Emergency Care Textbook PDF - Chest, Abdominal, and Pelvic Injuries

11 Chest, Abdominal, and Pelvic Injuries Key Content Chest Injuries........................... 216 Rib Fractures......................... 216 Hemothorax......................... 218 Pneumothorax..................... 218 Subcutaneous Emphysema (SCE)................................... 219 Penetrating...

11 Chest, Abdominal, and Pelvic Injuries Key Content Chest Injuries........................... 216 Rib Fractures......................... 216 Hemothorax......................... 218 Pneumothorax..................... 218 Subcutaneous Emphysema (SCE)................................... 219 Penetrating Chest Injuries.... 219 Abdominal Injuries.................. 220 Evisceration.......................... 222 Abdominal Aortic Aneurysm (AAA)................................ 222 Pelvic Injuries........................... 223 Pelvic Binding....................... 224 Genital Injuries..................... 225 Injuries to the chest, abdomen, and pelvis include both soft tissue injuries (e.g., internal organ damage) and fractures (e.g., of the ribs or pelvic bones). While ribs are thin and more susceptible to fractures, a powerful force (e.g., from a fall or motor vehicle collision) is required to cause serious injury to the pelvic bones. Because the chest, abdomen, and pelvis contain many of the body’s vital organs, injuries to these areas can be immediately life-threatening. A force that causes a severe injury in these areas may also cause injury to the spine. All injuries described in this chapter should cause serious concern: Any patient with a serious chest, abdomen, or pelvic injury should be placed in the rapid transport category. CHEST, ABDOMINAL, AND PELVIC INJURIES Introduction 215 General care for chest, abdomen, and pelvic injuries includes controlling any external bleeding, limiting movement of any injured areas as much as possible (especially if fractures are suspected), and taking steps to mitigate the effects of shock (which is common when internal organs are damaged). CHEST INJURIES Chest injuries can occur when either a blunt or penetrating force is applied to the chest. Motor vehicle collisions, industrial accidents, falls, and intentional violence (e.g., knife injuries) are common causes (Figure 11–1). Chest wounds are categorized as either open or closed. Open chest wounds occur when an object (e.g., a knife or bullet) penetrates the chest wall. An open chest wound can also occur when fractured ribs break through the skin. A chest wound is closed if the skin is not broken. Closed chest wounds are generally caused by blunt force (e.g., a fall). CHEST, ABDOMINAL, AND PELVIC INJURIES Signs and Symptoms of Chest Injuries 216 The signs and symptoms of a serious chest injury include: Respiratory distress or arrest. Pain at the site of the injury that increases with deep respirations or movement. Obvious deformity (as with other fractures). Unequal or paradoxical movement of the chest wall. Flushed, pale, or bluish skin. Coughing up blood. These signs and symptoms of a serious chest injury can occur in both open and closed wounds. A patient with a serious chest injury is at risk of respiratory arrest (see Chapter 6). If a patient has sustained a chest injury or is complaining of chest pain, the chest must be exposed for proper assessment. Figure 11–1: Injuries to the chest may result from blunt or penetrating forces. Types of Chest Injury RIB FRACTURES Rib fractures are usually caused by an external bluntforce impact to the chest (Figure 11–2). Although painful, a simple rib fracture is rarely life-threatening unless the fractured bone causes damage to organs (e.g., the lungs) or major blood vessels. You should suspect a rib fracture in the following situations: The patient’s respiration presents as painful and shallow or laboured. The patient attempts to ease the pain by leaning toward the side of the fracture. Figure 11–2: An external blunt-force impact to the chest can cause a fracture of the ribs or sternum. Chest injuries involving multiple rib fractures are more serious and can be life-threatening. Multiple rib fractures should be suspected if the MOI involves a severe blunt-force impact or crush injury to the chest. Multiple rib fractures often cause internal hemorrhaging and difficulty breathing (dyspnea), creating the risk of shock. Care for Rib Fractures If you suspect a rib fracture, perform the following steps: 1. Position the patient to facilitate respiration (a Semi-Fowler’s position is often most comfortable). 2. Support and immobilize the injured area using a soft, bulky object, such as a pillow or rolled blanket. 3. Provide interventions for respiratory distress or arrest if indicated (e.g., supplemental oxygen, assisted ventilations). If enough force is applied, a flail chest may also involve the sternum. A flail sternum occurs when the sternum is separated from the rest of the ribs. Care for Flail Chest If you suspect a flail chest injury, perform a focused exam of the ribs, gently palpating the area to locate the flail segment. Stabilize the flail segment by placing bulky dressings—at least 1.3 cm (½ in.) thick—over the entire injured area, ensuring that the dressing extends beyond the edges of the segment on all sides. This will allow sufficient pressure to be applied without Flail Chest Multiple rib fractures can result in a section of the rib cage breaking free from the surrounding tissues, a condition referred to as flail chest (see Figure 11–3). The loose section of the chest wall will not move normally during respiration. Usually, this loose section (commonly referred to as a flail segment) will move in the opposite direction from the rest of the chest (i.e., will move inwards during inhalation and outwards on exhalation); this is called paradoxical movement. Figure 11–3: Multiple rib fractures can result in flail chest, where a flail segment becomes disconnected from the rib cage. CHEST, ABDOMINAL, AND PELVIC INJURIES The patient tries to stabilize the fracture by putting pressure on the injured area. 217 causing unnecessary damage to the injured area. Secure the dressings in place with long strips of tape, taking care to avoid aggravating the injury or impairing the patient’s respiration. HEMOTHORAX Hemothorax is bleeding into the pleural space around the lungs (Figure 11–4). This can be caused by blunt or penetrating trauma to the chest that results in a lacerated lung or laceration of a blood vessel in the chest. Hemothorax can occur with closed or open chest wounds. The severity of the hemothorax depends on the amount of bleeding into the pleural space. As the chest fills with blood, the lung on the affected side will become increasingly unable to expand and may collapse. The patient will present with dyspnea, and the onset of shock will occur if bleeding continues. Blood in the pleural space will also create pressure on the heart and lungs, resulting in further complications. Figure 11–4: A hemothorax is bleeding into the pleural space. Interventions for Hemothorax Provide care for respiratory distress or arrest (e.g., if the patient is hypoxic, provide high-concentration supplemental oxygen). Assisted ventilations are usually indicated for a patient with shallow or inadequate respirations. If the hemothorax is a result of a penetrating chest injury, the patient may require interventions for an open pneumothorax as well. A patient with a hemothorax will often require emergency surgery and should be placed in the rapid transport category. CHEST, ABDOMINAL, AND PELVIC INJURIES PNEUMOTHORAX 218 Pneumothorax is a condition caused by air entering the pleural space around the lung (Figure 11–5). It may occur as a result of blunt or penetrating trauma, or it may be spontaneous (spontaneous pneumothorax). A one-time escape of air into the pleural space is referred to as a simple pneumothorax. The patient’s presentation will vary depending on how much air has entered the pleural space: The lung may be partially or totally collapsed, and this will be reflected in the patient’s signs and symptoms. Figure 11–5: A pneumothorax is a condition caused by air entering the pleural space. Signs and symptoms of pneumothorax may include: Pleuritic chest pain (pain increased by coughing or inhaling deeply). Dyspnea and/or tachypnea. Decreased or absent breath sounds on the affected side. Subcutaneous emphysema (page 219). Spontaneous Pneumothorax Pneumothorax can occur in otherwise perfectly healthy people without any associated trauma. This is referred to as spontaneous pneumothorax and is most frequently seen in young, thin, tall males. Typically, the patient complains of a sudden, sharp chest pain and sudden shortness of breath following strenuous exertion, coughing, or air travel. Tension Pneumothorax As the air continues to mount in the pleural space, pressure is placed on the unaffected lung, heart, and major blood vessels as well. Accompanying signs may include tachycardia, hypotension, tracheal deviation, and jugular venous distension (JVD). As the condition worsens, signs of hypoxia and a severe respiratory emergency will be evident. Provide any necessary interventions, such as supplemental oxygen or assisted ventilations, based on the patient’s presentation. A patient with a suspected tension pneumothorax should be placed in the rapid transport category. SUBCUTANEOUS EMPHYSEMA (SCE) Subcutaneous emphysema (SCE) is a rare condition that occurs when air becomes trapped in tissues beneath the skin. Damage to the respiratory system (especially penetrating trauma to the lungs and bronchial tube) can allow air to escape into the body. Affected areas often appear swollen. SCE produces an unusual crackling sensation when the affected area is touched. While usually not a serious condition in itself, SCE can be an indicator of serious internal trauma such as tension pneumothorax. Figure 11–6: A tension pneumothorax is caused by the continual flow of air into the pleural space, which is unable to escape. PENETRATING CHEST INJURIES A penetrating object can injure any structure within the chest, including the lungs, heart, and major arteries or veins, causing complications that range in severity from minor to life-threatening. A hole in the chest wall disrupts the intrathoracic pressure, which can prevent the lungs from functioning properly and cause respiratory distress. Puncture wounds may also allow air or blood to enter the chest cavity, causing pneumothorax or hemothorax. Care for Penetrating Chest Injuries Puncture wounds can cause varying degrees of internal and/or external bleeding. If the injury penetrates the rib cage and punctures the lungs, air will be able to pass freely in and out of the chest cavity, significantly impacting the patient’s respiration. With a penetrating chest wound, you may hear a sucking sound coming from the wound with each inhalation. This is referred to as a sucking chest wound, and is the primary sign of a penetrating chest injury. When providing treatment for a penetrating chest injury, your goal is to control any external hemorrhaging without increasing the pressure in the chest. CHEST, ABDOMINAL, AND PELVIC INJURIES In some cases, a pneumothorax can progress to a tension pneumothorax. While pneumothorax is caused by a single entry of air into the pleural space, tension pneumothorax occurs when lung tissue is torn, causing a continual flow of air into the pleural space and a steady increase in pressure (Figure 11–6). The mounting pressure of the air in the pleural space causes the lung to eventually collapse, diminishing the volume of air that can be inhaled and exhaled with each respiration. 219 Figure 11–7, a-b: a, Control an external hemorrhage by applying direct pressure to the wound with a gloved hand and/or a non-occlusive dressing; b, change saturated dressings immediately. CHEST, ABDOMINAL, AND PELVIC INJURIES The concern with a penetrating chest wound is that the wound will become occluded, meaning that the wound no longer allows air to enter or exit. Occlusion significantly increases the risk of a tension pneumothorax, so it must be prevented. If bleeding is minor, leave the wound exposed to the air or use a non-occlusive dressing. If an external hemorrhage is present, it must be quickly controlled: Apply direct pressure to the chest wound with your gloved hand and/or a nonocclusive dressing (Figure 11–7, a). If the dressing becomes saturated with blood, it will become occluded: Monitor the dressing closely and replace saturated dressings immediately (Figure 11–7, b). 220 If the patient is hypoxic, administer oxygen (if available), and take steps to minimize the onset of shock. Assisted ventilations may also be necessary. Place the patient in a position of comfort that allows for ease of breathing. If you roll the patient into the recovery position, make sure the injured side is towards the ground. ABDOMINAL INJURIES Unlike the chest, the abdomen is not surrounded by a cage of bone, so it is more susceptible to injury. Because it contains many vital organs (and these organs tend to bleed profusely), injuries to the abdomen are often life-threatening (see Figure 11–8). The liver is located in the upper right quadrant of the abdomen, partially protected by the lower ribs. The liver is rich in blood and can be damaged by blunt trauma or penetrated by a fractured rib. The resulting bleeding may be severe and can become fatal. When injured, the liver can also leak bile into the abdomen, which can cause severe infection. The spleen is located in the upper left quadrant of the abdomen, behind the stomach, and is protected somewhat by the lower left ribs. The spleen is easily damaged, as it may rupture when the abdomen is struck forcefully by a blunt object. Since the spleen stores blood, an injury can quickly lead to a severe loss of blood and become lifethreatening. The stomach is one of the main digestive organs. It changes shape depending on its contents, the stage of digestion, and the size and strength of the stomach muscles. Because the stomach is lined with many blood vessels and nerves, it can hemorrhage internally when injured, and food contents may empty into the abdomen, causing infection. Damage to the GI tract can cause internal hemorrhaging as well. If the contents of the intestines are spilled into the abdominal cavity, the risk of infection is very high. Spine Liver Spleen Liver Stomach Pancreas Stomach Spleen Gallbladder Kidneys GI tract Large intestine Small intestine Figure 11–8: The abdomen can be divided into four quadrants, each containing different vital organs. The signs and symptoms of serious abdominal injury include: Severe pain. Bruising. External bleeding. Nausea and vomiting (sometimes vomit containing blood). Pale, moist skin. Thirst. Pain, tenderness, or a tight feeling in the abdomen. Distension in the abdomen. Organs possibly protruding from the abdomen. Signs and symptoms of shock. Blunt trauma to the abdomen may not cause external signs of injury and may even be painless, even when serious injuries have occurred. You should suspect serious abdominal injuries if the MOI suggests that they are likely, even if the patient’s presentation does not suggest serious injuries. Penetrating wounds to the abdomen may cause internal hemorrhaging. The patient may also develop peritonitis (an infection of the abdominal lining) in the hours or days following the event. A patient who has experienced serious trauma to the abdomen should be in the rapid transport category, even if signs and symptoms of serious injury are absent. Care for Abdominal Injuries An injury to the abdomen may be either open or closed. Even with a closed wound, the rupture of an organ can cause internal hemorrhaging. This can be extremely painful and may result in shock. Serious complications can occur if organs leak blood or other contents into the abdomen. When caring for an abdominal injury, place the patient in a supine position. Bend the patient’s knees slightly, allowing the muscles of the abdomen to relax. Place rolled-up blankets or pillows under the patient’s knees. If moving the patient’s legs causes pain, leave them straight. If external bleeding is present, attempt to control it by applying trauma dressings and gentle pressure: Avoid applying firm pressure to the abdomen, as this can exacerbate internal injuries. If gentle pressure is not sufficient to control the bleeding, place the patient in the rapid transport category immediately. CHEST, ABDOMINAL, AND PELVIC INJURIES Signs and Symptoms of Abdominal Injury 221 a b c d Figure 11–9, a-d: a, Severe injuries to the abdominal cavity can result in protruding organs; b, remove clothing from around the wound; c, apply moist, sterile dressings loosely over the wound; and d, cover dressings lightly with a folded towel to maintain warmth. EVISCERATION CHEST, ABDOMINAL, AND PELVIC INJURIES When a major open wound occurs to the abdomen, abdominal organs may begin to protrude through the wound (Figure 11–9, a). Interventions you perform focus on protecting the organs from damage and mitigating the effects of shock until the patient can be transported to an emergency medical facility for advanced care. 222 Internal organs are usually protected by the body and so are very susceptible to environmental conditions. You should protect the organs from extremes of heat and cold, dust, etc. Avoid touching the exposed organs, and do not attempt to force protruding organs back into place. Remove clothing from around the wound (Figure 11–9, b) and cover the area lightly with moist, sterile dressings placed loosely over the wound. (Figure 11–9, c). Saline or warm tap water can be used to moisten the dressings. Cover the dressings loosely with plastic wrap, if available. Place a folded towel or blanket over the area to maintain warmth (Figure 11–9, d). If necessary, gently secure the towel or blanket in place with large bandages, but avoid putting pressure on the injured area. ABDOMINAL AORTIC ANEURYSM (AAA) An abdominal aortic aneurysm (AAA) occurs when the wall of the abdominal aorta weakens and bulges, creating a localized enlarged area (Figure 11–10). Initially, an abdominal aortic aneurysm may present few or no signs or symptoms (i.e., it may be asymptomatic). As the AAA expands, it may reach a stage at which it becomes very painful, accompanied by pulsating sensations in the abdomen or pain in the chest, lower back, or scrotum. As the aneurysm grows, the vessel walls become thinner and the risk of the aneurysm rupturing increases. A patient with an (AAA) may have absent or decreased femoral or pedal pulses on both sides Abdominal aorta Abdominal aortic aneurysm Figure 11–10: An abdominal aortic aneurysm (AAA). of the body. If you suspect an AAA, do not put pressure on the abdomen. Many older adults mistake AAA for renal colic, as the pain pattern is quite similar. Signs and symptoms of advanced AAA may include: Abdominal pain. Abdominal rigidity. Back pain. Nausea and vomiting. Pulsating mass in the abdomen. Diminished or absent femoral or pedal pulses. Tingling or numbness in the lower extremities. A patient with a ruptured AAA will present with signs and symptoms of internal bleeding, and will likely be in shock. Any patient with a suspected AAA should be in the rapid transport category. PELVIC INJURIES The pelvis is a ring-shaped bony structure consisting of the sacrum, the coccyx, and the three innominate bones: the ilium, the ischium, and the pubis. The pelvis is the lower part of The organs within the pelvis are well protected at the sides and rear, but not in the front (Figure 11–11). Forceful blows from blunt or penetrating objects are the most common cause of pelvic injuries. Fractured bones in the pelvis can puncture or lacerate internal organs and major blood vessels, causing severe internal hemorrhage. Injury to the nerves that travel through the pelvis can result in bowel, bladder, and sexual dysfunction. When assessing or treating a suspected pelvic injury, minimize movement of the pelvis, as any motion increases the risk of damage to internal structures. Signs and Symptoms of Pelvic Injury Signs and symptoms of pelvic injuries are very similar to those of abdominal injuries. Pain, pelvic instability, and crepitus are key indicators of a pelvic fracture. Certain pelvic injuries may also cause loss of sensation in the legs, decreased range of motion, or paralysis. This may indicate an injury to the lower spine or to the nerves of the pelvis. If there are internal injuries to pelvic organs, there may be visible bleeding (rectal, urethral, or vaginal). Depending on the MOI, there may also be soft tissue injuries to the genitals, including pain and hematoma. Care for Pelvic Injuries The care for pelvic injuries is similar to the care for abdominal injuries. Your priorities are to minimize additional damage, control external bleeding, and mitigate the effects of shock until the patient can be rapidly transported for advanced emergency interventions. If you suspect a fracture of one of the pelvic bones, perform a three-plane assessment to assess its stability. Apply gentle pressure to the pelvis, first inwards, then upwards, and finally downwards. This allows you to assess the pelvic girdle as a whole, followed by the pubis, and finally the sacral CHEST, ABDOMINAL, AND PELVIC INJURIES Inferior vena cava the trunk and contains the bladder, the female reproductive organs, and the lower portion of the large intestine (including the rectum). An array of arteries and nerves passes through the pelvis. 223 Liver Stomach Spleen GI tract Figure 11–11: Unlike the organs of the chest or pelvis, organs within the abdominal cavity and front of the pelvic cavity are not well protected. CHEST, ABDOMINAL, AND PELVIC INJURIES coccygeal spine. If the pressure causes the patient any pain, stop the assessment and initiate pelvic binding (described below). 224 Keep the patient supine and as still as possible. If necessary (and within your scope of practice), immobilize the patient on a backboard. Avoid any unnecessary movement of the patient, and avoid putting pressure on the pelvis. If any organs are visibly protruding, provide care for evisceration (see page 222). PELVIC BINDING Pelvic binding is a technique that creates even pressure on a fractured pelvis from all sides, supporting the bones and reducing the risk of additional damage to internal structures. It may be used when fractures of the pelvic bones make the pelvis unstable (and if indicated by your scope of practice and local protocols). Patients with an unstable pelvic injury may benefit from pelvic binding because it provides the following benefits: Assists in controlling an internal hemorrhage by stabilizing the pelvic ring to encourage clot formation Maintains circumferential immobilization and stability Reduces the volume within the pelvic cavity Allows for easy access to the abdomen, femoral vessels, and perineum Pelvic bindings are not recommended for patients who sustain fractures from low-energy or lateral impacts. There are various methods and commercial tools available for pelvic binding. Follow the manufacturer’s instructions for correct application when using a commercial pelvic binder. 9. Reassess sensation and distal circulation in the lower extremities to ensure that they have not been affected. 10. Reassess the binding periodically to ensure the tension is maintained. During pelvic binding, patient safety is paramount. Pelvic binding needs to be performed early in the course of treatment. Once the binding is applied, it should not be removed until the patient reaches the hospital. Gentle application is recommended because manipulation and movement of an injured pelvis can cause severe damage. A scoop or clamshell stretcher is ideal. A log roll should not be used if there is a suspected pelvic injury. Genital Injuries Pelvic injuries may involve the genitals. Genital injuries are soft tissue injuries and may be either closed wounds (e.g., contusions) or open wounds (e.g., lacerations). Due to the large number of vascular structures, genital wounds often hemorrhage. Care for injuries to the genitals is the same as care for any other soft tissue injuries (see Chapter 9). Injuries to the genital area can be embarrassing for the patient. Act in a confident and professional manner, and briefly explain the interventions you intend to provide to the patient before proceeding. Attempt to maintain the patient’s privacy as much as possible while providing care. CHEST, ABDOMINAL, AND PELVIC INJURIES If a commercial binding device is unavailable, you may use a modified method, securing a flannel blanket or bed sheet in place with clamps. To do so, perform the following steps: 1. Remove outer clothing and bring the legs together. 2. Place a narrow, folded sheet—20 to 30 cm (8 to 12 in.) wide—across a multi-level stretcher. The width of the sheet should correlate with the distance between the patient’s iliac crest and pubis symphysis. 3. Pad the spaces between the knees and ankles, and secure the legs together. 4. Lift the patient with a scoop stretcher (clamshell stretcher) onto the prepared folded sheet on the multi-level stretcher. If a multilevel stretcher is not readily accessible, insert the folded sheet from under the knees, and slide it up and under the pelvis. 5. Ensure that the top of the sheet is level with the iliac crest. 6. Cross the ends of the sheet on the anterior side of the pelvis and apply gentle tension or twist the sheet’s end until the desired tension is reached. Synchronize the movements of each side of the sheet to ensure even pressure is applied. Avoid any movement of the patient. 7. Secure the binding with clamps (or by knotting the ends) to prevent loss of tension. Position clamps laterally to avoid obstructing X-ray views. 8. Carefully tuck any loose ends of the sheet away so they will not interfere with the transporting of the patient. 225 SUMMARY CHEST INJURIES Notes Signs and Symptoms Respiratory distress or arrest Pain at site of the injury that increases w  ith deep respirations or movement Obvious deformity Unequal or paradoxical chest wall movement Flushed, pale, or bluish discolouration ofthe skin Coughing up blood Open chest wound: The chest wall has been penetrated. Closed chest wound: The skin has not broken.  Treatment varies depending on the type of chest injury. Types of Chest Injuries Rib fractures Flail chest Hemothorax Pneumothorax Subcutaneous emphysema (SCE) Penetrating chest injuries ABDOMINAL INJURIES General Treatment Signs and Symptoms CHEST, ABDOMINAL, AND PELVIC INJURIES Severe pain Bruising External bleeding Nausea and vomiting Pale, moist skin Thirst Pain, tenderness, or tight feeling in the abdomen Distension in the abdomen Pale, moist skin Evisceration Signs and symptoms of shock 226 1. Place patient in a supine position. 2. Bend the knees if it does not cause pain and place a rolled blanket or pillow under them. 3. If external bleeding is present, apply trauma dressings and  gentle pressure; if gentle pressure is insufficient, place patient in the rapid transport category. Factors that Vary Treatment Evisceration Abdominal aortic aneurysm (AAA) PELVIC INJURIES General Treatment Signs and Symptoms Signs and symptoms of abdominal injuries Pain Pelvic instability Crepitus Numbness in legs Decreased range of motion Paralysis Rectal, urethral, or vaginal bleeding Hematoma 1. 2. 3. 4.  eep patient supine and avoid movement if possible. K If it’s within your training, immobilize patient. Avoid putting pressure on the pelvis. Ensure patient is in the rapid transport category. Factors that Vary Treatment Suspected pelvic fracture Pain during three-plane assessment Evisceration