Chapter 34 Chest Trauma Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren Copyright 2010 by Pearson Education, Inc. All rights reserved. Objectives 1. Define key terms introduced in this chapter. 2. List the major structures of the thoracic cavity (slides 11-12). 3. Define and list specific types of open chest injury (slides 13-14). 4. Define and list specific types of closed chest injury (slides 15-16). Objectives 5. Explain the pathophysiology of each of the following injuries (slides 17-36): a. Flail segment b. Pulmonary contusion c. Open pneumothorax, tension pneumothorax, hemothorax d. Traumatic asphyxia e. Cardiac contusion f. Pericardial tamponade g. Rib injury 1
Objectives 6. Discuss an assessment-based approach to manage patients with chest trauma (slides 37-50). 7. Discuss the following aspects of chest trauma care (slides 43-48): a. General emergency care for chest trauma b. Specific emergency care for an open chest wound c. Specific emergency care for a flail segment Topics The Chest CASE STUDY Dispatch 2
EMS Unit 106 Respond to the corner of Market Street and Breaden Avenue for a man down. Call made by a passerby. Time out 2206 Upon Arrival Person lying in a prone position on the sidewalk You look around for any other people or activity It s a cold night, and the patient is dressed in a heavy overcoat You hear him moaning as you step out of the unit How would you proceed to assess and care for this patient? 3
The Chest Back to Topics Anatomy of the Chest Back to Objectives 4
General Categories of Chest Injuries Open Chest Injury Back to Objectives Open Chest Injury Causes Sucking chest wound Tension pneumothorax General Categories of Chest Injuries Closed Chest Injury Back to Objectives 5
Closed Chest Injury Cause Injury Flail segment Specific Chest Injuries Flail Segment Back to Objectives Flail Segment Definition Paradoxical movement Effect on respiration Emergency medical care 6
Specific Chest Injuries Pulmonary Contusion Causes Signs and symptoms Emergency medical care Pulmonary Contusion Specific Chest Injuries Pneumothorax 7
Pneumothorax Causes Signs and symptoms Specific Chest Injuries Open Pneumothorax Open Pneumothorax Cause Signs and symptoms Emergency medical care 8
Specific Chest Injuries Tension Pneumothorax Cause Effect on body Severity Signs and symptoms Emergency medical care Tension Pneumothorax Specific Chest Injuries Hemothorax 9
Hemothorax Definition Cause Signs and symptoms Emergency medical care Specific Chest Injuries Traumatic Asphyxia Cause Signs and symptoms Emergency medical care Traumatic Asphyxia 10
Specific Chest Injuries Cardiac Contusion Cardiac Contusion Cause Signs and symptoms Emergency medical care Specific Chest Injuries Pericardial Tamponade 11
Pericardial Tamponade Definition Causes Signs and symptoms Specific Chest Injuries Rib Injury Rib Injury Effect Signs and symptoms Emergency medical care 12
Assessment-Based Approach: Chest Trauma Scene Size-Up Back to Objectives Scene Size-Up Scene safety Mechanism of injury Assessment-Based Approach: Chest Trauma Primary Assessment 13
Primary Assessment In-line spine stabilization General impression Expose chest ABCs Mental status Treat life threats Assessment-Based Approach: Chest Trauma Secondary Assessment Secondary Assessment Head-to-toe assessment Lung sounds Accessory muscle use History Signs and symptoms 14
Assessment-Based Approach: Chest Trauma General Emergency Care Chest Trauma Back to Objectives General Emergency Care Chest Trauma Maintain open airway Continue O 2 therapy Reevaluate breathing status Stabilize impaled objects Immobilize patient on long backboard, if needed Treat for shock Assessment-Based Approach: Chest Trauma Emergency Medical Care Open Chest Wound 15
Emergency Care Open Chest Wound Seal open wound with gloved hand immediately Apply occlusive dressing to seal wound Continuously assess patient s respiratory status Assessment-Based Approach: Chest Trauma Emergency Care Flail Segment Emergency Care Flail Segment Place hand over flail segment Initiate positive pressure ventilation, if needed Stabilize with bulky dressings 16
Assessment-Based Approach: Chest Trauma Reassessment Reassessment Evaluate interventions Watch for worsening signs and symptoms Monitor for tension pneumothorax Reassess vital signs CASE STUDY Follow-Up 17
CASE STUDY Primary Assessment Establish in-line stabilization Patient only moans to questions Airway open and clear of secretions RR: 40 and shallow Start BVM Radial pulse weak and rapid Skin cool, moist, and pale CASE STUDY Secondary Assessment No JVD; trachea midline Expose chest and find what appears to be a small-caliber gunshot wound to right anterior chest, third intercostal space Place gloved hand over wound, then occlusive dressing Do not find exit wound CASE STUDY Secondary Assessment BP: 80/60 mmhg; P: 138; RR: 35 Place cervical collar; immobilize patient to backboard Initiate rapid transport 18
CASE STUDY Treatment and Reassessment Mental status unchanged; insert NPA P: 130; cyanosis subsides slightly Patient suddenly becomes more difficult to ventilate; P: 148; patient becomes cyanotic Lift occlusive dressing; air escapes; patient improves CASE STUDY Treatment and Reassessment Upon arrival, give report and transfer care Patient now in surgery; prognosis unknown Critical Thinking Scenario Unknown age male driver of a vehicle involved in a frontal collision with another vehicle The patient was not wearing his seat belt The air bag deployed during the crash 19
Critical Thinking Scenario Physical exam: Patient responds to verbal stimuli with moans Large contusion to his left upper chest Upon inhalation, the left upper chest moves inward Moans loudly when his chest is palpated Pedal pulses are absent Critical Thinking Scenario Vital signs: BP: 72/64 mmhg Radial pulse is 124 bpm and barely palpable RR: 34 per minute with shallow chest rise Skin is pale, cool, and clammy SpO 2 gives continuous error reading Critical Thinking Questions 1. What emergency care would you provide in the primary assessment? 2. What signs and symptoms in this patient are indicators of shock? 3. What type of chest injury is the patient suffering from? 4. How would you manage the chest injury? 5. What overall emergency care would you provide? 20
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