L3 AAP Chest Injuries Aug24 v5 PDF

Support the management of trauma in the Emergency and Urgent Care Setting Component 8 Chest Injuries  Chest Injuries – Component 8 OBJECTIVE Understand signs and symptoms, complications and treatment for chest...

Support the management of trauma in the Emergency and Urgent Care Setting Component 8 Chest Injuries  Chest Injuries – Component 8 OBJECTIVE Understand signs and symptoms, complications and treatment for chest injuries. Explain when interventions may be required. Describe time critical injuries and when action should be taken. © Department of Clinical Education & Standards 2  Chest Injuries – Component 8 Chest trauma accounts directly for 25% of all trauma deaths and is a contributing factor to approximately another 50% Despite the very high percentage of serious chest injuries, the vast majority of them can be managed in hospital with chest drainage and resuscitation and only 10-15% require surgery. Major causes of chest trauma are – RTCs, Industrial accidents & sporting injuries. The most common problem associated with major chest injuries is HYPOXIA caused either by impaired ventilation or secondary to hypovolaemia  Chest Injuries – Component 8 What Can Get Injured? Heart Blood Vessels Lungs Airways Soft Tissue Bones Spinal Cord Nerves © Department of Clinical Education & Standards 4  Chest Injuries – Component 8 THINK If the patient has rib injuries there could also be injuries to : Liver Kidneys Spleen (Stomach, Pancreas, Gall Bladder) ALWAYS remember – Could there be a neck/spinal injury © Department of Clinical Education & Standards 5  Mechanism of injury MOI MOI is an important guide to the likelihood of significant chest injuries. Blunt force (RTC/ fall/ sports injuries): On scene time of less than 20 minutes Penetrating trauma (Gun shot/ stab wounds/ industrial/ domestic): On scene time of minutes © Department of Clinical Education & Standards 6  Chest Injuries – Component 8 Mechanism of Injury THINK about : The force & energy delivered The duration & direction © Department of Clinical Education & Standards 7  Chest Injuries – Component 8 Consider Has the patient been stabbed Has the patient been shot Has the chest of the patient been crushed or compressed Did the driver of the car hit a wall at speed Has the patient been kicked / punched / hit with an object Did the patient fall from a height and what have they fallen onto. Is the patient elderly or a child/infant. Will you require advanced interventions from a senior clinician or assistance from police, LFB if so request assistance ASAP © Department of Clinical Education & Standards 8  Chest Injuries – Component 8 Possible Signs & Symptoms of a chest injury Hypoxia, Dyspnoea, Tachypnoea, Bradypnoea Shallow respirations, use of accessory muscles Abnormal chest wall movement Deformity, bruising, swelling, wounds Pain, tenderness Obvious blood loss, signs of clinical shock Reduced levels of consciousness Anxiety The severity of signs and symptoms can vary widely depending on the specific type and extend of injury ALWAYS THINK is the patient TIME CRITICAL © Department of Clinical Education & Standards 9  Chest Injuries – Component 8 Types of Injuries caused by chest trauma There are many different types of chest injuries your patient could suffer :- If the force of the injury is sufficient, the damage and deformity to the chest wall structures may induce tearing and contusion to the lungs and other structures causing respiratory problems and pain ( Rib injuries ) Myocardial Contusion – Caused by blunt trauma to the sternum, which may result in cardiac rhythm disturbances Damage to the lungs with bleeding causing a haemothorax or an air leak causing a pneumothorax Rapid deceleration injuries may result in sheering forces that are sufficient to rupture great vessels such as the aorta. © Department of Clinical Education & Standards 10  Chest Injuries – Component 8 Rib Injuries Fractured Rib Be suspicious for other injuries Most common chest injury Can cause the patient to breathe shallowly leading to inadequate ventilation Rib fractures can lead to 100ml blood loss Rib fractures could cause damage to soft tissue (including the lung) causing more serious injuries © Department of Clinical Education & Standards 11  Chest Injuries – Component 8 Rib Injuries Fractured Sternum Occurs in around 1 in 20 patients with blunt thoracic trauma In itself the # is not serious But it indicates SIGNIFICANT probability of other major injuries The sternum is such a strong bone that the force required to fracture it will have caused other injuries More than a quarter of patients with # sternum will die Request clinician intervention/evaluate if the patient is time critical © Department of Clinical Education & Standards 12  Chest Injuries – Component 8 Flail Chest Two or more rib and sternum fractures in two or more places Usually occurs from blunt trauma The chest wall will lose the rigid segment that usually supports the chest The flail segment will start to move inwards on inspiration and outwards on expiration, because of this movement the underlying lung may become inadequately ventilated It is possible that with each rib fracture there could be a loss of up to 100mls of blood © Department of Clinical Education & Standards 13  Chest Injuries – Component 8 Pneumothorax The lungs are surrounded by a plural membrane, which has two layers : The outer layer (parietal pleura) lines the chest wall The inner layer (visceral pleura) covers the lungs Between them is the pleural space, PNEUMOTHORAX is air in that pleural space. © Department of Clinical Education & Standards 14  Chest Injuries – Component 8 Pneumothorax Can be Spontaneous (ie no obvious cause) Can be caused by trauma (penetrating & blunt) Small simple pneumothoraces are a frequent occurrence in blunt trauma and if no known cause is found they are classified as spontaneous Spontaneous Pneumothorax can be common and benign AS LONG as it does not progress to a tension pneumothorax Symptoms depend on the size of the pneumothorax (the amount of air collecting in the thoracic cavity) some can be TIME CRITICAL and LIFE THREATENING © Department of Clinical Education & Standards 15  Chest Injuries – Component 8 Pneumothorax If more and more air is able to occupy the thoracic cavity it can put pressure on the lung causing it to collapse Eventually it can also cause other structures to ‘shift’ away from the pressure (eg trachea) It can also put pressure on the blood vessels returning blood to the heart and to the heart itself causing obstructive shock © Department of Clinical Education & Standards 16  Chest Injuries – Component 8 Open Pneumothorax Occurs from penetrating trauma – the resulting hole in the chest wall allows air to enter the pleural space As the chest wall expands during inspiration, air enters the pleural space. If the wound is large enough, there may be free movement of air into and out of the affected lung during respiration. This can be referred to as a “ Sucking chest wound” © Department of Clinical Education & Standards 17  Chest Injuries – Component 8 Tension Pneumothorax Life-Threatening Emergency Air enters the thoracic cavity (pleural space) and cannot escape Can occur from various causes – penetrating trauma, blunt trauma (perhaps from a # rib) or crushing injury or existing medical causes © Department of Clinical Education & Standards 18  Chest Injuries – Component 8 Tension Pneumothorax Life-Threatening Emergency As the tension pneumothorax expands it occupies space in the thoracic cavity – the lung collapses, structures shift away from the high pressure and blood flow can be impeded by the pressure placed upon the blood vessels Your patient will become increasingly – Dyspnoeic, tachycardic & hypotensive And you may notice – Reduced chest wall movement, reduced (or absent) breath sounds, distended neck veins, tracheal deviation © Department of Clinical Education & Standards 19  Chest Injuries – Component 8 Tension Pneumothorax Your patient needs advanced clinical interventions © Department of Clinical Education & Standards 20  Chest Injuries – Component 8 Haemothorax Blood in the thoracic (pleural) cavity Usually occurs from penetrating trauma injuring major blood vessels but could be blunt deceleration shearing injury As blood fills the thoracic cavity it takes up space normally occupied by the lungs and they collapse The patient has a dual problem – hypoxia & hypovolaemia Depending on the severity of the injury and blood loss a haemothorax can be TIME CRITICAL and LIFE THREATENING © Department of Clinical Education & Standards 21  Chest Injuries – Component 8 Cardiac Tamponade Excessive fluid in the pericardial sac compresses the heart limiting its ability to pump More common in penetrating injury Only requires 20 – 30ml of blood to cause tamponade This is TIME CRITICAL AND a LIFE THREATENING condition © Department of Clinical Education & Standards 22  Chest Injuries – Component 8 Assessment Assess C ABCDE Is there a catastrophic haemorrhage Is there an airway issue Is there a breathing issue Is there a circulation issue Does the patient require other interventions - request APP, HEMS, Paramedic ASAP Is the patient TIME CRITICAL Is there a disability issue Some major chest injuries will fail at B – if you cannot correct the problem, undertake a time critical transfer to a major trauma unit © Department of Clinical Education & Standards 23  Chest Injuries – Component 8 Assessment Primary Survey - Breathing - EXPOSE THE CHEST !!!!!!! COUNT respiratory rate, assess effort of breathing, assess SPO2 levels LOOK for wounds, swelling, deformity, bruising LOOK at chest wall movement (symmetrical, paradoxical) LOOK (don’t forget ) at the back of the chest & the axilla LOOK at the neck – distended neck veins, tracheal deviation (TWELVE) LISTEN – once to both lungs to confirm air entry FEEL – injuries, deformities, instability, tenderness, depth & symmetry of movement Some major chest injuries will fail at B – if you cannot correct the problem, undertake a time critical transfer to a major trauma unit © Department of Clinical Education & Standards 24  Subcutaneous Emphysema Associated with severe thoracic injury Extra-pleural Intra-pleural Focus on ABC management TWELVE mnemonic (JRCALC) © Department of Clinical Education & Standards 25  Chest Injuries – Component 8 Assessment Secondary Survey Done enroute to hospital if patient is time critical Assess for all other injuries (top to toe examination) ECG Listen to chest sounds – report findings Pain Score Thorough review of MOI PMHx © Department of Clinical Education & Standards 26  Chest Injuries – Component 8 Management Oxygen JRCALC Guidelines Major Trauma (including chest trauma) 15 litres per minute Reservoir mask (non-rebreather mask) “Administer the initial oxygen dose until the vital signs are normal, then reduce oxygen dose and aim for target saturation within the range of 94-98%” © Department of Clinical Education & Standards 27  Chest Injuries – Component 8 Analgesia Entonox JRCALC –Contra-indication – Do not give nitrous oxide for patients with chest injuries and a clinically suspected pneumothorax JRCALC – Caution - Avoid using Entonox in a patient with a chest injury as there is a risk of enlarging a pneumothorax Request Paramedic intervention – Morphine, IV Paracetamol as soon as possible if required. © Department of Clinical Education & Standards 28  Chest Injuries – Component 8 Wound Dressings Russell Chest Seal Corius Seal Dressing © Department of Clinical Education & Standards 29