Transcript Mosby`s EMT-Basic Textbook

Chapter 27
Chest and Abdominal Trauma
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Anatomy and Physiology
of the Chest
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Slide 2
Anatomy and Physiology
of the Chest
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Slide 3
Thoracic Cavity

Subdivided into two smaller spaces

Mediastinum – in center
• Contains heart, great vessels, esophagus, trachea,
nerves

Pleural spaces – on either side of mediastinum
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Chest Trauma –
Mechanisms of injury

Blunt

Sudden deceleration of chest wall against a fixed
object
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Penetration
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Slide 5
Rib Fractures
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Most often the result of blunt trauma
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Isolated rib fracture usually not a serious emergency

Can puncture lung or blood vessel

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Pneumothorax, hemothorax, flail chest
Lower rib fractures may injure abdominal organs

Liver, spleen, kidneys
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Slide 6
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.
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Slide 7
Flail Chest

Two or more ribs fractured in two or more
places


Paradoxical chest movement
Look for signs of underlying injury (e.g.,
pneumothorax)
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Slide 8
Flail Chest – Management

Splint chest wall
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Blanket, towel, sheet
Rigid splint
Positive-pressure ventilation

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When hypoventilation is present and patient can tolerate
Restores adequate ventilation
Otherwise nonrebreather device
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Slide 9
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
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Traumatic Asphyxia
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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.
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Pneumothorax
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Occurs when air enters visceral and parietal pleura
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

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Collapses lung
Less alveolar surface for diffusion of oxygen
Results in hypoxia
Two mechanisms
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Trauma
Spontaneous rupture
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Traumatic

Penetrating
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Missile
Sharp object
Broken rib
Blunt

Person takes deep breath just before auto collision
• “Paper bag effect”
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Spontaneous

Ruptured bleb in lung tissue

Young, muscular males

COPD patients
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Open Pneumothorax
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Open Pneumothorax –
Assessment and Recognition
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Sucking wound

Dyspnea

Pleuritic chest pain
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Open Pneumothorax –
Assessment and Recognition

Absent or diminished breath sounds on affected side
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Signs of respiratory distress

Subcutaneous emphysema

Historical profile
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Open Pneumothorax –
Management

Check ABCs.
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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.
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Closed Pneumothorax
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Also called simple pneumothorax
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Management

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High-concentration oxygen; possible PPV
Transport without delay.
• Watch for signs of a developing tension pneumothorax.
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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.”
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Tension Pneumothorax
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Tension Pneumothorax
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Air trapped within pleural space
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Acts as a one-way valve
Increased intrathoracic pressure
Can collapse superior and inferior vena cavae
• Reduces blood return to heart

Causes profound shock
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Tension Pneumothorax –
Assessment and Recognition
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Increasing respiratory distress
and cyanosis
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Breath sounds absent on
affected side
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Distended neck veins
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Tracheal shift
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Signs of shock
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Tension Pneumothorax –
Management
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If airtight dressing was applied, remove dressing
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Reapply dressing after air escapes.
Watch for further tension.
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Transport immediately.

Consider ALS intercept (for needle decompression).
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Hemothorax
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Blood within the pleural space
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Thorax has the capacity for massive blood loss.
Physiologic effects
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Primary effect – hypovolemic shock
May exist with or without an associated pneumothorax
May occur due to penetrating injuries or to rib fractures
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Hemothorax –
Assessment and Recognition
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Signs of hypovolemic shock
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Delayed or absent capillary refill (children)
Pale, cool, sweaty skin
Tachycardia
Rapid and shallow breathing
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Hemothorax –
Assessment and Recognition

Breath sounds absent on the affected side
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Hemoptysis (coughing blood)
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Hypotension (late sign)
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Altered mental state (late sign)
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Cardiovascular collapse (cardiac arrest)
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Hemothorax – Management

Establish a patent airway.
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Suction available to manage hemoptysis
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High-concentration oxygen; possible PPV

Transport immediately.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Pulmonary Contusion
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From severe blows to chest wall
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Can result in swelling and fluid buildup
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Decreases diffusion of oxygen into capillaries
Management

High-concentration oxygen
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Cardiac Tamponade

Fluid accumulation in the pericardial sac
caused by bleeding or fluid loss
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May result from blunt or penetrating trauma
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Cardiac Tamponade —
Physiologic Effects
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Bleeding places pressure on atria, ventricles,
and vena cava.
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Venous return is obstructed.
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Interferes with the normal dynamics of contraction.
Cardiac output is decreased.
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Cardiac Tamponade —
Assessment and Recognition

Penetrating wound or precordial contusion may be present.
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Signs of shock
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Decreased pulse pressure
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Muffled heart sounds
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Distended neck veins
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Cardiac Tamponade —
Management

Early recognition and rapid hospital
intervention – most essential
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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.
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Aortic Tear

Complete tear results in exsanguination and death.
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Partial tear causes leak and hemorrhage.
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Hypovolemic shock is main problem.
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Mortality is very high from massive hemorrhage.
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80% die within first hour
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Abdominal Trauma
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Anatomy and Physiology
of the Abdomen
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Anatomy and Physiology
of the Abdomen
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Anatomy and Physiology
of the Abdomen
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Abdominal Injuries

Large vessels and highly vascular organs within abdomen
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Rapid blood loss and death
 Maintain high level of suspicion

May be from blunt or penetrating trauma
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Primary goal

Recognize life-threatening injuries.
 Administer essential life support.
 Transport without delay (requires surgical intervention).
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
Mechanism of Injury

Blunt trauma
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Compression injuries
Deceleration injuries
Seat belt injuries
Penetrating trauma
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Assessment

Scene size-up
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Obtain MOI
Initial assessment

Look for signs of hypovolemia
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Assessment

Focused history and physical examination
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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.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
Assessment

Focused history and physical examination (continued)
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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
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Management

Management occurs in hospital.

Treat for shock.

Transport without delay.
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Special Considerations

Evisceration
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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.
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Evisceration
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Special Considerations

Urinary tract injuries
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Injuries to male genitalia
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Look for bruises over flank.
Injuries to pelvis can cause bladder or urethral tears.
May result in lacerations, bruising, avulsion, or amputation
Injuries to female genitalia

May occur from direct trauma or straddle injuries
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Acute Abdomen

Recent onset of abdominal pain

Requires early diagnosis and surgical
intervention
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Acute Abdomen – Assessment
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Identify life threats and transport immediately.
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Initial assessment
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If shock present, rapid transport.
Establish and maintain patent airway.
Administer high-concentration oxygen.
Place patient in position of comfort, if not contraindicated.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51
Acute Abdomen – Assessment

Focused history

Gather SAMPLE history with O-P-Q-R-S-T approach.
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SAMPLE History for
Patients with Abdominal Complaints
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SAMPLE History for
Patients with Abdominal Complaints
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SAMPLE History for
Patients with Abdominal Complaints
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Acute Abdomen – Assessment

Focused physical examination
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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.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56