Chest Injury

Treat a Casualty with a Chest Injury

INTRODUCTION

Many casualties with multiple injuries have an associated chest injury. Severe thoracic injuries may result from vehicle accidents, falls, gunshot wounds, crush injuries, stab wound, and/or burn injuries. Thoracic injuries are treatable if the casualty is evacuated, assessed, and treated in a timely and effective manner.

Review anatomy of the thorax, mechanism of injury, and general assess of thoracic trauma

Review anatomy

Bones

(a) Clavicles

(b) Scapula

(i) In front, ten of the twelve pairs of ribs attached to sternum

(ii) Two are floating ribs (no anterior attachment)

Organs of the chest

(a) Heart

(b) Trachea

(d) Lungs

(e) Mediastinum - cavity between lungs

(e) Major blood vessels

(i) Carotid Artery

(ii) Pulmonary Artery

(iii) Aorta

(iv) Pulmonary Vein

(v) Jugular Vein

Upper abdominal organs are also protected by the lower rib cage

(a) Spleen

(b) Kidneys

(d) Stomach

(e) Pancreas

Muscles within the thorax

(a) Intercostal - muscles between adjacent ribs that function as secondary ventilary muscles

(i) External

(ii) Internal

Diaphragm

A musculofibrous partition separating the thoracic and abdominal cavities which will vary in location based on what phase of respiration

Determine mechanism of injury

A penetrating thoracic wound at the fourth intercostal space (level of the nipples) or lower should be assumed to be an abdominal injury as well as thoracic injury

Thoracic injuries may be result of penetrating objects or blunt trauma

(a) Penetrating injuries

(i) Gunshot or stab wounds

(ii) Distribute forces of injury over a lesser area

(iii) Trajectory of a bullet can be unpredictable and all thoracic structures are at risk

(b) Blunt trauma

(a) Force is distributed over a large area

(b) Visceral injuries occur from:

(i) Deceleration

(ii) Compression

(iii) Bursting

(iv) Sheering forces

Assess the casualty

Identify signs and symptoms

(a) Major symptoms of chest injury include:

(i) Shortness of breath

(ii) Respiratory distress

(iii) Chest pain

(b) Signs indicative of chest injury include:

(i) Shock

(ii) Cyanosis

(iii) Hemoptysis

(iv) Chest wall contusion

(v) Flail chest

(vi) Open wounds

(vii) Distended neck veins

(viii) Tracheal deviation

(ix) Subcutaneous emphysema

Assess vital signs

(a) Pulse

(b) Blood pressure

(i) Hypertension

(ii) Hypotension

(i) Tachypnea

(ii) Bradypnea

(iii) Labored

(iv) Retractions

(v) Evidence of respiratory distress

Assess skin

(a) Diaphoresis: secretion of sweat

(b) Pallor: absence of color

(d) Open wounds

Ecchymosis

Assess the neck

(a) Position of trachea

(b) Subcutaneous emphysema

(d) Penetrating wounds

Assess chest

(a) Contusions

(b) Tenderness

(d) Open wounds or impaled objects

(e) Crepitation

(f) Paradoxical movement

(g) Lung sounds

(i) Absent or decreased

* Unilateral

* Bilateral

(ii) Location

(iii) Bowel sound in lung area

(h) Lung sounds - percussion

(i) Hyperresonance

(ii) Hyporesonance

(i) Heart sounds

(i) Muffled

(ii) Distant

Identify major, immediate life-threatening thoracic injuries

Pneumothorax

Blunt or penetrating trauma

Fractured ribs may be caused in blunt trauma

Caused by accumulation of air within potential space between visceral and parietal pleura

Diagnosis is based:

(a) Pleuritic chest pain

(b) Dyspnea

(d) Hypertympany to percussion

Management

(a) Administer oxygen

(b) Establish two large bore IVs

(d) Chest tube as directed by physician/PA

(e) Constant Monitoring

Open pneumothorax

Caused by 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

(a) Ensure an airway

(b) Quickly close chest wall defect by any available means

(i) Occlusive dressing may cause casualty to develop a tension pneumothorax

(ii) To avoid, tape occlusive dressing on three sides to produce a flutter valve: air escapes but will not enter the chest

(d) Insert two large-bore IVs 0.9% Normal Saline to keep vein open (TKO)

(e) Transport to nearest treatment facility

Tension pneumothorax -closed

Occur when a one-way valve is created from either penetrating or blunt trauma (not open to the outside i.e. penetrating rib etc.)

(a) Air can leave pleural space

(b) Causes collapse of affected lung, pushes mediastinum in opposite direction

Clinical signs include:

(a) Dyspnea

(b) Anxiety

(d) Diminished breath sounds

(e) Hyperresonance to percussion on affected side

(f) Distended neck vein

(g) Hypotension

(h) The development of decreased lung compliance in intubated casualty should alert you to the possibility to tension pneumothorax

(i) Late finding is tracheal deviation and its absence does not rule out the presence of a tension pneumothorax

Management

(a) Establish an open airway

(b) Administer high-concentration oxygen

(c) Decompress the affected side of the chest needle decompression. Indication to perform emergency decompression includes:

(i) Loss of radial pulse

(ii) Loss of consciousness

(iii) Respiratory distress

(iv) Cyanosis

(d) Insert two large bore IVs 0.9% Normal Salin TKO

(e) Transport to nearest treatment facility

Massive hemothorax

At least 1500 cc blood loss into thoracic cavity or 200 ml/hr from chest tube

Signs and symptoms include:

(a) Hypotensive, from:

(i) Blood loss

(ii) Compression of heart or great veins

(b) Neck veins are usually flat secondary to profound hypovolemia, but could be distended due to mediastinal compression

Management

(a) Secure an airway

(b) Apply high-flow oxygen

(d) Carefully replace volume after IV insertion

(e) Maintain BP just high enough to maintain a peripheral pulse

(f) Closely observe for possible development of a tension pnuemothorax, which would require acute chest decompression

Flail chest

Occurs when three or more adjacent ribs are fractured in at least two places

(a) Result is a segment of chest wall that is not in continuity with the thorax

(b) Flail segment moves with paradoxical motion relative to the rest of chest wall

(c) Force necessary to produce this injury also bruises the underlying lung tissue: a pulmonary contusion will also contribute to hypoxia

(d) Casualty is at risk for development of hemothorax or pneumothorax and may be in marked respiratory distress

(e) Chest wall palpation may reveal crepitus in addition to the abnormal respiratory motion

Management

(a) Ensure airway

(b) Administer oxygen

(d) Rapid transport to appropriate echelon of care

(e) Establish IV

(f) Initiate manual pressure to stabilize the flail segment

(i) Stabilize casualty on backboard

(ii) Try to maintain manual pressure on flail segment while performing log-rolling(in the opposite direction of site of injury) can be dangerous to maintain a stable spine

(g) Monitor heart - myocardial trauma is frequent

Pulmonary contusion

Common chest injury produced by blunt trauma. This bruising of the lung can produce marked hypoxemia

Management consists of:

(a) Oxygen administration

(b) IV insertion

Myocardial contusion

Potentially lethal lesion resulting from blunt chest injury

(a) Blunt injury to anterior chest is transmitted via the sternum to the heart

(b) In the field, a casualty with significant chest trauma is assumed to have a myocardial contusion

Cardiac Contusion

(a) Chest pain

(b) Dysrhythmia

Management

(a) Administer oxygen

(b) Establish two large bore IVs 0.9% Normal Saline

(d) Transport to nearest treatment facility

Cardiac tamponade

Usually from a penetrating injury

Pericardial sac is an inelastic membrane surrounding the heart

(a) When blood rapidly collects between heart and pericardium form a cardiac injury, the ventricles of the heart compress

(b) Small amount of pericardial blood can compromise cardiac filling

Diagnosis (common but not always present):

(a) Hypotension

(b) Muffles heart sounds

Management

(a) Ensure airway and administer oxygen

(b) Initiate two large bore IVs 0.9% Normal Saline - electrolyte solution may increase the filling of the heart and increase cardiac output

(c) Cardiac tamponade is rapidly fatal and cannot be readily treated in the field by medic but may be treated by physician/PA

(d) Evacuate to nearest treatment facility immediately

Identify thoracic injuries

Fracture of the scapula - first or second rib requires a large force

Transport to appropriate echelon of care after:

(a) Airway is open

(b) IV access initiated

Simple rib fracture

Pain will prohibit casualty from breathing adequately

On palpation, area of rib fracture may be unstable and will be tender

Management

(a) Give oxygen

(b) Monitor of pneumothorax or hemothorax

(d) Pain Management

Diaphragmatic tears

Can result from a sever blow to the abdomen

(a) Sudden increase in intra-abdominal pressure can tear the diaphragm and allow herniation of the abdominal organs into the thoracic cavity

(b) Large radial tears in the diaphragm result from blunt trauma

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 chest is auscultated

Abdomen can appear scaphoid if a large quantity of abdominal contents are in the chest

Management

(a) Ensure an airway

(b) Administer oxygen

(d) Transport to appropriate echelon of care

Traumatic asphyxia

Results from severe compression injury to the chest

Sudden compression of heart and mediastinum transmits to force the capillaries of the neck and head

Casualties appear similar to those of strangulation with cyanosis and swelling of the head and neck

Lips and tongue may be swollen and conjunctival hemorrhage may be evident

Management includes:

(a) Airway maintenance

(b) IV access

(d) Transport to appropriate echelon of care

Impalement injuries

Caused by penetrating object

Do NOT remove object

Management

(a) Ensure airway

(b) Stabilize object

(d) Transport to appropriate echelon of care

Traumatic aortic rupture

Most common cause of death in falls from heights

Diagnosis is impossible in the field and may be missed in the MTF. History from the field is critically important since many of these casualties have no obvious signs of chest trauma

Management

(a) Ensure an airway

(b) Administer oxygen

(d) Establish two 14 gauge IV access

(e) Administer fluids

Tracheal or bronchial tree injury

Resulting from penetrating or blunt trauma

(a) Penetrating upper airway injuries frequently have associated major vascular injuries and extensive tissue destruction

(b) A blunt injury can rupture the trachea or main stem bronchus near the carina

Presenting signs include:

(a) Subcutaneous emphysema of the chest, neck, or face

(b) Associated pneumothorax or hemothorax

Management

(a) Prompt transport to appropriate echelon of care

(b) Observe for signs of a pneumothorax or hemothorax

SUMMARY

In multiple trauma casualties, chest injuries are common and many times are considered life threatening. You must have the ability to identify the injury while performing the primary survey and appropriately treat the injury to salvage the casualty.