Ruptured diaphragm happens when
Abdominal contents herniate into the chest and compress the lungs, heart, and mediastinum
What side does a diaphragm usually tear on?
Left.. the right has the liver to protect you
How can a diaphragm rupture?
Air bag – bulls stepping on cowboy stomach
What happens to the heart during diaphragm rupture
It gets shifted to the right side of chest - heart sounds over right side
Why does dysphagia happen to ruptured diaphragm
Esophagus is all twisted up
Ribs 1-3
Short, STRONG
Great force to break
If you break these..it’s probably the least of your problems - 40% die
Great vessel injury
Ribs 4-12
Long bone
Easily fractured
What lies under ribs 4-9
Lung
What lies under 10-12 on the right
Liver
What lies under 10-12 on the left
Spleen
Flail Chest
Two or more adjacent ribs are fractured in two or more locations or detachment of the sternum
Paradoxical chest movement
Free-floating segment of the chest
Doesn’t follow breathing
Why aren’t pulmonary contusions seen often in the ED
Develop over time
What is the visceral pleura
Adhering to the lung
Adhering to the chest wall is the
Pleural cavity
PAIN: Fluid
Fluid sinks
Low ache on side of fluid
PAIN: Air
Air rises
Higher up / radiate over shoulder
FREMITUS: Fluid
Absent
Sound is absorbed by fluid
FREMITUS: Air
Decreased
Hemothorax can be from
Venous - usually self limiting
Arterial - Pressures higher (1500 ml can get stuck in pleural space)
Autotransfusion
Arterial hemothorax and you chest tube…
Drain..just refills
Only tx for hemothorax
Thoracotomy
Autotransfusion - while you wait
Why can blood from the blood bank not be good?
Sitting for 30 days
Some of the RBC have died = hyperkalemia
Highly acidotic - breathing in a bag
How do you practice fremitus
Have pt say “99” while holding hands against the chest.
Vibrations will transmit through air NOT fluid
Egophony
“e” while holding a stethoscope near the top of the fluid line
“e” will sound like “a” through fluid
Simple Pneumo
Air enters the pleural space causing a negative intrapleural pressure
Inside out
Open Pneumo
Outside in
A penetrating wound
Tension Pneumo
Accumulation of air in the pleural space that can’t get out
Needle thoracostomy
Place needle just above the 3rd rib at the midclavicular
14-16 gauge adult
18-20 gauge ped
