United States Department of Transportation

National Highway Traffic Safety Administration

Paramedic: National Standard Curriculum

(Reprinted with permission)

http://www.nhtsa.dot.gov/people/injury/ems/

Trauma: 4

Thoracic Trauma: 7

UNIT TERMINAL OBJECTIVE

4-7 At the completion of this unit, the paramedic student will be able to integrate pathophysiological principles and the assessment findings to formulate a field impression and implement a treatment plan for a patient with a thoracic injury.

COGNITIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

4-7.1 Describe the incidence, morbidity, and mortality of thoracic injuries in the trauma patient. (C-1)

4-7.2 Discuss the anatomy and physiology of the organs and structures related to thoracic injuries. (C-1)

4-7.3 Predict thoracic injuries based on mechanism of injury. (C-2)

4-7.4 Discuss the types of thoracic injuries. (C-1)

4-7.5 Discuss the pathophysiology of thoracic injuries. (C-1)

4-7.6 Discuss the assessment findings associated with thoracic injuries. (C-1)

4-7.7 Discuss the management of thoracic injuries. (C-1)

4-7.8 Identify the need for rapid intervention and transport of the patient with thoracic injuries. (C-1)

4-7.9 Discuss the pathophysiology of specific chest wall injuries, including: (C-1)

a. Rib fracture

1. Flail segment

2. Sternal fracture

4-7.10 Discuss the assessment findings associated with chest wall injuries. (C-1)

4-7.11 Identify the need for rapid intervention and transport of the patient with chest wall injuries. (C-1)

4-7.12 Discuss the management of chest wall injuries. (C-1)

4-7.13 Discuss the pathophysiology of injury to the lung, including: (C-1)

3. Simple pneumothorax

4. Open pneumothorax

5. Tension pneumothorax

6. Hemothorax

7. Hemopneumothorax

8. Pulmonary contusion

4-7.14 Discuss the assessment findings associated with lung injuries. (C-1)

4-7.15 Discuss the management of lung injuries. (C-1)

4-7.16 Identify the need for rapid intervention and transport of the patient with lung injuries. (C-1)

4-7.17 Discuss the pathophysiology of myocardial injuries, including: (C-1)

a. Pericardial tamponade

9. Myocardial contusion

10. Myocardial rupture

4-7.18 Discuss the assessment findings associated with myocardial injuries. (C-1)

4-7.19 Discuss the management of myocardial injuries. (C-1)

4-7.20 Identify the need for rapid intervention and transport of the patient with myocardial injuries. (C-1)

4-7.21 Discuss the pathophysiology of vascular injuries, including injuries to: (C-1)

a. Aorta

11. Vena cava

12. Pulmonary arteries/ veins

4-7.22 Discuss the assessment findings associated with vascular injuries. (C-1)

4-7.23 Discuss the management of vascular injuries. (C-1)

4-7.24 Identify the need for rapid intervention and transport of the patient with vascular injuries. (C-1)

4-7.25 Discuss the pathophysiology of diaphragmatic injuries. (C-1)

4-7.26 Discuss the assessment findings associated with diaphragmatic injuries. (C-1)

4-7.27 Discuss the management of diaphragmatic injuries. (C-1)

4-7.28 Identify the need for rapid intervention and transport of the patient with diaphragmatic injuries. (C-1)

4-7.29 Discuss the pathophysiology of esophageal injuries. (C-1)

4-7.30 Discuss the assessment findings associated with esophageal injuries. (C-1)

4-7.31 Discuss the management of esophageal injuries. (C-1)

4-7.32 Identify the need for rapid intervention and transport of the patient with esophageal injuries. (C-1)

4-7.33 Discuss the pathophysiology of tracheo-bronchial injuries. (C-1)

4-7.34 Discuss the assessment findings associated with tracheo-bronchial injuries. (C-1)

4-7.35 Discuss the management of tracheo-bronchial injuries. (C-1)

4-7.36 Identify the need for rapid intervention and transport of the patient with tracheo-bronchial injuries. (C-1)

4-7.37 Discuss the pathophysiology of traumatic asphyxia. (C-1)

4-7.38 Discuss the assessment findings associated with traumatic asphyxia. (C-1)

4-7.39 Discuss the management of traumatic asphyxia. (C-1)

4-7.40 Identify the need for rapid intervention and transport of the patient with traumatic asphyxia. (C-1)

4-7.41 Integrate the pathophysiological principles to the assessment of a patient with thoracic injury. (C-1)

4-7.42 Differentiate between thoracic injuries based on the assessment and history. (C-3)

4-7.43 Formulate a field impression based on the assessment findings. (C-3)

4-7.44 Develop a patient management plan based on the field impression. (C-3)

AFFECTIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

4-7.45 Advocate the use of a thorough assessment to determine a differential diagnosis and treatment plan for thoracic trauma. (A-3)

4-7.46 Advocate the use of a thorough scene survey to determine the forces involved in thoracic trauma. (A-3)

4-7.47 Value the implications of failing to properly diagnose thoracic trauma. (A-2)

4-7.48 Value the implications of failing to initiate timely interventions to patients with thoracic trauma. (A-2)

PSYCHOMOTOR OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

4-7.49 Demonstrate a clinical assessment for a patient with suspected thoracic trauma. (P-1)

4-7.50 Demonstrate the following techniques of management for thoracic injuries: (P-1)

a. Needle decompression

13. Fracture stabilization

14. Elective intubation

15. ECG monitoring

16. Oxygenation and ventilation

DECLARATIVE

I. Introduction

A. Epidemiology

1. Incidence

2. Morbidity and mortality of thoracic injuries

3. Risk factors

4. Prevention strategies

a. Gun safety education

b. Sports training

c. Seat belts

d. Other

B. Mechanism of injury

1. Classification

a. Blunt thoracic injuries

(1) Deceleration

(2) Compression

b. Penetrating thoracic injuries

2. Injury patterns

a. General Types

(1) Open injuries

(2) Closed Injuries

b. Thoracic cage

c. Cardiovascular

d. Pleural and pulmonary

e. Mediastinal

f. Diaphragmatic

g. Esophageal

h. Penetrating cardiac trauma

3. Blast injury

a. Confined spaces

b. Shock wave

C. Anatomy and physiology review of the thorax

1. Anatomy

a. Skin

b. Bones

(1) Thoracic cage

(2) Sternum

(3) Thoracic spine

c. Muscles

(1) Intercostal

(2) Trapezius

(3) Latisissimus dorsi

(4) Rhomboids

(5) Pectoralis major

(6) Diaphragm

(7) Sternocleidomastoid

d. Trachea

e. Bronchi

f. Lungs

(1) Parenchyma

(2) Alveoli

(3) Alveolar - capillary interface

(4) Pleura

(a) Visceral

(b) Parietal

(5) Lobes

g. Vessels

(1) Arteries

(a) Aorta

(b) Carotid

(d) Intercostal arteries

(e) Innominate

(f) Internal mammary

(2) Veins

(a) Superior vena cava

(b) Inferior vena cava

(d) Internal jugular

(3) Pulmonary

(a) Arteries

(b) Veins

h. Heart

(1) Ventricles

(2) Atria

(3) Valves

(4) Pericardium

i. Esophagus

(1) Thoracic inlet

(2) Course through chest

(3) Esophageal foramen through diaphragm

j. Mediastinum

(1) Structures located in mediastinum

(a) Heart

(b) Trachea

(d) Aorta

(e) Esophagus

2. Physiology

a. Ventilation

(1) Expansion and contraction of thoracic cage

(a) Bellows system

(b) Musculoskeletal structure

(d) Diaphragm

(e) Accessory muscles

(f) Changes in intrathoracic pressure

b. Respiration

(1) Neurochemical control

(2) Gas exchange

(a) Alveolar-capillary interface

(b) Capillary-cellular interface

(d) Cardiac circulation

(e) Acid-base balance

i) Henderson-Hasselbach equation

ii) Respiratory alkalosis

iii) Respiratory acidosis

iv) Compensation for metabolic acidosis and alkalosis

II. General system pathophysiology, assessment and management of thoracic trauma

A. Pathophysiology

1. Impairments in cardiac output

a. Blood loss

b. Increased intrapleural pressures

c. Blood in pericardial sac

d. Myocardial valve damage

e. Vascular disruption

2. Impairments in ventilatory efficiency

a. Chest bellow action compromise

(1) Pain restricting chest excursion

(2) Air entering pleural space

(3) Chest wall fails to move in unison

b. Bleeding in pleural space

c. Ineffective diaphragmatic contraction

3. Impairments in gas exchange

a. Atelectasis

b. Contused lung tissue

c. Disruption of respiratory tract

B. Assessment findings

1. Pulse

a. Deficit

b. Tachycardia

c. Bradycardia

2. Blood pressure

a. Narrow pulse pressure

b. Hypertension

c. Hypotension

d. Pulsus paradoxus

3. Respiratory rate and effort

a. Tachypnea

b. Bradypnea

c. Labored

d. Retractions

e. Other evidence of respiratory distress

4. Possible hypothermia

5. Skin

a. Diaphoresis

b. Pallor

c. Cyanosis

d. Open wounds

e. Ecchymosis

f. Other evidence of trauma

6. Hemoptysis

7. Neck

a. Position of trachea

b. Subcutaneous emphysema

c. Jugular venous distention

d. Penetrating wounds

8. Chest

a. Contusions

b. Tenderness

c. Asymmetry

d. Lung sounds

(1) Absent or decreased

(a) Unilateral

(b) Bilateral

(2) Location

(3) Bowel sounds in hemithorax

e. Abnormal percussion finding

(1) Hyperresonance

(2) Hyporesonance

f. Heart sounds

(1) Muffled

(2) Distant

(3) Regurgitant murmur

g. Shift of apical impulse

h0 Open wounds

i0 Impaled object or penetration

j0 Crepitation

k0 Paradoxical movement of chest wall segment

9 Scaphoid abdomen

10 Decreased level of consciousness

11 ECG

a0 ST - T wave elevation or depression

b0 Conduction disturbances

c0 Rhythm disturbances

12 History

a0 Dyspnea

b0 Chest pain

c0 Associated symptoms

(1) Other areas of pain or discomfort

(2) Symptoms prior to incident

d0 Past history of cardiorespiratory disease

e0 Use of restraint in motor vehicle crash

C0 Management

1 Airway and ventilation

a0 Oxygen therapy

b0 Endotracheal intubation

c0 Needle cricothyrotomy

d0 Surgical cricothyrotomy

e0 Positive pressure ventilation

f0 Occlude open wounds

g0 Stabilize chest wall

2 Circulation

a0 Manage cardiac dysrhythmias

b0 Intravenous access

3 Pharmacologic

a0 Analgesics

b0 Antiarrhythmics

4 Non-pharmacologic

a0 Needle thoracostomy

b0 Tube thoracostomy - in hospital management

c0 Pericardiocentesis - in hospital management

5 Transport considerations

a0 Appropriate mode

b0 Appropriate facility

III Chest wall injuries

A0 Rib fractures

1 Epidemiology

a0 Incidence

(1) Infrequent until adult life

(2) Most often elderly patients

(3) Significant force required

b0 Morbidity/ mortality

(1) Can lead to serious consequences

(2) Older ribs more brittle and rigid

(3) Associated underlying pulmonary or cardiovascular injury

(4) Increases with

(a) Age

(b) Number of fractures

2 Anatomy and physiology review

3 Pathophysiology

a0 Most often caused by blunt trauma, bowing effect with midshaft fracture

b0 Ribs 4 to 9 are most often fractured (thin and poorly protected)

c0 Respiratory restriction due to pain and splinting

(1) Atelectasis

(2) Ventilation/ perfusion mismatch

d0 May be associated with underlying lung or cardiac contusion

e0 Intercostal vessel injury

f0 Associated complications

(1) First and second ribs are injured by severe trauma

(a) Rupture of aorta

(b) Tracheobronchial tree injury

(2) Left lower rib injury associated with splenic rupture

(3) Right lower rib injury associated with hepatic injury

(4) Multiple rib fractures

(a) Atelectasis

(b) Hypoventilation

(d) Pneumonia

(5) Open rib fracture associated with visceral injury

(6) Posterior rib fracture

(a) Fifth through ninth ribs most frequently injured

(b) Lower ribs associated with spleen and kidney injury

4 Assessment findings

a0 Localized pain

b0 Pain that worsens

(1) Movement

(2) Deep breathing

(3) Coughing

c0 Point tenderness

d0 Crepitus or audible crunch

e0 Splinting on respiration

f0 Anteroposterior pressure elicits pain

5 Management

a0 Airway and ventilation

(1) Oxygen therapy

(2) Positive pressure ventilation

(3) Encourage coughing and deep breathing

b0 Pharmacological

(1) Analgesics

c0 Non-pharmacological

(1) Splint - but avoid circumferential splinting

d0 Transport consideration

(1) Appropriate mode

(2) Appropriate facility

e0 Psychological support/ communication strategies

B0 Flail segment

1 Epidemiology

a0 Incidence

(1) Most common cause is vehicular crash

(2) Falls from heights

(3) Industrial accidents

(4) Assault

(5) Birth trauma

b0 Morbidity/ mortality

(1) Significant chest trauma

(2) Mortality rates 20-40% due to associated injuries

(3) Mortality increased with

(a) Advanced age

(b) Seven or more rib fractures

(d) Shock

(e) Head injuries

2 Pathophysiology

a0 Three or more ribs fractured in two or more places producing a free floating segment of chest wall

b0 Respiratory failure due to

(1) Underlying pulmonary contusion

(2) Associated intrathoracic injury

(3) Inadequate bellow action of chest

c0 Paradoxical movement of the chest

(1) Minimal because of muscle spasm

(2) Must be large to compromise ventilation

d0 Pain

(1) Reduces thoracic expansion

(2) Decreases ventilation

e0 Pulmonary contusion

(1) Decreased lung compliance

(2) Intra alveolar-capillary hemorrhage

(3) Alveolar hemorrhage

f0 Decreased ventilation

g0 Impaired venous return with resultant ventilation-perfusion mismatch

h0 Hypercapnia

i0 Hypoxia

3 Assessment findings

a0 Chest wall contusion

b0 Respiratory distress

c0 Paradoxical chest wall movement

d0 Pleuritic chest pain

e0 Crepitus

f0 Pain and splinting of affected side

g0 Tachypnea

h0 Tachycardia

i0 Possible bundle branch block on ECG

4 Management

a0 Airway and ventilation

(1) Positive pressure ventilation may be needed

(2) Oxygen (high concentration)

(3) Evaluate the need for endotracheal intubation

(4) Stabilize flail segment (may be controversial locally)

(5) Positive end expiratory pressure (PEEP)

b0 Circulation

(1) Restrict fluids

c0 Pharmacologic

(1) Analgesics

d0 Non-pharmacologic

(1) Positioning

(2) Endotracheal intubation and positive pressure ventilation for internal splinting effect

e0 Transport considerations

(1) Appropriate mode

(2) Appropriate facility

f0 Psychological support/ communication strategies

C0 Sternal fracture

1 Epidemiology

a0 Incidence

(1) 5-8% in blunt chest trauma

(2) Deceleration compression injury

(a) Steering wheel

(b) Dashboard

(3) Blow to chest

(4) Severe hyperflexion of thoracic cage

(5) Occur at or below the manubriosternal junction

b0 Morbidity/ mortality

(1) 25-45% mortality

(2) High association with myocardial or lung injury

(a) Myocardial contusion

(b) Myocardial rupture

2 Pathophysiology

a0 Associated injuries cause morbidity and mortality

(1) Pulmonary and myocardial contusion

(2) Flail chest

(3) Vascular disruption of thoracic vessels

(4) Intraabdominal injuries

(5) Head injuries

b0 Rarely is fracture displaced posteriorly to directly impinge on heart or vessels

3 Assessment findings

a0 Localized pain

b0 Tenderness over sternum

c0 Crepitus

d0 Tachypnea

e0 ECG changes associated with myocardial contusion

f0 History of blunt trauma

4 Management

a0 Airway and ventilation

b0 Circulation

(1) Restrict fluids if pulmonary contusion is suspected

5 Pharmacologic

a0 Analgesics

6 Non-pharmacologic

a0 Allow chest wall self-splinting

7 Transport considerations

a0 Appropriate mode

b0 Appropriate facility

8 Psychological support/ communication strategies

IV Injury to the lung

A0 Simple pneumothorax

1 Epidemiology

a0 Incidence

(1) 10-30% in blunt chest trauma

(2) Almost 100% with penetrating chest trauma

b0 Morbidity/ mortality

(1) Extent of atelectasis

(2) Associated injuries

2 Pathophysiology

a0 Lung 1-3 cm away from the chest wall

b0 May have stable amount of accumulation of air

c0 Pulmonary function may be good

d0 Internal wound allows air to enter the pleural space

e0 Small tears self-seal, larger one may progress

f0 Paper bag syndrome

g0 If standing air will accumulate in the apices, check there first for diminished breath sounds otherwise, if supine it accumulates in the anterior chest

h0 Trachea may tug towards the effected side

i0 Ventilation/ perfusion mismatch

3 Assessment findings

a0 Tachypnea

b0 Tachycardia

c0 Respiratory distress

d0 Absent or decreased breath sounds on affected side

e0 Hyperresonance

f0 Decreased chest wall movement

g0 Dyspnea

h0 Chest pain referred to shoulder or arm on affected side

i0 Slight pleuritic chest pain

4 Management

a0 Airway and ventilation

(1) Positive pressure ventilation if necessary

(2) Monitor for development of tension pneumothorax

b0 Non-pharmacologic

(1) Needle thorocostomy

c0 Transport consideration

(1) Appropriate mode

(2) Appropriate facility

5 Psychological support/ communication strategies

B0 Open pneumothorax

1 Epidemiology

a0 Incidence

(1) Penetrating trauma

b0 Morbidity/ mortality

(1) Profound hypoventilation could result

(2) Death related to delayed management

2 Pathophysiology

a0 Open defect in the chest wall

(1) Allows communication between pleural space and atmosphere

(2) Prevents development of negative intrapleural pressure

(3) Produces collapse of ipsilateral lung

(4) Inability to ventilate affected lung

(5) Ventilation/ perfusion mismatch

(a) Shunting

(b) Hypoventilation

(d) Large functional dead space

b0 Air will enter pleural space during inspiratory phase

c0 Air may exit during exhalation phase

d0 Resistance to air flow through respiratory tract may be greater than through open wound resulting in ineffective respiratory effort

e0 One way flap valve may let air in but not out resulting in built up pressure in pleural space

f0 Direct lung injury may be present

g0 Vena cava kinked from swaying of mediastinum

h0 Preload decreased from knifing of inferior vena cava

3 Assessment findings

a0 To and fro air motion out of defect

b0 Defect in the chest wall

c0 Penetrating injury to the chest which does not seal itself

d0 Sucking sound on inhalation

e0 Tachycardia

f0 Tachypnea

g0 Respiratory distress

h0 Subcutaneous emphysema

i0 Decreases breath sounds on affected side

4 Management

a0 Airway and ventilation

(1) Positive pressure ventilation if necessary

(2) Monitor for development of tension pneumothorax

b0 Non-pharmacologic

(1) Occlude open wound

(2) Tube thoracostomy - in hospital management

c0 Transport consideration

(1) Appropriate mode

(2) Appropriate facility

5 Psychological support/ communication strategies

C0 Tension pneumothorax

1 Epidemiology

a0 Incidence

(1) Penetrating trauma

(2) Blunt trauma

b0 Morbidity/ mortality

(1) Profound hypoventilation could result

(2) Death related to delayed management

(3) Immediate life-threatening chest injury

2 Pathophysiology

a0 Defect in airway allowing communication with pleural space

b0 Blunt trauma

(1) Penetration by rib fracture

(2) Sudden increase in intrapulmonary pressure

(3) Bronchial disruption from shear forces

c0 Air trapped in pleural space with build up of pressure

d0 Lung collapse on affected side with mediastinal shift to contralateral side

e0 Lung collapse leads to right-to-left intrapulmonary shunting and hypoxia

f0 Reduction in cardiac output

(1) Increased intrathoracic pressure

(2) Deformation of vena cava reducing preload (decreased venous return to heart)

3 Assessment findings

a0 Unilateral decreased or absent breath sounds

b0 Dyspnea

c0 Tachypnea

d0 Respiratory distress

e0 Extreme anxiety

f0 Cyanosis

g0 Bulging of intercostal muscles

h0 Tachycardia

i0 Hypotension

j0 Narrow pulse pressure

k0 Subcutaneous emphysema

l0 Jugular venous distention

m0 Tracheal deviation

n0 Hyperresonance

4 Management

a0 Airway and ventilation

(1) Positive pressure ventilation if necessary

b0 Circulation

(1) Relieve tension pneumothorax to improve cardiac output

c0 Non-pharmacologic

(1) Occlude open wound

(2) Needle thoracentesis

(a) Equipment

(b) Technique

(3) Tube thoracostomy - in hospital management

d0 Transport consideration

(1) Appropriate mode

(2) Appropriate facility

e0 Psychological support/ communication strategies

D0 Hemothorax

1 Epidemiology

a0 Incidence

(1) Associated with pneumothorax

(2) Blunt or penetrating trauma

(3) Rib fractures are frequent cause

b0 Morbidity/ mortality

(1) Life-threatening injury that frequently requires urgent chest tube and/ or surgery

(2) Hemothorax associated with great vessel or cardiac injury

(a) 50% will die immediately

(b) 25% live five to ten minutes

2 Pathophysiology

a0 Accumulation of blood in the pleural space

b0 Bleeding from

(1) Penetrating or blunt lung injury

(2) Chest wall vessels

(3) Intercostal vessels

(4) Myocardium

c0 Pulmonary parenchyma is low-pressure vascular system

d0 Bleeding from pulmonary contusion generally causes 1000 to 1500 cc blood loss

e0 Massive hemothorax indicates great vessel or cardiac injury

f0 Collapse of ipsilateral lung

g0 Respiratory insufficiency dependent on amount of blood

h0 Hypoxia

i0 Hypotension and inadequate perfusion may result from blood loss

j0 Chest cavity can hold 2,000 to 3,000 ml of blood

k0 Classified by amount of blood loss

l. Tissue pressure effects of legs, arms and abdomen versus thorax

(1 La Place law

(2 Extraluminal pressure in legs

(3 Extraluminal pressure in thorax

m. An intercostal artery can easily bleed 50 ccs per minute

n. Intrapulmonary hemorrhage

(1 Bronchus

(2 Parenchyma

3. Assessment findings

a. Tachypnea

b. Tachycardia

c. Dyspnea

d. Respiratory distress

e. Hypotension

f. Narrow pulse pressure

g. Pleuritic chest pain

h. Pale, cool, moist skin

i. Dullness on percussion

j. Decreased breath sounds

4. Management

a. Airway and ventilation

(1 Positive pressure ventilation if necessary

b. Circulation

(1 Re-expand the affected lung to reduce bleeding

c. Non-pharmacological

(1 Needle chest decompression

(2 Tube thoracostomy - in hospital management

d. Transport considerations

(1 Appropriate mode

(2 Appropriate facility

e. Psychological support/ communication strategies

E. Hemopneumothorax

1. Pathophysiology

a. Pneumothorax with bleeding in pleural space

2. Assessment

a. Findings and management same as hemothorax

3. Management

a. Management is the same as a hemothorax

F. Pulmonary contusion

1. Epidemiology

a. Incidence

(1 Blunt trauma to chest

(a Most common injury from blunt thoracic trauma

(b 30-75% with blunt trauma have pulmonary contusion

(2 Associated commonly with rib fracture

(3 High energy shock waves from explosion

(4 High velocity missile wounds

(5 Rapid deceleration

(6 High incidence of extrathoracic injuries

(7 Low velocity - ice pick

b. Morbidity/ mortality

(1 Missed due to high incidence of other associated injuries

(2 Mortality between 14-20%

2. Pathophysiology

a. Three physical mechanisms

(1 Implosion effect

(a Overexpansion of air in lungs secondary to positive-pressure concussive wave

(b Rapid excessive stretching and tearing of alveoli

(2 Inertial effect

(a Strips alveoli from heavier bronchial structures when accelerated at varying rates by concussive wave

(3 Spalding effect

(a Liquid-gas interface is disrupted by shock-wave

(b Wave releases energy

(c Differential transmission of energy causes disruption of tissue

b. Alveolar and capillary damage with interstitial and intraalveolar extravasation of blood

c. Interstitial edema

d. Increased capillary membrane permeability

e. Gas exchange disturbances

f. Hypoxemia and carbon dioxide retention

g. Hypoxia causes reflex thickening of mucous secretions

(1 Bronchiolar obstruction

(2 Atelectasis

h. Blood is shunted away from unventilated alveoli leading to further hypoxemia

3. Assessment findings

a. Tachypnea

b. Tachycardia

c. Cough

d. Hemoptysis

e. Apprehension

f. Respiratory distress

g. Dyspnea

h. Evidence of blunt chest trauma

i. Cyanosis

4. Management

a. Airway and ventilation

(1 Positive pressure ventilation if necessary

b. Circulation

(1 Restrict intravenous fluids (use caution restricting fluids in hypovolemic patients)

c. Transport considerations

(1 Appropriate mode

(2 Appropriate facility

d. Psychological support/ communication strategies

V. Myocardial injuries

A. Pericardial tamponade

1. Epidemiology

a. Incidence

(1 Rare in blunt trauma

(2 Penetrating trauma

(3 Occurs in less than 2% of chest trauma

b. Morbidity/ mortality

(1 Gunshot wounds carry higher mortality than stab wounds

(2 Lower mortality rate if isolated tamponade is present

2. Anatomy and physiology

a. Pericardium

(1 Tough fibrous sac

(2 Encloses heart

(3 Attaches to great vessels at the base of heart

(4 Two layers

(a Visceral forms epicardium

(b Parietal regarded as sac itself

(5 Purposes

(a Anchor heart

(b Restricts excess movement

(c Prevents kinking of great vessels

(6 Parietal layer is acutely nondispensable but can chronically distend by as much as 1,000 to 1,500 ml

(7 Space between visceral and parietal layer is "potential space"

(8 Space normally filled with 30-50 ml of straw-colored fluid secreted by visceral layer

(a Lubrication

(b Lymphatic drainage

(c Immunologic protection for heart

3. Pathophysiology

a. Rapid accumulation of fluid over a period of minutes to hours leads to increases in intrapericardial pressure

b. Increased intrapericardial pressure

(1 Compresses heart and decreases cardiac output due to restricted diastolic expansion and filling

(2 Hampers venous return

c. Myocardial perfusion decreases due to pressure effects on walls of heart and decreased diastolic pressures

d. Ischemic dysfunction may result in infarction

e. Removal of as little as 20 ml of blood may drastically improve cardiac output

4. Assessment findings

a. Tachycardia

b. Respiratory distress

c. Narrow pulse pressure

d. Pulsus paradoxus

e. Cyanosis

(1 Head

(2 Neck

(3 Upper extremities

f. Beck’s triad - advanced stage seen in only 30% of patients

(1 Hypotension

(2 Neck vein distention

(3 Muffled heart tones

g. Kussmaul's sign

h. ECG changes

5. Management

a. Airway and ventilation

b. Circulation

(1 Fluid challenge

c. Non-pharmacological

(1 Pericardiocentesis - in hospital management

d. Transport considerations

(1 Appropriate mode

(2 Appropriate facility

e. Psychological support/ communication strategies

B. Myocardial contusion (blunt myocardial injury)

1. Epidemiology

a. Incidence

(1 16-76% of blunt trauma

b. Morbidity/ mortality

(1 Significant cause of morbidity and mortality in the blunt trauma patient

2. Pathophysiology

a. Hemorrhage with edema and fragmented myocardial fibers

b. Cellular injury

c. Vascular damage may occur

d. Hemopericardium may occur from lacerated epicardium or endocardium

e. Fibrinous reaction at contusion site may lead to

(1 Delayed rupture

(2 Ventricular aneurysm

f. Areas of damage are well demarcated

g. Conduction defects

3. Assessment findings

a. Associated injuries

(1 One to three rib fractures

(2 Sternal fracture

b. Retrosternal chest pain

c. ECG changes

(1 Persistent tachycardia

(2 ST elevation, T wave inversion

(3 Right bundle branch block

(4 Atrial flutter, fibrillation

(5 Premature ventricular contractions

(6 Premature atrial contractions

d. New cardiac murmur

e. Pericardial friction rub (late)

4. Management

a. Airway and ventilation

(1 Oxygen therapy

b. Circulation

(1 Intravenous fluid volume

c. Pharmacological

(1 Antiarrhythmics

(2 Vasopressors

d. Transport considerations

(1 Appropriate mode

(2 Appropriate facility

e. Psychological support/ communication strategies

C. Myocardial rupture

1. Associated with immediate trauma or delayed for 2-3 weeks

2. Associates with blunt trauma

a. Compression between sternum and vertebrae

3. Penetrating trauma

a. Rib

b. Missile

c. Sternal bone

4. History of trauma with a presentation of

a. Congestive heart failure

b. Cardiac tamponade

5. Immediate onset of congestive heart failure following trauma

a. Rupture of cardiac valves

b. Intraventricular septal rupture

6. Management is supportive

VI. Vascular injuries

A. Aortic dissection/ rupture

1. Epidemiology

a. Incidence

(1 Blunt trauma

(a Motor vehicle crash

(b Falls

(2 15% of all blunt trauma deaths

2. Morbidity/ mortality

a. 85-95% die instantaneously

b. 10-15% survive to arrive at hospital

(1 33% of survivors die within six hours

(2 33% of survivors die within twenty-four hours

(3 33% survive three days or longer

3. Pathophysiology

a. Shear injury

b. Separation of the aortic intima and media

c. Blood enters media through a small intima tear

d. Tear due to effect of high speed deceleration on portions of the aorta at points of relative fixation

e. Increased intraluminal pressure results from impact

f. Thinned out layer may rupture

g. Descending aorta at the isthmus just distal to left subclavian artery is most common site of rupture (ligamentum arteriosom)

h. Ruptures of ascending aorta much less common

4. Assessment findings

a. Retrosternal or interscapular pain

b. Dyspnea

c. Dysphagia

d. Ischemic pain of the extremities

e. Upper extremity hypertension with absent or decreased amplitude of femoral pulses

f. Harsh systolic murmur over precordium or interscapular region

5. Management

a. Airway and ventilation

b. Circulation

(1 Do not over hydrate

c. Transport considerations

(1 Appropriate mode

(2 Appropriate facility

d. Psychological support/ communication strategies

B. Penetrating wounds of the great vessels

1. Usually involve

a. Chest

b. Abdomen

c. Neck

2. Wounds are accompanied by

a. Massive hemothorax

b. Hypovolemic shock

c. Cardiac tamponade

d. Enlarging hematomas

3. Hematomas may cause compression of any structure

a. Vena cava

b. Trachea

c. Esophagus

d. Great vessels

e. Heart

4. Management

a. Manage hypovolemia

(1 PASG not recommended

b. Relief of tamponade if present

c. Expeditious transport

VII. Other thorax injuries

A. Diaphragmatic injury

1. Epidemiology

a. Incidence

(1 Blunt trauma

(2 Penetrating trauma

(3 Frequently encountered injury

b. Morbidity/ mortality

(1 Could be life-threatening

2. Pathophysiology

a. High-pressure compression to abdomen with resultant intra-abdominal pressure increase

b. Can produce very subtle signs and symptoms

c. Bowel obstruction and strangulation

d. Restriction of lung expansion

(1 Hypoventilation

(2 Hypoxia

e. Mediastinal shift

(1 Cardiac compromise

(2 Respiratory compromise

3. Assessment findings

a. Tachypnea

b. Tachycardia

c. Respiratory distress

d. Dullness to percussion

e. Scaphoid abdomen

f. Bowel sounds in affected hemithorax

g. Decreased breath sounds

4. Management

a. Airway and ventilation

(1 Positive pressure ventilation if necessary

(2 Caution IPPB may worsen the injury

b. Non-pharmacologic

(1 Do not place patient in Trendelenburg position

c. Transport consideration

(1 Appropriate mode

(2 Appropriate facility

d. Psychological support/ communication strategies

B. Esophageal injury

1. Epidemiology

a. Incidence

(1 Penetrating trauma most frequent cause

(2 Rare in blunt trauma

b. Morbidity/ mortality

(1 Could be life-threatening if missed

2. Pathophysiology

a. Missile and knife wounds penetrate esophagus

b. Can perforate spontaneously

(1 Violent emesis

(2 Carcinoma

(3 Anatomic distortions produced by diverticulae or gastric reflux

3. Assessment findings

a. Pain

b. Fever

c. Hoarseness

d. Dysphagia

e. Respiratory distress

f. Cervical esophageal perforation

(1 Local tenderness

(2 Subcutaneous emphysema

(3 Resistance of neck on passive motion

g. Intrathoracic esophageal perforation

(1 Mediastinal emphysema

(2 Mediastinitis

(3 Subcutaneous emphysema

(4 Mediastinal crunch

(5 Splinting of chest wall

h. Respiratory distress

i. Shock

4. Management

a. Airway and ventilation

b. Transport consideration

(1 Appropriate mode

(2 Appropriate facility

c. Psychological support/ communication strategies

C. Tracheo-bronchial injuries

1. Epidemiology

a. Incidence

(1 Rare injury - less than 3% of chest trauma

(2 Penetrating trauma

(3 Blunt trauma

b. Morbidity/ mortality

(1 High mortality rate - greater than 30%

2. Pathophysiology

a. Majority occur within 3 cm of carina

b. Tear can occur anywhere along tracheal/ bronchial tree

c. Rapid movement of air into pleural space

d. Tension pneumothorax refractory to needle decompression

e. Continuous flow of air from needle of decompressed chest

f. Severe hypoxia

3. Assessment

a. Tachypnea

b. Tachycardia

c. Massive subcutaneous emphysema

d. Dyspnea

e. Respiratory distress

f. Hemoptysis

g. Signs of tension pneumothorax that doesn't respond to needle decompression

4. Management

a. Airway and ventilation

b. Circulation

c. Transport consideration

(1 Appropriate mode

(2 Appropriate facility

D. Traumatic asphyxia

1. Epidemiology

a. Incidence

b. Morbidity/ mortality

2. Pathophysiology

a. Sudden compressional force squeezes the chest

b. Blood backs up into the head and neck

c. Jugular veins engorge, capillaries rupture

3. Assessment

a. Cyanosis to the face and upper neck

b. Jugular venous distention

c. Swelling or hemorrhage of the conjunctiva

d. Skin below area remains pink

e. Hypotension when pressure released

4. Management

a. Airway and ventilation

b. Circulation

(1) Expect hypotension once compression is released

c. Pharmacological

(1) Sodium bicarbonate should be guided by ABGs in hospital

d. Transport considerations

(1) Appropriate mode

(2) Appropriate facility

VIII. Integration