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Thoracic Trauma

Lesson

5

Prehospital Trauma Life Support

Copyright 2003, Elsevier Science (USA). All rights reserved.

PROVIDER COURSE

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Objectives

Review the anatomy of the chest

Discuss the mechanics of breathing

Detail the assessment process

Cover the management of: Rib fracture Hemothorax

Flail chest injury Blunt cardiac injury

Pulmonary contusion Pneumothorax

(open and tension)


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Thoracic injuries are a leading cause of

trauma deaths each year

Thoracic injuries often go unrecognized

Injuries may result in inadequate

ventilation, hypoxia, hypercarbia, andshock

Our goal is to find these injuries early and

treat them aggressively


5-3

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Anatomy

Trachea Aorta

Bronchi Heart

Esophagus Vena cava

Lobes of the lungs

Identify these structures inthe thorax:


5-4

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Physiology

What happens during inspiration?

What happens during expiration?


5-5

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Gas Exchange in the Lungs

How does thoracic

trauma interfere with

gas exchange in the

lung?


5-6

Capillary

endothelium

Alveolus

Alveolar

epithelium

Connective tissue

CO2

O2O2

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Neurochemical Control

How does the CO2 level in the blood affect VR?

Can thoracic trauma alter the blood level of CO2?


5-7

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Assessment

Kinematics will give important clues to the

presence of thoracic trauma

Most significant chest injuries will beidentified in the primary survey


5-8

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Assessment

Observation What are we looking for?

Auscultation

What are we listening for in the chest?

Palpation

Why are we feeling the chest?


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Thoracic Trauma

Mechanisms of injury causing thoracic trauma

fall into two categories:

Blunt

Penetrating

Can you give some examples for each?


5-10

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Responding to a call at a police station, youencounter a 19-year-old male complaining of

chest pain and dyspnea. You learn that your

patient was kicked in the chest during a fight.

What injuries could occur with this mechanism?


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Primary Survey

A - PatentB - Left chest pain during inspiration; BS equal,

VR fast

C - No external bleeding, normal pulse rateD - GCS score 15

What injuries can you rule out?

How should this patient be managed?


5-12

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A 35-year-old motorcycle rider lost control ofhis bike. You find him lying on the gravel in

obvious ventilatory distress. The scene is

safe. He admits to having one beer.


5-13

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Primary Survey

A - PatentB - Paradoxical motion of the right chest,

diminished BS on right side, VR rapid

C - No external bleeding, radial pulse fastD - GCS score 14 (E-4, V-4, M-6)

What injuries do you suspect?

How would you manage this patient?


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You respond to a call and find a 16-year-oldmale who has been shot in the right upper

chest. Police inform you that the weapon was

a .22-caliber handgun.

What do you know about .22-caliber bullets?


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Primary Survey

A - PatentB - VR fast, BS diminished on right; no exit

wound noted; air not bubbling through

wound

C - No external bleeding, fast pulse rate

D - GCS score 15


How would you manage this patient?


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You respond to a call at a construction site

where a 45-year-old male has fallen 25 ft (8

m) from a scaffolding and landed on a stack

of lumber. On your arrival you find the patientcomplaining of chest pain and dyspnea.


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Primary SurveyA - Patent

B - VR rapid and shallow, speaks in 2 to 3 word

bursts, BS absent on left, no obvious JVD

C - No external bleeding; rapid, weak carotid

pulse; no radial pulse palpable

D - GCS score 15

What is the most life-threatening problem?What are your treatment priorities?


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Simple Pneumothorax

Mechanism of injury Ventilation

Decreased or absent BS

Mild respiratory distress

Treatment

Oxygen

Monitor

Rapid transport


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Mechanism of injury Ventilation

Decreased or absent BS

Mild respiratory distress

Hemodynamic compromise

Treatment

Oxygen

Needle decompression

Rapid transport


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Tension Pneumothorax

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An intoxicated 50-year-old male is

found with a self-inflicted injury to his

left chest. A steak knife is impaled inthe left third intercostal space on the

midclavicular line.


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Primary Survey

A - PatentB - VR rapid; normal BS bilaterally

C - No external bleeding, fast pulse rate, no

palpable radial pulse, muffled heart tones

D - GCS score 14 (E-4, V-4, M-6)

E - JVD noted

What do these findings suggest?What is your management?


5-22

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Your patient is a 60-year-old female who wasinvolved in a head-on MVC. Looking at the

vehicle, you surmise that this was a high-

energy impact. The steering wheel is bent

and the patient denies using her seat belt.The patient has been extricated on your

arrival.


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Primary Survey

A - Patent

B - VR normal; BS clear; bruising over sternum

C - No external bleeding; irregular pulse; normal

pulse rate

D - GCS score 15



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Blunt Cardiac Injury

Blunt cardiac injury can result in:

Contusion with possible electrical conduction

disturbance

Acute valvular injury Rupture of the myocardial wall


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Summary

The thoracic cavity contains the vital organsthat oxygenate and distribute blood to the rest

of the body

Only a few key interventions can be

performed in the field

Early recognition and management of

thoracic injuries should result in improved

patient outcomes


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Prehospital Trauma Life Support

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