Thoracic Trauma
Athens Technical College
EMS Programs
1
Chest Trauma
Second leading cause
of trauma deaths
after head injury
About 20% of all
trauma deaths
 25% of MVC deaths are
due to thoracic trauma
12,000 annually in US
 Abdominal injuries are
common with chest
trauma.
2
Anatomy of the chest
Heart
Lungs
Aorta
Vena Cavas
Great blood vessels
Trachea
Esophagus
3
Pathophysiology of Thoracic Trauma
Penetrating Trauma
 Low Energy
Arrows, knives, handguns
Injury caused by direct contact
and cavitation
High Energy
Military, hunting rifles & high
powered hand guns
Extensive injury due to high
pressure cavitation
Trauma.org
Pathophysiology of Thoracic Trauma
 Blunt Trauma
Results from kinetic energy forces
Subdivision Mechanisms
Blast
•
•
•
•
Pressure wave causes tissue disruption
Tear blood vessels & disrupt alveolar tissue
Disruption of tracheobronchial tree
Traumatic diaphragm rupture
Crush (Compression)
• Body is compressed between an object and a hard surface
• Direct injury of chest wall and internal structures
Deceleration
• Body in motion strikes a fixed object
• Blunt trauma to chest wall
• Internal structures continue in motion
– Ligamentum Arteriosum shears aorta
5
Chest Trauma
Initial exam directed toward:
Open pneumothorax
Flail chest
Tension pneumothorax
Massive hemothorax
Cardiac tamponade
6
Rib Fracture
Most common chest injury
More common in adults than children
Especially common in elderly
Ribs form rings
Consider possibility of break in two places
7
Rib Fracture
Most commonly 5th
to 9th ribs
Poor protection
8
Rib Fracture
Fractures of 1st, 2nd, 3rd
ribs require high force
Frequently have injury to
aorta or bronchi
30% will die
9
Rib Fracture
Fractures of 8th to 12th ribs can damage
underlying abdominal solid organs:
Liver
Spleen
Kidneys
10
Rib Fracture
Signs and Symptoms
Localized pain, tenderness
Increases when patient:
Coughs
Moves
Breathes deeply
Chest wall instability
Deformity, discoloration
Associated pneumo or hemothorax
11
Rib Fracture
Management
High concentration O2
Splint using pillow,
swathes
Encourage patient to
breath deeply
12
Flail Chest
Two or more adjacent ribs broken in two
or more places
Produces free-floating chest wall segment
Usually secondary to blunt trauma
More common in older patients
13
Flail Chest
Signs and Symptoms
Paradoxical movement
May NOT be present initially due to
intercostal muscle spasms
Be suspicious in any patient with chest
wall:
• Tenderness
• Crepitus
14
Flail Chest
Consequences
Pain, leading to
decreased ventilation
Increased work of
breathing
Contusion of lung
15
Flail Chest
Management
Establish airway
Suspect spinal injuries
Assist ventilation with BVM and oxygen
Stabilize chest wall
16
Simple Pneumothorax
Air in pleural
space
Partial or
complete lung
collapse occurs
17
Simple Pneumothorax
Causes
Chest wall penetration
Fractured rib lacerating lung
Paper bag effect
May occur spontaneously following:
Exertion
Coughing
Air Travel
18
Simple Pneumothorax
Signs and Symptoms
Pain on inhalation
Difficulty breathing
Tachypnea
Decreased or absent breath sounds
Severity of symptoms depends on size of
pneumothorax, speed of lung collapse,
and patient’s health status
19
Simple Pneumothorax
Management
Establish airway
Suspect spinal injury based on mechanism
High concentration O2 with NRB
Assist decreased or rapid respirations with BVM
Monitor for tension pneumothorax
20
Open Pneumothorax
Hole in chest wall
Allows air to enter pleural space
Larger hole = Greater chance air will
enter there than through trachea
“Sucking Chest Wound”
21
Open Pneumothorax
Management
Close hole with
occlusive dressing
High concentration O2
Assist ventilations
Consider transport on
injured side
Monitor for tension
pneumothorax
22
Tension Pneumothorax
One-way valve forms in lung or chest wall
Air enters pleural space; cannot leave
Air is trapped in pleural space
Pressure rises
Pressure collapses lung
23
Tension Pneumothorax
Trapped air pushes heart, lungs away
from injured side
Vena cavae become kinked
Blood cannot return to heart
Cardiac output falls
24
Tension Pneumothorax
Signs and Symptoms
Extreme dyspnea
Restlessness, anxiety,
agitation
Decreased breath
sounds
Hyperresonance to
percussion
Cyanosis
Subcutaneous
emphysema
25
Tension Pneumothorax
Signs and Symptoms
Rapid, weak pulse
Decreased BP
Tracheal shift away
from injured side
Jugular vein
distension
Early dyspnea/hypoxia - Late shock
26
Tension Pneumothorax
Management
Secure airway
High concentration O2
with NRB
If available, request
ALS intercept for
pleural decompression
27
Hemothorax
Blood in pleura space
Most common result of major chest wall
trauma
Present in 70 to 80% of penetrating,
major non-penetrating chest trauma
28
Hemothorax
Signs and Symptoms
Rapid, weak pulse
Cool, clammy skin
Restlessness, anxiety
Thirst
Chills
Hypotension
Collapsed neck veins
29
Hemothorax
Signs and Symptoms
Decreased breath sounds
Dullness to percussion
Dyspnea
Ventilatory failure
Shock precedes ventilatory failure
30
Hemothorax
Management
Secure airway
Assist breathing with high concentration O2
Rapid transport
31
Traumatic Asphyxia
Blunt force to chest causes
Increased intrathoracic pressure
Backward flow of blood out of heart into
vessels of upper chest, neck, head
32
Traumatic Asphyxia
Signs and Symptoms
Possible sternal fracture or central flail chest
Shock
Purplish-red discoloration of:
Head
Neck
Shoulders
Blood shot, protruding eyes
Swollen, cyanotic lips
33
Traumatic Asphyxia
Name given because patients
looked like they had been
strangled or hanged
34
Traumatic Asphyxia
Management
Airway with C-spine
control
Assist ventilations
with high
concentration O2
Spinal stabilization
Rapid transport
35
Cardiovascular Trauma
Any patient with significant
blunt or penetrating trauma to
chest has heart/great vessel
injury until proven otherwise
36
Myocardial Contusion
Bruise of heart muscle
Most common blunt cardiac injury
Usually due to steering wheel impact
37
Myocardial Contusion
Behaves like acute MI
May produce arrhythmias
May cause cardiogenic shock,
hypotension
38
Myocardial Contusion
Signs and Symptoms
Cardiac arrhythmias after blunt chest trauma
Angina-like pain unresponsive to nitroglycerin
Chest pain independent of respiratory
movement
Suspect in all blunt chest trauma
39
Myocardial Contusion
Management
High concentration O2
Transport
Consider ALS intercept
40
Cardiac Tamponade
Rapid accumulation of blood in space
between heart, pericardium
Heart compressed
Blood entering heart decreases
Cardiac output falls
41
Cardiac Tamponade
Signs and Symptoms
Hypotension unresponsive to treatment
Increased central venous pressure
(distended neck/arm veins in presence of
decreased arterial BP)
Small quiet heart (decreased heart
sounds)
Beck’s Triad
42
Cardiac Tamponade
Signs and Symptoms
Narrowing pulse
pressure
Pulsus paradoxicus
Radial pulse becomes
weak or disappears
when patient inhales
43
Cardiac Tamponade
Management
Secure airway
High concentration O2
Rapid transport
Definitive treatment is pericardiocentesis
followed by surgery
44
Aortic rupture
Usually blunt trauma involving
deceleration forces; especially RTAs
~90% die within minutes
Most common site near ligamentum
arteriosum
Dx: clinical suspicion, CXR, aortography,
contrast CT or TOE
Rx: surgical…poor prognosis
Management of the Chest Injury Patient
General Management
 Ensure ABC’s
High flow O2 via NRB
Intubate if indicated
Consider RSI
Consider overdrive ventilation
If tidal volume less than 6,000 mL
BVM at a rate of 12-16
• May be beneficial for chest contusion and rib fractures
• Promotes oxygen perfusion of alveoli and prevents atelectasis
 Anticipate Myocardial Compromise
 Shock Management
Fluid Bolus: 20 mL/kg
AUSCULTATE! AUSCULATE! AUSCULATE!
Questions?
47