What is the most common result of blunt injury to the thorax?
chest wall contusion
___ fractures are found in more than ___% of cases of significant chest trauma from blunt mechanism.
Rib ; 50
What are the most commonly fractured ribs and why?
Ribs 4 through 8 because they are least protected by other structures and are firmly fixed on both ends (to the spine and sternum)
What are fracture of ribs 9 through 12 frequently associated with?
Serious trauma and splenic and hepatic injury
Why are pediatric patients at increased risk of more serious injury with rib injuries?
Their ribs are flexible, which permits more internal injury before fracture occurs
What increases the mortality rate with rib fractures?
Number of fractures
Extremes of age
What are the S/S of chest wall injuries?
-Blunt or penetrating trauma to chest
-Pain on breathing
-Limited breath sounds
-Paradoxical motion of chest wall
Why will rib fracture more greatly limit respiratory excursion than chest wall contusion?
Because it is more painful
What are the most likely mechanisms of sternal fracture and dislocation?
Direct bow, fall against a fixed object, blunt force of the sternum against the steering wheel or dashboard
What is the overall incidence of sternal fracture in thoracic trauma patients?
5 to 8%
Sternal fracture is frequently associated with serious ___ injury.
Sternal anterior dislocation creates a noticeable ____ anterior to the ___.
deformity ; manubrium
Sternal posterior dislocation displaces the head of the ___ behind the ___ where it may compress or lacerate underlying great vessels or compress/injure the ___ and ___.
clavicle ; sternum ; trachea ; esophagus
What is the defect in the chest wall that allows for free movement of a segment; breathing will cause paradoxical chest wall motion; and includes two or more ribs in two or more places?
What are the most common mechanisms of injury causing flail chest?
Blunt trauma from falls, motor vehicle crashes, industrial injuries, and assaults
Flail chest reduces the volume of ___ moved with each breath, and it displaces the ___ toward and then away from the injury site with each breath.
air ; mediastinum
Overtime, the muscles splinting the flail segment will ___, and the ___ respiration will become more evident.
fatigue ; paradoxical
What is it called when lung tissue is disrupted and air leaks into the pleural space?
With simple pneumothorax (aka closed pneumothorax), pressure within the ___ does not exceed normal ___ pressures and there is no associated ___ shift.
thorax ; expiratory ; mediastinal
What is “paper bag syndrome”?
Alveolar rupture from sudden increase in intrathoracic pressure as the chest impacts the steering column with fully expanded lungs and a closed glottis
Pneumothorax may produce local ___ ___ with ___ as the pleurae become irritated (___ ___).
chest pain ; respiration ; respirophasic pain
What are S/S of pneumothorax?
- Trauma to chest
- Chest pain
- Hyperinflation of chest
- Diminished breath sounds on affected side
What are S/S of open pneumothorax?
- Penetrating chest trauma
- Sucking chest wound
- Frothy blood at wound site
Open pneumothorax creates ___ ___ quicker.
What causes the “sucking” sound in “sucking chest wounds”?
On exhalation, the contracting chest wall and rising diaphragm increase the internal pressure and force air outward through the wound
How big must the opening in the chest wall be for air movement to occur through the opening?
Two-thirds the diameter of the trachea
What is the buildup of air under pressure within the thorax that results in compression of the lung severely reducing the effectiveness of respirations?
What further complicates a patient’s condition with open pneumothorax?
Reduced intrathoracic pressure developed during inspiration do not complement venous return to the heart as they do with intact thorax and respiratory effort.
What are S/S of tension pneumothorax?
- Chest trauma
- Severe dyspnea
- Ventilation/perfusion mismatch
- Hyperinflation of affected side of chest
- Hyperresonance of affected side of chest
- Diminished, then absent, breath sounds
- Altered mental status
- Jugular venous distention
Tension pneumothorax may also occur as an ___ pneumothorax is sealed and an internal injury/defect permits the buildup of ___.
open ; pressure
In tension pneumothorax, the increasing ___ pressure collapses the ___ on the ___ (same or injury) side, causes ___ and ___ bulging, and begins to exert pressure against the ___.
intrapleural ; lung ; ipsilateral ; intercostal ; suprasternal ; mediastinum
What is a very late and rare finding in tension pneumothorax commonly seen in the young trauma victim? Why?
Tracheal shit as the mediastinal structures are pushed away from the increasing pressure
–Seen more in young trauma victims because the pediatric mediastinum is more mobile than an adult’s
The opposite or ___ side of the chest becomes somewhat dull to ___ with progressively fainter ___ sounds as the tension pneumothorax becomes worse.
contralateral ; percussion ; respiratory
How is tension pneumothorax corrected?
Reliving the intrapleural pressure by inserting a needle through the chest wall to convert the tension pneumothorax to an open pneumothorax
What does the thoracic cavity contain?
Heart, great vessels, esophagus, tracheobroncial tree, and lungs
How much blood can each side of the thorax hold?
Up to 3,000 mL (or half the total blood volume)
What is hemopneumothorax?
Condition where air and blood are in the pleural space; often accompanies pneumothorax
What is hemothorax?
blood within the pleural space
What are the S/S of hemothorax?
- Blunt or penetrating chest trauma
- S/S of shock
- Dull percussive sounds over site of collecting blood
___ arteries an bleed at a rate of 50 mL/min. The bleeding into the ___ is more rapid than would occur elsewhere because the pressure within the ___ is often less than ___ pressure (law of Laplace).
Intercostal ; chest ; chest ; atmospheric
What are the two specific mechanisms of injury that allow transfer of energy to the pulmonary tissue and result in pulmonary contusions?
- Deceleration injury occurs as the moving body strikes a fixed object
- Pressure wave assocated with either passage of high-velocity bullet or explosion, which dramatically compresses and stretches the lung tissue
T or F. Pulmonary contusion is generally associated with low-speed penetration of the chest and laceration of the lung tissues and structures.
False - it is NOT generally associated with low-speed penetration
What factors affect the magnitude of pulmonary injury?
Degree of deformity or stretch
Velocity at which it occurs
The thickening wall reduces efficiency of ____ and results in ___, while the stiffening makes ___ more ___ consuming.
respiration ; hypoxemia ; respiration ; energy
How will a patient present with a pulmonary contusion?
- Increasing dyspnea
- Increasing respiratory effort
- Show signs f hypoxia
What are the S/S of pulmonary contusion?
- Blunt or penetrating chest trauma
- Increasing dyspnea
- Increasing cracles
- Diminishing breath sounds
- S/S of shock
What is hemoptysis?
Coughing of blood that originates in the respiratory tract
What injuries are the subset of thoracic trauma that leads to the most fatalities?
Myocardial contusion carries a high ___ rate and occurs most commonly with sever ___ ___ chest trauma.
mortality ; blunt anterior
What will the resulting myocardial contustion likely affect?
- Right atrium
- Right ventricle
A ___ friction rub and murmur may e auscultated over the ___ but it is more likely to occur weeks after the injury and is associated with the development of an inflammatory ___ effusion.
pericardial ; precordium ; pericardial
What is a restriction to cardiac filling caused by blood (or other fluid) within the pericardial sac?
What are the results of pericardial tamponade?
-Reduced right ventricular output limiting outflow to the pulmonary arteries and the venous return to the left heart which results in decreasing cardiac output and systemic hypotension
What are S/S of pericardial tamponade?
- Dyspnea and possible cyanosis
- Jugular venous distention
- Weak thready pulse
- Decreasing BP
- Narrowing pulse pressure
How might a patient with pericardial tamponade present?
- Ashen in appearance
- Cyanosis may be noted in head/neck/upper extremities
- Beck’s triad (JVD, distant heart tones, hypotension) is indicative but may not be recognized early on
- Kussmaul’s sign (decrease/absence of JVD during inspiration)
What is pulsus paradox?
Drop in systolic BP of greater than 10 mmHg as the patient inspires during the normal respiratory cycle; normally systolic BP drops just lsightly with each inspiration)
Why does pulsus paradox result?
Because cardiac output increases with the minimal relief of the tamponade associated with the reduced intrathoracic pressure of inspiration
If myocardial rupture occurs, how might a patient present?
- If rupture contained within pericardial sac: may have S/S of pericardial tamponade
- If pathology only affects valve: may have S/S of right or left heart failure
- If the is myocardial aneurysm: rupture may be delayed but when it happens patient will suddenly present with absence of vital signs or S/S of pericardial tamponade
The aorta areas of fixation are the ___ ___ where the aorta joins the heart, the ___ ____ where it is joined by the ligamentum arteriosum, and the ___ where it exits the chest.
aortic annulus ; aortic isthmus ; diaphragm
How do severe deceleration events commonly affect the descending aorta?
Shear forces separate the layers of the artery, specifically the interior surface (the tunica intima) from the muscle layer (tunica media)
___ rupture or perforation is more common in patients sustaining ___ trauma to the ___ chest, which has 30 to 40% incidence of abdominal organ and tissue involvement.
Diaphragm ; penetrating ; lower
Remember that during ___ the diaphragm may move ___ to the level of the ___ intercostal space (nipple level) ___ and the ___ intercostal space ___.
expiration ; superiorly ; fourth ; anteriorly ; sixth ; posteriorly
What side do diaphragmatic perforation and herniation occur on most frequently and why?
Left side because assailants are most frequently right handed and the size and solid nature of the liver protect the diaphragm on the right.
What are the S/S of diaphragmatic rupture?
- S/S similar to tension pneumothorax including dyspnea, hypoxia, hypotension, and JVD
- History of blunt abdominal trauma or penetrating trauma to the lower thorax or upper abdomen
- Abdomen may appear hollow
- Bowel sounds noted in one side of the thorax (most commonly the left)
How might a patient with disruption of the trachea or mainstem bronchi present?
- Respirator distress with:
- -Massive subcutaneous emphysema (some cases)
When percussing what might a dull resonance suggest?
Collecting blood or other fluid
When percussing what might a hyperresonance suggest?
Air or air under pressure in a pneumothorax or tension pneumothorax
What should you be prepared to do if a patient’s systolic BP is below 80 mmHg?
Administer fluids quickly (in 250- to 500-mL boluses)
How do you provide tension pneumothorax patient care?
Perform needle thoracentesis by inserting a long 14-gauge intravascular catheter into the second intercostal space, midclavicular line on the side of the thorax with decreased breath sounds and hyperinflation
Do not give ___ to myocardial contusion patients.
What are S/S of traumatic asphyxia?
- Obstructive shock
- Swollen tongue
- Bulging eyes
Consider the administration of ___ mEq/kg of ___ ___ just before and during decompression of the chest if entrapment has lasted more than 20 minutes.
1 ; sodium bicarbonate
The structures of the trachea and the bronchi, together, are called the:
During a football game, a 17-year-old male is tackled and knocked to the ground. Although he reports hearing a “bone crack,” he initially appears to be stable. The team manager summons the paramedics. By the time they arrive, the patient states that he is “feeling funny” and having difficulty breathing. Upon primary assessment, a rapid weak pulse and a low BP are noted. The patient’s appearance suggests he may be developing shock. You suspect a rib fracture and possibly:
Which of the following S/S is most commonly seen in association with sever chest wall contusion?
You have elected to apply occlusive dressing to your patient who has sustained a stab wound to the chest. You realize you should secure the dressing:
On three sides
Your patient has received significant deceleration trauma to his chest. He presents with absent radial and brachial pulses in the left upper extremity and severe hypotension. He reported that he felt a tearing sensation in his chest before quickly losing consciousness. He most likely has experienced:
traumatic aortic aneurysm
The type of crash impact most commonly associated with aortic rupture hen the patient has been involved in a motor vehicle collision is:
The following mechanism of injury most likely to cause traumatic asphyxia is:
blunt trauma, compressive force
You and your partner are called to the scene of fa motor vehicle collision. When you arrive, you note that a car has struck a parked vehicle. Your 30-year-old female patient complains of difficulty breathing you note that breath sounds are diminished bilaterally. The patient states that, at the last minute, she anticipated the impending accident and held her breath. You suspect “paper-bag syndrome” in which the sudden pressure exerted on her expanded lungs, with closed glottis preventing the escape of air, caused the rupture of:
The most appropriate prehospital management for a patient with flail segment and no other suspected underlying injury is:
The most appropriate prehospital management for a patient with a traumatic rupture of the aorta is to:
expedite transport to a trauma center; administer conservative IV fluids en route
What is the first sign/symptom of pneumothorax?
Followed by decreased breath sounds and unequal chest rise
What will the BP do in a pneumothorax?
Stay same or go up
What will the BP do in a hemothorax?
Stays the same or goes down
SHOCK IS ASSOCIATED
Needle decompression needle is placed where to relieve tension pneumothorax?
Above 3rd or 6th rib
What is becks triad?
Signs and symptoms of cardiac tamponade
MUFFLED HEART TONES
NARROWING PULSE PRESSURE
______ is when alveoli are not inflated and collapse decreasing the surface area.
JVD is most common with?
What is the treatment for a traumatic asphyxia?
If trapped for 20 minutes or more - 1mEq sodium bicarbonate
What is the presentation for a triple A?
Pulsating abdominal motion every time the heart contracts
What are the signs and symptoms of TRIPLE A?
Decreased/absent pulses in legs