Emergency Care Chapter 9

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Formed by 12 pairs of ribs that join posteriorly on spine and anteriorly along sternum
The intercostal neurovascular bundle runs along inferior surface of each rib

Thin layer of tissue lining thoracic cavity and lungs
The area between the two layers of pleura is only a potential space
May be occupied by air (pneumothorax)
May be occupied by blood (hemothorax)
Can hold 3 L of fluid on each side in adult

Mediastinum Cavity
Between chest cavity and abdominal cavity
Superior and Inferior Vena Cava
Major Bronchi

Upper abdominal organs protected by lower rib cage
Thoracic Spine
Consists of 12 vertebrae connected facet joints
Disc with a lining and a center filled with gelatinous fluid lies between vertebrae
Acts a shock absorber
Provides flexibility

Muscle groups
2 sets of paraspinals

Spinal Column
Within spinal cord is massive trunk of nerves that run from brain to sacrum
Smaller nerves branch off of these
Smaller nerves travel out to rest of body

Evaluation and Assessment.
Always assume the worst
Search first for most serious injuries
MOI very important
May be result of blunt or penetrating trauma
Blunt trauma can be distributed over large area effecting many viscera
Visceral trauma usually occurs from deceleration, shearing forces, compression, or bursting
Penetrating trauma is less common
Occurs from objects outside the body on a more specific area; usually much smaller surface area

Injuries to thoracic region typically cause tissue hypoxia
Inadequate oxygen delivery to tissue outside of airway obstruction

S&S of thoracic injury
Respiratory Distress
Chest wall contusion
Flail chest
Open wounds
Distended neck veins
Tracheal deviation

Evaluation and Assessment
Check lung sounds
Life threatening conditions should be ruled out immediately

Airway Obstruction
Recognition is vital
Always assume spinal injury in unconscious victim

Tension Pneumothorax
One way valve created by either blunt or penetrating force
Air can enter but not leave plerual space
Leads to increase in intrathoracic pressure which can collapse lung and increase mediastinum pressure
Eventually pressure will collapse superior and inferior vena cava
trachea and mediastinum may shift (usually late sign and doesn’t always occur) to side away from pneumothorax compromising ventilation of other lung

S&S Tension Pneumothorax
apprehension, agitation, cyanosis, diminished breath sounds, hyperresonnance to percussion on effected side, cold and clammy skin, distended neck veins, and hypotension

Spontaneous Pneumothorax
Pneumothorax occurring with an absence of blunt traumatic injury or disease
Rare in athletics but is fatal if not detected promptly
Recognizing S&S is vital for diagnosis
Classic complaint is chest pain; can be vague and usually localized to the side of the affected lung and can radiate to shoulder, neck, and/or back
Family history and a tall, thin frame has been associated with spontaneous pneumothorax
Patient must be transported to ER for chest decompression with a chest tube

Massive Hemothorax
Occurs when blood enters the pleural space
Massive is defined as at least 1500 cc of blood in the pleural space
3000 cc is the max a cavity can hold
Usually cause by penetrating trauma but can also occur from blunt trauma
As blood accumulates, the lung to that side is compressed
If enough blood accrues, the mediastinum will shift away from hemothorax with compresses superior and inferior vena cava as well as the contralateral lung

S&S Massive Hemothorax
hypotension, anxiety, apprehension, confusion, difficulty breathing, neck veins usually flat, decreased or absent breath sounds on side of injury, and chest percussion is dull

Flail Chest
Fracture of 2 or more adjacent ribs in at least 2 places
Typical in contact sports such as football, hockey, wrestling, and lacrosse
Can occur by a torsion mechanism in noncontact sport but is rare
Force needed to create fix probably bruised underlying lung tissue
Athlete suffering from flail chest are at high risk of pneumothorax or hemothorax
Palpation of chest may reveal crepitus in addition to abnormal respiratory movement

Tracheal or Bronchial Tree Injury
Rare in sports because they are usually result of penetrating or blunt trauma
Can be fatal condition

S&S Tracheal or Bronchial Tree Injury
SOB, mediastinum shift, subcutaneous emphysema, and hemoptysis (coughing up blood)

Diaphragment Tears
May result from sever blow to abdomen and can occur in large variety of sports
Sudden increase in intraabdominal pressure such as a kick or punch to abdomen is a typical MOI
Herniation of abdominal organs into thoracic cavity is usually present
Typically occur more on the left side rather than the right due to the liver’s placement protecting the diaphram
Can be difficult to diagnose

S&S Diaphragment Tears
diminished breath sounds, respiratory distress, infrequent bowel sounds
Abdomen may appear with sucked in appearance if large amounts of abdominal contents are in the chest

Esophageal Injury
Usually due to penetrating trauma and is rare in sports
Can be fatal is unrecognized

S&S Esophageal Injury
stridor, hoarseness, dysphagia, subcutaneous emphysema, and oropharyngeal/ nasopharyngeal bleeding

Pulmonary Contusion
Commonly occurs from blunt trauma
Bruising occurs due to shock wave through tissue of lung
Injuries involving high velocity rather than slow crushing are more likely to be cause
May produce hypoxemia (low level of oxygen in blood)
Rarely diagnosed on physical exam
Typically present with other injuries present thus often overlooked
Refer for further evaluation

Sternal Fracture/ Contusion
Result from high impact blunt force trauma
Common in automobile accidents but can occur in sports
Hard to differentiate in field between a fracture or contusion so x-ray will help

S&S Sternal Fracture/Contusion
point tenderness over sternum that will worsen with deep inspiration or forceful expiration, signs of shock

Rib Fracture/ Contusion
Common in sports
Frequent in collision sports
MOI typically direct blow to rib cage
Intercostal muscles are essential to breathing so patient may have pain with expiration, inspiration, coughing, laughing, or sneezing
Point tenderness over rib cage and pain with compression of rib cage
Ribs 5-9 are the most commonly fx
Direct blow rib fx typically cause most damage due to displacement of ribs inward with fragmentation that may cut, tear, or perforate tissue of the chest and abdomen
Indirect blows typically cause ribs to displace outward producing a transverse or oblique fx
Stress fx can also occur with repetitive movements such as rowing and throwing or coughing and sneezing
Either easily detected or difficult
Athlete should be examined for any underlying conditions that may be present

Costochondral Separation/ Dislocation
Occur from direct blows to anterolateral aspect of thorax or indirectly from a sudden twist or fall on a ball that compresses rib cage
Many S&S similar to fx
To differentiate between fx and seperation, pain typically located at junction of bone and cartilage of rib
Complaints of sharp pain with sudden movements and difficulty breathing deeply

Costochondrial Separation/Dislocation Management
is ice and referral to physician for follow up

Rib Fracture/Contusion Management
is to immediately stabilize and transport to medical facility if possibility instable fx

Thoracic Spine Fracture
Occur whenever forces exceed strength and flexibility of spine
More common in lower thoracic spine
MOI typically include hyperflexion, vertical compression, hyperextension, and shearing
Hyperflexion can include: flexion with compression, lateral flexion, flexion with rotation, and flexion with distraction
Patient may experience pain or point tenderness in thoracic region or paralysis below the chest or waist
Lower extremities may feel cool to the touch

Esophageal Injury Management
includes treatment for shock, provide oxygen, package patient for transport to ER ASAP.
Operative repair required

Diaphragment Tears Management
includes treatment for shock, assisting with breathing, supplemental oxygen, and immediate transfer to ER

Tracheal or Bronchial Tree Injury Management
includes maintaining open airway, activating EMS, oxygen administration, and immediate hospital transportation

Flail Chest Management
include stablizing flailed segment with manual pressure or a bulky dressing or pillow secured to chest

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