Any injury at the ______ should be considered both a thoracic injury and an abdominal injury.
Spinal cord injuries at ___ or above can completely lose their ability to breathe spontaneously.
Spinal cord injuries at ___ level or below may lose the ability to move intercostal muscles, but the diaphragm will still contract.
How can the diaphragm still contract if a spinal cord injury at C5 level occurs?
The phrenic nerve remains intact due to location of injury.
Central chemoreceptors are found in the ____.
Peripheral chemoreceptors are located in the ____ and ____ bodies.
Which chemoreceptors are the main influence on CO2 levels?
Result of hyperventilation
CO2 level fall causing a reduction in carbonic acid.
Always related to body’s inability to remove CO2
Chest trauma common cause
Buildup of CO2
s/s of chest injury
Pain at site of injury Pain exacerbated by breathing Chest wall bruising Crepitus Penetrating injury Dyspnea Hemoptysis Asymmetric movement Rapid, weak pulse and hypotension Cyanosis around lips or fingernails
What does hemoptysis usually indicate?
Damage to lung parenchyma or airway passages
What does loos of peripheral pulses during inspiration suggest?
Pulsus paradoxus and cardiac tamponade
Drop in systolic BP of 10 mmHG or more
What would you expect in a patient w/ a spinal cord injury at C5?
Breathing by diaphragm only
Paralysis of all muscles below the shoulders
Loss of sensation from the shoulders down
What are you looking for during a rapid exam in your primary survey?
Obvious injuries Presence of blood Difficulty breathing Cyanosis Irregular breathing Asymmetrical chest rise and fall Accessory muscle use JVD
Muffled heart tones is a clue of?
Tension pneumothorax or cardiac tampondae
Hyperresonance of chest percussion is:
tympani, drum-like sound indicating present of air. Suggests air in pleural spar or pneumothorax.
Hyporresonance of chest percussion is:
Dull sound indicating solid or fluid suggesting presence of blood or hemothorax,
JVC suggests increased intravenous pressure resulting from :
R-sided heart failure
Life-threatening chest injuries that should be detected and managed during the primary survery?
Airway obstruction Bronchial disruption Diaphragmatic tear Esophageal injury Open pneumo Tension pneumo Hemothorax Flail chest Cardiac tamponade
Life-threating chest injures that may be identified during secondary assessment?
Thoracic aortic dissection
What should you assess during the breathing portion of your primary survery?
DCAP-BTLS Breath sounds Heart sounds Paradoxical motion Equal chest rise and fall Percussion of chest
What should you assess during the circulation portion of your primary survey?
Control external bleeding
What should you do in your secondary assessment?
Look for injuries w/ potential to compromise ABCs
Repeat rapid full-body scan
Vital signs - HR, BP, respirations, oxygen sat, mental status, skin condition, pupils, and capnography
Signs of impending cardiopulmonary arrest
Decrease in RR and HR
JVD is best assess in which position?
Semi-fowler at 45 degrees
Why is a fracture to one of the upper four ribs a sign of a very severe MOI?
These four ribs are well protected by the bony girdle of the clavicle and scapula.
What injuries should you suspect with a fracture to the first and second ribs?
First and second : ruptured aorta, tracheobronchial tree injury or vascular injury
Lower rib fractures are associated with injuries to ?
Spleen, kidneys, and liver
Why is a fracture to the floating ribs a sign of s severe MOI?
These ribs are protected by the abdominal musculature which suggest a strong potential for life-threatening injuries.
Assessment of rib fractures
Located TTP, crepitus, pain w/ application of anteroposterior pressure
Exacerbated pain w/ inspiration, expiration, deep breathing, or coughing
Hold affected area of rib cage
Management of rib fractures
Focus on managing ABCs and evaluating pt for other, more lethal injuries.
Splint chest wall w/ pillow or blanket
Assessment of flail chest
DCAP-BTLS Chest wall contusions Respiratory distress Accessory muscle use Paradoxical motion Pleuritic chest pain Crepitus Tacypnea Tahycardi
Management of flail chest
Assess the need for positive pressure ventilation
Provide positive pressure ventilation via BVM or CPAP
What injuries should you have a high index of suspicion if a sternal fx is present?
Pulmonary contusion Myocardial contusion Flail chest Vascular disruption of thoracic vessel Intra-abdominal injuries Head injuries
Management of sternal fx
Positive pressure ventilations PRN
Administer isotonic crystalloid solution only to maintain systolic BP on 80-90
Elevate the head of long board to reduce pressure in thoracic cavity and facilitate lung expansion
How would you splint a clavicle fx?
Sling and swathe
Chest wall impact directly over the heart, especially over the left ventricle.
Indicators of commotio cordis
Unresponsiveness Apnea Absent pulse Cyanosis Tonic-clonic seziures Chest wall contusions/localized bruising
V-fib in a patient w/ commotio cordis responds positively to ear defibrillation within the first _____ minutes.
During which phase of the cardiac cycle can immediate cardiac arrest occur if the chest wall is struck directly over the heart?
Accumulation of air in the pleural space
Weak area of the lung surface ruptures spontaneously
s/s simple pneumothorax
Tachypnea Tachycardia Hyperresonance w/ percussion Dyspnea Chest pain referred to shoulder or arm on affected side Pleuritic chest pain Subcutaneous emphysema Hypovolemia Cardiac dysrhythmias Tracheal deviation (late sign)
s/s of larger pneumothoraces
Increasing dyspnea Agitation AMS Tachycardia Tachypnea Cyanosis Lower pulse ox readings Pulsus paradoxus Absent breath sounds on affected side
Where does the air accumulate in a pneumothorax when the patient is standing? When the patient is supine?
Standing : apices
Supine : anterior portion of the chest
Management of simple pneumothorax
Cover any open wounds w/ occlusive dressing
Positive pressure ventilations sparingly
Accumulation of air or gas in the pleural space, resulting from penetrating trauma to the chest.
s/s of open pneumothorax
Tachycardia Tachypnea Subcutaneous emphysema Decreased breathing sounds on affected side Hypovolemia Cardiac dysrhythmias
Management of open pneumothorax
Cover sucking chest wounds with occlusive dressing
Positive pressure ventilations sparingly
Accumulation of air or gas in the pleural space that progressively collapses the lung, decreases cardioac output, and pushes the mediastinum to the opposite pleural cavity.
Classic signs of tension pneumothorax
Absence of breath sounds on affected side Unequal chest rise Pulsus paradoxus Tachycardia Dysrhythmias which progress to v-tach and v-fib Narrow pulse pressure JVD (late sign) Tracheal deviation (very late sign)
s/s of tension pneumothorax
Pleuritic chest pain Dyspnea Hypoxia Anxiety Tachycardia Tachypnea Cyanosis Hypotension (late sign)
Management of tension pneumothorax
Cover any open wounds with occlusive dressing
Call ALS for dart
Space between the parietal and visceral pleural is violated and blood accumulates w/in this space.
Most common causes of hemothorax
Rib fractures and injuries to lung parenchyma
Accumulation of more than 1,500 mL of blood w/in the pleural space
s/s of hemothorax
Tachypnea Tachycardia Dyspnea Respiratory distress Hypotension Hyporessonance on percussion Pleuritic chest pain Pale, cool, moist skin Decreased or unequal chest sounds Neck veins will be flat or distended
How would you differentiate from a pneumothorax and a hemothrorax?
Signs of hypovolemia along with respiratory compromise
Describe why hypoxia and hypotension occurs with hemothorax.
Hypoxia results from decreased gas exchange and hypotension and inadequate profusion result from blood loss.
Pneumothorax w/ air and bleeding in the pleural space
Management of hemothorax and hemopneumothorax
Administer oxygen and provided positive ventilations as needed.
Establish IV access
Fluid bolus to maintain systolic BP of 80-90 mmHG only if signs of hypovolemia
Three physical mechanisms for creating pulmonary contusion
Overexpansion of air in the lungs secondary to a pressure wave causes blunt trauma and results in rapid, excessive stretching and tearing of the alveoli.
Alveoli are stripped from the heavier bronchial structures when the alveoli are pulled at varying rates by a pressure wave.
Liquid-gas exchange is disrupted by a shock wave.
How does the body compensate for a large pulmonary contusion?
Vasoconstricting pulmonary blood flow and increasing cardiac output.
s/s of pulmonary contusion
Hemoptysis Contusion Tenderness Crepitus Paradoxical motion Wheezes, rhonchi, rales or diminished breath sounds in the affected area Cyanosis and low o2 stats
Management of pulmonary contusion
Establish IV access
Small amount of fluid only to improve CO as needed, titrating to a systolic BP of 80-90
Blood or other fluid collects in pericardium preventing the heart from filling during the diastolic phase, lower BP
Function of the pericardium
Anchor the heart, restricting excess movement and preventing kinking of the great vessels.
Why does hypotension occur with cardiac tampondae?
Pressure w/in pericardial sac reduces the prefusion leading to hypotension.
Classic signs of cardiac tamponade
Beck triad - narrowing pulse pressure, JVD, and muffled heart tones
Only occurs in advance stages
s/s cardiac tamponade
Weak or absent peripheral pulses Diaphoresis Dyspnea Cyanosis AMS Tachycardia Tachypnea Agitation Beck triad
Physical findings in a patient w/ cardiac tampondae
Hypotension JVD Tachycardia AMS Signs of hypoperfusion Trachea midline Equal breath sounds Normal chest percussion Muffled heart sounds
Management of cardiac tamponade
Administer oxygen and positive ventilation as needed
Establish IV access
Rapid fluid bolus to maintain systolic BP at 80-90
Bruising of the heart muscles
Myocardial contusions result in the following :
Hemorrhage w/ edema
Fragmented myocardial fibers
Injuries associated w/ myocardial contusion
1-3 rib fx and/or sternal fx Sharp, retrosternal chest pain Bruising Crackles or rales Irregular pulse rate
Management of myocardial contusion
Establish IV access
Call ALS early for tx of life-threatening dysrhythmias
Acute perforation of the ventricles, atria, intraventricular septum, intra-atrial septum, chordae tendineae, papillary muscles, or valves.
Traumatic aortic disruption
dissection or rupture of aorta
Assessment findings of traumatic aortic disruption
Restrosternal or interscapular “tearing” pain
Hoarseness or stridor
Ischemic pain of the extremities
UE hypertension w/ absent or decreased strength of femoral pulses
Hypotension and signs of shock
Management of traumatic aortic disruption
Establish IV access
Small bolus to maintain adequate perfusion
Management of potential injuries to great vessels
Establish IV line
Consider air transport if transport to Level I trauma center is delayed due to distance
Injuries to the great vessels are accompanied by :
Physical findings in the acute phase of a diaphragmatic injury
Begins at the time of injury and ends w/ recover from other injuries. Other injuries may overshadow diaphragmatic injury.
Physical findings in the latent phase of diaphragmatic injury.
Intermittent abdominal pain due to periodic herniation or entrapment of abdominal contents in the defect.
Physical findings in the obstructive phase of diaphragmatic injury.
Abdominal contents herniate through the defect, cutting off their blood supply.
s/s of diaphragmatic injury
Tachypnea Tachycardia Respiratory distress Hyporessonance to persuccions Scaphoid abdomen Bowel sounds in affected hemithorax Decreased breath sounds
Management of diaphragmatic injuries
Elevate head of backboard or stretcher
Positive pressure ventilation
s/s esophageal injury
Pleuritic chest pain Exacerbation of pain w/ swallowing Hoarseness Dysphagia Respiratory distress Shock
Cervical esophageal perforation : local tenderness and subcutaneous emphysema
s/s intrathroacic esophageal injury
Mediastinal emphysema Mediastinitis Subcutaneous emphysema Mediastinal crunch Splinting of chest wall
Management of esophageal injuries
Manage ABCs and sxs
Findings of tracheobronchial injuires
Hoarseness Tachypnea Tachycardia Massive subcutaneous emphysema Dyspnea Respiratory distress Hemoptysis Signs of tension pneumo w/o improvement from needle decompression
Management of tracheobronchial injuries
Earl recognition and rapid transport.
Ventilate as needed
Sudden, severe compression injury of the chest, which produces a rapid increase in intrathoracic pressure
Signs of traumatic asphyxia
JVD Cyanosis in face, upper neck, UE, and torso Swelling and cyanosis of tongue and lips Subconjunctival hematoma Exophthalmos
Management of traumatic asphyxia
Early recognition and rapid transport. Treat sxs, position patient appropriately, and ventilate as needed. C-spine and spinal immobilization Establish two large-bore IV lines Transport to nearest trauma center