Chest Trauma

Objectives
 Anatomy of Thorax
 Main Causes of Chest Injuries
 S/S of Chest Injuries
 Different Types of Chest Injuries
 Treatments of Chest Injuries
Anatomy of the chest

Two Lungs (right and left)

Heart
Diaphragm
Anatomy of the chest

Pleural Space
Anatomy of the chest
 Main Causes of Chest Trauma
 Blunt Trauma- Blunt force to chest.

 Penetrating Trauma- Projectile that enters

chest causing small or large hole.

 Compression Injury- Chest is caught

between two objects and chest is
compressed.
 Chest Trauma
 Injuries to the chest wall
 Pulmonary injury (injury to the lung) and
injuries involving the pleural space
 Injury to the airways
 Cardiac injury
 Blood vessel injuries
 Injuries to other structures within the torso
 Injuries to the chest wall
– Chest wall contusions or hematomas.
– Rib fractures
– Flail chest
– Sternal fractures
– Fractures of the shoulder girdle
 Pulmonary injury (injury to the lung) and injuries involving
the pleural space
– Pulmonary contusion
– Pulmonary laceration
– Pneumothorax
– Hemothorax
– Hemopneumothorax
 Injury to the airways
– Tracheobronchial tear
 Cardiac injury Pericardial tamponade
– Myocardial contusion
– Traumatic arrest
 Blood vessel injuries
– Traumatic aortic rupture,
– Thoracic
– Aorta injury, aortic dissection
 And injuries to other structures within the
torso
– Esophageal injury (Boerhaave syndrome)
– Diaphragm injury
Priorities In treatment of patients
with Chest Injury
 Airway
– Assessement : Is the airway patient clear?
– Intervention : Clear Obstruction : Vomitus, Teeth, teongue
blood, secretions, foreign Bodies
 Breathing :
– Assessement :
» Respiratory effort
» Asymetric chest movement (flail Chest)
» Wounds (open pneumothorax)
» Hyper expansion (tension penumothorax)

 Intervention :
 » Subcutaneous air (Tracheal and bronchial tears)
» Breath Sounds
» Oxygen saturation
» Ventilation
– Intervention
» Administer supplemental oxygen
» Assist ventilation (BVM, Ventilator)
» Cover open wounds
» Perform needle torachostomy
» Insert chest tubes
» Draw arterial blood gas sample
 Circulation
– Assessement
» Pulses : Presents, absent, weak, strong, fast, slow
» Skin Signs: Color, temperature, moisture, CRT
» Cardiac rithm
» Hearth Sound
» Blood pressure and pulses
– Intervention
» Insert two (or more) large – bore (14-16 gauge) IV Catheter
» Infuse warmed, isotonic crystaloid solutions; RL or Normal Saline
» Tranfuse blood component as needed

– Assessement

– Intervention
 » Perform pericardiocentesis
» Perform closed chest compressions
» Perform emergency thoracotomy
 Disability
– Asessement
» Level of consciousness
» Complaints: Paint, dypsnea, numbness
» Gross Motor or sensory function
– Intervention
» Initiate or maintain spinal immobilization
» Obtain spinal radiograph
 Miscellaneous
– Asessement
» Mechanism of injury and pre hospital events
» Medical history
» Chest Entrance or exit wounds
» Major injury to other body sites
– Intervention
» Obtain chest radiograph
» Perform a 12-lead ECG
» Insert indwelling urinary (Foley) Catheter and monitor output
» Place orogastric or nasogastric tube for stomach decompressions
» Facilitate surgical interventions
 Injuries of chest
 Simple/Closed  Cardiac Tamponade
Pneumothorax  Traumatic Aortic
 Open Pneumothorax Rupture
 Tension  Traumatic Asphyxia
Pneumothorax  Diaphragmatic
 Flail Chest Rupture
 Simple/Closed Pneumothorax
 Opening in lung tissue
that leaks air into chest
cavity
 Blunt trauma is main
cause
 May be spontaneous
 Usually self correcting
 S/S of Simple/Closed
Pneumothorax
 Chest Pain
 Dyspnea
 Tachypnea
 Decreased Breath Sounds on Affected Side
 Treatment for Simple/Closed
Pneumothorax
 ABC’s with C-spine control
 Airway Assistance as needed
 If not contraindicated transport in semi-
sitting position
 Provide supportive care
 Contact Hospital and/or ALS unit as soon
as possible
 BLS Plus Care
 Cardiac Monitor
 IV access and Draw Blood Samples
 Provide Airway Management which
includes possible Intubation
 Monitor for Development of Tension
Pneumothorax
 Open Pneumothorax
 Opening in chest
cavity that allows air
to enter pleural cavity
 Causes the lung to
collapse due to
increased pressure in
pleural cavity
 Can be life threatening
and can deteriorate
rapidly
Open Pneumothorax
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothoarx
Inhale
Open Pnuemothorax
Inhale
 Sing/Symptom of Open
Pneumothorax
 Dyspnea
 Sudden sharp pain
 Subcutaneous Emphysema
 Decreased lung sounds on affected side
 Red Bubbles on Exhalation from wound
( a.k.a. Sucking chest wound)
 Subcutaneous Emphysema
 Air collects in subcutaneous fat from
pressure of air in pleural cavity
 Feels like rice crispies or bubble wrap
 Can be seen from neck to groin area
Sucking Chest Wound
 Treatment for Open
Pneumothorax
 ABC’s with c-spine control as indicated
 High Flow oxygen
 Listen for decreased breath sounds on
affected side
 Apply occlusive dressing to wound
 Notify Hospital and ALS unit as soon as
possible
Occlusive Dressing
 Occlusive Dressing
 Asherman Chest Seal
 BLS Plus Care
 Monitor Heart Rhythm
 Establish IV Access and Draw Blood
Samples
 Airway Control that may include Intubation
 Monitor for Tension Pneumothorax
 Tension Pneumothorax
 Air builds in pleural space with no where
for the air to escape
 Results in collapse of lung on affected side
that results in pressure on mediastium,the
other lung, and great vessels
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
The trachea is
pushed to
the good side

Heart is being
compressed
 S/S of Tension Pneumothorax
 Anxiety/Restlessness  Accessory Muscle Use
 Severe Dyspnea  JVD
 Absent Breath sounds  Narrowing Pulse
on affected side Pressures
 Tachypnea  Hypotension
 Tachycardia  Tracheal Deviation
 Poor Color (late if seen at all)
 Treatment of Tension
Pneumothorax
 ABC’s with c-spine as indicated
 High Flow oxygen including BVM
 Treat for S/S of Shock
 Notify Hospital and ALS unit as soon as
possible
 If Open Pneumothorax and occlusive
dressing present BURP occlusive dressing
 BLS Plus Care
 Monitor Cardiac Rhythm
 Establish IV access and Draw Blood
Samples
 Airway control including Intubation
 Needle Decompression of Affected Side
 Needle Decompression
 Locate 2-3 Intercostal space midclavicular line
 Cleanse area using aseptic technique
 Insert catheter ( 14g or larger) at least 3” in length
over the top of the 3rd rib( nerve, artery, vein lie
along bottom of rib)
 Remove Stylette and listen for rush of air
 Place Flutter valve over catheter
 Reassess for Improvement
Needle Decompression
 Flutter Valve
 Asherman Chest Seal
makes good Flutter
Valve .
 Also can use a Finger
from a Latex Glove
 Or A Condom works
also
 Hemothorax
 Occurs when pleural space fills with blood
 Usually occurs due to lacerated blood
vessel in thorax
 As blood increases, it puts pressure on heart
and other vessels in chest cavity
 Each Lung can hold 1.5 liters of blood
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax
 Hemothorax

May put pressure on the heart

 Hemothorax
Where does the blood come from.

Lots of blood vessels

 S/S of Hemothorax
 Anxiety/Restlessness
 Tachypnea
 Signs of Shock
 Frothy, Bloody Sputum
 Diminished Breath Sounds on Affected
Side
 Tachycardia
 Flat Neck Veins
 Treatment for Hemothorax
 ABC’s with c-spine control as indicated
 Secure Airway assist ventilation if necessary
 General Shock Care due to Blood loss
 Consider Left Lateral Recumbent position if not
contraindicated
 RAPID TRANSPORT
 Contact Hospital and ALS Unit as soon as
possible
 BLS Plus Care
 Monitor Cardiac Rhythm
 Establish Large Bore IV preferably 2 and draw blood
samples
 Airway management to include Intubation
 Rapid Transport
 If Development of Hemo/Pneumothorax needle
decompression may be indicated
 Blood in the cavity can be removed by inserting a
drain (chest tube) in a procedure called a tube
thoracostomy
Flail Chest

 The breaking of 2
or more ribs in 2
or more places
Flail Chest
 Sing/Symptom of Flail Chest
 Shortness of Breath
 Paradoxical Movement
 Bruising/Swelling
 Crepitus( Grinding of bone ends on
palpation)
Flail Chest is a True Emergency
 Treatment of Flail Chest
 ABC’s with c-spine control as indicated
 High Flow oxygen that may include BVM
 Monitor Patient for signs of Pneumothorax
or Tension Pneumothorax
 Use Gloved hand as splint till bulky
dressing can be put on patient
 Contact hospital and ALS Unit as soon as
possible
Bulky Dressing for splint of Flail
Chest
 Use Trauma bandage
and Triangular
Bandages to splint
ribs.
 Can also place a bag
of D5W on area and
tape down. (The only
good use of D5W I
can find)
 BLS Plus Care
 Monitor Cardiac Rhythm
 Establish IV access
 Airway management to include Intubation
 Observe for patient to develop Pneumothorax and
even worse Tension Pneumothorax
 If Tension Develops Needle Decompress affected
side
 Rapid Transport! Remember a True Emergency
 Pericardial Tamponade
 Blood and fluids
leak into the
pericardial sac
which surrounds the
heart.
 As the pericardial
sac fills, it causes
the sac to expand
until it cannot
pericardial sac expand anymore
Pericardial Tamponade
 Once the pericardial
sac can’t expand
anymore, the fluid
starts putting
pressure on the heart

 Now the heart can’t

fully expand and
can’t pump
effectively.
Pericardial Tamponade
 With poor pumping the
blood pressure starts to
drop.
 The heart rate starts to
increase to compensate
but is unable
 The patient’s level of
conscious drops, and
eventually the patient
goes in cardiac arrest
 S/S of Pericardial Tamponade
 Distended Neck Veins
 Increased Heart Rate
 Respiratory Rate increases
 Poor skin color
 Narrowing Pulse Pressures
 Hypotension
 Death
 Treatment of Pericardial
Tamponade
 ABC’s with c-spine control as indicated
 High Flow oxygen which may include
BVM
 Treat S/S of shock
 Rapid Transport
 Notify Hospital and ALS Unit as soon as
possible
 BLS Plus Care
 Cardiac Monitor
 Large Bore IV access
 Rapid Transport
 What patient needs is pericardiocentesis,
Although not accepted practice in KY pre-
hospital setting( exception is that the Flight
nurse’s of STATCARE may perform this
procedure in KY)
 Pericardiocentesis
 Using aseptic technique, Insert at least 3” needle
at the angle of the Xiphoid Cartilage at the 7 th rib
 Advance needle at 45 degree towards the clavicle
while aspirating syringe till blood return is seen
 Continue to Aspirate till syringe is full then
discard blood and attempt again till signs of no
more blood
 Closely monitor patient due to small about of
blood aspirated can cause a rapid change in blood
pressure
 Pericardial Tamponade

Is A Dire Emergency

Traumatic Aortic Rupture
The heart, more or less, just
hangs from the aortic arch
Much like a big pendulum.

If enough motion is placed on

the heart (i.e.. Deceleration
From a motor vehicle
accident, striking a tree while
skiing etc) the heart may tear
away from the aorta.
Traumatic Aortic Rupture
The chances of survival are
very slim and are based on the
degree of the tear.

If there is just a small tear then

the patient may survive. If the
aorta is completely transected
then the patient will die
instantaneously
S/S Of Traumatic Aortic Rupture
 Burning or Tearing Sensation in chest or
shoulder blades
 Rapidly dropping Blood Pressure
 Pulse Rapidly Increasing
 Decreased or loss of pulse or b/p on left
side compared to right side
 Rapid Loss of Consciousness
 Treatment of Traumatic Aortic
Rupture
 ABC’s with c-spine control as indicated
 High Flow oxygen that may include BVM
 Treatment for Shock

RAPID TRANSPORT
 Contact Hospital and ALS Unit As soon as
possible
 BLS Plus Care
 Monitor Cardiac Rhythm
 Large Bore IV therapy probably 2 and draw
blood samples
 Airway management that may include
Intubation
RAPID TRANSPORT
 WHAT PATIENT NEEDS IS BRIGHT
LIGHTS AND COLD STEEL
 Traumatic Asphyxia
 Results from sudden compression injury to
chest cavity
 Can cause massive rupture of Vessels and
organs of chest cavity
 Ultimately Death
 S/S of Traumatic Asphyxia
 Severe Dyspnea
 Distended Neck Veins
 Bulging, Blood shot eyes
 Swollen Tounge with cyanotic lips
 Reddish-purple discoloration of face and
neck
 Petechiae
 Treatment for Traumatic
Asphyxia
 ABC’s with c-spine control as indicated
 High Flow oxygen including use of BVM
 Treat for shock
 Care for associated injuries
 Rapid Transport
 Contact Hospital and ALS Unit as soon as
possible
 BLS Plus Care
 Cardiac Monitor
 Establish IV Access and draw blood
samples
 Airway control including Intubation
 Rapid transport
 Diaphragmatic Rupture
 A tear in the Diaphragm that allows the
abdominal organs enter the chest cavity
 More common on Left side due to liver
helps protect the right side of diaphragm
 Associated with multipile injury patients
Diaphragm Rupture
 S/S of Diaphragmatic Rupture
 Abdominal Pain
 Shortness of Air
 Decreased Breath Sounds on side of rupture
 Bowel Sounds heard in chest cavity
 Treatment of Diaphragmatic
Rupture
 ABC’s with c-spine control as indicated
 High Flow oxygen which may include
BVM
 Treat Associated Injuries
 Rapid Transport
 Contact Hospital and ALS Unit as soon as
possible
 BLS Plus Care
 Cardiac Monitor
 Establish IV access and draw blood samples
 Airway management including Intubation
 Observe for Pneumothorax due to compression on
lung by abdominal contents
 Possible insertion of NG tube to help decompress
the stomach to relieve pressure
 Rapid transport, Patient needs BRIGHT LIGHTS
AND COLD STEEL
 Summary

Chest Injuries are common and often life threatening

in trauma patients. So, Rapid identification and
treatment of these patients is paramount to patient
survival. Airway management is very important and
aggressive management is sometimes needed for
proper management of most chest injuries.
When Minutes Matter
 The END
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