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C191 w4tc cmast chest trauma management


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C191 w4tc cmast chest trauma management

  2. 2. General Chest injuries may result from: – Gunshot wounds (GSW) – Shrapnel – Explosions – Motor vehicle crashes (MVC) – Falls – Crush injuries – Stab wounds CMAST 2
  3. 3. Organs of the Thorax Heart Epicardium Myocardium CMAST 3
  4. 4. Organs of the Thorax Trachea Bronchi Lungs Mediastinum CMAST 4
  5. 5. Organs of the Abdomen CMAST 5
  6. 6. Organs of the Abdomen Muscles CMAST 6
  7. 7. Organs of the Abdomen Diaphragm CMAST 7
  8. 8. Determine the MOI Penetrating trauma. – GSW or stab wounds – Concentrates forces over smaller area – Bullet trajectories unpredictable Blunt trauma. – Force distributed over larger area – Visceral injuries occur from: • Deceleration • Compression • Sheering forces • Bursting CMAST 8
  9. 9. Assess the Casualty Identify signs and symptoms: – Assess mental status (AVPU) – Assess the airway – Assess the breathing – Assess the circulation CMAST 9
  10. 10. Signs Indicative of Chest Injury Shock. Cyanosis. Hemoptysis. Chest wall contusion. Flail chest. Open wounds. Jugular vein distention (JVD). Tracheal deviation. CMAST 10
  11. 11. Assess Respirations Respiratory rate and effort: – Tachypnea – Bradypnea – Labored – Retractions – Progressive respiratory distress CMAST 11
  12. 12. Assess the Neck Position of trachea. Subcutaneous emphysema. JVD. CMAST 12
  13. 13. Assess the Chest Wall Contusions. Tenderness. Asymmetry. Open wounds or impaled objects. Crepitation. Paradoxical movement. CMAST 13
  14. 14. Assess the Chest Wall Lung sounds: – Absent or decreased Unilateral Bilateral – Location – Bowel sounds in chest? CMAST 14
  15. 15. Assess the Chest Wall Lung sounds – Percussion. – Hyperresonance Pneumothorax Tension pneumothorax – Hyporesonance (hemothorax) CMAST 15
  16. 16. Assess the Chest Wall  Compare both sides of the chest at the same time when assessing for asymmetry. CMAST 16
  17. 17. Chest Physiology Chest normally has negative pressure. Penetrating wound creates a positive pressure in chest cavity. Air will enter the easiest route. If a hole in the chest is smaller than 2/3 the size of the trachea, air will enter through the trachea preferentially and not through the hole in the chest. CMAST 17
  18. 18. Open Pneumothorax Caused by penetrating thoracic injury. May present as a “sucking chest wound” if > 2/3 diameter of the trachea. CMAST 18
  19. 19. Open Pneumothorax CMAST 19
  20. 20. Open Pneumothorax Click on picture for video CMAST 20
  21. 21. Open Pneumothorax Click on picture for video CMAST 21
  22. 22. Open Pneumothorax Management: – Ensure an open airway – Close the chest wall defect, both entrance and exit with an occlusive dressing, petrolatum gauze or Asherman Chest Seal® – Place the casualty in the sitting position – Monitor respirations after an occlusive dressing is applied CMAST 22
  23. 23. Open Pneumothorax Petroleum Gauze can also be used to seala sucking chest wound. CMAST 23
  24. 24. "Asherman Chest Seal " CMAST 24
  25. 25. Tension Pneumothorax One-way valve created from penetrating trauma. Air enters thoracic space but cannot escape. Pressure builds: CMAST 25
  26. 26. Tension Pneumothorax If after sealing the open pneumothorax, the casualty develops progressive difficulty breathing, consider this a tension pneumothorax and perform a needle chest decompression. If no capability of NCD exists and the casualty continues to have progressive respiratory distress, remove the occlusive dressing and stick a gloved finger into the open wound and attempt to “burp” the wound. CMAST 26
  27. 27. Tension PneumothoraxAir pushes over heartand collapses lung Air outside lung from wound Heart compressed not able to pump well CMAST 27
  28. 28. Tension Pneumothorax Clinical presentation: – Anxiety, agitation, apprehension – Diminished or absent breath sounds – Increasing dyspnea with cyanosis – Tachypnea – Hyperresonance to percussion on affected side – Hypotension, cold clammy skin – Casualty begins to deteriorate rapidly CMAST 28
  29. 29. Tension Pneumothorax Clinical presentation (cont’d): – JVD and cyanosis – Decreased lung compliance (intubated) – Tracheal deviation (late) * These signs are hard to detect in a combat environment. CMAST 29
  30. 30. Tension Pneumothorax Management: – Ensure an open airway – Decompress the affected side Indications: – Penetrating chest wound with progressive respiratory distress CMAST 30
  31. 31. Needle Chest Decompression Procedure:  Identify the second ICS on the anterior chest wall, MCL: CMAST 31
  32. 32. Needle Chest Decompression Prep the area with an antimicrobial agent. Insert a 14 ga. Catheter at a 90 angle over the top of the 3rd rib, into the 2nd ICS at the MCL. Needle should be long enough to enter the chest cavity (2½ – 3 inches). CMAST 32
  33. 33. Needle Chest Decompression If a tension pneumothorax is present, a “hiss of air” may be heard escaping from the chest cavity. Remove the needle, leave the catheter in place. CMAST 33
  34. 34. Needle Chest Decompression Tape the catheter hub to the chest wall. The casualtys condition should rapidly improve. Evacuate ASAP. CMAST 34
  35. 35. Needle Chest Decompression Questions: – Over top or bottom of rib? Why? – What if casualty doesnt have a tension pneumothorax and you perform NCD? • Already has hole(s) in chest • Probably larger than diameter of 14 ga. needle • No additional damage CMAST 35
  36. 36. Needle Chest Decompression Questions: – Will lung re-inflate after pressure is released from chest cavity? – No; to re-inflate the lung you must have a chest tube with suction and or positive pressure ventilation. CMAST 36
  37. 37. Needle Chest Decompression Questions: – So if the NCD does not re-inflate the lung what does it do? – We are simply converting a tension pneumothorax to a standard pneumothorax; this is much more survivable than a tension pneumothorax. CMAST 37
  38. 38. Needle Chest Decompression Complications: – Insertion of the needle over the top of the rib prevents laceration of the intercostal vessels or nerve which can cause hemorrhage or nerve damage. CMAST 38
  39. 39. Summary Injuries to the chest are fewer in nature secondary to modern body armor; however, it doesnt protect 100%. Penetrating wounds to the chest can be rapidly fatal if not identified early and treated appropriately. CMAST 39
  40. 40. Questions? CMAST 40