U.S. ARMY MEDICAL DEPT.

CENTER & SCHOOL CORRESPONDENCE PHASE 91B BNCOC TECHNICAL TRAINING Chest (Thoracic) Trauma I. REFERENCE.

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Campbell, J.E. (Ed.), Basic Trauma Life Support (Advanced). (3rd Ed.) Englewood Cliffs, N.J.: PrenticeHall, Inc. 1995. II. OBJECTIVES. A. Terminal Learning Objective. Given a patient with chest trauma, evaluate and stabilize the patient IAW cited reference. B. Enabling Learning Objectives. 1. 2. 3. III. Given a list, identify the basic anatomy of the thorax IAW cited reference. Given a list, identify the pathophysiology of thoracic trauma IAW cited reference. Given a list, identify the signs, symptoms, and management procedures of thoracic injuries IAW cited reference.

EXPLANATIOIN. Given a list, identify the basic anatomy of the thorax IAW cited reference. Anatomy. a. b. Twelve (12) pair of ribs, joined posteriorly with the thoracic spine and anteriorly with the sternum, form the body cavity. Each thoracic cavity is occupied by one lung. The mediastinum is between the two chest cavities and contains the heart, aorta, superior and inferior vena cava, trachea, esophagus and major bronchi. The diaphragm separates the thoracic organs from the abdominal cavity. The upper abdominal organs, including the spleen, kidneys, liver, stomach, and pancreas, are protected by the lower rid cage. A penetrating thoracic wound at the fourth intercostal space (level of the nipples) or lower should be assumed to be a abdominal injury as well as thoracic injury. Thoracic and abdominal structures are often injured by blunt deceleration injuries such as steering wheel injuries.

Objective 1. A.

c. d. e. f. Objective 2. B.

Given a list, identify the pathophysiology of thoracic trauma IAW cited reference. Pathophysiology.

M C2000193 0797 a. b. Follow assessment priorities, when evaluating a victim, to avoid missing life-threatening injuries. Look for the most dangerous injuries first. Thoracic injuries may be the result of penetrating objects or blunt trauma. (1) Penetrating injuries, i.e., gunshot or stab wounds, distribute the forces of injury over a lesser area. The trajectory of a bullet can be unpredictable, and all thoracic structures are at risk. Blunt trauma - force is distributed over a large area. Visceral injuries occur from deceleration, compression, bursting, or sheering forces.

(2) Objective 3. C.

Given a list, identify the signs, symptoms, and management procedures of thoracic injuries IAW cited reference. Assessment. 1. The major symptoms of chest injury include shortness of breath, respiratory distress, and chest pain. The signs indicative of chest injury include shock, cyanosis, hemoptysis, chest wall contusion, flail chest, open wounds, distended neck veins, tracheal deviation, or subcutaneous emphysema. Check lung fields for presence and equality of breath sounds. Major thoracic injuries - the deadly dozen. a. Immediate life-threatening. (1) Airway obstruction - remains a major challenge in the care of any trauma victim. Assume there is an associated cervical spine injury when securing the airway. Open pneumothorax. (a) Caused by a penetrating thoracic injury and may present as a sucking chest wound. Air does not enter the lung, oxygenation of the blood is reduced, ventilation is impaired and hypoxia results. Management. 1 2 Ensure an airway. Quickly close the chest wall defect by any available means (defibrillation pad, Vaseline gauze, plastic dressing, rubber glove). Risk involved - an occlusive dressing may cause the patient to develop a tension pneumothorax. To avoid this problem, tape the occlusive dressing on three sides to produce a flutter valve: air escapes but will not enter the chest. Administer oxygen. 2

2.

(2)

(b)

M C2000193 0797 4 5 6 (3) Insert a large-bore I.V. Monitor the heart. Transport rapidly to the appropriate hospital.

Tension pneumothorax - can occur when a one-way valve is created from either penetrating or blunt trauma. Air can enter but not leave the pleural space. This causes collapse of the affected lung, pushes the mediastinum in the opposite direction causing kinking of the superior and inferior vena cava with loss of venous return to the heart. (a) Clinical signs - dyspnea, anxiety, tachypnea, diminished breath sounds and hyperresonance to percussion on the affected side, distended neck vein and hypotension. The development of decreased lung compliance (difficulty in squeezing the bagvalve device) in the intubated patient should alert you to the possibility of tension pneumothorax. A late finding is tracheal deviation and its absence does not rule out the presence of a tension pneumothorax. Management. 1 2 3 Establish an open airway. Administer high-concentration oxygen. Decompress the affected side of the chest. Indications to perform emergency decompression include: loss of radial pulse (hypotension - late shock), loss of consciousness, respiratory distress and cyanosis.

(b)

NOTE: If personnel are not authorized to decompress the chest, transport immediately. A temporary but life saving measure is the needle decompression. 4 5 6 (4) Insert an I.V. Rapidly transport to the appropriate hospital. Notify medical staff.

Massive hemothorax - at least 1500 cc blood loss into the thoracic cavity. (a) Signs and symptoms: Produced by hypovolemia and respiratory compromise. Hypotensive (from blood loss and compression of the heart or great veins), and anxiety and confusion (produced by hypovolemia and hypoxemia). Signs 3

M C2000193 0797 of hypovolemic shock may be apparent. Neck veins are usually flat secondary to profound hypovolemia, but could be distended due to mediastinal compression. Dullness to percussion on the affected side and decreased breath sounds. (b) Management: 1 2 3 4 Secure an airway. Apply high-flow oxygen. Rapid transport to the appropriate hospital. Carefully replace volume after I.V. insertion. Maintain the BP just high enough to maintain a peripheral pulse (90 - 100 mm Hg systolic).

CAUTION:

While the major problem in massive hemothorax is usually hemorrhagic shock, elevating the blood pressure will increase the bleeding into the chest. 5 6 Notify medical staff. Closely observe for possible development of a tension hemopneumothorax, which would require acute chest decompression.

(5)

Flail chest. (a) Occurs when three or more adjacent ribs are fractured in at least two places. Result is a segment of the chest wall that is not in continuity with the thorax. The flail segment moves with paradoxical motion relative to the rest of the chest wall. The force necessary to produce this injury also bruises the underlying lung tissue - a pulmonary contusion will also contribute to hypoxia. The patient is at risk for the development of a hemothorax or pneumothorax and may be in marked respiratory distress. A chest wall palpation may reveal crepitus in addition to the abnormal respiratory motion. Management. 1 2 3 Ensure an airway. Administer oxygen. Assist ventilation or intubate. Pneumothorax is commonly associated with a flail chest - chest decompression may be needed. Rapid transport to the appropriate hospital. 4

(b)

M C2000193 0797 5 6 Establish an I.V. Limit fluid administration - volume overload can worsen the hypoxemia. Initiate manual pressure than bulky dressings taped to the chest wall to stabilize the flail segment. Stabilized patient on a backboard - trying to maintain manual pressure on a flail segment while performing log-rolling can be dangerous to maintaining a stable spine. Notify medical staff. Monitor the heart - myocardial trauma is frequent.

7 8 (6)

Cardiac tamponade. (a) Usually from a penetrating injury. The pericardial sac is an inelastic membrane surrounding the heart. When blood rapidly collects between the heart and pericardium from a cardiac injury, the ventricles of the heart compress. A small amount of pericardial blood can compromise cardiac filling. As the compression of the ventricles increase, the heart is less able to refill and cardiac output falls. Diagnosis relies upon the triad of hypotension, muffled heart sounds and distended neck veins. If the patient loses his peripheral pulse during inspiration, this is suggestive of a paradoxical pulse and the presence of cardiac tamponade. The patient will be in shock with a midline trachea and equal breath sounds. Management. 1 2 Ensure an airway and administer oxygen. An intravenous infusion of electrolyte solution may increase the filling of the heart and increase cardiac output. However, since there may be associated intrathoracic bleeding, administer only enough fluid to maintain a pulse (90 - 100 mm Hg systolic). Lesion is rapidly fatal and cannot be readily treated in the field. Load the patient and proceed rapidly to the appropriate hospital. Notify medical staff.

(b)

4 b.

Potentially life-threatening. (1) Traumatic aortic rupture.

M C2000193 0797 (a) The most common cause of death in falls from heights and motor vehicle accidents - ninety percent of these patients die immediately. Injuries due to deceleration injury with heart and aortic arch moving suddenly anteriorly, and transecting the aorta where it is fixed at the ligamentum arteriosum. Diagnosis is impossible in the field and may be missed in the hospital. The history from the field is critically important since many of these patients have no obvious signs of chest trauma. Infrequently, the patient may present with upper extremity hypertension and diminished lower extremity pulses. Management. 1 2 3 4 5 (2) Ensure an airway. Administer oxygen. Rapidly transport to the appropriate hospital. Establish I.V. access. Notify medical facility.

(b)

Tracheal or bronchial tree injury. (a) Resulting from penetrating or blunt trauma. Penetrating upper airway injuries frequently have associated major vascular injuries and extensive tissue destruction. A blunt injury can rupture the trachea or mainstem bronchus near the carina. Presenting signs include subcutaneous emphysema of the chest, neck, or face or an associated pneumothorax or hemothorax. Management - difficult. 1 A cuffed endotracheal tube should be passed beyond the site of the rupture. This may not be feasible and emergency surgical intervention may be needed to obtain an airway. Prompt transport to the appropriate hospital.

(b)

M C2000193 0797 3 (3) Observe the patient for signs of a pneumothorax or hemothorax.

Myocardial contusion. (a) Potentially lethal lesion resulting from blunt chest injury. Blunt injury to the anterior chest is transmitted via the sternum to the heart. Injury may include valvular rupture, cardiac rupture or pericardial tamponade. Myocardial contusion frequently and commonly occurs. Bruising of the heart is the same injury as an acute myocardial infarction and also presents with chest pain, dysrhythmia, or cardiogenic shock (rare). All patients with blunt anterior chest trauma should be presumed to have a myocardial contusion. Management. 1 2 3 4 Administer oxygen. Establish I.V. access. Monitor the heart. Treat dysrhythmias as they present.

(b)

(4)

Diaphragmatic tears. (a) Can result from a severe blow to the abdomen. A sudden increase in intra-abdominal pressure, such as a kick to the abdomen or seat belt injury, can tear the diaphragm and allow herniation of the abdominal organs into the thoracic cavity. Large radial tears in the diaphragm result from blunt trauma. Difficult to diagnose. Marked respiratory distress is caused from herniation of abdominal contents into the thoracic cavity. Diminished Breath sounds and infrequently bowel sounds may be heard when the chest is auscultated. The abdomen can appear scaphoid if a large quantity of abdominal contents are in the chest. Management. 1 2 3 4 Ensure an airway. Administer oxygen. Transport to the appropriate hospital. Insert an I.V. Associated injuries are possible and hypovolemia may occur.

(b)

M C2000193 0797 5. (5) Notify medical staff.

Esophageal injury. (a) (b) Produced normally by penetrating trauma. Management of associated trauma including airway or vascular injuries is generally more urgent than an esophageal injury. However, if unrecognized in the hospital, an esophageal injury is lethal.

(6)

Pulmonary contusion. (a) (b) Common chest injury produced by blunt trauma. This bruising of the lung can produce marked hypoxemia. Management consists of intubation (if indicated), oxygen administration, I.V. insertion, and transport.

3.

Other chest injuries. a. b. Impalement injuries - caused by a penetrating object. Do Not remove object. Ensure an airway, stabilize the object, insert an I.V., and transport. Traumatic asphyxia - condition is not caused by asphyxia. Results from a severe compression injury to the chest. The sudden compression of the heart and mediastinum transmits this force to the capillaries of the neck and head. The patients appear similar to those of strangulation with cyanosis and swelling of the head and neck. The lips and tongue are swollen, and conjunctival hemorrhage is evident. The skin below the level of the crush injury to the chest will be pink unless there are other problems. Management includes airway maintenance, I.V. access, treating other injuries, and rapid transport. Fracture of the scapula - first or second rib requires a large force. Transport after an airway, I.V., and oxygen have been started. Simple pneumothorax - blunt or penetrating trauma. Fractured ribs are the usual cause in blunt trauma. Caused by accumulation of air within the space between the visceral and parietal pleura. Totall or partial collapse of a lung.. Diagnosis is based on pleuritic chest pain, dyspnea, decreased breath sounds on the affected side and hypertympany to percussion. Simple rib fracture - most frequent injury to the chest. Pain will prohibit the patient from breathing adequately. On palpation, the area of rib fracture may be unstable and will be tender. Give oxygen and monitor for pneumothorax or hemothorax while encouraging the patient to breathe deeply.

c. d.

e.