C191 w4tc cmast chest trauma management

Chest Trauma ManagementChest Trauma Management

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

CMASTCMAST 22

Chest injuries may result from:Chest injuries may result from:– Gunshot wounds (GSW)Gunshot wounds (GSW)

– ShrapnelShrapnel

– ExplosionsExplosions

– Motor vehicle crashes (MVC) Motor vehicle crashes (MVC)

– FallsFalls

– Crush injuriesCrush injuries

– Stab woundsStab wounds

GeneralGeneral

CMASTCMAST 33

Organs of the ThoraxOrgans of the Thorax

MyocardiumEpicardium

Endocardium

HeartHeart

CMASTCMAST 44

Organs of the ThoraxOrgans of the Thorax

TracheaTrachea BronchiBronchi LungsLungs

MediastinumMediastinum

CMASTCMAST 55

Organs of the AbdomenOrgans of the Abdomen

CMASTCMAST 66


Muscles

CMASTCMAST 77


DiaphragmDiaphragm

CMASTCMAST 88

Penetrating trauma.Penetrating trauma.– GSW or stab woundsGSW or stab wounds– Concentrates forces over smaller areaConcentrates forces over smaller area– Bullet trajectories unpredictable Bullet trajectories unpredictable

Blunt trauma.Blunt trauma.– Force distributed over larger areaForce distributed over larger area– Visceral injuries occur from:Visceral injuries occur from:

• DecelerationDeceleration• CompressionCompression• Sheering forcesSheering forces• BurstingBursting

Determine the MOIDetermine the MOI

CMASTCMAST 99

Assess the CasualtyAssess the Casualty Identify signs and symptoms:Identify signs and symptoms:

– Assess mental status (AVPU)Assess mental status (AVPU)– Assess the airwayAssess the airway– Assess the breathingAssess the breathing– Assess the circulationAssess the circulation

CMASTCMAST 1010

Signs Indicative of Chest InjurySigns Indicative of Chest Injury

Shock.Shock. Cyanosis.Cyanosis. Hemoptysis.Hemoptysis. Chest wall contusion.Chest wall contusion. Flail chest.Flail chest. Open wounds.Open wounds. Jugular vein distention (JVD).Jugular vein distention (JVD). Tracheal deviation.Tracheal deviation.

CMASTCMAST 1111

Assess RespirationsAssess Respirations

Respiratory rate and effort:Respiratory rate and effort:– TachypneaTachypnea– BradypneaBradypnea– LaboredLabored– RetractionsRetractions– Progressive respiratory distressProgressive respiratory distress

CMASTCMAST 1212

Assess the NeckAssess the Neck

Position of trachea.Position of trachea.

Subcutaneous Subcutaneous emphysema.emphysema.

JVD.JVD.

CMASTCMAST 1313

Assess the Chest WallAssess the Chest Wall

Contusions.Contusions. Tenderness.Tenderness. Asymmetry.Asymmetry. Open wounds or Open wounds or

impaled objects.impaled objects. Crepitation.Crepitation. Paradoxical movement.Paradoxical movement.

CMASTCMAST 1414


Lung sounds:Lung sounds:– Absent or decreasedAbsent or decreased

• UnilateralUnilateral• BilateralBilateral

– LocationLocation– Bowel sounds in Bowel sounds in

chest?chest?

CMASTCMAST 1515


Lung sounds – Percussion.Lung sounds – Percussion.– HyperresonanceHyperresonance

• PneumothoraxPneumothorax• Tension pneumothoraxTension pneumothorax

– Hyporesonance (hemothorax)Hyporesonance (hemothorax)

CMASTCMAST 1616


Compare both Compare both sides of the chest sides of the chest at the same time at the same time when assessing for when assessing for asymmetry.asymmetry.

CMASTCMAST 1717

Chest PhysiologyChest Physiology

Chest normally has negative pressure.Chest normally has negative pressure. Penetrating wound creates a positive Penetrating wound creates a positive

pressure in chest cavity.pressure in chest cavity. Air will enter the easiest route. If a hole in Air will enter the easiest route. If a hole in

the chest is smaller than 2/3 the size of the the chest is smaller than 2/3 the size of the trachea, air will enter through the trachea trachea, air will enter through the trachea preferentially and not through the hole in preferentially and not through the hole in the chest. the chest.

CMASTCMAST 1818

Open Pneumothorax Open Pneumothorax

Caused by penetrating Caused by penetrating

thoracic injury.thoracic injury.

May present as a May present as a

“sucking chest wound” “sucking chest wound”

if > 2/3 diameter of the if > 2/3 diameter of the

trachea.trachea.

CMASTCMAST 1919

Open Pneumothorax Open Pneumothorax

CMASTCMAST 2020

Open PneumothoraxOpen Pneumothorax

Click on picture for video

CMASTCMAST 2121

Open PneumothoraxOpen Pneumothorax

Click on picture for video

CMASTCMAST 2222

Open PneumothoraxOpen Pneumothorax Management:Management:

– Ensure an open airwayEnsure an open airway

– Close the chest wall defect, both entrance Close the chest wall defect, both entrance

and exit with an occlusive dressing, and exit with an occlusive dressing,

petrolatum gauze or Asherman Chest Sealpetrolatum gauze or Asherman Chest Seal®®

– Place the casualty in the sitting positionPlace the casualty in the sitting position

– Monitor respirations after an occlusive Monitor respirations after an occlusive

dressing is applieddressing is applied

CMASTCMAST 2323

Open Pneumothorax Open Pneumothorax Petroleum Gauze can also be used to seal Petroleum Gauze can also be used to seal a sucking chest wound.a sucking chest wound.

CMASTCMAST 2424

"Asherman Chest Seal"Asherman Chest Seal""

CMASTCMAST 2525

Tension PneumothoraxTension Pneumothorax

One-way valve One-way valve created from created from penetrating trauma. penetrating trauma.

Air enters thoracic Air enters thoracic space space but cannot escape. but cannot escape.

Pressure builds:Pressure builds:

CMASTCMAST 2626


If after sealing the open pneumothorax, the If after sealing the open pneumothorax, the casualty develops progressive difficulty casualty develops progressive difficulty breathing, consider this a tension pneumothorax breathing, consider this a tension pneumothorax and perform a needle chest decompression.and perform a needle chest decompression.

If no capability of NCD exists and the casualty If no capability of NCD exists and the casualty continues to have progressive respiratory continues to have progressive respiratory distress, remove the occlusive dressing and distress, remove the occlusive dressing and stick a gloved finger into the open wound and stick a gloved finger into the open wound and attempt to “burp” the wound.attempt to “burp” the wound.

CMASTCMAST 2727


Air pushes over heart and collapses lung

Heart compressed not able to pump well

Air outside lung from wound

CMASTCMAST 2828


Clinical presentation:Clinical presentation:– Anxiety, agitation, apprehensionAnxiety, agitation, apprehension– Diminished or absent breath soundsDiminished or absent breath sounds– Increasing dyspnea with cyanosisIncreasing dyspnea with cyanosis– TachypneaTachypnea– Hyperresonance to percussion on affected Hyperresonance to percussion on affected

sideside– Hypotension, cold clammy skinHypotension, cold clammy skin– Casualty begins to deteriorate rapidly Casualty begins to deteriorate rapidly

CMASTCMAST 2929


Clinical presentation (cont’d):Clinical presentation (cont’d):– JVD and cyanosis JVD and cyanosis – Decreased lung compliance (intubated)Decreased lung compliance (intubated)– Tracheal deviation (Tracheal deviation (latelate))

* These signs are hard to detect in a combat * These signs are hard to detect in a combat environment.environment.

CMASTCMAST 3030


Management:Management:– Ensure an open airwayEnsure an open airway– Decompress the affected sideDecompress the affected side

Indications:Indications:– Penetrating chest wound with progressive Penetrating chest wound with progressive

respiratory distressrespiratory distress

CMASTCMAST 3131

Needle Chest DecompressionNeedle Chest Decompression Procedure:Procedure:

Identify the second ICS on the anterior chest Identify the second ICS on the anterior chest wall, MCL:wall, MCL:

CMASTCMAST 3232

Needle Chest DecompressionNeedle Chest Decompression

Prep the area with an Prep the area with an antimicrobial agent.antimicrobial agent.

Insert a 14 ga. Catheter at Insert a 14 ga. Catheter at a 90 a 90 angle over the top of angle over the top of the 3 the 3rdrd rib, into the 2 rib, into the 2ndnd ICS ICS at the MCL. at the MCL.

Needle should be long Needle should be long enough to enter the chest enough to enter the chest cavity (2cavity (2½½ – 3 inches). – 3 inches).

CMASTCMAST 3333


If a tension pneumothorax is present, If a tension pneumothorax is present, a “hiss of air” may be heard escaping a “hiss of air” may be heard escaping from the chest cavity. from the chest cavity.

Remove the needle, leave the catheter in place.Remove the needle, leave the catheter in place.

CMASTCMAST 3434


Tape the catheter hub to the chest wall.Tape the catheter hub to the chest wall. The casualty's condition should rapidly improve.The casualty's condition should rapidly improve. Evacuate ASAP.Evacuate ASAP.

CMASTCMAST 3535

Needle Chest DecompressionNeedle Chest Decompression Questions:Questions:

– Over top or bottom of Over top or bottom of rib? Why?rib? Why?

– What if casualty doesn't have What if casualty doesn't have a tension pneumothorax and you perform a tension pneumothorax and you perform NCD?NCD?

• Already has hole(s) in chestAlready has hole(s) in chest• Probably larger than diameter of 14 ga. needleProbably larger than diameter of 14 ga. needle• No additional damageNo additional damage

CMASTCMAST 3636


Questions:Questions:– Will lung re-inflate after pressure is released Will lung re-inflate after pressure is released

from chest cavity?from chest cavity?

– No; to re-inflate the lung you must have a No; to re-inflate the lung you must have a chest tube with suction and or positive chest tube with suction and or positive pressure ventilation.pressure ventilation.

CMASTCMAST 3737


Questions:Questions:– So if the NCD does not re-inflate the lung So if the NCD does not re-inflate the lung

what does it do?what does it do?

– We are simply converting a tension We are simply converting a tension pneumothorax to a standard pneumothorax; pneumothorax to a standard pneumothorax; this is much more survivable than a tension this is much more survivable than a tension pneumothorax.pneumothorax.

CMASTCMAST 3838


Complications:Complications:– Insertion of the needle over the top of the rib Insertion of the needle over the top of the rib

prevents laceration of the intercostal vessels prevents laceration of the intercostal vessels or nerve which can cause hemorrhage or or nerve which can cause hemorrhage or nerve damage.nerve damage.

CMASTCMAST 3939

SummarySummary

Injuries to the chest are fewer in nature Injuries to the chest are fewer in nature secondary to modern body armor; secondary to modern body armor; however, it doesn't protect 100%.however, it doesn't protect 100%.

Penetrating wounds to the chest can be Penetrating wounds to the chest can be rapidly fatal if not identified early and rapidly fatal if not identified early and treated appropriatelytreated appropriately..

CMASTCMAST 4040

Questions?Questions?

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C191 w4tc cmast chest trauma management