Definitions, problem recognition, and treatment for major chest injuries. Quick and easy

1. Chest Injuries
First Aid and Treatment Options
Anas Bahnassi PhD
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2. Anas Bahnassi PhD CDM CDE 2

3. • External trauma to the chest:
– Blunt
– Penetrating
• Possible damage to underlying organs:
– Heart
– Lungs
• Possible spinal injury.
• Chest injuries are responsible for 25% of
trauma related deaths.
Introduction

4. Tri-modal peak of Mortality
1st peak: Non-
survivable
severe CNS or
CVS injuries
Location of
death: Pre-
hospital
environment
2nd peak: First few
hours after injury,
most often due to
hypoxia and
hypovolemic shock
Usually can be
saved
3rd peak: Within 6
weeks of injury
Cause: Multisystem
failure and sepsis

5. The Golden Hour
• Treat the greatest threat to life first
• Treat despite lack of a definitive diagnosis
• Treat despite complete history

6. The Golden Hour
• A = Airway with c-spine protection
• B = Breathing
• C = Circulation, stop the bleeding
• D = Disability/Neurological
status
• E = Exposure and
Environment

7. Three Stage Approach
1. Primary Survey: ABCDE
– sequential yet actually simultaneous
– includes resuscitation efforts
– normalization of vital signs
2. Secondary Survey:
– AMPLE history
– head-to-toe and x-rays
3. Definitive Care: Specialist treatment of
identified injuries

8. Primary Assessment
ABCDE
Injury
Resuscitation
Re-evaluation Secondary Survey
Head-to-toe + X-Ray
Re-evaluation
Transfer
Definitive Care

9. Initial Assessment
Starting with the ABCDE
A.Airway
B.Breathing
C.Circulation
D.Disability
E.Exposure and Environment

10. Airway: Preventable Deaths
• Failure to recognize need
• Inability to establish
• Incorrectly placed airway
• Displacement
• Failure to ventilate
• Aspiration

11. Airway: Problem Recognition
• Objective Signs – Airway Obstruction:
– agitation, cyanosis = hypoxia
– obtundation = hypercarbia
– abnormal sounds
– tracheal location
– external trauma

12. Airway: Problem Recognition
• Altered Levels of Consciousness
– closed head injury
– intoxication
• Maxillofacial Trauma
– hemorrhage
– dislodged teeth
– mandible fracture

13. Airway: Problem Recognition
• Penetrating Neck
Trauma
– laceration of trachea
– hemorrhage with
tracheal deviation/
obstruction
– patient may initially maintain airway
– prophylactic intubation?

14. Airway: Problem Recognition
• Blunt Neck Trauma
– hemorrhage with
tracheal deviation/
obstruction
– disruption of the larynx
• hoarseness
• subcutaneous
emphysema
• palpable fracture
– prophylactic
intubation?

15. Airway: Management
Always Assume This…. So Do This….
C-Spine Stabilization

16. Airway: Management
• Airway Maintenance
Techniques:
• chin lift
• jaw thrust
• oral airway
• nasal trumpet
• Definitive Airway:
• orotracheal or nasotracheal intubation
• surgical airway

17. Airway: Cricothyroidotomy
Vertical skin incision – make it longer than you
think you need….

18. Circulation: Preventable Deaths
• Address:
– Immediately Life-Threatening Chest Injuries:
• Tension Pneumothorax
• Open Pneumothorax (sucking chest wound)
• Flail Chest
• Disruption of Tracheo-Brochial tree
– Potentially Life-Threatening Chest Injuries:
• Pulmonary contusion
• Diaphragmatic rupture
• esophageal rupture

19. Check:
1. Vital signs
2. ECG
3. Pulse oximetry
4. End-Tidal Carbon Dioxide
5. Arterial Blood Gas
6. Urinary output
7. Urethral Catheterization
8. Nasogastric tube
9. Chest X-Ray
10.Pelvic X-Ray

20. Breathing: Problem Recognition
Look
Listen
Feel
Assess:
Look
• Respiratory rate
• Shallow, gasping or labored breathing:
Respiratory failure?
• Cyanosis: Hypoxia
• Paradoxical Respiration: ‘Pendulum’ breathing
with asynchronisation of chest and abdomen:
Respiratory failure or Structural damage.
• Unequal chest inflation: Pneumothorax or Flail
chest
• Bruising or contusion: ‘Seat-Belt’ sign.
• Penetrating chest injury
• Distended neck veins: venous return-Tension
pneumothorax or cardiac tamponade

21. Breathing: Problem Recognition
Look
Listen
Feel
Assess:
LISTEN
• Absent breath sounds: Apnoea or tension
pneumothorax
• Noisy breathing/ Crepitations/ Stridor/ Wheeze:
Partially obstructed airway
• Reduced air entry: Pneumothorax, Haemothorax,
Heamo-pnemothorax, flail chest

22. Breathing: Problem Recognition
Look
Listen
Feel
Assess:
FEEL
• Tracheal deviation: Mediastinal shift
• Tenderness: Chest wall contusion and/ rib fracture
• Crepitus / Instabilty: Underlying rib fracture
• Surgical emphysema: ‘Bubble-wrap’ sign

23. Breathing: Management
The patient’s hemodynamic status dictates
imaging and management.
• Chest tube, chest tube,
chest tube
• Occlusive dressing
• Ventilatory support
• Thoracotomy?

24. Indications for thoracotomy
1. Internal cardiac massage
2. Control of haemorrhage from injury to the heart
3. Control of haemorrhage from injury to the
lungs/intrapleural haemorrhage
4. Cardiac tamponade
5. Ruptured oesophagus
6. Aortic transection
7. Control of massive air leak
8. Traumatic diaphragmatic tear

25. Circulation: Preventable Deaths
• Hypotension = Hemorrhage
• Assess:
– level of consciousness
– pulse / skin color
• Address:
– external bleeding
– massive hemothorax
– cardiac tamponade
– massive hemoperitoneum
– unstable pelvic fracture

26. Circulation: Classes of Shock

27. Circulation: Classes of Shock
Example:
• 1 year old falls off
the stairway (10 kg)
• “lost ¾ cup of blood”
• blood volume =
70cc/kg x 10kg
• EBL = ¾ cup=6
oz=180cc
• 180cc / 700cc =
25%blood loss
• Class II/III shock

28. Circulation: Causes of Shock
Hypovolemic = Hemorrhage:
5 spaces = chest, abdomen, pelvis, long-bones, street
• Fractures:
– rib = 100-200 cc
– tibia = 300-500 cc
– femur = 800-1200 cc
– pelvis = 1500 and up

29. Circulation: Causes of Shock
• Neurogenic: spinal cord injury
• Septic
• Cardiogenic:
• tension
Pnemothorax
• cardiac tamponade
or contusion
• air embolism
• primary cardiac
disease

30. 30
Fractured Ribs: Problem Recognition
• Pain at site which increases
with movement or touch
• Pain at site when breathing in
• Difficulty breathing, Rapid
shallow breathing
• Rapid pulse
• Bruising
• Deformity
• Bloody sputum
• ‘Guarding’ of the injury

31. Fractured Ribs: Management
• Primary survey - ABCDE
• Position of comfort (often sitting
position with the injured side
downwards).
• Stabilize the fracture site - Put
the arm on the injured side in a
‘collar and cuff’ or a sling.
• Seek medical aid
• Provide supplemental oxygen if
available
• Observe for respiratory
compromise
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32. Fractured Ribs: Management
• Reduction of pain with 2 week follow
up
• Analgesics :
– Opiods
– NSAID’s
• Intercostal Blocks
• Strapping of chest: relieves pain by
immobilizing the ribs
• Breathing exercises

33. Pneumothorax (collapsed lung)
• Air enters the between the lungs and the inside of the chest wall
(pleural space).
• The air takes up space, causing a section of the lung to collapse.
• If air continues to enter - tension pneumothorax.
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34. 34
Pneumothorax: Problem Recognition
• Severe chest pain
• Breathing distress (Rapid,
shallow breathing)
• Rapid pulse
• Bluish skin color (cyanosis)
• Possible altered conscious
state
• Possible deviated windpipe
(trachea)
• Distended neck veins

35. 35
Pneumothorax: Management
• Seek immediate medical aid,
• Primary Survey
• Oxygen provision
• Resuscitation
if required

36. 36
Flail Segment
• When ribs and/or the breastbone are fractured in a
number of places and result in a free-floating section
of bone.

37. 37
Flail Segment: Problem Recognition
• As for fractured rib but more severe
• Paradoxical breathing
• Mediastinal Flutter
• Pendular Movement of air
• Associated injuries:
Pulmonary Contusion!
• Hypoventilation

38. Flail Segment: Management
• Primary Survey
• Urgent medical assistance
• Position of comfort. (This is often a sitting
position with the injured side downwards).
• Stabilize the fracture site as for a fractured rib
• Provide supplemental oxygen
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39. Open Chest Wound:
Problem Recognition
• Open wound to chest
• Severe breathing difficulty
• Rapid pulse
• Sound of air being sucked in through wound
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40. Open Chest Wound: Management
• Urgent medical assistance
• Position the victim in a sitting position with
the injured side downwards
• Cover the wound site with some air tight
material (e.g. polythene).
• This dressing needs to be taped on three
sides with the bottom edge left free. This
will stop air being sucked in but will allow
trapped air to escape
• Provide supplemental oxygen if able
• Continuously monitor and reassure the
victim
• If the victim becomes unconscious, conduct
a Primary Survey and take appropriate
action
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41. Clinical Pharmacy VI:
First Aid
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Anas Bahnassi PhD CDM CDE