeduetobloodloss
2.
Increasedintrapleuralpressuresreducevenousreturn
3.
Bloodinpericardialsacreducespreload
4.
Decreasedstrokevolumeduetobluntcardiacinjury
5.
Myocardialvalvedamage
6.
Vasculardisruption
7.
Metabolicacidosis:causedbyhypoperfusiontotissues
Primaryassessmentpearls
A.
Clinically evident, immediately life-threatening injuries should be considered, found and
resuscitatedassoonasadeficitisdiscovered.AVOIDHYPOXICINJURY.
B.
Ifagitationoralteredmentalstatusispresent,assumethatthepatienthasanairway,breathing,
and/or perfusion problem especially if objective criteria support these findings, e.g., decreased
oxygen saturation, change in capnogram, or pulse deficits. Do not initially attribute abnormal
findingtodrugsorethanolabuseuntillife-threateningproblemshavebeenruledout.
C.
Ifcervicalspinestatusisunclear,spinemotionrestrictionmustbemaintainedifamechanismof
injurysuggestspotentialc-spineinjury.
D.
Etiologyofinadequateventilations/impairedgasexchange
1.
Ventilationdeficiencies:Pulmonary,musculoskeletal,orneurologic
C.
II.
III.
IV.
Page 7
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Diffusiondeficiencies:Pulmonarycontusion,previousdisease
Inspection
1.
Visuallyinspectthethoraxforappearance,contour,symmetryofexcursion,andanygross
abnormalities, i.e., deformity, contusions, abrasions, penetrating wounds, bruising,
lacerations, subcutaneous or tissue edema, paradoxical movements, retractions, or
impaledobjects,etc.
2.
Determineadequacyofventilations
a.
Generalrespiratoryrate,depth;andeffort(tachypnea,bradypnea)
b.
Workofbreathing;useofaccessorymuscles;nasalflaring
c.
Capnographynumberandwaveform
3.
Determineoxygenationstatus
a.
Clinical presentation i.e. mental status, skin color (cyanosis of the lips or nail
beds)etc.
b.
Pulseoximetry(SpO2)
4.
Neckveins
a.
Normalanatomiclocationofneckveins
(1)
External jugulars are above the clavicle and cross over the
sternocleidomastoidmuscles.
(2)
Internal jugulars run parallel to the sternocleidomastoid muscles near
thecarotidarteries.
(3)
If a patient is positioned at a 45° angle, the venous pulses should not
ascendmorethanonetotwocmabovetheclavicle.
b.
Markedly distended neck veins occur when blood cannot drain into the right
atria.Inthepresenceofchesttrauma,JVDmayindicatetensionpneumothorax
orcardiactamponade.
5.
Observeforthetype,amount,andnatureofsecretions
F.
Palpation
1.
Pointtenderness
2.
Lossofchestwallintegrity;instability
3.
Crepitus;subcutaneousemphysema
4.
Edema
5.
Trachealposition:Deviationisdifficulttoappreciateclinically
G.
Percussion
1.
Hyperresonance/tympany(pneumothorax)
2.
Dullorflattone(hemothorax)
H.
Listen without a stethoscope for noisy ventilatory efforts, air being sucked in or out of an open
chestwound.
I.
Auscultateimmediatelyifinventilatorydistress;Listenposteriorly,laterally,andanteriorly
1.
Breathsoundspresentorabsent;unilateralorbilateraldeficits
2.
Ifdecreased,attempttodiscernetiology;treatappropriately
3.
Adventitioussounds:treatduringfocusedexamphase
4.
Presenceofbowelsoundsinthechest-maysignifyaruptureddiaphragm
InjuriesthatmustbefoundatB(Breathing)astheyjeopardizeventilationsand/orgasexchange
A.
Tensionpneumothorax
1.
Etiology
a.
Results from any of the causes of a simple
pneumothorax
b.
Damage to lung parenchyma (tissue) usually from
blunttrauma
c.
In ventilated patients, it may occur secondary to
positive pressure ventilations resulting in a sudden
increaseinintrapulmonarypressure(barotrauma).
d.
Penetrationofpleurabyribfracture
e.
Tracheobronchialtreeinjuriesfromshearforces
2.
Pathophysiology
a.
Mostcommonlyoccursfromblunttrauma.
b.
Startswithasimplepneumothorax
2.
E.
V.
Page 8
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 9
Aclosedpneumothoraxprogressivelyaccumulatesairwithinthepleuralspaceon
inspirationthatcannotescapeonexpiration,creatingaone-wayvalve.
d.
This accumulation produces an increase in intrapleural pressure (tension) that
collapsesthelungontheaffectedsideanddepressesthediaphragm.
e.
Whenpressureinthepleuralspaceexceedspressureintheatriaandvenacavae,
theycollapse.Thiscreatesamechanicalobstructionofbloodreturntotheright
heart resulting in markedly decreased preload and cardiac output –
OBSTRUCTIVESHOCK
f.
Then…Rising intrathoracic pressure depresses diaphragm & shifts mediastinum
awayfromaffectedside,furthercompressingvenacavae&compromisingintact
lungsooppositesidebecomespressuredaswell
g.
Hemodynamicdysfunctionproduceshypoxiaandobstructiveshock.
h.
Life-threatening emergency due to cardiovascular compromise. Must be
suspectedclinicallyassoonaspossible.
3.
Assessment–classicfindings
a.
Inspection
(1)
Complaintofseverepainwithbreathing(pleuriticchestpain)
(2)
Restlessness,severeanxiety,agitation
(3)
Dyspnea,tachypnea,retractionsandothersignsofrespiratorydistress
(4)
Asymmetric chest movement, hyperdistended hemithorax on the
affectedside,bulgingofintercostalmuscles
(5)
JVD:Collapseofthesuperiorvenacavaandrightatriumpreventsblood
fromreturningtotherightsideoftheheartproducingincreasedcentral
venouspressure.HypovolemiawillpreventJVD.
(6)
Desaturationandcyanosis(latesign)
b.
Palpation
(1)
Tachycardia,weak,threadypulsesreflectreducedcardiacoutput
(2)
Subcutaneousemphysemainface,neckandupperchest
(3)
Trachealdeviation(latesign)–Tracheaissolidlytetheredanddoesnot
moveeasilyabovesternalnotch.Hardtodetectwithoutachestx-ray.
c.
Percussforhyperresonanceonaffectedside
d.
Auscultation
(1)
Absentordecreasedbreathsoundsonaffectedside
(2)
Distantheartsounds(ifmediastinalshifttoright)
(3)
Displacementofapicalimpulsetoleftlateralchestwallifshifttotheleft
(4)
Hypotension(narrowedpulsepressure)
4.
Emergencyinterventions-seelabmanual
a.
Applyoxygen12-15L/NRM
b.
Needlepleuraldecompressionisatemporizing
measure
(1)
Equipment needed: 10 g IV catheter
or use s commercial device;
Chlorhexidinewipe.
(2)
Proceduralsteps:Insertneedleata90
nd
rd
degreeangletothechestwallinthe2 or3 ICSinthemidclavicular
linetoreleaseairunderpressureinpleuralspace.USEEXTREMECAREin
selecting the correct site and inserting the needle using the correct
anglesoitpenetratesintothepleuralspace.
th th
Analternatesiteofneedleinsertioninthe4 -5 intercostalspaceinthemidaxillarylineisNOTapprovedintheNWC
EMSSduetothepossibilityofdiaphragmandliver/spleenpenetrationbyblindneedleinsertioninasupinepatient.
(3)
Iftheneedlehitsarib,gentlygooverthetopoftheribtoavoidinjuryto
theneuralvascularbundlerunningundereachrib.
(4)
Once in place, remove the needle and leave only the catheter in the
chest. A retained needle has the potential to penetrate the heart or a
ventilatedlung.
(5)
Release of pressurized air should relieve the patient’s acute distress,
improve ventilations, and re-establish venous return (and thus
c.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
B.
Page 10
peripheralpulses)butitwillnotre-expandthelung(breathsoundswill
still be absent). Will need a chest tube at the hospital to expand the
lung.
(6)
Frequently reassess catheter patency. May need to repeat procedure
withadditionalneedle.
c.
Venousaccess;IVNSupto1L
d.
Time-sensitivepatient–needsexpeditioustransporttoaLevelItraumacenter
5.
Complications
a.
Pneumothoraxifmisdiagnosedpriortoprocedure
b.
Hemothoraxifapulmonary,internalmammaryorintercostalvesselistransected
c.
Lunglaceration
d.
If tension pneumothorax presents unrecognized and therefore not treated, the
patient's condition may deteriorate to pulseless electrical activity (PEA) and
respiratory-cardiacarrest
6.
How can you tell the difference between a pneumothorax & tension pneumothorax
(bothhaveabsentbreathsounds)?
7.
Howcanyoutellthedifferencebetweenahemothorax&tensionpneumothoraxwhen
bothhaveunequalBS&lowBP?
Openpneumothorax(suckingchestwound)
1.
Etiology: Usually caused by penetrating chest trauma secondary to gun shot or stab
wound,butcanalsobecausedbyanimpaledobject.
2.
Pathophysiology
a.
Penetrating trauma through the chest wall
creates an opening allowing air to enter the
intrathoraciccavitythatdependsonnegative
pressures and intact pleural membranes to
allow
inspiration
through
the
tracheobronchialtree.
(1)
Sincechestwallandpleuralintegrity
is lost, the involved lung
paradoxically
collapses
on
inspiration and expands minimally during expiration moving air in and
outofthedefect,producinga"sucking"sound.
(2)
Criticaldiameter:Airisgas,soitflowsalongthepathofleastresistance
(high→lowpressure).Ifthewoundapproximates2/3thediameterof
thetrachea,resistancetoairflowthroughtherespiratorytractmaybe
greater than through the open wound, so air preferentially moves
through the chest wall defect into the pleural space instead of the
trachea to equalize intrathoracic and atmospheric pressure during
ventilatoryattempts.
(3)
Increased intrapleural pressure leads to lung collapse on the affected
sidewithpossiblemediastinalshift
(4)
Ventilation/perfusionmismatch
(a)
Shunting
(b)
Hypoventilation
(c)
Hypoxia
(d)
Largefunctionaldeadspace
(5)
Air may exit the wound during the exhalation phase producing a
frothingorbubblingatthesite
b.
Aone-wayflapvalvemayallowairinbutnotoutresultinginanaccumulationof
pressureinthepleuralspace
c.
Directlunginjurymaybepresent
3.
Morbidity/mortality:Patientdiesfrominadequateventilationandimpairedgasexchange
4.
Assessment
a.
Inspect
(1)
Visiblechestwalldefect;suckingsoundoninhalation
(2)
Complaintofpainwithbreathing
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Restlessness,dyspnea,tachypneaandothersignsofventilatorydistress,
hypoxia,andhypercarbia
(4)
Asymmetricalchestexpansion,subcutaneousemphysema
(5)
Cyanosis(latesign)
(6)
Aphasia: Patient cannot speak if they are unable to move air through
thetrachea.
b.
Palpateforsubcutaneousemphysemainneckandupperchest;tachycardia
c.
Auscultateforabsentordecreasedbreathsoundsonaffectedside(orbothsides
withsignificantinjury).
5.
Emergencyinterventions
a.
TheSMITHPAPYRUS,writtensometimearound3,000B.C.,containstheearliest
recognized reference to "thoracic trauma". Work describes 58 patients (2 had
thoracic injuries). Recommended treatment for penetrating injury was fresh
meat poultice the first day, followed by grease, honey and lint on subsequent
days
b.
If detectable, there is an immediate life-threat. Convert to a closed
pneumothorax.Immediatelycoverwithglovedhand.Then…
(1)
Askacooperativepatienttomaximallyexhaleorcough
(2)
Immediately apply occlusive dressing (Vaseline gauze, plastic wrap,
defib pad or commercial device). Dressings should be at least 3 or 4
timesthesizeofthedefect.
(3)
Maytapeon3sidestocreatefluttervalve
(4)
MonitorVS,ventilatory/circulatorystatus,jugularveinsafterapplication
ofocclusivedressing.
c.
Intubateifnecessaryandmonitorventilations
d.
Oxygen 12-15 L/NRM; assist with BVM as necessary. Use positive pressure
ventilations with caution in patients who have penetrating chest wounds. High
ventilatory pressures may force air from an injured bronchus into an adjacent
openpulmonaryvein,producingsystemicairemboli.Thismayaccountformany
of the dysrhythmias and sudden deaths that occur in patients with severe
penetratingchestwounds.
e.
AdministersedativescautiouslyperOLMCtoallowforcontrolofventilations
f.
Tension pneumothorax usually does not occur in the presence of an open
pneumothorax but may develop if
penetrating wound has a one-way flap
orissealedwithanocclusivedressing.
If patient becomes dyspneic and BP
drops,
assess
for
tension
pneumothorax and temporarily lift or
removedressingtoreleasepressure.
g.
Assess need for needle pleural
decompression if no improvement
followingremovalofdressing
h.
Noprobingofwounds
(1)
Givesnoinformation
(2)
Maycreateafalsepassage
(3)
Precipitateshemorrhage
(4)
Mayconvertaclosedtoanopenpneumothorax
Flailchest
1.
Mostsevereformofbluntchestwallinjury.
2.
Mechanismofinjury:usuallyduetobluntchesttrauma
a.
HighspeedMVC
b.
Falls
c.
Auto-pedestriantrauma
d.
Motorcycletrauma
e.
Severecompressiontrauma
3.
Pathophysiology
(3)
C.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
a.
b.
c.
5.
Flailchestoccurswhentwoormoreadjacentribsand/orcartilagesonbothsides
Bledsoe, 2006
of an impact point are broken at two points resulting in a freely mobile or
"floating"segment.
Maybeidentifiedbylocationorsize
(1)
Anterior,posterior,orlateral
(2)
Separationofthesternumfromadjacentbrokenribsorcostochondral
joints:sternalflailchest
Freesegmentmovesseparatelyandintheoppositedirection(paradoxically)to
the rest of the thoracic wall
duringtheventilatorycycle.
Paradoxicalmotionoftheflail
segment interferes with the
normal inspiratory/expiratory
cycle due to the lack of bony
support and changes in
intrathoracicpressures.
e.
Subatmospheric intrathoracic pressure during inspiration pulls the segment
inward. Positive intrathoracic pressures during expiration move the segment
outward.
f.
The most significant life-threat accompanying flail chest is the insult to lung
parenchymathatcreatesapulmonarycontusion.Contusedlungproducesmore
than the normal amount of interstitial and intra-alveolar fluid resulting in
impaired gas exchange. Pulmonary contusion occurs in 30-75% of all blunt
thoracictrauma(East,2006)andisthemajorcauseofrespiratorycompromise.
g.
Localeffects
(1)
Lacerationtolungtissue
(2)
Hemorrhage-filledalveoli
(3)
Reducedcomplianceleadingtoreducedventilation
(4)
Increased shunt fracture with decrease in pO2 and increase in AaDO2
(alveolar-arterialoxygendifference)
(5)
Increasedpulmonaryvascularresistance
(6)
Decreasedpulmonarybloodflow
(7)
Injuredanduninjuredlung(ipsilateralandcontralateral(EAST,2006)
h.
Pain from multiple rib fractures discourages breathing effort. Even if made
initially, fatigue, CNS depression, or increased tracheobronchial secretions will
eventuallyoutweighanypatientefforts.
i.
Hypoventilation,impairedoxygendiffusion,pulmonaryphysiologicshuntingand
venous admixture results in a decreased PaO2, decreased lung compliance,
decreased tidal volume and vital capacity, and decreased venous return with
ventilation/perfusion (VA/Q) mismatch. CO2 retention results in hypercarbia.
Impairedcoughresultsinatelectasis.
Morbidity/mortality
a.
Forces sufficient to produce a flail chest, are also sufficient to cause
pneumothoraxandseriousinjurytotheunderlyinglung.
b.
Mortality rates of 10% to 20% are typically accompanied by a significant
pulmonarycontusion.Mortality:5-50%duetoassociatedinjuries
c.
Mortalityincreasedwith
(1)
Advancedage:makeupabout10%ofthecasesbutconsume30%ofthe
clinicalresources(East,2006)
(2)
Sevenormoreribfractures
(3)
Threeormoreassociatedinjuries
(4)
Shock
(5)
Headtrauma
Assessment
a.
Inspect: Unclothed chest must be viewed from anterior, posterior, and lateral
anglestodetectpresenceofaflailsegment.
d.
4.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Evidence of chest wall trauma to soft tissues (abrasion, laceration or
ecchymosis)
(2)
Complaintofseverepleuriticchestpainatfracturesites,splinting
(3)
Dyspnea, altered RR (>35 or < 8 min), cough, and other signs of
respiratorydistress
(4)
Paradoxical chest movements - Not always apparent in an awake
patient with muscle spasms, shallow respirations, and splinting
secondarytopain.Seenaspatienttires,usuallywithinfirst24hours.
(5)
Poortidalvolume(shallowbreathing),pulseoximetrydesaturation,and
cyanosis(latesign)
b.
Palpate (or auscultate) for subcutaneous emphysema in neck and upper chest,
tenderness,crepitus,andpainatfracturesites,tachycardia.
c.
Auscultate for absent or decreased breath sounds on affected side, respiratory
stridor.
Interventions
a.
Goalsoftherapy
(1)
Promoteoxygenationandgasexchange.
(2)
Achieveandmaintainadequatepaincontrol.
(3)
Achieveandmaintaineuvolemia.
b.
Gainairwaycontrol;suction.
(1)
Intubation and mechanical ventilation should be avoided (East, 2006).
Mechanical ventilation should be used to correct abnormalities of gas
exchangeratherthantoovercomeinstabilityofthechestwall.
(2)
Clinical signs of progressive fatigue and deterioration should prompt
intubationandmechanicalventilations.
(a)
Respiratoryrate>35or<8breaths/min
(b)
PaO2<60mmHgatFiO2>50%
(c)
PaCO2>50mmHgatFiO2>50%
c.
CPAP:AtrialofmaskCPAPshouldbeconsideredinalert,compliantpatientswith
marginal respiratory status regimen (EAST, 2006). No external mechanical
stabilizationorsplintingoftheflailsegmentisindicated.
(1)
WhyisCPAPhelpful?
(a)
ProlongsO2diffusiontimeby50%
(b)
Improvesgasexchange
(c)
↓workofbreathing
(d)
↓respiratorymusclefatigue
(e)
↑functionalreservecapacity
(f)
↑cardiacoutput
(2)
ContraindicationsforCPAP:
(a)
DecreasedLOC
(b)
Unabletomaintainpatentairway
(c)
Aspirationrisk;inabilitytoclearsecretions
(d)
Needforimmediateintubation
(e)
Needforventilatoryassistance
(f)
ECGinstability
(g)
Evidenceofpneumothorax
(h)
Gastricdistention
(i)
↑ICP
(j)
Facial trauma/burns or recent surgery to face/mouth that
wouldcomplicatemaskseal
(k)
Epistaxis
(l)
Ptunabletotoleratemaskorpressure
(3)
CriteriatodiscontinueCPAPinthefield
(a)
Inabilitytotoleratemask
(b)
Needfortrachealintubationorassistedventilations
(c)
↓BP(SBP<90;DBP<60)(MAP<65)
d.
Needearlyventilatorysupport
(1)
6.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Presenceofshock
Associatedsevereheadinjury
Associatedinjuryrequiringsurgery
Previouspulmonarydisease
Age>65years
Fractureofeightormoreribs
e.
MonitorECG
f.
IVF as necessary with NS to maintain signs of adequate tissue perfusion. (East,
2006).Donotoverhydrate.
g.
Pain management is essential to promote ventilation and to prevent untoward
effectsofpaini.e.,splinting,atelectasis,andhypoventilation.Somepatientsmay
desaturate purely from inadequate pain management. Use of narcotic agents
maydecreasetherespiratorydrive,worsenhypoxia,andcause↓BPandshould
beusedwithextremecautioninthepresenceofchesttrauma.Balanceriskwith
benefit in the field. Alternative pain interventions are used at the hospital like
epiduralanalgesiaandlocalnerveblocks.
h.
Noexternalsplintingindicated
i.
If patient suffers a cardiac arrest: an impedance threshold device (ResQPod) is
contraindicated
7.
Complications
a.
** Flail chest serves as a red flag for significant underlying intrathoracic injury,
usually pulmonary contusion. Also suspect intrathoracic injuries such as
hemothoraxandpneumothorax.SuspectifSpO2remains<90despite15LO2.
b.
Pneumonia may occur secondary to a combination of factors: hypoventilation,
intubation,aspiration,inadequatepainmanagement,atelectasis,andpoolingof
secretions.
c.
Prolonged tracheal intubation can lead to associated complications such as
trachealstenosis,vocalcordparalysis,andvocalcordulceration.
d.
Long-termsymptomsincludecomplaintsofdyspneaandchestpain.
C:Circulation=Injuriesthatjeopardizecirculation/perfusion
A.
Assessforhemodynamicstability
1.
Mental status: Restlessness, progressive agitation, mental confusion and irrational or
uncooperativebehavior
2.
Pulses:Presence/absence,rate(generallyfastorslow),quality(full/thready),rhythmicity
(regular/irregular), location (carotid, femoral, or radial), symmetry, deficit, or loss on
inhalation (pulsus paradoxus). Tachycardia is not specific to one cause, but may give an
indicationofshock.
3.
Skinperfusion:Color/temperature/moisture.Lookforpale,cool,diaphoreticskindueto
sympatheticnervoussystemresponse.
4.
Evaluateneckveins
5.
MonitorECGrhythm
1.
Hearttones
a.
Heartsoundsarebestnotedoverthefollowingareas:
(1)
Mitralvalve:5thleftintercostalspace(LICS)inthemidclavicularline
(2)
Tricuspidvalve:lowerleftsternalborderatthe4thintercostalspace
(3)
Aorticvalve:2ndrightintercostalspaceatthesternalborder
(4)
Pulmonicvalve:2ndleftintercostalspaceatthesternalborder
a.
Heart sounds are often difficult to assess while examining the multiply
traumatized patient. However, muffled or distant heart tones are noteworthy
becausethisfindingmayindicatecardiactamponadeoratensionpneumothorax
withsignificantmediastinalshift.
6.
Shiftofapicalimpulse
B.
Because many of the organs in the chest are so vascular, hemorrhagic shock is a common
complication. The lungs are a low pressure system. Continuous hemorrhage indicates rupture of
majorvessel.
1.
Chest trauma patients in shock had a mortality of 7%. If respiratory distress was also
present,alongwithshock,themortalityincreasedto73%.
(1)
(2)
(3)
(4)
(5)
(6)
VI.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 15
Mostfrequentsourcesofbleedingcausingshockinthoracictrauma
a.
Bluntchesttrauma
(1)
Pelvicorextremityfractures
(59%)
(2)
Intraabdominalinjuries (41%)
(3)
Intrathoracicbleeding
(26%)
In addition, 15% had myocardial contusion and 7% had SCI which can contribute to hypotension from decreased
myocardialcontractilityanddiminishedsympathetictone.
b.
Penetratingchesttrauma
(1)
Intrathoracicbleeding(74%)oftenfrommultiplesites:
(a)
Lung(36%)
(b)
Cardiac,usuallywithtamponade(25%)
(c)
Greatvessel(14%)
(d)
Intercostal/internalmammaryarteries(10%)
(2)
Othercontributingsources:40%
C.
Pericardialtamponade
1.
Definition: Tamponade comes from the French word, "tampon", meaning "to plug".
Pericardialtamponadeliterallymeansapluginthepericardialsac.Itpracticallymeansan
accumulation of blood and/or clot in the pericardium causing an increase in
intrapericardialpressure.
2.
Etiology: Can occur with blunt or penetrating trauma, however, penetrating is more
common from small projectiles (ice pick or stiletto
knife).Becauseblunttraumacausessuchalargetear,
the patient generally exsanguinates before the lesion
cansealover.
3.
Epidemiology
a.
Incidence
(1)
Occurs in less than 2% of chest
trauma
(2)
Tamponade occurs in 10% of
patients with blunt chest trauma
(Yamamotoetal,2005).
(3)
Approximately80-90%ofpatientswithstabwoundstotheheartshow
evidenceoftamponade.
Occursin93%ofallrightventricularwounds;43%ofleftventricularwounds(Chappell,p.14)
(4)
CanoccurwithacuteMIandmyocardialrupture
(5)
Rare–CPR
b.
Morbidity/mortality
(1)
Estimatedmortality15-60%
(2)
Gunshotwoundscarryhighermortalitythanstabwounds
(3)
Lowermortalityifisolatedtamponadeispresent
(4)
Clinical severity depends on pericardial compliance, rate of fluid
accumulationandamountoffluidinpericardium
4.
Anatomicalconsiderations
a.
Thepericardiumisatough,fibroussac,enclosingtheheartandattachingtothe
greatvesselsatthebaseastheyleavetheheart
b.
Visceralandparietallayersservetoanchortheheart,restrictingexcessmotion
duringaccelerationorrepositioningofthebody.Theyalsopreventkinkingofthe
greatvessels.
c.
Thespacebetweenthelayersisa“potentialspace”
d.
Parietal,fibrousportionisnon-distensible.Spaceisnormallyfilledwith30-50ml
of straw-colored fluid secreted by the visceral pericardium. Fluid provides
lubrication,lymphaticdrainageandimmunologicprotectionfortheheart.
5.
Pathogenesisofpericardialtamponade
a.
Bleeding from the myocardium or
coronary arteries accumulates in the
pericardialsac.Thepericardiumhasanonlinear pressure compliance curve. In
2.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
D.
Page 16
chronicdisease,theremaybeaslow,progressiveaccumulationoffluidthatmay
distendthesacfrom1000-1500mLyetmaintainadequateoutput.
b.
Intraumaticinjury,rapidlyaccumulatingamountsof>50mLcanoveraperiodof
minutes to hours increases intrapericardial pressure and overcomes the
compliancecurveasthereisnotimeforthetissuestostretchandaccommodate
for the excess fluid. The most compressible structures within the sac collapse -
atria,greatveins.
c.
The combination of pressure and vascular collapse decreases venous return to
therightsideoftheheart(preload),restrictsdiastolicexpansionandfillingand
reducesstrokevolume.
d.
Initially, mechanisms such as an increased heart rate, increased myocardial
contractility, and an increase in ventricular filling pressure are used to
compensateforthedecreaseinstrokevolume(CO=SVXHR).
e.
Once the limits of compensation are reached, further increases in pericardial
volumecauseasevereimpairmentofcardiacfunctioning.
f.
Myocardialperfusiondecreasesduetopressureeffectsonthewallsoftheheart
anddecreaseddiastolicpressures.
g.
Ischemicdysfunctionmayresultininfarction
h.
Becauseofthedynamicsofthepressurecompliancecurve,removalofaslittleas
20to50mlofbloodmaydrasticallyimprovecardiacoutput
i.
Same mechanism of death as a tension pneumothorax = Inadequate venous
returnanddecreasedCO.
6.
Assessment
a.
Clinicalpresentationdependsontheinteractionbetweenpericardialcompliance,
rateoffluidaccumulation,andtheamountoffluidpresentinthepericardium.
b.
Beck'striad:advancedstagesseeninonly30%ofpatients
(1)
JVD(firstsign):Kussmaul’ssign(neckveinsfillduringinspiration,empty
duringexpiration)
(2)
Decreased arterial pressure (Systolic BP less than 100 mm Hg); pulsus
paradoxusandnarrowedpulsepressure
(3)
Muffled(subjective)heartsounds
c.
Evidenceofshock/hypoxemia
(1)
Thready/absent peripheral pulses (PEA): peripheral pulse 0 (absent) or
1+ (thready of a 4+ scale). Cardiac arrest may occur secondarily to
unrecognizedpericardialtamponade.Patientswhosurvivearrestmay
sustain other complications such as sepsis, anoxic encephalopathy, or
ischemicbowelifthearrestisprolonged
(2)
Diaphoresis
(3)
Dyspneaandothersignsofrespiratorydistress;cyanosisofupperhalfof
body
(4)
Alteredmentalstatus,agitation
(5)
Tachycardia,tachypnea
(6)
Pulsusparadoxus:SystolicBPdecreases>10mmHgwithinspiration
d.
ContinuousECGmonitoring–assessandrecordtracings
e.
Maybedifficulttodifferentiatebetweenatensionpneumothoraxandpericardial
tamponadeinthefieldastheysharemanyofthesamesignsandsymptoms.
7.
Emergencyinterventions
a.
Gainairwaycontrol;12-15Loxygen
b.
IVNStoachieveaminimumSBPof80.
c.
MonitorforPEA:TreatperTraumaticArrestSOPwhileenroute.
d.
Pericardiocentesis is a controversial temporizing intervention due to the risk of
possiblecardiacdamage.Itmayelicitmarkedimprovementinthepatientwhois
hemodynamicallycompromisedifenoughbloodisremovedfromthepericardial
sac to allow right heart filling again. This procedure is NOT done in the NWC
EMSS.
e.
Prepareresuscitativeequipment
Massivehemothorax
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
1.
2.
3.
4.
5.
6.
Page 17
Definition: Accumulation of 1500 mL or more blood in the pleural space (Class III or IV
hemorrhage).Pleuralspacescanholdtheentirebloodvolume.
Etiology:Bluntorpenetratinginjurywithtraumatosystemicorpulmonaryvessels,lung,
orheart
a.
Bleedingsourcesonleftside,indecreasingorderoffrequency
(1)
Ribfracture
(2)
Pulmonaryparenchyma
(3)
Aorticisthmus
(4)
Spleen
(5)
Heart
(6)
Intercostalartery:Caneasilybleed50ml/min
(7)
Supra-aorticvessel
(8)
Majorpulmonaryvessel
(9)
Diaphragm
b.
Bleedingsourcesonrightsideindecreasingorderoffrequency
(1)
Ribfracture
(2)
Pulmonaryparenchyma
(3)
Liver
(4)
Intercostal/internalmammaryartery
(5)
Supra-aorticvessel
(6)
Pulmonaryvessel
(7)
Aorticisthmus
(8)
Heart
(9)
Diaphragm
Morbidity/mortality
a.
Life-threateninginjurythatfrequentlyneedsurgentchesttubeinsertionand/or
surgeryatthehospital
b.
Hemothoraxassociatedwithgreatvesselorcardiacinjury
(1)
50%willdieimmediately
(2)
25%livefivetotenminutes
(3)
25%maylive30minutesorlonger
Pathophysiology
a.
Bloodaccumulatesinpleuralspacecausingpartialortotal
lungcollapsewithpossiblemediastinalshiftandimpaired
venousreturn
b.
Patientpresentsinhypovolemicshockandinrespiratory
distress. Cause of death = exsanguination leading to
cardiacarrest.
c.
Ventilatoryinsufficiencydependsontheamountofbloodinpleuralspace
Assessment
a.
Inspection
(1)
Signsofhypovolemicshock(pale,cool,moistskin)
(2)
Dyspnea, tachypnea, and other signs of respiratory distress;
desaturationonpulseoximeter
(3)
Asymmetric chest expansion, complaint of chest tightness, pleuritic
chestpain
(4)
Ecchymosesoveraffectedlung
(5)
Hemoptysisorbloodysputum
(6)
Neckveinsshouldbeflat
b.
Palpation
(1)
Tracheashouldnotbedeviated
(2)
Diminishedpulsequality,tachycardia
c.
Percussfordullnessonaffectedside
d.
Auscultate for decreased or absent lung sounds on affected side; BP for
hypotension,narrowedpulsepressure
Emergencyinterventions
a.
Gainairwaycontrol
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
12-15Loxygen;assistventilationsasnecessary
InsertlargeboreperipheralIVline
AdministerNStocorrecthypotensiontominimumacceptablelevels(SBP80with
penetratingtraumaand90withblunttrauma).Ifhypotensionlastslessthan30
minutes,mortalitymayonlybe11%.Ifhypotensionisprolonged:mortalityrises
to40%-50%.Ifpatienthasunderlyingdisease
& is 65 years or older, the mortality with
hypotension for > 30 minutes may be over
90%.
e.
Hospitals will insert chest tubes, perhaps
autotransfuse the patient and determine if
rapidoperativeinterventionisnecessary.
E.
Myocardialrupture
1.
Associated with immediate trauma or delayed for 2-3
weeks
2.
Associated with blunt trauma as the heart is compressed between the sternum and
vertebrae
3.
Penetratingtrauma:Rib,missile,sternalbone
4.
Historyoftraumawithapresentationof
a.
Heartfailure
b.
Cardiactamponade
5.
Immediateonsetofheartfailurefollowingtrauma
a.
Ruptureofcardiacvalves
b.
Intraventricularseptalrupture
6.
Managementissupportive
F.
Commotiocordis:Blowtothechestthatproducescardiacarrest.Thismaybemorecommonthan
once thought. Any blow to the chest, regardless of its intensity or velocity or force is capable of
producing cardiac arrest, especially in younger children whose rib cages are narrow and have
underdeveloped chest muscles. Patients have experienced death due to a blow from softballs,
baseballs, hollow toy baseball bats, snowballs, chest blows during shadow boxing, playing with a
familydogortryingtoremedyhiccups(Cooke,2002).
G.
Traumaticasphyxia
1.
Pathophysiology
a.
Suddencompressionalforcesqueezesthechest
b.
Vascularpressureincreasesinthehead,neck,andkidneys
c.
Jugularveinsengorge,capillariesrupture
2.
Clinicalpresentation
a.
Inspection
(1)
Bluntchesttrauma,mayhaveflail
(2)
Profoundshock
(3)
Cyanosisofface,neck,andshoulder
(4)
Swelling or hemorrhage of the conjunctiva; may exhibit exophthalmos
(protrudingeyes)
(5)
Swollen,cyanotictongueandlips
(6)
JVD
(7)
Skinbelowarearemainspink
(8)
Bloodyvomiting(hematemesis)
b.
Auscultation:Hypotensionwhenpressureisreleased
3.
Emergencyinterventions
a.
Gainairwaycontrol
b.
12-15LoxygenviaBVMortransportventilator.
c.
Spinemotionrestrictiononalongspineboard
d.
Timesensitivepatient;beginexpeditioustransport
e.
Venousaccessenroute;fluidadministrationperITC
Secondaryassessment
A.
Once the initial assessment is completed and life-threatening injuries have received resuscitative
intervention, proceed with focused history and exam. With chest trauma, any negative change
b.
c.
d.
VII.
Page 18
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
B.
C.
D.
E.
F.
Page 19
fromtheinitialassessmentisasignofpossibletrouble.
Fullsetofvitalsigns
1.
Pulse:Rate,quality,rhythmicity,deficits
2.
Bloodpressure
a.
Narrowedpulsepressure
b.
Hypertension
c.
Hypotension
d.
Pulsusparadoxus
3.
Respirations:Rate,pattern,depth
SAMPLE–history
1.
Symptoms
2.
Allergies
3.
Medications
4.
Pastmedicalhistory
5.
Lastoralintake/LMP
6.
Eventssurroundingtheincident–mechanismofinjury
Continue to use maneuvers of inspection, palpation, percussion and auscultation to detect
additionalinjuries.
1.
Chest wall injuries are characterized by pain, ineffective ventilation, and secretion
retention
2.
Injuries to the lung include pulmonary contusions and hematomas. Both cause bleeding
intothealveoliwhichimpairsgasexchange.
3.
Pleuralspaceinjuries:pneumothoraces,hemothorax,andtracheobronchialtears
Injuriestosuspect/findnow
1.
Aortictransection
2.
Penetratingwoundsofthegreatvessels
3.
Bronchialdisruption
4.
Esophagealinjury;traumaticdiaphragmatichernia
5.
Bluntcardiacinjury(myocardialcontusion)
6.
Pulmonarycontusion
7.
Simplepneumothorax
8.
Hemopneumothorax
9.
Fracturedribs
10.
Sternalfracture
Thoracicaortadissection/transection
1.
Etiology
a.
Mostcommonlyinjuredfromblunttrauma;usuallyhighspeedMVCswithlateral
impactsandsometimesfallsfromaheight.
b.
Produces15%ofallblunttraumadeaths.
c.
Penetrating injuries may occur at any point and usually result in massive
hemorrhage. Patients do not respond to CPR or volume replacement until
continuinglossiscontrolled.
2.
Morbidity/mortality
a.
80-85%dieatscene
b.
Ofthosewhosurvive,10-15%survivetoarrivalathospital
c.
33%diewithinsixhours
d.
33%diewithin24hours
e.
33%survivethreedaysorlonger
3.
Pathogenesis
a.
Impactproducesincreasedintraluminalpressures
b.
Pointsofattachment
(1)
Isthmusatligamentumarteriosum 85%
(2)
Aorticannulus 9%
(3)
Diaphragm
3%
(4)
Other 3%
c.
Whenthebodyisinmotionandcomestoasuddenhalt,shearingforcesorstress
on fixation points cause tears of the intimal layer at points of attachment or
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
thinningwhichallowsittoseparatefromthemedia.
Mediaandadventitiaaremoreelasticandmaynottearinitially
Blood dissects between the two layers causing a bulge on the vessel (false
aneurysm).
Assessment
a.
In those who are not immediately exsanguinating, the physical exam may be
unremarkable. There are no specific symptoms… patients present with a vast
spectrumofclinicalfindings.Maintainahighindexofsuspicion.
b.
Inspection
(1)
Complaintofretrosternalchestorinterscapularpain(80%)
(2)
Ischemicpainoftheextremities
(3)
Signsofhypovolemicshock;pallor
(4)
Severedyspnea,stridor
(5)
Decreasinglevelofconsciousness,restlessness,apprehensiveness
(6)
Dysphagia(fromhematoma-inducedesophagealcompression)
(7)
Hoarseness(fromhematoma-inducedlaryngealcompression)
c.
Palpation
(1)
Pulsedifferentialbetweenarmsorgreaterpulseamplitudeinarmsthan
in legs (may reflect ruptured descending aorta), decreased or absent
femoralpulses
(2)
Trachealshift
(3)
Tachycardia.
d.
Auscultation
(1)
Hypotension-25%duetoleakageandhypovolemia
(2)
Hypertension-25%duetostretchingofsympatheticnervesintheaorta
neartheligamentumarteriosum
(3)
Pressuredifferentialbetweenrightandleftarms(mayreflectruptured
subclavianarteryonsidewithlowerpressure)
(4)
Harsh systolic murmur over precordium or interscapular region due to
turbulenceasthebloodexitstheheartandpassesthedisruptedblood
vesselwall.
e.
Besuspiciousif:
(1)
+physicalexam;decreasedBPtolowerlimbs;
(2)
1st-2ndribfracture;
(3)
sternalfracture;or
(4)
significantdeceleration>35mph.
ClinicalS&S
a.
Respiratorydistress
b.
Signsofpericardialtamponade
c.
Physicalevidenceofmajorchesttraumae.g.,steeringwheelimprintonchest
d.
Pulse differential between arms or between upper and lower extremities:
decreasedorabsentfemoralpulses
e.
UpperextremityhypertensionorBPdifferentialbetweenarms
f.
Enlarginghematomaatthethoracicoutlet
g.
Interscapularmurmur
h.
Palpablefracturesofsternumand/orthoracicspines
i.
Traumawhichmaybesuspiciousforoccultinjuries
j.
Scapulafracture
k.
Multipleleftribfractures
l.
Flailchest
m.
Claviclefractureinthemulti-systeminjuredpatient
n.
Firstribfracture
Emergencyinterventions
a.
Airwaycontrol
b.
Monitorforsignsofdecreasedtissueperfusion/hypovolemicshock
c.
IVFtoachieveBPjustupto80-90mmHg.Donothydratetooquickly-raisingthe
BP may complete the separation or rupture the remaining vascular walls.
d.
e.
4.
5.
6.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Permissivehypotensionispreferred.
Monitorthepatient'sresponsetofluidadministration;VS
Monitorfordysrhythmiasandalterationsinconsciousness
Time sensitive patient. They need immediate surgical intervention. Transport
ASAPtoahospitalwithcardiothoracicsurgerycapabilities.
7.
Complications
a.
Paraplegia:vascularsupplytocorddisruptedinthoracicsegments
b.
Bowelischemia
c.
Renalfailure
d.
Anoxia
e.
Braininjury
f.
Leftventricularfailure
Penetratingwoundsofthegreatvessels
1.
Usuallyinvolve
a.
Chest
b.
Abdomen
c.
Neck
2.
Woundsareaccompaniedby
a.
Massivehemothorax
b.
Hypovolemicshock
c.
Cardiactamponade
d.
Enlarginghematomas
3.
Hematomasmaycausecompressionofanystructure
a.
Venacavae
b.
Trachea
c.
Esophagus
d.
Greatvessels
e.
Heart
4.
Emergencyinterventions
a.
Managehypovolemia
b.
Reliefoftamponadeifpresent
c.
Time-sensitivepatient;expeditioustransport
Bluntcardiacinjury(oldmyocardialcontusion)
1.
Mostcontroversialofallinjuries
2.
Incidence: 13-75% of trauma patients experience blunt cardiac trauma. Disparity
explainedduetolackofa"goldstandard"diagnostictestatthehospital.Itoccursmore
frequentlyinyoungerpatients.
3.
Morbidity: Rarely fatal alone, but may cause significant morbidity. Mortality: 8-20%;
deaths secondary to dysrhythmias or ventricular failure. May be the most common
unsuspectedvisceralinjuryfoundafterfatalcrashes.
4.
Mechanismofinjury
a.
90%occurduetoMVCs.Speedsof20-35mphcancausecontusionw/oexternal
chesttrauma
b.
Extent of injury is related to the magnitude of the force, duration over which
forceisapplied,andtherateofchangeovertime.
c.
Forces: Compression (RV absorbs impact against sternum ("clapper against a
bell"),acceleration/deceleration,intra-abdominalcavitycompressedandkinetic
energydirectedupward(hydraulicrameffect).
5.
Associatedinjuriescausingincreasedindexofsuspicion
a.
Sternalfractures
b.
Anteriorflails
c.
Aortictransection
d.
Pelvicfractures
e.
Cardiogenicshockifcontusion>40%ofventricularsurface
6.
Pathophysiology
a.
Areasofdamagearewelldemarcated
b.
Hemorrhagewithedemaandfragmentedmyocardialfibers
d.
e.
f.
G.
H.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Cellularinjury
Vasculardamagemayoccur
Pericardial tamponade: hemopericardium from lacerated epicardium or
endocardium
f.
Decreasedventricularfunction
(1)
RVmostfrequentlyinjuredduetoproximitytochestwall
(2)
LV dysfunction secondary to increase in RV afterload with subsequent
shift of the intraventricular septum to the left - causing decreased LV
complianceandstrokevolume.
g.
Dysrhythmiasecondaryto
(1)
activationofectopicpacemakers;
(2)
re-entrypathways;
(3)
hypoxia/ischemia;or
(4)
alcoholingestion.
Sequelae(complications)ofbluntcardiactrauma–muchlikeAMI
a.
Dysrhythmiasusuallyabsentinchildren.Thelocationoftheinjuryinfluencesthe
typeofdysrhythmiathatoccurs.
b.
VSD:ventricularseptaldefect
c.
Valvulardisruption
d.
Coronaryarteryocclusion
e.
Ventricularaneurysmandmyocardialrupture
f.
Fibrinousreactionatcontusionsitemayleadtodelayedpericardialrupturewith
cardiacherniation
Clinicalpresentation
a.
Chiefcomplaintisoftenretrosternalchestpainorshortnessofbreath:typically
sharp and well localized but may mimic ischemic pain. Often difficult to
distinguishfromchestwallpain.
b.
Inspect for ecchymosis on anterior chest, complaint of retrosternal angina, and
signs of hemodynamic instability and cardiogenic shock (but be aware that
patientmaybeasymptomatic).
c.
Palpateforpointtenderness,crepitusoversternumorribs
d.
Auscultateforcrackles,hearttonesandforapericardialfrictionrub;S3gallop
e.
ECGs: Abnormal in 40%-80% of contusions, but abnormal in 50% of patients
withoutcontusionswithchesttrauma.
(1)
Cardiac injury causes alterations in cardiac depolarization and
repolarizationandcardiacischemia.ECGchangesareoftennotedwithin
24 hours and return to normal in a much shorter time than those
produced by myocardial infarction. Most resolve spontaneously,
without treatment. One of the limitations of the conventional ECG is
that the recordings are dominated by the larger mass of the left
ventricle, while the more anteriorly placed RV is the more commonly
injured chamber. The ECG is therefore not a sensitive or specific
indicator of MC. Use only to increase index of suspicion. There is no
typicalECGpatternforcardiaccontusion.
(2)
Dysrhythmias: 90% present at impact. Should revert to normal in 3-4
months.
(a)
Persistenttachycardia
(b)
DeathinfieldcausedbyVTorVF
(c)
Atrialflutter/fib
(d)
PACs,PVCs-frequentlyresolvebyarrivalathospital
(3)
Conductionabnormalities:trendtowardoverdiagnosis
(a)
RBBB
(b)
AVblocks
(c)
ShortPRsyndrome
(d)
Leftorrightatrialenlargement
(e)
Non-specificST-Twavechanges-80%.Mustproveitwaspreexistentorassumeitwascausedbyinjury
c.
d.
e.
7.
8.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
(f)
Page 23
ProlongedQTinterval
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 24
Emergencyinterventions
a.
Gainairwaycontrol
b.
Oxygentherapybasedonclinicalpresentation
c.
MonitorHR,andperipheralpulses,andBP.Notifymedicalcontrolof
(1)
changesinmentalstatus,
(2)
systolicBPbelow100mmHg,
(3)
absentorthreadyperipheralpulses.
d.
Continuallyassesspatientforsignsof
(1)
pulsusparadoxus,
(2)
neckveindistention,
(3)
muffledheartsounds,and/or
(4)
hypotension.
e.
AdministerIVFtomaintainBPat90
f.
Pressoragentssuchasdopamineinhighdosesforhypotension:Befamiliarwith
dose and administration calculations prior to the time the patient requires
pressorsupport.
g.
Antidysrhythmicagentsasneeded
I.
Pulmonarycontusion:seeflailchest
1.
Incidence:Presentin30to75percentofpatientswithsignificantbluntchesttrauma
2.
Mechanismofinjury
a.
Commonlyassociatedwithribfracture
b.
Highvelocitymissilewithblasteffect
c.
Highenergyshockwavesfromexplosion
d.
Rapiddeceleration
e.
Lowvelocity:projectileslikeanicepick
3.
Mortalityandmorbidity
a.
Missedduetohighincidenceofotherassociatedinjuries
b.
Mortalitybetween14-20%
4.
Pathophysiology
a.
Threephysicalmechanisms
(1)
Implosioneffect
(a)
Overexpansion of air in lungs secondary to positive-pressure
concussivewave
(b)
Rapidexcessivestretchingandtearingofalveoli
(2)
Inertialeffect
Stripsalveolifromheavierbronchialstructureswhenacceleratedatvaryingratesbyconcussivewave
(3)
Spaldingeffect
(a)
Liquid-gasinterfaceisdisruptedbyshock-wave
(b)
Wavereleasesenergy
(c)
Differentialtransmissionofenergycausesdisruptionoftissue
b.
Alveolarandcapillarydamage
c.
WBCandplateletaggregationinpulmonaryvesselsleadstoreleaseofvasoactive
substances
d.
Loss of pulmonary capillary integrity with increased membrane permeability;
movement of water and plasma proteins into alveolar and interstitial spaces =
interstitialedemaandcongestiveatelectasis
e.
Surfactantdilutionresultsindecreasedlungcompliance
f.
The amount of oxygen delivered across the pulmonary capillary bed in the
injured segment is decreased resulting in hypoxemia and carbon dioxide
retention.
g.
Hypoxiacausesreflexthickeningofmucoussecretions
(1)
Bronchiolarobstruction
(2)
Atelectasis
h.
If the contusion is large, the body compensates by vasoconstricting pulmonary
blood flow and increasing cardiac output to shunt blood around the area of
minimal oxygenation. There is deceased functional reserve capacity due to this
9.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
J.
Page 25
pulmonary shunting which causes mixed venous blood to be returned to the
heartresultinginfurtherhypoxemia.
5.
Assessment
a.
The adverse effects of pulmonary contusion usually do not become clinically
evidentuntil24hoursafterinjury.
b.
Inspection
(1)
Signs of respiratory distress, dyspnea, tachypnea, restlessness,
apprehension
(2)
Ineffectivecough
(3)
Hemoptysis
(4)
Possiblechestwallabrasionsorcontusions
(5)
Increased pulmonary secretions, decreased pulmonary compliance,
desaturationonpulseoximeter,andcyanosis
c.
Palpateforpossibletendernessoverchestwall,tachycardia
d.
Auscultateforcracklesandwheezes,areasofdecreasedbreathsounds
6.
Emergencyinterventions
a.
Gainairwaycontrol
b.
15Loxygen;assistventilationsasnecessary
c.
RestrictIVfluidsunlesshypovolemic
d.
Analgesicsasindicated
Tracheobronchialinjuries
1.
Epidemiology
a.
Incidence:Rare:lessthan3%ofchesttrauma
b.
Trachealinjuriesareusuallycausedbypenetratingtrauma
c.
Bronchialinjuriesareusuallycausedbydeceleration(blunt)mechanisms
d.
Morbidity/mortality: High mortality rate: greater than 30% due to associated
airway obstruction. Majority of the patients die at the scene secondary to
asphyxia.
2.
Pathophysiology
a.
Siteofinjury
(1)
Tearcanoccuranywherealongtracheal/bronchialtree
(2)
Transverseruptureisthemostcommontypeoftrachealinjury
(3)
>80%occurwithin2.5cmofthecarina(pointoffixation)
b.
Rapidmovementofairintopleuralspace
c.
Tensionpneumothoraxrefractorytoneedledecompression
d.
Continuousflowofairfromneedledecompressionsite
e.
Severehypoxia
f.
Associated injuries: Esophageal, great vessels, lung, cardiac, and cervical spine
injuries are noted because of anatomical location and mechanism. Mechanism
canalsoaccountforassociatedheadinjuriesandfacialinjuries.
3.
Clinicalpresentation
a.
Variability in presentation: ranging from asymptomatic to severe
dyspnea/cyanosis
b.
Inspection:Hoarseness,dyspnea,tachypnea,ventilatorydistress,hemoptysis
c.
Palpation:Massivesubcutaneousemphysema
d.
Auscultation
(1)
Decreasedorabsentbreathsoundsassociatedwithpneumothorax
(2)
Hamman's sign may be present (crunching sound noted with heart
auscultation)
e.
S&Stensionpneumothorax
4.
Emergencyintervention
a.
Gainairwaycontrol
b.
15 L oxygen; do not use high pressures without preparing for needle
decompression
c.
Vascularaccess,prepareresuscitationequipment
(1)
Tracheobronchial rupture/tear via blunt trauma occurs secondary to
crushing or compressive injury that causes a sudden decrease in
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
(2)
(3)
(4)
anterior/posterior diameter and increase in lateral diameter (i.e., lap
belt across the throat in MVC). Since the lungs may move laterally in
response to the force, the trachea/bronchi may transect secondary to
exceededstretch.
Thecricoidringandcarinaserveasfixedpointsforthetrachea.When
there is an acute acceleration/deceleration force, a shearing force is
producedatthesefixedpointsandcreatesatrachealinjury.
Directinsulttoahyperextendedcervicaltracheamaycauserupture,e.g.
strikingthedashboard,steeringwheel.
Rapid increase in intrathoracic pressures concomitant with a closed
glottis may produce a "blowout" injury to the trachea with a linear
rupture.(Similartomechanismprecipitatingclosedpneumothorax.)
Sternalfracture
1.
Epidemiology
a.
Incidence:5-8%ofallthoracicinjuries
b.
Mechanism of injury is anterior blunt chest trauma at or below the
manubriosternal junction. Classic example is when the chest hits the steering
wheelordashboardinanMVC.Otherinjurymechanismsincludedirectblowto
thesternumorcompressionofthesternumassociatedwithhyperflexionsternal
injury
c.
Potentiallifethreateninginjuriesincludemyocardialcontusion,cardiacrupture,
cardiactamponade,orseverepulmonaryinsult
d.
Morbidity/mortality
(1)
25-45%mortality
(2)
Highassociationwithmyocardialorlunginjury
(a)
Myocardialcontusion
(b)
Myocardialrupture
(c)
Pulmonarycontusion
2.
Pathophysiology
a.
Severeimpactasareaiswellsupportedbytheribsandclavicles
b.
Associatedinjuriescausemorbidityandmortality
(1)
Pulmonaryandmyocardialcontusion
(2)
Flailchestifribattachmentsaredisruptedonbothsides
(3)
Vasculardisruptionofthoracicvessels
(4)
Intraabdominalinjuries
(5)
Headtrauma
c.
Rarelyisfracturedisplacedposteriorlytodirectlyimpingeonheartorvessels,but
itdoesoccur
3.
Clinicalfindings
a.
Inspect for anterior chest pain, sternal deformity, contusion, localized pain,
tachypnea,ECGchangesassociatedwithmyocardialcontusion
b.
Palpatefortenderness,instability,crepitusoversternum
c.
Unstablefracturesmayresultinaflailchest
d.
ECGchanges
4.
Emergencyinterventions
a.
Gainairwaycontrol
b.
Oxygenbasedonclinicalpresentation
c.
Restrictfluidsifpulmonarycontusionispresent
d.
Provideanalgesicsperlocalprotocols
e.
Allowchestwallself-splinting
Otherchestinjuries
A.
Simplepneumothorax
1.
Epidemiology
a.
Incidence
(1)
10-40%ofallbluntchesttrauma(checkcurrentdata)
(2)
Almost100%inpenetratingchesttrauma
b.
Morbidity/mortality:Dependsonextentofatelectasisandassociatedinjuries
K.
VIII.
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Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Classificationofpneumothoraxisdeterminedbythedegreeofcollapse:
(1)
Small:15%orlessoccupationofthepleuralcavity
(2)
Moderate:15%-60%occupationofthepleuralcavity
(3)
Large:60%orgreateroccupationofthepleuralcavity
2.
Pathophysiology
a.
Lungis1-3cmawayfromthechestwall.Pneumothoraxresultsfromaone-time
leakofastableamountofairintothepleuralspace.
b.
Disruptionofpleuralintegritymayresultfromalacerationcausedbyafractured
rib,penetratingmissile,orbarotraumaasseeninthe“paperbagsyndrome”or
mayoccurspontaneouslyfollowingstrenuousexercise,severecoughingepisodes
(particularlyinpatientswithCOPD),afterairtravel,orinpatientswithMarfan’s
Syndrome.
c.
Lossofintrapulmonary/intrapleuralsubatmosphericpressure
d.
Elastic recoil of lung tissue allows it to collapse when pleural integrity is
disrupted.
e.
Pulmonaryfunctionmaybegoodinahealthyperson
f.
Smalltearsmayself-seal;largeronesmayprogress
g.
Respiratorycompromisedepends onthedegreeofcollapseandtheamountof
pulmonaryreserve.LargerpneumothoracesproduceadecreasedareaforVA/Q
matchingresultinginaphysiologicshuntinthelungsandhypoxemia
3.
Clinicalpresentation
a.
Inspectfordyspnea,tachypnea,ventilatorydistress;sudden,pleuriticchestpain
thatmayrefertoshoulderorarmonaffectedside;mayhavealteredchestwall
movementand/orventilationperfusionmismatchandsignsofhypoxia
b.
Percuss:Hyperresonanceonaffectedside
c.
Palpate: Tachycardia; trachea may tug towards affected side; difficult to
appreciatewithaclinicalexam
d.
Auscultate: Decreased or absent breath sounds on affected side. If upright, air
will accumulate in the apices. Assess there first for altered breath sounds. If
supine,airaccumulatesintheanteriorchest.
4.
Emergencyinterventions
a.
Optimizeventilationsandgasexchangewith12-15LO2;situp
b.
Monitorforsignsoftensionpneumothorax
c.
PeripheralvenousaccessandadministerNSorLR
Ribfractures
1.
Epidemiology
a.
Incidenceandsignificance
(1)
Most common thoracic injury; seen in more than 50% of cases with
significant blunt chest trauma. Significant chiefly because the pain
involvedinhibitsthepatientfromtakingadequatebreaths.
(2)
Pediatric patients have cartilaginous ribs that bend easily. They
experiencedecreasedincidenceoffractures,butincreasedincidenceof
pulmonaryinjury.
(3)
Geriatricpatientshavecalcifiedribsthatarelessflexibleandmoreeasily
fractured. Also tend to have increased morbidity due to co-morbid
conditionsanddecreasedpulmonaryreserves.
b.
Etiology
(1)
Causedbydirectblowstothechest:Mechanismusuallyassociatedwith
age-relatedinjuries:
(a)
Sports/recreationalinjuriesinadolescents
(b)
MVC/assaultsinadults
(c)
Fallsinthegeriatricpopulation
(2)
Occurs at the point of impact or along the border of the object that
impactsthechest.Mayalsooccurataweakenedpointwheretheribs
flex(posteriorangle).
(3)
Ribs 4 through 9 are most commonly fractured as they are the least
protected. The first three ribs are relatively protected by the shoulder
c.
B.
Page 27
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
(4)
2.
3.
4.
5.
6.
7.
CJM:S10;S15
Page 28
girdleandthelowestribs(the“floatingribs”)arelessexposedandmore
mobile,soarealsorelativelyprotected.
Morbidityincreaseswiththenumberoffractures,extremesofage,and
associated chronic respiratory or cardiac conditions - especially in the
elderly. Two or more rib fractures are associated with an increased
incidenceofinternalinjury
Pathophysiology
a.
Becausetheribsarepartofaring,whenaribbreaks…
b.
Decreasedminuteventilationduetosplintingfrompain
c.
Whenever a person breathes shallowly, for any reason, the alveoli do not get
fullyinflated;littlebylittle,theybegintocollapseandtheprogressiveatelectasis
makes the lungs more vulnerable to pneumonia. Additionally, there may be
decreased surfactant production that normally lowers surface tension and
facilitates alveolar opening. This results in shunting of blood to nonventilated
alveoli that can lead to arterial hypoxemia, plugging of proximal airways,
segmentalandlobarcollapse,pneumonia,andbronchiectasis.
Concomitantinjuries
a.
1st through 3rd ribs take great force to fracture. Assoc. w/ fractures of neck,
clavicle, scapula, and great vessel injury (subclavian artery/vein, aortic injury)
severe intrathoracic injury (tracheobronchial injury, aortic rupture, and other
vascularinjuries,especiallyifmultipleribsareinvolved.
b.
Fractures of the ninth, tenth, and eleventh ribs are associated with
intraabdominal injury: lower left rib fractures: splenic injury; lower right rib
fractures:liverinjury.
c.
Sternal fractures are associated with pulmonary contusion and/or blunt cardiac
injury
Cartilaginousinjuriesaresimilar,butoftenmorepainfulandtakelongertoheal
Clinicalpresentation
a.
Inspection
(1)
Chest wall pain localized to the site of injury aggravated by breathing,
coughing,ormovement
(2)
Mayhaveoverlyingchestwallcontusionordeformity
(3)
Subcutaneousemphysemaimplies…
(4)
Shallowventilatoryeffortandreducedchestwallexcursion
(a)
Hypoxia
(b)
Hypoventilation–atelectasis
(c)
Musclespasmatfracturesite
(5)
Splinting:Patientwilloftenleantowardthefracturetorelievemuscular
tensiononthesite
(6)
Inadequatecough
b.
Palpation
(1)
Pointtendernesstopalpation;maybeunstable
(2)
Deformity,crepitus(gratingsensation)atfracturesite
Complications
a.
Pneumo/hemothoraxduetolacerationofbronchiorintercostalarteries
b.
Pneumomediastinum
c.
Tensionpneumothorax
d.
Non-unionoffracture;Costochondralseparation
e.
Pneumonia(largeprobleminelderly)
f.
Neurologicdeficitsiflacerationofintercostalnerves
g.
Pitfall: Do not underestimate the severe pathophysiology of rib fractures,
especiallyinelderlypatients.
Emergencyinterventions
a.
Optimize ventilations to prevent atelectasis and pneumonia. Encourage patient
tocoughanddeepbreathe.Splintchestwithpillow.
b.
Administeranalgesicstofacilitatechestwallmotion.
Chest and Abdominal Trauma Case Studies
NWC EMSS CE November 2015
Page 29
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