Chest Trauma Management
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Transcript of Chest Trauma Management
Thoracic and Abdominal Trauma
Chest Trauma Management
Department of Combat Medic Training
C168W014
Thoracic TraumaThoracic Trauma
Department of Combat Medic Training
C168W014
Terminal Learning ObjectiveTerminal Learning Objective
Given a combat casualty with a suspected thoracic injury,
treat the thoracic injury, IAW the principles of Tactical Combat Casualty
Care and Pre-Hospital Trauma Life Support Chapter 10 and 21.
Enabling Learning Objective 1Enabling Learning Objective 1
Given a combat casualty with a thoracic injury,
Assess for a thoracic injury,IAW the standards of Tactical Combat Casualty
Care and Prehospital Trauma Life Support Chapter 10.
Anatomy and PhysiologyAnatomy and Physiology
Anatomy and PhysiologyAnatomy and Physiology
Anatomy and PhysiologyAnatomy and Physiology
PleuraPleura
Rib
Rib
PleuraPleura
Rib
Rib
Lung
Visceral Pleura
Parietal Pleura
Pleural Space
Anatomy and PhysiologyAnatomy and Physiology
Mechanism of InjuryMechanism of Injury
Blunt or Penetrating?
What caused the trauma?
Mechanism of InjuryMechanism of Injury
What was the trajectory of the penetrating trauma?
A penetrating thoracic wound at the 4th
intercostal space or lower should be
assumed to be an abdominal injury and
thoracic injury.
Chest Trauma on the BattlefieldChest Trauma on the Battlefield
Hemorrhagic Sources Heart and/or associated vessels in the thoracic cavity
In most cases, surgery must be imminent to save casualty or the outcome is often fatal
What are the hemorrhagic sources?
Cardiac contusion
Penetrating wounds to the heart or blood vessels
Pericardial Tamponade
Hemothorax
Chest Trauma on the BattlefieldChest Trauma on the Battlefield
Additional examples of chest trauma include:
Pneumothorax
Tension Pneumothorax
Diaphragmatic Tears
Simple Rib Fractures
Flail Chest
Traumatic Asphyxia
Tracheal Bronchial Tree Injury
Casualty AssessmentCare Under Fire
Casualty AssessmentCare Under Fire
Defer treatment of thoracic injuries to the tactical field care phase.
Direct self aid/buddy aid, if necessary.
Something as simple as a hand placed over an open chest wound can slow or stop the progression of the
injury.
Casualty AssessmentTactical Field Care
Casualty AssessmentTactical Field Care
Assess and manage breathing:Remove the casualty's equipment, including IBA and
expose the torso
Equal rise and fall of the chest
Spontaneous respiratory effort.
Pulse oximeter reading, if available.
Inspect and palpate chest wall
Manage chest wounds, if present.
Monitors casualty's respiratory effort.
Position casualty to facilitate respiratory effort.
Chest TraumaChest Trauma
What signs or symptoms would be consistent with chest trauma?
Palpable BPTachypnea or Bradypnea
LaboredRetractionsHemoptysis
Short sentencesAgitation
DiaphoresisPallor
CyanosisSounds (lungs, bowel, heart)
Trachea Position (late)Subcutaneous Emphysema
Jugular DistentionBruises
TendernessAsymmetry
Open WoundsCrepitus
Flail Segment
Check on your Learning…Check on your Learning…
Q: While assessing a casualty, what clues would indicate that a thoracic injury is getting worse?
Q: How should thoracic injuries be dealt with during Care under Fire?
A: Direct Self Aid/Buddy Aid – Hand over the wound
A: Progressive respiratory distress, JVD, Tracheal deviation, unequal rise and fall of chest, rising
pulse, falling BP, cyanosis, loss of consciousness
Check on your Learning…Check on your Learning…
Q: During what part of your assessment should you assess for and treat thoracic injuries and why?
During Tactical Field Care
Assessment and Management of Breathing
Enabling Learning Objective 2Enabling Learning Objective 2
Given a combat casualty,
treat a casualty with an open chest injury,
IAW the principles of Tactical Combat Casualty Care and Prehospital Trauma Life Support
Chapter 10 and 21.
The PneumothoraxThe Pneumothorax
A pneumothorax is an accumulation of air within the potential space between the visceral and
parietal pleura.
Pneumothorax Pneumothorax
The casualty will complain of pleuritic chest pain and exhibit signs and symptoms of
respiratory distress. What does a casualty in respiratory distress look like?
“In this injury, auscultation over the apices of the lungs is more likely to demonstrate
decreased breath sounds than the mid lung fields.”
This is extremely hard to detect during the noise of battle and not
recommended.
PneumothoraxPneumothorax
The difference between a closed and open pneumothorax depends on the type of
trauma that caused either an open wound or a closed wound.
RIB
RIB
RIB
RIB
Open PneumothoraxOpen PneumothoraxLUNG
AIR AIRAIR
INJURY
A projectile penetrates the chest wall and
pleura.
Pneumothorax Developing
As the casualty breathes, air is sucked in
the hole in the chest (sucking chest wound).The air separates the
pleura and fills the pleural space.
Pneumothorax Worsening
This continues and the air in the pleura grows.
Air may move in and out of the chest wound.
The lung starts to collapse (deflate).
The collapsed lung is less effective at gas exchange because of decreased;•Lung capacity•Tidal volume•Surface area
A sucking chest woundIf the open wound is large enough, at least 2/3 the
size of the trachea, it will present with a “sucking” sound.
Factoids:The trachea in an adult is around 1 inch (2.5 cm) in
diameter.
Males have wider tracheas than females.
Open PneumothoraxOpen Pneumothorax
Open PneumothoraxOpen Pneumothorax
To suffer exclusively from an open pneumothorax is rare.
A penetrating object to the chest will sever vessels and cause bleeding.
You should assume the wounds encountered are some variation of a hemothorax and
pneumothorax (hemo/pneumo).
Hemo/PneumoHemo/Pneumo
What is the field intervention for a hemothorax?
Evacuation
You may not know a hemothorax is present, but
should suspect. Evacuate as an urgent
surgical casualty as soon as possible.
Open PneumothoraxOpen Pneumothorax
If one wound is found, ALWAYS assess for multiple wounds and an exit wound.
ManagementManagement
As soon as an open wound to the thorax is identified, what should you do?
Quickly close chest defect with an occlusive dressing. (First wound found - first wound treated.)
2. Assess for any additional wounds and treat immediately with an occlusive dressing
3. Continuously monitor the casualty's respiratory effort looking for signs of
progressive respiratory distress.
ManagementManagement
How should these casualty be transported?
If the Casualty is Able
Transport casualty in position of comfort. For conscious casualties, that normally means sitting
up.
If Casualty is Unable
Transport casualty on his side or recovery position with injured side down.
Additionally provide:
pulse oximetry, high flow oxygen, cardiac monitoring
ManagementManagement
Check on your Learning…Check on your Learning…
What is a pneumothorax?An accumulation of air within the potential space
between the visceral and parietal pleura.
Your casualty has a thoracic entrance and exit wound. In what order should the wounds be
covered?First wound found - first wound treated.
Check on your Learning…Check on your Learning…
What is the difference between an open pneumothorax and a sucking chest wound?
If the open wound is large enough, at least 2/3 the size of the trachea, it will present with a sucking
sound.
What is the definitive treatment for a pneumothorax?A Chest Tube
Check on your Learning…Check on your Learning…
What type of pneumothorax is the most immediately life-threatening and why?
OpenClosed Tension
Occlusive DressingsOcclusive Dressings
Air tightMade from any nonporous material
Sterile or Non-sterileThe critical action is to seal the wound.
Large enough to extend past the edges of the wound a minimum of 2 inches.
Occlusive DressingsOcclusive Dressings
To Vent or
Not to Vent?
Occlusive DressingsOcclusive Dressings
Blood, sweat and dirt can cause adhesive and tape not to perform as intended.
Always consider a gross cleaning of the area before applying and securing the
dressings.
Occlusive DressingsOcclusive Dressings
How far should the dressing extend pass the edges of the wound?
At least 2 inches on all sides
When should an occlusive dressing be taped?If the dressing is improvised (does not have adhesive)
The dressing does not properly adhere to the chest
Occlusive DressingsOcclusive Dressings
What if the casualty is hairy?Shave or use tape to remove hair
Check on your Learning…Check on your Learning…
What items found in your classroom could be used as an improvised occlusive dressing.
(Find at least five.)
Are vents a requirement for an effective occlusive dressing? Why or why not?
No. No medical study has determined that an occlusive dressing should contain a one way valve
or vent.
Check on your Learning…Check on your Learning…
How many sides of an improvised occlusive dressing are taped to the casualty? What if
the piece of material that you use as an occlusive dressing is circular?
Ensure all sides of the dressing extend at least 2 in. passed the edges of the wound
regardless of the shape of the dressing
and are secured on all sides.
Occlusive DressingsImprovised and Commercial
Demonstrationand
Practical Exercise
Enabling Learning Objective 3Enabling Learning Objective 3
Given a casualty with penetrating trauma to the thorax and progressive respiratory distress,
perform needle chest decompression,
Safely, IAW the principles of tactical combat casualty care and Prehospital Trauma Life
Support Chapter 21.
Watch Video:Open Pneumothorax
Tension PneumothoraxTension Pneumothorax
Signs and Symptoms Include:Anxiety, apprehension, agitation
Diminished or absent breath sounds
Progressive respiratory distress, tachypnea
Hypotension, cold clammy skin, cyanosis
Distended neck veins (may not be present with a hemothorax)
The development of decreased lung compliance (The BVM will be harder to compress.)
Tracheal deviation (late finding)
Tension PneumothoraxTension Pneumothorax
In what phase of care should a tension pneumothorax be treated?
Tactical Field Care
Tension PneumothoraxTension Pneumothorax
In a combat environment, what two things need to be present for you to assume the casualty is suffering from a tension pneumothorax?
Unilateral penetrating torso injury (previously treated appropriately with an occlusive dressing)
Development of progressive respiratory distress
You are the MedicYou are the Medic
Your unit comes under effective hostile fire while on mission.
Control of the area is achieved and the tactical leader directs you to provide care for a local man that was
injured during the fire fight.
You move the man behind cover and fire
superiority is achieved. What phase of care are
you in?
Tactical Field Care
You are the MedicYou are the Medic
Hemorrhage is controlled.
The patient is speaking to you,
though you cannot understand what he is
saying.
Upon assessment of the chest you find this.
What should you do?
Treat with an occlusive dressing
You are the MedicYou are the Medic
This injury is treated, next?
Look for additional wounds.
No additional wounds found.
After 10 minutes, the interpreter states the
casualty is complaining he cannot breathe. You see
he is speaking just a couple syllables at a time.
What should you do next?
Needle Chest Decompression
Needle Chest DecompressionNeedle Chest Decompression
What is needle chest decompression (NCD) and how does it work?
A needle placed into the pleural space.
Allows the trapped/accumulated air under pressure to escape from the chest and relieved the pressure being placed on the good lung, heart and major
vessels.
Needle Chest DecompressionNeedle Chest Decompression
NCD is a stop gap measure for tension pneumothorax until the casualty arrives at the
MTF.
The casualty requires evaluation from a MO.
Definitive care for a tension pneumothorax includes a chest tube.
Based on the extent of the internal damage, surgical intervention may be necessary.
NCD EquipmentNCD Equipment
14 gauge needle and catheter, 3.25 inches in length
Antiseptic wipe
Watch Video:Needle Length Importance in NCD
NCD LandmarkNCD Landmark
Mid Clavicular Line
NCD LandmarkNCD Landmark
Mid Clavicular
Line
NCD LandmarkNCD Landmark
Find your Second Intercostal Space.
NCD LandmarkNCD Landmark
Directly over the top of the third rib.
Directly under each rib is an artery, vein and
nerve
(neurovascular bundle)
Needle DepthNeedle Depth
NCD Gone WrongNCD Gone Wrong
1.5 inches
1st Rib
Right Lung
2nd Rib
Clavicle
1.5 inches
2 inch cath
NCD Gone WrongNCD Gone Wrong
Check on your Learning…Check on your Learning…
What are the indications for needle chest decompression?
Unilateral penetrating torso injury (previously treated appropriately with an occlusive dressing)
Development of progressive respiratory distress
Why wouldn’t other signs and symptoms be used to determine if a casualty was suffering
from a tension pneumothorax? Other signs and symptoms are hard to detect in a
combat environment or they appear very late.
Check on your Learning…Check on your Learning…
When performing NCD, why must you….Use a 14 gauge, 3.25 in needle and catheter?
So the needle is long enough to reach the space.
Place the needle in the (ICS)?
So the needle reaches the space.
Use (MCL) as a landmark?
So the needle reaches the space and does not enter the cardiac box
Insert the needle directly over the top of the third rib?
To avoid the neurovascular bundle
Problem Solving NCDProblem Solving NCD
NCD may relieve a tension pneumothorax for minutes or hours.
How will you know if the NCD is no longer effective?
If the patient has already received NCD once and begins to suffer from a reoccurrence of
progressive respiratory distress, you should assume the needle is no longer relieving the tension and
take action.
Problem Solving NCDProblem Solving NCD
If you believe the NCD is no longer relieving the tension:
If you have an additional supply of 14 gauge, 3.25" needle catheters, insert a second needle directly along side (laterally) of the first in an attempt to
repeat the intervention.
If you do not have a supply of 14 gauge, 3.25" needle catheters, flush the previously placed catheter with
1-2 ml of sterile IV solution.
Problem SolvingProblem Solving
What if you have exhausted all of your supplies or you do not have a 14 gauge needle available
Burp the Wound
1. Lift the edge of the occlusive dressing. If you hear air escape the wound and the casualty reports a
relief, reseal the occlusive dressing to the wound.
2. If tension remains, place a gloved finger into the wound.
3. Reseal the occlusive dressing to the wound.
Check on your Learning…Check on your Learning…
What can you do if the casualty begins to develop progressive respiratory distress even after the
wound has been dressed and NCD performed?
Perform another NCD directly along side of the first Flush the first NCD
Burp the Wound
Check on your Learning…Check on your Learning…
What is burping the wound?
Raise the edge of the occlusive dressing in the hopes that some trapped air will escape.
If necessary, place a finger into the wound to create an opening for the trapped air to escape.
Needle Chest Decompression
Demonstrationand
Practical Exercise
SummarySummary
You will now view a video of a casualty that sustained a GSW during combat. While you watch make note
of the following:
How does the casualty react?
How do fellow non-medical Soldiers react?
How does the medic react?
How much time does it take from the time of wounding until the casualty is treated?
Is the treatment appropriate?
How should the casualty be transported?
SummarySummary
Watch Video:
GSW to Back
SummarySummary
How did the medic react to the wounded casualty?
He did not react because there was no medic on the mission. Treatment was given by non-medics.
YOU have the responsibility to ensure fellow Soldiers are trained on basic skills. In the absence of
training, the Soldiers did the best that they knew to do for their buddy.
The right intervention at point of wounding can make the difference between life and death of casualties.
SummarySummary
How long did it take to expose the wound?
2:15 minutes
How long did it take to get the first bandage placed?
3:48 minutes
Did that “feel” like a long time to you?
What treatment was given?
An Emergency Trauma Bandage was placed on the wound.
SummarySummary
What treatment is appropriate?
An occlusive dressing should have been placed on the wound.
How long did it take to apply the wrong intervention?
2.5 minutes
Did they fully expose and check for additional wounds?
No
SummarySummary
How should the casualty be transported?
Position of comfort – sitting up.
What should be done en-route for this wound?
Monitor the casualty for progressive respiratory distress.
Do you think the non-medics that will transport the casualty will have the equipment and know how to
perform NCD?
Abdominal TraumaAbdominal Trauma
Department of Combat Medic Training
C168W013
Terminal Learning ObjectiveTerminal Learning Objective
Given a casualty with a suspected abdominal injury in a combat environment,
treat an abdominal injuryIAW Prehospital Trauma Life Support Chapter
11 and 21
The QuadrantsThe Quadrants
Abdominal TraumaAbdominal Trauma
What are examples of solid abdominal organs and vascular structures of the abdomen?
Answer will vary, but may include…
Liver, spleen, kidneys, inferior vena cava, descending aorta.
What are examples of hollow abdominal organs?
Answer will vary, but may include…
Small and large intestine, gallbladder, urinary bladder, stomach.
Vascular SystemUpper Abdomen Vascular SystemUpper Abdomen
Vascular SystemAbdomen
Vascular SystemAbdomen
Internal BleedingHollow vs. Solid
Internal BleedingHollow vs. Solid
Intestines Kidneys
Abdominal TraumaAbdominal Trauma
What is peritonitis and sepsis?Peritonitis - Inflammation of peritoneum or ABD lining.
Sepsis - massive systemic infection. (includes hypotension, decreased urine output and
AMS)
Hollow organs can release digestive acids, enzymes, bacteria and partially digested food
(chyme) into the retroperitoneal space.
The DiaphragmThe Diaphragm
Penetrating TraumaPenetrating Trauma
Mentally visualize the path of all penetrating trauma of the abdomen and thorax.
Do NOT probe with fingers or instruments.
On the following picture, estimate the path of the bullet and the organs damaged based on
the location of the entrance wound.
Penetrating TraumaPenetrating Trauma
Were you right?Were you right?
Blunt TraumaBlunt Trauma
Why is blunt trauma so deadly?
Difficult to diagnose.
Objective evidence of blunt trauma may not appear on the casualty for hours.
People may assume they are “OK” when they are bleeding internally.
KinematicsKinematics
15% of stab wounds require surgical intervention.
(low energy)
KinematicsKinematics
85% of gunshot wounds require surgical intervention.
(medium and high energy)
Fragmentation wounds are the most common cause of penetrating injuries in combat.
Index of SuspicionIndex of Suspicion
What are important indicators for establishing a high index of suspicion for abdominal
injuries?
Obvious signs of trauma
Signs of hypovolemic shock without obvious cause
Degree of shock greater than would be expected by other injuries
Presence of peritoneal signs
Mechanism of injury
Want to Save Lives?Want to Save Lives?
The single most important decision you can make when assessing a casualty
with abdominal trauma is simply
deciding if there IS IS an injury.
The major cause of morbidity and mortality in abdominal trauma is the delay in determining
if an injury exists and the resulting delay in treatment.
Gather a HistoryGather a History
Position of vehicle and casualty?
Extent of damage?
Blast? Was the casualty thrown?
Blast pressure?
HistoryHistory
Type of weapon used? Casualty’s distance from
the weapon?
Was safety equipment used?
Physical ExaminationPhysical Examination
What is the most reliable indicator of intraabdominal bleeding?
The presence of hypovolemic shock from an unexplained source.
Should you auscultate trauma bellies in combat? Why or why not?
No. Regardless of your findings, casualty treatment before reaching the MTF will not change.
Physical ExaminationPhysical Examination
Inspection findings are NOT reliable indication of abdominal trauma.
Soft tissue injuries due to blunt trauma may not be apparent for hours after the injury.
An adult peritoneal cavity can hold up to
1.5 liters of fluid before evidence of
distention is apparent.
Physical ExaminationPhysical Examination
In a combat environment, how would you palpate the abdomen?
Light palpation of each quadrant.
Pain or rigidity in any quadrant of a combat casualty requires surgical exploration.
Why is deep palpation bad for combat trauma casualties?
It may dislodge blood clots, promote existing hemorrhage and increase spillage of contents of the
GI tract.
Check on your Learning…Check on your Learning…
The most reliable indicator or intraabdominal bleeding is?
The presence of hypovolemic shock from an unexplained source.
Why are soft tissue injuries not a good indication of intraabdominal bleeding?
They may not be apparent for hours after the injury.
Check on your Learning…Check on your Learning…
Describe the physical exam completed on a combat casualty with an abdominal injury. Why must the exam change compared to what you
learned during the Limited Primary Care module?
No auscultation.
Minimal Inspection (for penetrating trauma).
Light palpation of quadrants.
The tactical environment may not allow for a thorough examination.
Casualty ManagementCasualty Management
Assess and manage the H-ABCs.Initiate a saline lock.
Follow fluid resuscitation algorithm
Consider antibiotics.
In what position should the casualty be evacuated?
With knees bent, when possible.
You are the Medic…You are the Medic…Remove it?
No
What can be done?Stabilize manually or with
bulky dressings.
Should this abdomen be palpated?
NO
What if the area around the knife begins to bleed?Direct pressure on the
bleeding site
You are the Medic…You are the Medic…
How is the protruding segment protected?
If the wound is large consider putting contents back the
abdomen.
or
Wrap in plastic, cover with bandage.
or
Place moist dressings directly over segments with larger dry
bandage over top.
PregnancyPregnancy
The placenta and uterus are highly vascular and can result
in profound hemorrhage. - Can be concealed within the uterus.
- Casualty may lose 30% to 35% of total blood volume BEFORE
showing signs of hypovolemia(A late term pregnancy)
Vaginal bleeding secondary to trauma should be evacuated
expeditiously.
PregnancyPregnancyAverage profile by month.
Until about week 12, the uterus
remains protected by the pelvis
Systolic and diastolic blood pressure drop 5 to 15 mm Hg, but will return to normal by
term.
By the 36th week the mother's blood
volume has increased about
50%.
*
PregnancyPregnancy
What is the single most effective way to ensure survival of the fetus?
Aggressive resuscitation and transport of the mother
In what position are pregnant casualties
transported?
Transport the casualty on her left side
Local female approximately eight months pregnant.
Genitourinary InjuriesGenitourinary Injuries
Damage to the kidneys, ureters and bladder often present with hematuria, which will not be noted unless the casualty has a urinary catheter. (unlikely
in a combat environment)
Injuries to external genitalia result in hemorrhage, pain and psychological concern.
Control Hemorrhage.
Manage amputations to the best of your ability given the limited supplies in a combat environment.
Check on your Learning…Check on your Learning…
What options do you have when treating an abdominal evisceration?
A small plastic bag can be used in conjunction with an abdominal bandage. Wrap the plastic bag around the
intestines and cover with an abdominal dressing.
or
2. Apply moist dressings to the segment and an additional larger dry bandage.
(to protect the casualty from hypothermia)or
3. If the wound is large and you are able, put abdominal contents back into the hole in the abdomen and cover with
abdominal bandage.
Check on your Learning…Check on your Learning…
How should an obviously pregnant female be transported?
Transport the casualty on her left side, tilt the right side of the spine board, elevate the casualty's right
leg or manually displace the uterus to the left to relieve supine hypotension.
Check on your Learning…Check on your Learning…
What is the proper way to manage an amputated part?
(based on your EMT training )
Wrap in sterile gauze, place in a plastic bag, and keep the part cool.
How practical is this in a combat environment?Supplies may not be available and access to a cool
environment for the part may not practical.
Manage Abdominal Trauma Demonstration and Practical Exercise
With a partner, practice interventions for:
An impaled object.
An evisceration.
Questions?