OEC Chapters 22-23

1. OEC Chapters 22-23

2. 22. Chest Injuries23. Abdominal & Genitalia Injuries

3. Bechtel’s Rules of Engagement • I discourage note-taking. I will post presentation online www.middlebury.edu/~patrol. Notes distract you from interacting and learning. • You must pay attention. • You must interact. Ask questions. • You must not fall asleep (I will throw something at you – probably my shoe, which is heavy and smells rank enough to knock out a bull elephant). • Tell me if I’m boring. Just yell, “you suck, Bechtel.” But I might yell back something worse (ran out of my sedatives yesterday so you never know what might happen … I’m like a loaded gun). • I go fast (got a lot to cover). Speak up if I go too fast.

4. Chapter 15 – Chest Injuries – Why Do We Care? *Importance of chest area: contains organs responsible for carrying out vital functions of respiration and circulation. • NORMAL FUNCTION OF RESPIRATORY SYSTEM REQUIRES … • O2 ratio. • Airways. • Pleural space intact. • Chest wall fucntion. • Intercostal/diaphragm synchronized. • Nervous system intact. • NORMAL FUNCTION OF CIRCULATORY SYSTEM REQUIRES REQUIRES … • Effective heart. • Blood volume. • Vessel efficacy.

5. Pleural Space Normal pleural space = closed sac in which negative pressure is essential for normal lung expansion during breathing Physics review: Areas of high pressure will move into areas of lower pressure … inhalation and exhalation function. “OPEN” vs. “CLOSED” chest injuries: open injuries have significant potential to compromise efficacy of pleural space and therefore respiratory function. Also potential for infection of exposed vital organs/systems, plus cavity area can pool blood quickly (internal bleeding).

6. Signs and Symptoms of Serious Chest Injury • OPEN WOUND: bloody air bubbles, whistling sound from chest wound when patient breathes. • RESPIRATORY DISTRESS: difficult/labored breathing (dypsnea), increased breathing rate (tachypnea), increased breathing depth (hypernea). • Coughing up blood (hemoptysis). • Failure of one or both sides of chest to expand normally (collapsed lung). • Deviation of trachea to side opposite of injury (very specific case – will explain); very late, bad sign. • Subcutaneous emphysema (air under the skin) usually in chest or neck (serious!) • Cyanosis (bluish skin discoloration) – result of inadequate resp. system (blood not adequately oxygenated). • Always be alert for potential of heart injury (weak or irregular heartbeat, low blood pressure, distended neck veins). • Shock. Again – chest cavity is large, significant potential for blood pooling.

7. Rib Fractures (Fx) • MOI: Falls or collisions. • Single or multiple ribs Fx’ed. • Complications: • Paradoxical motion of chest wall (“Flail Chest”): • PNEUMOTHORAX (to be explained). • HEMOTHORAX (more later). • VERY PAINFUL!!! Usually localized. • Presentation: Patient usually prefers sitting position, and tries to splint chest by leaning to injured side.

8. EXTREMELY SERIOUS CHEST INJURIES • PENETRATING INJURIES (SUCKING CHEST WOUND). • MASSIVE COMPRESSION INJURIES. • INJURIES TO BACK OF CHEST. • PNEUMOTHORAX. • TENSION PNEUMOTHORAX. • HEMOTHORAX. • SUBCUTANEOUS EMPHYSEMA. • MYOCARDIAL CONTUSION. • PERICARDIAL TAMPONADE. • INJURY TO GREAT VESSELS. It is easier to remember and develop Tx’s when you understand the “how” and “why” the body operates … for this reason we will review the types of injuries first and then discuss Tx’s.

9. Penetrating Chest Injuries (Sucking Chest Wound) • MOI: Penetration. • Blood or air in pleural space. • Massive bleeding and shock. • Small may self-seal. • If large “sucking chest wound.” • SCW = open hole in chest wall that forms a vent between the pleural space and outside air; lung on that side collapses and during breathing air moves in and out of hole rather than in and out of the lung through normal airway (remember physics: neg vs. positive pressures and easiest route of travel). • SCW gets its name from the“peculiar sucking noise usually heard as the air moves in and out of the hole.”

10. Massive Compression Injuries/Back of Chest • MASSIVE COMPRESSION • cave-ins and explosions. • Crushing, penetrating MOIs. • “Ballooning” • Patient usually cyanotic, severe respiratory distress, and rapid descent into shock. • BACK OF CHEST • Access to organs, exit wounds, etc. SCENARIO: What if this pleasant low-angle Snow Bowl powder day triggered a cataclysmic avy, entrapping this Bowl Patroller in a snowy “trash compactor”? Not likely …

11. breathe …

12. Pneumothorax • Air in the pleural space. • Open (pentrating) or closed (rib Fx). • Almost always requires surgery. • RESP DISTRESS and PAIN. • Spontaneous pneumothorax.

13. Tension Pneumothorax • Serious complication of pneumothorax… • one-way valve develops at injury site (SCW becomes one-way, filling pleural space with outside air and collapsing lung). • Px inhales, valve opens, air drawn into pleural space. • Px exhales, valve closes and air cannot escape. • Pressure accumulates in pleural space, collapsing lung’s space to expand normally. • The mediastinum displaced  tracheal deviation. • Pressure in pleural space exceeds pressure in venae cavae or mediastinal shift causes them to kink; blood can no longer flow back to heart. • Px rapidly descends into cardiogenic shock and dies. • Spontaneous pneumothoraxTension Pneumo. • Open and closed chest injuriesTension pneumo. • After Tx of SCW. • Signs and symptoms: severe, rapidly increasing resp distress, weak rapid pulse, falling BP, cyanosis. Tracheal deviation, engorged neck veins, bulging chest wall tissues b/w ribs and above clavicles on involved side. • Condition progresses rapidly and death can occur within a few minutes. To relieve a tension penumo., physician or EMT-P decompresses chest by piercing with a large needle or tube (not our protocol!!!).

14. Tension Pneumothorax

15. Hemothorax • Blood in pleural space. • Possible collapse of lung. • S/S and shock. • Difficult to distinguish from pneumothorax in field. • Accompanied by air in pleural space (hemopneumothorax). • If pneumothorax patient is worsening, assume a tension pneumo or hemopneumo progression. Another rough day at the office for the Bowl Patrol …

16. Subcutaneous Emphysema • Air bubbles in subcutaneous tissues. • Crackling sensation during palpation (“crepitation”). • Typically found in a compression injury to chest wall with damage to underlying lung from a FX’d rib. Also caused by laceration of trachea or large bronchi.

17. Myocardial Contusion • Bruising of heart muscle. • Possibly decreased BP and enlarged neck veins. In early stages, BP and pulse may still be normal. • Large contusions may cause cardiogenic shock. • Trama to midanterior chest (driver who strikes chest on steering wheel in head-on).

18. Pericardial Tamponade • Blood or other fluid in the pericardial sac. • Penetrating injuries. • Pressure buildup from fluid accumulation in sac limits heart’s ability to fill and expel with each heartbeat, manifesting s/s of BP falling and cardiogenic shock. • Weak, fast pulse; falling BP; progressively falling pulse pressure (diff b/w systolic and diastolic pressures). Neck vein distension and facial swelling. Oh … I’m nasty … the trademark Bechtel Iron Cross McTwist w/ Inverted Fakey “Money Grab” … yeah right …

19. Great Vessel Injury • Rapid deceleration forces, compression trauma and laceration. • Aorta, venae caeva or their larger branches. Vessel walls lacerated or entire vessels can be sheared/fractured. • Aortic injuries rapidly fatal because of massive internal bleeding. Oh no, we’ve lost another boarder to mid-move aortic injury! … I’m not passing a judgement on snowboarders … I didn’t say they were “knuckle-druggers”, or “neanderthal thugs” … ha ha

20. Saucer boy = abdominal injury waiting to happen… Abdomen and Genitalia Injuries Chapter 23

21. Abdominal Anatomy *remember to orient quadrants based on Px’s directions! Kidneys on back/sides

22. Hollow v. Solid Organs Hollow Abdominal Organs Solid Abdominal Organs

23. Closed v. Open Abd Injuries • Closed Abdominal Injuries • Severe blow to abdomen w/o breaking the skin. • “Blunt injuries.” • Ex: striking abd on bike handlebars or steering wheel of car. • Open Abdominal Injuries • Foreign object enters the abdomen and opens peritoneal cavity to outside. • “Penetrating injuries.” • Ex: stab wounds, gunshot wounds, impaled ski poles, tree branches, etc.

24. Signs and Symptoms | Assessment • Assessment • Assume worst (organ damage). • Baseline + subsequent vitals extremely important. • Vomit. • Signs/Symptoms of Abd Injury • PAIN. • Sig abd injury: Tachycardia. • Shock (later). • Distended abdomen. • Bruising. • Firmness on palpation. • Entry/exit wounds. • Localized pain.

25. Transport Position for Abd Injuries Supine with knees slightly flexed and supported.

26. Blunt Abdominal Wounds Some combination of … Severe bruising of abd wall. Laceration of liver and spleen. Rupture of intestine, stomach or any hollow organ. Tears in mesentary, membranous folds that attach intestines to the walls of the body, injury to blood vessels within folds. Kidney rupture, tearing of kidneys from their arteries and veins. Bladder rupture, especially if bladder was full (toxic!). Severe intra-abdominal hemorrhage. Peritonitis.

27. Penetrating Abd Injuries • Depth of injury. • Severe bleeding. • Impaled objects. • Entrance/exit wounds.

28. Abdominal Evisceration (Disembowelment) Cover your eyes if you can’t handle gross stuff…

29. Tx of Abdominal Evisceration

30. Genitourinary System

31. Genitourinary Injuries KIDNEY INJURIES BLADDER INJURIES (see left) INJURIES TO EXTERNAL MALE GENITALIA (watch the guy next to you cringe as he reads this) INJURIES TO FEMALE GENITALIA

32. Review • Normal function of the respiratory system requires what? • Normal function of the circulatory system requires what? • What is the pleural space? How does it work? • What is the other name for “flail chest”? Explain. • What is a sucking chest wound? • What causes a pneumothorax? • What is the difference between a pneumothorax, a tension pneumothorax, and a hemothorax? • What is subcutaneous emphysema? • What is a myocardial contusion? • What is pericardial tamponade? • Who is James Black’s father? (see right) • What are the different primary concerns in injuries to hollow vs. solid abdominal organs? • In what position do you generally transport a Px with abdominal injuries? • List 4 or more suspected injuries associated with blunt abdominal trauma. • What should and shouldn’t you do with impaled objects in the abdomen (or anywhere else)? • Describe Tx of a Px with abdominal evisceration. • What should you do to “unstick” a male zipper snarl? • What kind of medical dressings should you use to control female genital bleeding? • What is typically of utmost importance to any Px suffering from a genitourinary injury?