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Chapter 23

Chapter 23. Chest and Abdominal Trauma. Overview. Anatomy Review Chest Trauma Chest Injuries Abdominal Trauma Abdominal Injuries. Anatomy Review. Thoracic cavity and abdominal cavity: two spaces in the trunk of the body They contain some of the body’s most important organs. Chest Trauma.

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Chapter 23

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  1. Chapter 23 Chest and Abdominal Trauma

  2. Overview • Anatomy Review • Chest Trauma • Chest Injuries • Abdominal Trauma • Abdominal Injuries

  3. Anatomy Review • Thoracic cavity and abdominal cavity: two spaces in the trunk of the body • They contain some of the body’s most important organs

  4. Chest Trauma • Chest injuries result in a significant number of deaths each year • The chest contains organs vital to life • Damage to vital organs threatens life • Most common consequence is hypoxia

  5. Chest Trauma • Mechanism of injury (MOI): Blunt chest trauma • Most common cause of serious chest injuries • Motor vehicle collisions (MVCs), falls, direct blows, and crushing injuries • Many injuries are not immediately apparent in physical exam

  6. Chest Trauma • Mechanism of injury (MOI): Blunt chest trauma • Injuries linked to size of object applying force and most important, to speed • Speed kills

  7. Chest Trauma • MOI: Blunt chest trauma • Evaluating MOI at a motor vehicle collision • Significant damage to vehicle’s exterior? • Damage to interior of vehicle? • Broken or bent steering wheel means significant force was applied to the driver’s chest • The higher the forces, the higher the suspicion for serious injury to patient

  8. Chest Trauma • MOI: Penetrating trauma • Increasingly common in today’s society • Immediate result can be severe bleeding or impaired breathing

  9. Chest Trauma • MOI: Penetrating trauma • Any chest wound can involve underlying organ injury • No matter how superficial it looks • Injuries to the heart, lungs, and great vessels can quickly lead to shock and cardiac arrest

  10. Chest Trauma • Signs and symptoms • Most common symptoms: pain and difficulty breathing • Signs are obvious injury to the chest wall • Use DCAP-BTLS, looking at both the front and back of the chest • Note any subcutaneous emphysema, or air present under the skin

  11. Chest Trauma • Assessment • Follow all steps in the assessment of the trauma patient

  12. Chest Trauma • Management • Ensure patient has adequate oxygenation and perfusion • Provide high-flow oxygen, ventilating when necessary • Halt any obvious bleeding

  13. Chest Trauma • Management • Support circulation when needed • Rapidly transport patient to definitive care

  14. Chest Trauma • Transport • Transport patient to a hospital with the capability to diagnose and treat serious traumatic injuries • Arrange for ALS intercept as guided by local protocols • Notify receiving hospital so staff can prepare

  15. Chest Injuries • Open chest wounds • A sharp object penetrates the skin on the chest wall • Laceration of vessels such as the vena cava or aorta will likely cause bleeding between the lung and the chest wall • The accumulation of blood in the pleural space is called a hemothorax

  16. Chest Injuries • Open chest wounds • If penetrating object has pierced pleura, outside air can enter the thoracic cavity • As the volume of air in the thoracic cavity expands, the lung starts to collapse • Air within the pleural space is called a pneumothorax

  17. Chest Injuries • When air enters between the lung and the chest wall, pneumothorax is created

  18. Chest Injuries • Open chest wounds • As air passes in and out of an open wound, it can create a sucking-type sound • Sucking chest wound means possibility of pneumothorax • Signs of pneumothorax: difficulty breathing, cyanosis, diminished breath sounds on the affected side

  19. Chest Injuries • Open chest wounds: Management • Cover open chest wounds with occlusive dressing • Gloved hand is an effective temporary occlusive dressing • Secure dressing on three sides

  20. Chest Injuries • Open chest wounds: Management • High-flow oxygen • Transport with unaffected side slightly elevated • Arrange for ALS intercept

  21. Open Chest Wound • Watch this animation illustrating management of an open chest wound.

  22. Stop and Review • Name three signs of a simple pneumothorax.

  23. Chest Injuries • Tension pneumothorax • Buildup of pressure in pleural space resulting in decrease in blood pressure • Potentially life-threatening condition that must be treated immediately • Can occur in blunt or penetrating chest trauma

  24. Chest Injuries • Increasing pressure in the lung pushes the heart and the great vessels to the opposite side of the chest.

  25. Chest Injuries • Tension pneumothorax: Signs • Include all those of a pneumothorax • Jugular venous distension (JVD) • If ventilating becomes more difficult, significant lung compression is indicated

  26. Chest Injuries • Tension pneumothorax: Signs • Tracheal deviation is a late sign • If patient is hypotensive, immediately lift a corner of the occlusive dressing • Transport this patient rapidly • Consider ALS intercept

  27. Chest Injuries • Rib fractures • Local swelling and tenderness may be the only sign of a broken rib • Can be very painful • Patients often present with guarding and shallow breathing

  28. Chest Injuries • Rib fractures: Management • Move the patient carefully to prevent the bone ends from puncturing a lung • Administer oxygen

  29. Chest Injuries • Rib fractures: Management • Allow patient to self-splint by assuming the most comfortable position possible • Encourage patient to limit movement

  30. Chest Injuries • Flail segment • When three or more ribs are broken in two or more places, a rib-cage segment may detach from the rest • Flail segment is free floating

  31. Chest Injuries • Flail segment • Paradoxical movement: movement of flail segment in opposite direction of the rest of the chest wall • Paradoxical movement can significantly impair breathing and cause injury to the underlying lung

  32. Flail Chest Segment • Watch this animation of a flail chest segment.

  33. Chest Injuries • Flail segment: Management • Quickly stabilize flail segment by placing gloved hand over injured area • After manual stabilization, place folded universal dressing over segment and tape securely

  34. Chest Injuries • Flail segment: Management • Consider assisting patient’s breathing if tachypnea increases • Transport on side with unaffected lung on top

  35. Chest Injuries • Pulmonary contusion • Bleeding into the lung itself is a pulmonary contusion • Bleeding and edema can impair gas exchange, causing hypoxia • Soft crackles may be heard over injury site • Chest pain, point tenderness, and localized swelling over area of impact

  36. Chest Injuries • Pulmonary contusion: Management • Support ventilation as needed • Supply high-flow supplemental oxygen • Transport to hospital

  37. Chest Injuries • Cardiac contusion • Can impair heart’s ability to pump • Bleeding into heart tissue can cause heart to beat irregularly • Irregular pulse should alert EMT to possibility of a cardiac contusion

  38. Chest Injuries • Cardiac contusion: Management • High-flow oxygen • Ventilation support as needed • Support of circulation if appropriate • Prompt transport • Request ALS backup

  39. Chest Injuries • Pericardial tamponade • Bleeding around heart and into pericardial sac that encloses the heart can cause pericardial tamponade • Usually results from a penetrating chest trauma with laceration to the heart itself

  40. Chest Injuries • Pericardial tamponade • Blood filling the pericardial sac compresses heart, causing blood to back up • JVD is a telltale sign of pericardial tamponade • Narrowed pulse pressures

  41. Chest Injuries • Pericardial tamponade: Management • High-flow oxygen • Treat patient for shock • Transport rapidly to ED • Request ALS intercept • Notify hospital so staff can properly prepare

  42. Chest Injuries • Aortic injury • In sudden decelerations such as high-speed head-on MVCs, body organs are thrown forcefully against the front of the body • Most significant tear: aorta • If tear is complete, patient will die in minutes • Incomplete tears bleed severely

  43. Chest Injuries • Aortic injury: Management • High-flow oxygen • Treat patient for shock • Transport rapidly to ED • Notify hospital so staff can properly prepare

  44. Chest Injuries • Traumatic asphyxia • Rapid ejection of blood and air out of chest • Rapid compression of chest increases internal pressure dramatically • Blood is immediately forced out of the chest and into the vessels in the neck, head, and face

  45. Chest Injuries • Traumatic asphyxia • Neck veins immediately become distended • Cyanosis is apparent in face • Bleeding in the eyes’ sclera may occur

  46. Chest Injuries • Traumatic asphyxia: Management • High-flow oxygen • Treat patient for shock • Transport rapidly to ED • Notify hospital so staff can properly prepare

  47. Abdominal Trauma • MOI: Penetrating abdominal trauma • Stab or gunshot wound to abdomen, no matter how superficial, can seriously injure internal organs

  48. Abdominal Trauma • MOI: Penetrating abdominal trauma • Inquire • Kind of knife and length? • Caliber of gun? • How many shots were fired? • Trajectory?

  49. Abdominal Trauma • MOI: Blunt abdominal trauma • External signs of injury may not be readily apparent • Injury potential is as great as that of a penetrating trauma • Most vehicle air bags don’t protect against abdominal injury from lateral impacts in an MVC • Improper use of seat belts may cause abdominal injury in a collision

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