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ASSESSMENT FINDINGS IN CHEST TRAUMA
The assessment of a patient with chest trauma is best learned by studying the anatomy and physiology of the organs and structure in the chest cavity. In this section, we will review the skeletal, pulmonary, vascular, and cardiac systems; and their function/dysfunction in relation to trauma of the chest. This assessment builds upon the ABC's that are learned at the EMR level to create a better picture of what is affecting the patient, with the goal of providing a higher level of care.
Chest Trauma Assessment of the Skeletal System
The skeletal system has the most externally obvious signs of injury but also has the greatest number of areas to inspect. As such, it is beneficial to use a standardized approach which you can apply to every patient. These vital steps are to question, inspect, palpate, and re-assess.
QUESTION: Ask about any areas of impact or pain to target your detailed assessment.
INSPECT: Visually inspect the entire neck, ribcage, spine, and both clavicles. Watching for signs of injury such as abnormal movement, guarding, bruising, bleeding, and asymmetry. It is important to inspect all skin surfaces to look for hidden injuries, then turn a detailed focus to the abnormal areas brought up in the question step.
PALPATE: Gentle pressure should be applied to all areas that are identified as abnormal in the previous two steps. The purpose of this is to assess for severity of underlying fractures. This takes on special importance in the rib cage. Areas of suspected trauma in the ribcage that give way to gentle pressure may indicate a "compound fracture" which predisposes patients to flail chest. Always palpate the sternum, as sternal fracture implies a high energy mechanism of injury.
RE-ASSESS: The status of a patient with injuries to any of the vital organs, blood vessels, or airway structures can change minute to minute. Since all of these vital structures are contained within the chest, chest trauma patients have a significant risk of sudden decompensation. Regularly repeat questioning, inspection, and palpation at regular intervals or if patient status suddenly changes.
Chest Trauma Assessment of the Pulmonary, Cardiac, and Vascular Systems
Due to the close association between the pulmonary, cardiac, and vascular systems, they are assessed together; using many of the same techniques to elicit signs and symptoms. Each of these systems is vital in ensuring the delivery of oxygen to the cells and/or the acquisition of said oxygen from the environment.
Due to the difficulties in localizing the symptoms of injury to a single organ system, suspected injury to any one of the above should prompt the investigation of all. The symptoms of damage to one of these systems commonly include altered mental status, shortness of breath, pain, and alterations in vital signs. This next section will describe the changes in vital signs and physical exam findings that should prompt concern for the above body systems.
HEART RATE: Initially elevated due to psychological effects of trauma, sudden changes in heart rate more than a short time following trauma should prompt alarm. Increased heart rate is often seen in hypovolemia or hypoxia; while abnormal rhythms are often due to arrhythmia. Both of these findings are signs of damage to the heart muscle, lungs, or the great vessels that enter/leave the heart.
BLOOD PRESSURE: The body has many mechanisms to maintain a healthy blood pressure. The body can increase the cardiac output or the constriction of the blood vessels extremely rapidly, this is why hypotension is a very late sign of severe hemorrhage. Sudden hypotension very shortly after trauma points to damage to a large blood vessel and probably high volume internal/external bleeding. Instant hypotension combined with neurological dysfunction points to nerve damage preventing blood vessel constriction.
- RESPIRATORY RATE: The respiratory rate is one of the first signs that something is wrong with any of the above-listed systems. As with heart rate, the fight-or-flight reflex can increase the respiratory rate, but sudden changes outside of the trauma window should prompt alarm. A decrease in breathing rate can be associated with nerve damage or brain damage; while rapid breaths are oft due to fractures of the rib cage preventing deep breaths, or air-hunger due to low levels of oxygen reaching the cells. Deep and rapid breaths may indicate large volumes of fluid filling the lungs.
PHYSICAL EXAM FINDINGS
- Breath sounds may be decreased in hemothorax or pneumothorax.
- Abnormal movement of a segment of chest wall may indicate multiple rib or sternal fractures.
- Stridor or severe wheezing may indicate accompany tracheal/bronchial collapse/rupture.
- Pulmonary contusion and Acute respiratory distress syndrome (ARDS) are notable for minimal findings on physical exam despite low O2 saturation and dyspnea.
- Hemoptysis (coughing up blood) may indicate damage to the lung tissue, bronchi, or trachea itself has occurred.
- Changes in or absence of pulses in the extremities are a sign of possible vascular damage upstream of the limb or severe blood loss anywhere in the body.
- Distention of the veins in the neck indicates a problem getting blood through the heart, which can be due to damage of the great vessels (The vena cava, pulmonary arteries/veins, and aorta).
- A decrease in the level of consciousness may point to severe blood loss.
- Finally, the presence of a pulsatile mass is concerning for an aneurysm, which can uncommonly result from acute trauma.
CARDIAC: As above, distended neck veins may also signify direct cardiac damage. The other findings of cardiac damage are nonspecific.
- ECG and lab tests are required for rule out if cardiac trauma is suspected.
- Hypotension, tachycardia, bradycardia, cyanosis, and low SPO2% are all possible findings, which are unfortunately shared with many other complications of trauma.
- Arrhythmia or abnormal rhythms that are NEW to the patient are common in survivable cardiac trauma.
- By far the most common sign is sudden death due to cardiac arrest or induction of an unsurvivable rhythm.
- SKIN and EXTREMITIES: The skin and extremities cannot be ignored. While a full assessment of the extremities is often delayed until the initial workup of the chest is complete, there are several clues that the state of the extremities can provide that relate to a patient's chest injuries.
- Hypoperfusion is the most common condition that presents initially in the extremities--cyanosis, hypothermia, increased turgor, and diaphoresis are signs of hypoperfusion that are seen in the extremities. This could point to a major chest injury that is leading to severe blood loss.
Symptoms relating to the pulmonary, vascular, and cardiac systems are all intertwined. Any suspected dysfunction in the patient's oxygenation ability should prompt an investigation of all these systems. By far, a change in the level of consciousness and changes in vital signs shortly following trauma are the earliest indicators of an underlying issue.
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