27: Chest Injuries

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 (1 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.

Cognitive Objectives (2 of 2)

Psychomotor Objectives7. 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

• Pain aggravated by increased breathing

• Bruising to chest wall

• Crepitus with palpation of chest

• Penetrating injury to chest

• Dyspnea

• Hemoptysis

• Failure of chest to expand normally

• Rapid, weak pulse and low blood pressure

• Cyanosis around lips or fingernails

You are the Provider

• 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 continued

• What is the mechanism of injury?• What precautions should you take?

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.

You are the provider continued (1 of 2)

• 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

bubbles as your patient breathes.

You are the provider continued (2 of 2)

• 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.

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 are the provider continued

• You ensure that his airway is open. • 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.

You are the provider continued

• 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.

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 ofTension 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.