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What can get injured
- Heart
- Blood Vessels
- Lungs
- Airways
- soft tissue
- Bones
- Spinal Cord
- Nerves
- Remember front back sides of chest for injuries
- arteries in mediastinum
- vagus nerve - parasympathetic, diggestive system, lungs, heart
- frenic nerve - diaphragm 75% of breathing is via Diaphragm
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Force
Mass x Acceleration
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What can get injured
- Remember Diaphragm ..where was it Splits Thoracic and Abdo
- Liver
- kidneys
- spleen
- stomach pancreas gall bladder
- any neck injury
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MOI
- Blunt or Penetrating
- Force delivered
- Duration ( Repeated stabbing)
- Direction ( angles)
- Crush or Compression
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Consider
- Being Stabbed
- Shot
- Driver of a car hitting a wall at speed
- Being kicked punched hit with an object
- Falling onto something
- Elderly/children
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Assesment
- Primary Survey - D R C A (C) B C D E
- is there an issue with Airway,breathing, circulation, disability. Some Major chest injuries will fail at B - if you cant correct load and go.
- Expose the chest
- count RR, capnography
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Secondary Survey
- Done on Route if time allows
- Head to toe exam , cut clothing
- ECG
- Auscultate all lung fields
- Auscultate heart sounds ( 5th Intercostal space on left)
- Pain score
- Review MOI again
- PMHx ( past medical History)
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Assesment of Chest/Abdo
- I - Inspect
- P - Percuss
- P - Palpate
- A - Auscultate
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Twelve - Assessing chest/neck injuries
- T - Tracheal Deviation
- W - wounds, brusing or swelling
- E - emphysema ( surgical)
- L - Laryngeal Crepitus
- V - Venous Engoregement
- E - Excluding open/tension Pneumothorax, flail segment, haemothorax
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Chest injuries Signs and Symptoms
- Deformity, swelling, bruising, wounds
- Dyspnoea
- Tachypneoa/Bradypneoa
- Short of Breath
- Shallow Resps
- increased effort fo Breathing ( Use of Intercostal muscles)
- Abnormal Chest wall movement
- surgical emphysema - crackeling under skin
- abnormal/reduced breath sounds
- Pain/tenderness
- Blood loss
- Signs of clinical shock
- Anxiety
- reduced LOC
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Treatment
- Oxygen (Titrate 94-98%)
- Wound Dressing
- Analgesia ( entonox and Paramedic morphene etc)
- Assist ventilations
- patient position
- Paramedic intervention
- Time Critical transfer
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Flail Chest
- 2 or more ribs fractured in 2 or more places
- Usually from blunt trauma
- May see Paradoxical ( uneven) chest wall movement
- Bruised lung
- Hypoxia
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Fractured Sternum
- Will indicate significant probability of other injuries
- strong bones, requires lots fo force to fracture
- More than 25% of PTS with a fractured sternum will die
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Pneumothorax
- Air in thoracic cavity ( pleural space)
- Can be spontaneous
- Can be caused by blunt or penetrating trauma
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Pneumothorax
- if more air is able to occupy the thoracic cavity it can put pressure on the lung causing it to collapse
- Eventually it can cause other structures to shift away from the pressure ie tracheal deviation
- Can put Pressure on the blood vessels returning blood to the heart and to the heart itself causing obstructive shock
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Open Pneumothorax
- Occurs from Penetrating trauma
- Thoracic pressure changes with each inspiration air is drawn into the pleural space via the wound resulting in a sucking chest wound
- If wound is large enough air will enter via the wound rather than trachea, putting PT at risk of more Hypoxia
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Tension Pneumothorax
- Life Threatening Emergency
- air Enters the Thoracic cavity ( pleural cavity) and cant escape
- can occur from penetrating trauma, blunt trauma ie broken rib , crushing injury, blast wave etc. eg blowing a balloon until it bursts
- PT will become Dyspnoeic, tachycardic, hypotensive
- You may notice: reduced chest wall movement, reduced breath sounds, distended neck veins, tracheal deviation.
- Paramedic required for needle chest decompression
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Haemothorax
- Blood in the Pleural cavity
- Occurs from penetrating trauma
- Blood takes up space where normally occupied by the the lungs and they collapse
- Patient will be hypoxic and Hypovalemic
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Cardiac Tamponade
- Excessive fluid in the pericardial sac compresses the heart limiting its ability to pump
- common in penetrating injury
- only requires 20-30ml of blood to cause tamponade - check MOI
- can cause Obstructive and cardiogenic shock
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Cardiac Tamponade Signs
- MOI - Penetrating wound to heart
- Clinical Shock ( obstructive/cardiogenic)
- Distended neck Veins
- Reduced LOC
- HEMS required for Possible Thoracotomy
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