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• Chest injuries

  • Neurovascular bundles lies closely along the lowest margin of each rib
  • Visceral pleura covers each lung
  • Parietal pleura lines the thoracic cavity
  • Pleural space - filled with pleural fluid; allows lungs to move freely against the inner chest wall during ventilation
  • Negative pressure between parietal and visceral pleura allows us to breathe in and out; allows lungs to move with intercostal muscles to expand them
  • 12 pairs of ribs total, 10 pairs attach to costal cartilage, 2 pairs are "floating"
  • 12 pairs of ribs are attached posteriorly to thoracic vertebrae, 10 pairs are anteriorly connected via costal cartilage to sternum
  • Medistanum - contains the heart, great vessels, esophagus, and trachea
  • Diaphragm - muscle that seprarates the thoracic cavity from teh abdominal cavity; ceiling of abdominal cavity; floor of thoracic cavity
• Inhalation

  Intercostals and diaphragm contract
• Closed chest injuries

  • If heart is damaged, it may not be able to refill with blood or blood may not be pumped with enough force out of heart
  • Lung tissue bruising can result in exponential loss of surface area, rib fractures may cause further damage
• Pulmonary contusion

  Bleeding within lung tissue, bleeding occurs in and around the alveoli and into the interstitial space between alveoli and capillaries
• Pulmonary contusion


  Can lead to severe hypoxia and even death
• Pulmonary contusions often occurs with flail segment injury
• Pulmonary contusion treatment

  Oxygenate via NRB at 15 lpm or PPV with supplemental oxygen
• Rib injuries

  • High suspicious for spine injury; will be very painful to breath; guarding and shallow breathing
• Do not attempt to move or remove object - unless life saving measures are being interfered with or as a last resort if making transport impossible
• Signs and symptoms for chest injury

  • Pain at the site of injury
  • Localized pain aggravated with breathing
  • Ecchymosis to the chest wall
  • Crepitus
  • Dyspnea
  • Rapid, shallow respiration
  • Hemoptysis
  • Unequal or inadequate chest expansion
  • Rapid, weak pulse
  • Low BP
  • Cyanosis
  • Diminished, absent, unequal breath sounds
  • Low SPO2
• Pneumothorax

  Accumulation of air in the pleural space; blood passing through the lungs is NOT oxygenated; may hear diminished, absent, or abnormal breath sounds
• Open pneumothorax

  Sucking chest wound; wounds must be rapidly sealed with an occlusive (airtight and watertight) dressing; monitor pt for tension pneumothorax
• Tension pneumothorax

  Accumulation in pleural space; affected lung moves over, mediastinum is moved into the opposite pleural cavity, compressing healthy lung and heart; complete collapse of affected lung (hear absent or diminished breath sounds)
• In primary assessment - see tracheal deviation in tension pneumothorax and JVD
• JVD

  Right atrium is compressed, blood is getting backed up
• Hemothroax

  Blood collects in the pleural space form bleeding around the rib cage or from a lung or great vessel
• Signs and symptoms of hemothorax

  • Shock without any obviouss bleeding or apparent reason for shock
  • Decreased, muffled breath sounds on the affected sign
• Rapid transport
• Hemopneumothorax

  Presence of air and blood in pleural space
• Cardiac tamponade


  Protective membrane (pericardium) around the heart fills with blood or fluid; heart cannot pump and adequate amount of blood
• Signs and symptoms of cardiac tamponade

  • Low bp
  • Muffled heart sounds
  • JVD
  • Bruising to chest area
• Cardiac tamponade - Beck's triad, altered mental status
• Cardiac tamponade prehospital treatment

  Oxygenate/PPV, rapid transport
• Rib fractures

  • Common in old people, fracture of one of the upper four ribs is a sign of substantial MOI, fractured rib may cause a pneumothorax, hemothorax, hemopneumothorax
• Signs and symptoms of rib fractures

  • Localized tenderness and pain when breathing
  • Rapid, shallow respirations
  • Patient holding the affected portion of rib cage
• Prehospital treatment of rib fractures

  Supplemental oxygen
• Flail chest


  Multiple rib fractures that detach a segment of the chest wall; detached portion moves opposite to normal (parodoxical motion)
• Flail chest may indicate serious internal damage or spinal injury
• Flail chest prehospital treatment

  Maintain airway, provide respiratory support if necessary, if necessary, give supplemental oxygen, perform ongoing assessments for complications
• Pulmonary contusions should always be suspected in a patient with a flailed chest
• In a pulmonary contusion

  Pulmonary alveoli become filled with blood, leading to hypoxia
• Prehospital treatment for pulmonary contusion

  Supplemental oxygen and PPV as needed
• Sternal fractures


  • Increased index of suspicion for organ injury
• Clavicle fractures

  • Possible damage to neurovascular bundle
  • Suspect upper rib fractuures in medial clavical fractures
  • Be alert to pneumothorax in clavicle fractures
• Traumatic asphyxia

  Characterized by distended neck veins, cyanosis in the face and neck, and hemorrhage in the sclera of the eye
• Traumatic asphyxia suggests an underlying injury to the heart and possible a pulmonary contusion
• Prehospital treatment for traumatic asphyxia

  Ventilatory support and supplementary oxygen; monitor vital signs during immediate transport
• Blunt myocardial injury


  Bruising of the heart muscle; heart may be unable to maintain adequate bp
• Signs and symptoms of blunt myocardial injury

  • Irregular pulse rate
  • Chest pain or discomfort
• Suspect blunt myocardial injury in all cases of severe blunt injury to the chest