Prehospital Trauma Life Support

Lesson

Thoracic Trauma

Developed by the

National Association of Emergency Medical Technicians

In cooperation with

The Committee on Trauma, American College of Surgeons

This slide presentation is intended for use only in approved PHTLS courses.

5-1B

Lesson 5 Objectives

Review the anatomy of the chest.

Discuss the mechanics of breathing.

Detail the assessment process. Cover the management of rib fractures, flail chest, pulmonary contusion, pneumothorax, tension pneumothorax, myocardial contusion, pericardial tamponade, aortic rupture and traumatic asphyxia.
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Introduction
Chest injuries are the second leading cause of trauma deaths each year. Chest injuries often go unrecognized.

Missed injuries result in inadequate ventilation, hypoxia and hypercarbia. Our goal is to find these injuries early and treat them aggressively.
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Anatomy
Major structures in the thorax:

Trachea. Bronchi. Lobes of the lungs. Heart.

Aorta.
Vena cava. Esophagus.
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Physiology

What happens to the chest on inspiration and expiration?

How does air move into and out of the chest?
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Gas Exchange in the Lungs

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Neurochemical Control
The respiratory control center is located in the brainstem. It reacts to changes in the concentration of CO2 in the blood.

What happens when the CO2 level increases? What happens to the CO2 level if the patients ventilation decreases? Name some traumatic conditions that would increase the CO2 level in the blood.
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Assessment of Chest Trauma

The initial assessment should serve to detect most major chest injuries. The kinematics of the event will point to most major chest trauma. Pain from chest trauma tends to be provoked by deep inspiration and/or firm palpation.
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Assessment
Observation

What are we looking for?

Palpation

Why are we feeling the chest?

Auscultation

What are we listening for in the chest?

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Chest Trauma
Chest trauma falls into two categories, based on mechanism of injury.

Penetrating.
Blunt.

Can you name some mechanisms of injury for each?

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Scenario
You are responding to a call to the police

station, where a 19-year-old male

patient is complaining of chest pain. Upon arrival, you learn that your patient was kicked in the chest during a fight.

What injuries does the mechanism suggest?

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Findings
A - Clear. B - Left-sided chest pain during inspiration; BS equal. C - Normal pulse; no external bleeding. D - Alert, oriented x 3. Vitals: Pulse 98, RR 26, BP 122/74.
Given the findings, what injuries can you rule out? How should this patient be managed?
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Scenario
You are called to a farm for a worker who has fallen from a hay loft and impaled himself on a post. On arrival, you see him lying on the ground in obvious respiratory distress. The scene appears safe.

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Findings
A - Clear. BRapid, paradoxical movement of the right chest. BS diminished on that side.

C - Rapid radial pulse. D - Alert, oriented x3. Vitals: Pulse 118, RR 38, BP 106/80.
Given the findings, what injuries do you suspect? How should this patient be managed?
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Scenario
You respond to the aid of a 16-year-old male gunshot victim. Police inform you that the weapon was a .22-caliber handgun.

What do you know

about .22-caliber bullets?

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Findings
A B C DClear. Fast. BS diminished on right. Entrance wound noted in right anterior chest wall. Pulse rapid. No external bleeding noted. Alert, oriented x3.

Vitals: Pulse 114, RR 32, BP 108/78.

What is your major concern for this patient?
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Scenario
You respond to an industrial incident

where a 48-year-old male has fallen 15

feet from some scaffolding and landed on some equipment. On your arrival, you find him complaining of chest pain and difficulty breathing.

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Findings
A - Clear. BRapid, shallow; speaking in 2-3 word bursts. BS absent on left. Pain on palpation of left chest. JVD noted.

C - Rapid, weak pulse. No external bleeding noted. D - Alert, oriented x3. PEARL.
What are this patients problems? What are your treatment priorities?
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Tension vs. Simple Pneumothorax

Simple pneumothorax.

Decreased or absent breath sounds.

Mechanism of injury.

Tension pneumothorax.

Decreased or absent breath sounds. Mechanism of injury. Hemodynamic compromise.

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Scenario
Your patient is a 37-year-old female who was involved in a head-on MVC. Looking at the car, you surmise that this was a high-energy impact. The patient has been extricated on your arrival.

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Findings
A B C DClear. RR slightly elevated. BS clear. Bruising over sternum. Pulse irregular. No external bleeding. Alert, oriented x3. PEARL.

Vitals: Pulse 88 & irregular, RR 20, BP 132/80.

What is this patients problem?

How would you treat her?

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Myocardial Compression Injuries

There are three distinct injury patterns that can occur with compression of the chest:

Electrical conduction disturbance.

Myocardial contusion.

Myocardial rupture.

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Discussion
May decrease cardiac output.

May mimic a myocardial infarction.

Treatment:

Oxygen Rapid transport

Cardiac monitor (ALS intervention)

Drugs (ALS intervention)
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Myocardial Rupture/Cardiac Tamponade/Traumatic Asphyxia

Pressures as high as 800 mm Hg can develop in the heart and great vessels when the sternum is compressed. Rupture of the myocardium fills the fibrous sac that surrounds the heart with blood, eventually tamponading the heart.

Name the signs and symptoms of cardiac tamponade.

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Thoracic Trauma Summary

Because the thoracic cavity contains the vital organs that oxygenate and distribute blood to the rest of the body, timely recognition and treatment of chest injuries results in better patient outcomes.
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