Chest Trauma Management

Thoracic and Abdominal Trauma

Chest Trauma Management

Department of Combat Medic Training

C168W014

Thoracic TraumaThoracic Trauma


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



PleuraPleura

Rib

Rib

PleuraPleura

Rib

Rib

Lung

Visceral Pleura

Parietal Pleura

Pleural Space


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


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


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


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.


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.


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



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.


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


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.


To Vent or

Not to Vent?


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.


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


What if the casualty is hairy?Shave or use tape to remove hair


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.


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


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)


In what phase of care should a tension pneumothorax be treated?

Tactical Field Care


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


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


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


Mid Clavicular

Line


Find your Second Intercostal Space.


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


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.


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.


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


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


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


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


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.


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.


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.


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.


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.


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.


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.


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?

Education

Chest Trauma Management