Chest Trauma
With summer approaching, so begins trauma season. Nicer weather brings faster driving, social misadventures, and wilderness blunders. With this in mind, it seems as good a time as any to review traumatic injury management. I will be doing further posts on various traumatic injuries, but I chose to start with chest (thoracic) trauma, because the majority of the major injuries I have encountered have been in this particular region. The chest cavity is also second only to the cranial vault in terms of how critical the organs within are. I wont go over A&P here because there are great resources already available all over the place.
As far as chest trauma is concerned we are dealing with injuries to the thoracic cage, great vessels, heart, and lungs. There are essentially 7 injury types that we may encounter in trauma to the chest, 3 of which we need to be able to identify and correct during our rapid trauma survey, and 4 we need to consider and assess for during transport to the trauma centre.
Things we need to identify and treat immediately upon discovery:
1. Open or closed pneumothorax: Air entry into the pleural cavity can come from blunt or penetrating chest trauma, with the latter being most easily noted during our trauma assessment. In an open pneumothorax, a perforating wound noted in the chest wall, we will have a patient who presents with:
- Dyspnea
- Tachycardia
- Decreased SPO2
- Hypotension
- A bubbling or sucking chest wound
Treatment in this case is rather straightforward. Apply a gloved hand to cover the wound and have your partner hand you a chest seal, or a 3 sided occlusive dressing. Once that is in place, you can move on with your assessment, perhaps having your partner start an IV during this process.
If the patient has a closed pneumothorax, it will be noted during assessment and auscultation, and should present with some combination of:
- Chest pain
- One sided breath sounds
- Tachycardia
- Diminished SPO2
- Evidence of shock
In the event that you are an ACP/NREMT-P, you may be able to apply a needle thoracostomy to relieve the pressure. If not, we can still address this problem by placing the patient on high flow oxygen. We still need to call for ALS backup in this case, and monitor for the development of a tension pneumothorax, which will be indicated through the development of hypotension, tachycardia, JVD, and , in late stages, tracheal deviation.
2. Hemothorax: The introduction of blood into the pleural cavity presents similarly to the pneumothorax, with a couple of key findings that differentiate it. Flattened neck veins, and a dull note on percussion are key findings here. The patient will be hypotensive, tachycardic, and exhibit signs of shock. ACP/NREMT-P should perform a needle thoracostomy to attempt to relieve the pressure, although this may or may not be effective. Oxygen, and potentially PPV should be considered.
3. Flail chest: A flail segment is readily identified through observation of paradoxical chest wall movement in the affected region. The patient will have significant pain with inspiration due to the movement of the segment, and will likely have respiratory distress for this reason. Stabilization of the segment with a bulky dressing is indicated, while avoiding circumferential chest wrapping. Oxygen, and/or PPV should be implemented to assist the patient with adequate tidal volume. Pain management is indicated per local protocols.
These are the 3 chest injuries we need to find and treat immediately during ur rapid trauma survey, as they are life threatening if missed, and can be corrected in the prehospital environment.
These next injuries, while extremely dangerous, cannot be dealt with by paramedics, and require surgical intervention. Ultimately, our care needs to be ABC support with oxygen/PPV, fluid administration, and careful monitoring.
1. Aortic rupture: During rapid deceleration, the thoracic aorta may tear at its fixed points in the chest cavity. If this occurs, hemorrhage into the chest cavity can ensue. These patients will have tearing chest pain, evidence of shock, and deterioration in LOC. Mechanism of injury is a major clue. While we cannot fix this problem in the field, we need to consider aortic rupture and report our findings.
2. Cardiac contusion: Blunt chest trauma from a steering wheel, or a fall from height, can cause trauma to the anterior portion of the heart. Injury here can cause a contusion, leading to localized cellular hypoxia. The result is irregular cardiac impulse generation, usually in the form of arrhythmia. PVCs are common, although a variety of changes may be seen in the ECG. A 12-lead may reveal ischemia in the II,III,avF, or the precordial leads V1-3. The patient typically will complain of chest pain, and trauma to the exterior chest wall may be noted in the form of ecchymosis or deformity. There is nothing we can do for this condition in the ambulance, however it is critical to identify it and report it so that the trauma team can intervene.
3. Cardiac tamponade: Generally the result of penetrating chest trauma, a tear in the heart wall or the tunica of the thoracic aorta, can lead to pooling of blood in the pericardial sac. There only needs to be as little as 5cc of accumulation in this area to cause compression of the heart muscle. This reduces the ability of the heart to contract, and leads to acute heart failure and circulatory collapse. The classic presentation is Beck’s triad: JVD, Narrow pulse pressure, and muffled heart sounds. Additionally we may see low amplitude QRS complexes on the ECG, or electrical alternans. Chest pain, hypotension, and diminished LOC are common presentations. Treatment is pericardiocentesis and needs to be performed in the ED.
4. Pulmonary contusion: A blunt trauma to the thoracic cage, that is sufficient to fracture ribs, may cause localized damage to the lung tissue underneath. This leads to pooling of blood and fluid in the alveoli in the area of the contusion, dyspnea, hypoxia, chest pain, and potentially hemoptysis. Treatment is supportive, with oxygenation being a priority. Beware that an injury sufficient to cause a pulmonary contusion may cause a pneumothorax. Any fluid administration should be conservative so as not to worsen pulmonary edema. Contacting medical direction is advised.
So there we have the 3 thoracic injuries we can treat, and the 4 that we cannot. All of these need to be considered and identified during assessment. The first 3 we need to identify during the RTS, and treat immediately, while the latter we can look for during our secondary assessment enroute to the trauma centre.
Before we finish, I would like to revisit the rapid trauma survey and give a review of the process.
We begin the RTS immediately following our primary survey, so I will group the 2 together.
EMCAP
General impression
Patient position, appearance, work of breathing (sick/not sick)
Immediate life threatening bleeding or environmental factors?
LOA (AVPU)
C-Spine
Have your partner hold C-Spine
Airway
Is the airway patent?
Suction?
Adjunct required?
Breathing:
Rate, Rhythm, Depth
Oxygen consideration
PPV needed?
Circulation:
Radial and carotid rate, rhythm, strength
Cap refill <2 seconds?
Skin colour/condition
Disability:
A/O x4?
GCS?
Exposure: RAPID TRAUMA SURVEY
Head: Assess scalp for DCAP BTLS, Pupils for PERRL, Face, ears, nose mouth.
Neck: Point tenderness, instability, crepitus, step deformity, DCAP BTLS.
Clavicles: DCAP BTLS, if stable, apply cervical collar now.
Chest: DCAP BTLS, sternum for stability, thoracic cage and costal margins, Auscultate the bases.
Abdomen: Palpate for tenderness, asymmetry, rigidity, distention, or guarding, look for pulsations, scars, discolouration, distension, or masses.
Pelvis: Palpate in and down for stability, and if unstable bind it.
Femurs: Palpate for stability.
Lower limbs: Palpate for stability.
Upper limbs: Palpate for stability.
Back: Roll the patient and palpate the back and spine. Slide backboard behind them and roll them onto it.
Extricate, obtain vitals, and initiate transport. Additional treatment, and detailed secondary enroute to the trauma centre.
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