CHEST TRAUMA

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INTRODUCTION 

Optimal patient care requires that the EMT-I understands the mechanism of injury, signs and symptoms, and field management of chest trauma.  The following topics will be discussed during this lesson:

 

·          Mechanisms of injury

 

·          Signs and symptoms of chest trauma

 

·          Field stabilization, management, and transport of chest trauma

 

·          Transport decisions for chest trauma patients

 

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

 

1.                  State the significance of various mechanisms of injury in developing an index of  

            suspicion for chest trauma.

 

2.         Discuss the signs and symptoms of blunt chest trauma.

 

3.         Discuss the field management of penetrating thoracic injuries

 

4.         Verbalize appropriate field management and transport decisions for the patient suspected of having chest trauma.

 

SKILLS 

•         Application of occlusive dressing (sucking chest wounds)

•         Stabilization of flail chest

 

KEY VOCABULARY

 

The following terms will be used during this lesson:

 

·          Hemothorax - blood in the thoracic cavity (pleural space).

 

·          Pneumothorax - air in the thoracic cavity (pleural space).

 

·          Cardiac tamponade - blood or fluid in the pericardial sac.

 

·          MOI - mechanism of injury.

 

·          PSI - passenger space intrusion - part of the vehicle is forced into the space where the occupant.

 

·          Pleural space - potential or actual space between the layers of the pleura.

 

·          Mediastinum - the space between the pleural cavities which encloses the heart, large vessels, trachea, and esophagus.

 

·          Intrathoracic pressure - pressure within the chest cavity.

 

·          Auscultation - listening for sounds within a body cavity, usually with a stethoscope.

 

·          Percussion - tapping a body surface to determine resonance within a body cavity.

 

·          Subcutaneous emphysema - air under the skin.

 

KEYCONCEPTS 

The following section provides information and space for taking notes on the key concepts discussed by the instructor.

 

REVIEW OF THE RESPIRATORY SYSTEM

Components of the Respiratory System

·          Upper airway

·          Lower airway

·          Alveoli

·          Capillaries

·          Pleural space

 

·          Ventilation

·          Definition

·          Requirements

 

INDEX OF SUSPICION:  CHEST TRAUMA

Mechanism of injury

·          Vehicle damage

·          Bent steering wheel

·          Damaged dash

·          Fall greater than 15 feet

·          Auto vs. Pedestrian

·          Ejected from a vehicle

·          Survivor of a fatal accident

·          Penetrating chest, abdominal, or upper extremity trauma

·          GSW

·          Knife wound or other sharp object

 

RECOGNITION AND FIELD MANAGEMENT OF CHEST TRAUMA

 

Signs and Symptoms of Chest Trauma

·          Shortness of breath

·          Chest pain

·          Signs of respiratory distress

·          Shock

·          Delayed capillary refill

·          Tachycardia

·          Hypotension

·          Bruising

·          Pain on palpation

·          Diminished or absent breath sounds

 

 

MAJOR THORACIC INJURIES

 

Sucking Chest Wound

Definition:

A penetrating chest wall injury where, with each respiration, air enters and leaves the thorax through the wound.

 

 

Signs and symptoms:

·          “Bubbling” air sound with each respiration

·          History of penetrating trauma

·          Dyspnea/tachypnea

·          Diminished breath sounds on the affected side

 

 

Field management:

•        BLS Procedures

·          Seal the wound with an occlusive dressing

·          High flow O2 by mask

·          Assist with ALS procedures

 

•        ALS procedures

·          Advanced airway prn

·          Venous access (large bore)

·          Monitor

·          Rapid transport

·          Remove occlusive dressing (or Needle Thoracostomy) if signs of tension pneumothorax develop.

 

Flail Chest

Definition:

Two or more ribs broken in two or more places which causes a floating chest wall segment, usually due to blunt chest trauma.

 

 

Signs and Symptoms:

·          Dyspnea/tachypnea

·          Flail segment with paradoxical motion

·          Crepitus

·          Pain

 

 

Field Management:

•        BLS procedures

·          Position of comfort (unless spinal immobilization is required)

·          High flow O2 by mask

·          Support flail segment with gentle pressure

·          Assist with ALS procedures

 

•        ALS procedures

·          Advanced airway prn

·          Venous access (large bore)

·          Monitor

·          Rapid transport

 

 

Cardiac Tamponade

Definition:

Bleeding into the pericardial sac after penetrating or blunt chest trauma which causes reduction in chamber filling and stroke volume.

 

 

Signs and Symptoms:

·          Dyspnea/tachypnea

·          Shock

·          Distended neck veins

·          Loss of peripheral pulses during inspiration

·          Equal breath sounds

 

Field Management:

•        BLS procedures

·          High flow O2 by mask

·          Position of comfort (unless spinal immobilization is necessary)

·          Assist with ALS procedures

 

•        ALS procedures

·          Advanced airway prn

·          Venous access (large bore)

·          Monitor

·          Rapid transport

 

 

Hemothorax

Definition:

Blood in the pleural space caused by penetrating or blunt chest trauma

 

 

Signs and Symptoms:

·          Dyspnea/tachypnea

·          Shock

·          Decreased or absent breath sounds on the affected side

·          Dullness on percussion of the thoracic cavity

 

 

Field Management:

•        BLS procedures

·          Position of comfort (unless spinal immobilization is required)

·          High flow O2 by mask

·          Assist with ALS procedures

 

•        ALS procedures

·          Advanced airway prn

·          Venous access (large bore

·          Monitor

·          Rapid transport

 

 

Tension Pneumothorax

Definition:

Air enters the pleural space but can not escape after blunt or penetrating chest trauma, creating increased intrathoracic pressure.

 

Signs and Symptoms:

·          Increasing shortness of breath

·          Cyanosis

·          Shock

·          Decreased or absent breath sounds on the affected side

·          Anxiety/Confusion

·          Tracheal shift

·          Subcutaneous emphysema

·          Increased resonance on percussion

 

 

Field Management:

•        BLS procedures

·          High flow O2 by mask

·          Position of comfort (unless spinal immobilization is required)

·          Assist with ALS procedures

 

•        ALS procedures

·          Immediate needle thoracostomy

·          Airway management

·          Venous access (large bore)

·          Monitor

·          Rapid transport

 

Myocardial Contusion

Definition:

Bruising of the myocardium due to blunt chest trauma.

 

Signs and symptoms:

·          Chest pain

·          Dysrhythmias

·          Hypotension

·          Anterior wall chest bruising

 

Field Management:

•        BLS procedures

·          High flow O2 by mask

·          Position of comfort (unless spinal immobilization is required)

·          Assist with ALS procedures

•        ALS procedures

·          Advanced airway PRN

·          Venous access (large bore)

·          Monitor

·          Treat dysrhythmias - Lidocaine for PVCs

 

PATIENT TRANSPORT DECISIONS FOR CHEST TRAUMA PATIENTS

Considerations for ALS Transport

·        A patient in shock should be transported immediately; secondary assessment can be completed enroute.

 

·        ALS Transport to Trauma Center (L.A. County Reference #506)

·          Trauma patients with the following blood pressure

< 6 years with a B.P. < 70

> 7 years with a B.P. < 90

·          Penetrating thoracic injury between the midclavicular lines

·          Traumatic full arrest with penetrating torso injury

·          Patient surviving falls > 15 feet

·          Passenger space intrusion

·          Abnormal capillary refill

·          Gunshot wound to the torso

·          Blunt injury to the chest with unstable chest wall

 

Considerations for BLS Transport

·        BLS Transport time may be considered in life-threatening situations, if ALS response time is longer than BLS transport time (L.A. County Reference #808).

 

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