Transcript Introduction to Emergency Medical Care

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Chapter 27
Chest and Abdominal Trauma
Slide 1
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Anatomy and Physiology
of the Chest
Slide 2
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Anatomy and Physiology
of the Chest
Slide 3
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Thoracic Cavity
• Subdivided into two smaller spaces
 Mediastinum – in center
» Contains heart, great vessels, esophagus,
trachea, nerves
 Pleural spaces – on either side of
mediastinum
Slide 4
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Chest Trauma –
Mechanisms of injury
• Blunt
• Sudden deceleration of chest wall against a
fixed object
• Penetration
Slide 5
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Rib Fractures
•
Most often the result of blunt trauma
•
Isolated rib fracture usually not a serious emergency
•
Can puncture lung or blood vessel
 Pneumothorax, hemothorax, flail chest
•
Lower rib fractures may injure abdominal organs
 Liver, spleen, kidneys
Slide 6
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Case History
You respond to an MVC to find a 65-yearold female victim of a front end collision.
She is complaining of severe chest pain
and dyspnea. She is pale, cyanotic, and
diaphoretic. You notice that the steering
wheel is deformed.
Slide 7
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Flail Chest
• Two or more ribs fractured in two or
more places
 Paradoxical chest movement
• Look for signs of underlying injury (e.g.,
pneumothorax)
Slide 8
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Flail Chest – Management
• Splint chest wall
 Blanket, towel, sheet
 Rigid splint
• Positive-pressure ventilation
 When hypoventilation is present and patient can
tolerate
 Restores adequate ventilation
 Otherwise nonrebreather device
Slide 9
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Traumatic Asphyxia
•
Severe compression of thorax
 High-velocity or steering wheel injuries, heavy weight
dropped on chest
•
Heart compressed; blood driven to thorax and neck
 Ecchymosis and edema
 Life-threatening injury
•
•
Look for associated injuries to lungs and chest wall
Management: high-concentration oxygen, possible
PPV
Slide 10
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Traumatic Asphyxia
Slide 11
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Case History
You respond to a call for “difficulty
breathing” to find a 19-year-old male
complaining of dyspnea and chest pain. He
states that it started suddenly while he was
running. His breathing difficulty has gotten
worse over the last hour.
Slide 12
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Pneumothorax
• Occurs when air enters visceral and parietal
pleura
 Collapses lung
• Less alveolar surface for diffusion of oxygen
• Results in hypoxia
• Two mechanisms
 Trauma
 Spontaneous rupture
Slide 13
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Traumatic
• Penetrating
 Missile
 Sharp object
 Broken rib
• Blunt
 Person takes deep breath just before auto
collision
» “Paper bag effect”
Slide 14
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Spontaneous
• Ruptured bleb in lung tissue
• Young, muscular males
• COPD patients
Slide 15
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Open Pneumothorax
Slide 16
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Open Pneumothorax –
Assessment and Recognition
• Sucking wound
• Dyspnea
• Pleuritic chest pain
Slide 17
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Open Pneumothorax –
Assessment and Recognition
• Absent or diminished breath sounds on
affected side
• Signs of respiratory distress
• Subcutaneous emphysema
• Historical profile
Slide 18
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Open Pneumothorax –
Management
•
•
Check ABCs.
•
Administer oxygen; positive-pressure ventilation, if
needed (carefully).
Seal wound with airtight dressing on three sides.
•
Place patient in position of comfort.
•
Transport to definitive care.
Slide 19
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Closed Pneumothorax
• Also called simple pneumothorax
• Management
 High-concentration oxygen; possible PPV
 Transport without delay.
» Watch for signs of a developing tension
pneumothorax.
Slide 20
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Case History
You respond to an MVC and find a 32year-old female involved in victim of a front
end collision complaining of severe chest
pain and dyspnea. She is pale, cyanotic,
and diaphoretic. The police on scene says
she was fine when they arrived but she
suddenly started to become “very sick.”
Slide 21
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Tension Pneumothorax
Slide 22
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Tension Pneumothorax
• Air trapped within pleural space
 Acts as a one-way valve
 Increased intrathoracic pressure
 Can collapse superior and inferior vena
cavae
» Reduces blood return to heart
o
Causes profound shock
Slide 23
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Tension Pneumothorax –
Assessment and Recognition
•
Increasing respiratory
distress and cyanosis
 Breath sounds absent on
affected side
•
Distended neck veins
•
Tracheal shift
•
Signs of shock
Slide 24
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Tension Pneumothorax –
Management
• If airtight dressing was applied, remove
dressing
 Reapply dressing after air escapes.
 Watch for further tension.
• Transport immediately.
• Consider ALS intercept (for needle
decompression).
Slide 25
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Hemothorax
• Blood within the pleural space
 Thorax has the capacity for massive blood loss.
• Physiologic effects
 Primary effect – hypovolemic shock
 May exist with or without an associated
pneumothorax
 May occur due to penetrating injuries or to rib
fractures
Slide 26
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Hemothorax –
Assessment and Recognition
• Signs of hypovolemic shock
 Delayed or absent capillary refill (children)
 Pale, cool, sweaty skin
 Tachycardia
 Rapid and shallow breathing
Slide 27
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Hemothorax –
Assessment and Recognition
• Breath sounds absent on the affected side
• Hemoptysis (coughing blood)
• Hypotension (late sign)
• Altered mental state (late sign)
• Cardiovascular collapse (cardiac arrest)
Slide 28
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Hemothorax – Management
• Establish a patent airway.
• Suction available to manage hemoptysis
• High-concentration oxygen; possible PPV
• Transport immediately.
Slide 29
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Pulmonary Contusion
• From severe blows to chest wall
• Can result in swelling and fluid buildup
 Decreases diffusion of oxygen into
capillaries
• Management
 High-concentration oxygen
Slide 30
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Cardiac Tamponade
• Fluid accumulation in the pericardial sac
caused by bleeding or fluid loss
• May result from blunt or penetrating
trauma
Slide 31
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Cardiac Tamponade —
Physiologic Effects
• Bleeding places pressure on atria,
ventricles, and vena cava.
• Venous return is obstructed.
 Interferes with the normal dynamics of
contraction.
• Cardiac output is decreased.
Slide 32
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Cardiac Tamponade —
Assessment and Recognition
•
Penetrating wound or precordial contusion may be
present.
•
Signs of shock
•
Decreased pulse pressure
•
Muffled heart sounds
•
Distended neck veins
Slide 33
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Cardiac Tamponade —
Management
• Early recognition and rapid hospital
intervention – most essential
Slide 34
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Case History
You respond to a “man down” to find a 20-yearold construction worker who fell 30 feet from a
rooftop. He is complaining of pain in his chest
and back. He is pale and diaphoretic. His pulse
is 130 and thready. He is responsive to painful
but not verbal stimuli.
Slide 35
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Aortic Tear
•
Complete tear results in exsanguination and death.
•
Partial tear causes leak and hemorrhage.
•
Hypovolemic shock is main problem.
•
Mortality is very high from massive hemorrhage.
 80% die within first hour
Slide 36
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Abdominal Trauma
Slide 37
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Anatomy and Physiology
of the Abdomen
Slide 38
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Anatomy and Physiology
of the Abdomen
Slide 39
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Anatomy and Physiology
of the Abdomen
Slide 40
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Abdominal Injuries
•
Large vessels and highly vascular organs within
abdomen
 Rapid blood loss and death
 Maintain high level of suspicion
•
May be from blunt or penetrating trauma
•
Primary goal
 Recognize life-threatening injuries.
 Administer essential life support.
 Transport without delay (requires surgical intervention).
Slide 41
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Mechanism of Injury
• Blunt trauma
 Compression injuries
 Deceleration injuries
 Seat belt injuries
• Penetrating trauma
Slide 42
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Assessment
• Scene size-up
 Obtain MOI
• Initial assessment
 Look for signs of hypovolemia
Slide 43
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Assessment
• Focused history and physical examination
 Look for bruises, tire marks, seat belt marks.
 Is abdomen distended?
 DCAP-BTLS
 Palpate abdomen for tenderness and guarding.
» Save painful area for last.
 Palpate iliac crest.
» If pelvic bones move, stop examination.
Slide 44
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Assessment
•
Focused history and physical examination
(continued)
 Associated head or spinal injuries may present with loss of




pain perception.
SAMPLE history
Elderly?
History of medications that slow heart rate?
Signs of alcohol or drugs
Slide 45
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Management
• Management occurs in hospital.
• Treat for shock.
• Transport without delay.
Slide 46
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Special Considerations
• Evisceration
 Do not attempt to put organs back in
abdomen.
» Cover with moist, sterile dressing or airtight
dressing.
 Transport in supine position with hips and
legs flexed with pillow under knees.
Slide 47
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Evisceration
Slide 48
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Special Considerations
• Urinary tract injuries
 Look for bruises over flank.
 Injuries to pelvis can cause bladder or urethral
tears.
• Injuries to male genitalia
 May result in lacerations, bruising, avulsion, or
amputation
• Injuries to female genitalia
 May occur from direct trauma or straddle injuries
Slide 49
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Acute Abdomen
• Recent onset of abdominal pain
• Requires early diagnosis and surgical
intervention
Slide 50
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Acute Abdomen – Assessment
• Identify life threats and transport immediately.
• Initial assessment
 If shock present, rapid transport.
 Establish and maintain patent airway.
 Administer high-concentration oxygen.
 Place patient in position of comfort, if not
contraindicated.
Slide 51
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Acute Abdomen – Assessment
• Focused history
 Gather SAMPLE history with O-P-Q-R-S-T
approach.
Slide 52
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SAMPLE History for
Patients with Abdominal Complaints
Slide 53
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SAMPLE History for
Patients with Abdominal Complaints
Slide 54
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SAMPLE History for
Patients with Abdominal Complaints
Slide 55
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Acute Abdomen – Assessment
• Focused physical examination
 Look for findings associated with
abdominal complaints.
» Jaundice in sclera or skin?
» Signs of dehydration?
 Ask patient to point to area of pain.
» Palpate that quadrant last.
Slide 56
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