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First Aid in Chest Injuries

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Definitions, problem recognition, and treatment for major chest injuries. Quick and easy

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First Aid in Chest Injuries

  1. 1. Chest Injuries First Aid and Treatment Options Anas Bahnassi PhD 5
  2. 2. Anas Bahnassi PhD CDM CDE 2
  3. 3. • External trauma to the chest: – Blunt – Penetrating • Possible damage to underlying organs: – Heart – Lungs • Possible spinal injury. • Chest injuries are responsible for 25% of trauma related deaths. Introduction
  4. 4. Tri-modal peak of Mortality 1st peak: Non- survivable severe CNS or CVS injuries Location of death: Pre- hospital environment 2nd peak: First few hours after injury, most often due to hypoxia and hypovolemic shock Usually can be saved 3rd peak: Within 6 weeks of injury Cause: Multisystem failure and sepsis
  5. 5. The Golden Hour • Treat the greatest threat to life first • Treat despite lack of a definitive diagnosis • Treat despite complete history
  6. 6. The Golden Hour • A = Airway with c-spine protection • B = Breathing • C = Circulation, stop the bleeding • D = Disability/Neurological status • E = Exposure and Environment
  7. 7. Three Stage Approach 1. Primary Survey: ABCDE – sequential yet actually simultaneous – includes resuscitation efforts – normalization of vital signs 2. Secondary Survey: – AMPLE history – head-to-toe and x-rays 3. Definitive Care: Specialist treatment of identified injuries
  8. 8. Primary Assessment ABCDE Injury Resuscitation Re-evaluation Secondary Survey Head-to-toe + X-Ray Re-evaluation Transfer Definitive Care
  9. 9. Initial Assessment Starting with the ABCDE A.Airway B.Breathing C.Circulation D.Disability E.Exposure and Environment
  10. 10. Airway: Preventable Deaths • Failure to recognize need • Inability to establish • Incorrectly placed airway • Displacement • Failure to ventilate • Aspiration
  11. 11. Airway: Problem Recognition • Objective Signs – Airway Obstruction: – agitation, cyanosis = hypoxia – obtundation = hypercarbia – abnormal sounds – tracheal location – external trauma
  12. 12. Airway: Problem Recognition • Altered Levels of Consciousness – closed head injury – intoxication • Maxillofacial Trauma – hemorrhage – dislodged teeth – mandible fracture
  13. 13. Airway: Problem Recognition • Penetrating Neck Trauma – laceration of trachea – hemorrhage with tracheal deviation/ obstruction – patient may initially maintain airway – prophylactic intubation?
  14. 14. Airway: Problem Recognition • Blunt Neck Trauma – hemorrhage with tracheal deviation/ obstruction – disruption of the larynx • hoarseness • subcutaneous emphysema • palpable fracture – prophylactic intubation?
  15. 15. Airway: Management Always Assume This…. So Do This…. C-Spine Stabilization
  16. 16. Airway: Management • Airway Maintenance Techniques: • chin lift • jaw thrust • oral airway • nasal trumpet • Definitive Airway: • orotracheal or nasotracheal intubation • surgical airway
  17. 17. Airway: Cricothyroidotomy Vertical skin incision – make it longer than you think you need….
  18. 18. Circulation: Preventable Deaths • Address: – Immediately Life-Threatening Chest Injuries: • Tension Pneumothorax • Open Pneumothorax (sucking chest wound) • Flail Chest • Disruption of Tracheo-Brochial tree – Potentially Life-Threatening Chest Injuries: • Pulmonary contusion • Diaphragmatic rupture • esophageal rupture
  19. 19. Check: 1. Vital signs 2. ECG 3. Pulse oximetry 4. End-Tidal Carbon Dioxide 5. Arterial Blood Gas 6. Urinary output 7. Urethral Catheterization 8. Nasogastric tube 9. Chest X-Ray 10.Pelvic X-Ray
  20. 20. Breathing: Problem Recognition Look Listen Feel Assess: Look • Respiratory rate • Shallow, gasping or labored breathing: Respiratory failure? • Cyanosis: Hypoxia • Paradoxical Respiration: ‘Pendulum’ breathing with asynchronisation of chest and abdomen: Respiratory failure or Structural damage. • Unequal chest inflation: Pneumothorax or Flail chest • Bruising or contusion: ‘Seat-Belt’ sign. • Penetrating chest injury • Distended neck veins: venous return-Tension pneumothorax or cardiac tamponade
  21. 21. Breathing: Problem Recognition Look Listen Feel Assess: LISTEN • Absent breath sounds: Apnoea or tension pneumothorax • Noisy breathing/ Crepitations/ Stridor/ Wheeze: Partially obstructed airway • Reduced air entry: Pneumothorax, Haemothorax, Heamo-pnemothorax, flail chest
  22. 22. Breathing: Problem Recognition Look Listen Feel Assess: FEEL • Tracheal deviation: Mediastinal shift • Tenderness: Chest wall contusion and/ rib fracture • Crepitus / Instabilty: Underlying rib fracture • Surgical emphysema: ‘Bubble-wrap’ sign
  23. 23. Breathing: Management The patient’s hemodynamic status dictates imaging and management. • Chest tube, chest tube, chest tube • Occlusive dressing • Ventilatory support • Thoracotomy?
  24. 24. Indications for thoracotomy 1. Internal cardiac massage 2. Control of haemorrhage from injury to the heart 3. Control of haemorrhage from injury to the lungs/intrapleural haemorrhage 4. Cardiac tamponade 5. Ruptured oesophagus 6. Aortic transection 7. Control of massive air leak 8. Traumatic diaphragmatic tear
  25. 25. Circulation: Preventable Deaths • Hypotension = Hemorrhage • Assess: – level of consciousness – pulse / skin color • Address: – external bleeding – massive hemothorax – cardiac tamponade – massive hemoperitoneum – unstable pelvic fracture
  26. 26. Circulation: Classes of Shock
  27. 27. Circulation: Classes of Shock Example: • 1 year old falls off the stairway (10 kg) • “lost ¾ cup of blood” • blood volume = 70cc/kg x 10kg • EBL = ¾ cup=6 oz=180cc • 180cc / 700cc = 25%blood loss • Class II/III shock
  28. 28. Circulation: Causes of Shock Hypovolemic = Hemorrhage: 5 spaces = chest, abdomen, pelvis, long-bones, street • Fractures: – rib = 100-200 cc – tibia = 300-500 cc – femur = 800-1200 cc – pelvis = 1500 and up
  29. 29. Circulation: Causes of Shock • Neurogenic: spinal cord injury • Septic • Cardiogenic: • tension Pnemothorax • cardiac tamponade or contusion • air embolism • primary cardiac disease
  30. 30. 30 Fractured Ribs: Problem Recognition • Pain at site which increases with movement or touch • Pain at site when breathing in • Difficulty breathing, Rapid shallow breathing • Rapid pulse • Bruising • Deformity • Bloody sputum • ‘Guarding’ of the injury
  31. 31. Fractured Ribs: Management • Primary survey - ABCDE • Position of comfort (often sitting position with the injured side downwards). • Stabilize the fracture site - Put the arm on the injured side in a ‘collar and cuff’ or a sling. • Seek medical aid • Provide supplemental oxygen if available • Observe for respiratory compromise 31
  32. 32. Fractured Ribs: Management • Reduction of pain with 2 week follow up • Analgesics : – Opiods – NSAID’s • Intercostal Blocks • Strapping of chest: relieves pain by immobilizing the ribs • Breathing exercises
  33. 33. Pneumothorax (collapsed lung) • Air enters the between the lungs and the inside of the chest wall (pleural space). • The air takes up space, causing a section of the lung to collapse. • If air continues to enter - tension pneumothorax. 33
  34. 34. 34 Pneumothorax: Problem Recognition • Severe chest pain • Breathing distress (Rapid, shallow breathing) • Rapid pulse • Bluish skin color (cyanosis) • Possible altered conscious state • Possible deviated windpipe (trachea) • Distended neck veins
  35. 35. 35 Pneumothorax: Management • Seek immediate medical aid, • Primary Survey • Oxygen provision • Resuscitation if required
  36. 36. 36 Flail Segment • When ribs and/or the breastbone are fractured in a number of places and result in a free-floating section of bone.
  37. 37. 37 Flail Segment: Problem Recognition • As for fractured rib but more severe • Paradoxical breathing • Mediastinal Flutter • Pendular Movement of air • Associated injuries: Pulmonary Contusion! • Hypoventilation
  38. 38. Flail Segment: Management • Primary Survey • Urgent medical assistance • Position of comfort. (This is often a sitting position with the injured side downwards). • Stabilize the fracture site as for a fractured rib • Provide supplemental oxygen 38
  39. 39. Open Chest Wound: Problem Recognition • Open wound to chest • Severe breathing difficulty • Rapid pulse • Sound of air being sucked in through wound 39
  40. 40. Open Chest Wound: Management • Urgent medical assistance • Position the victim in a sitting position with the injured side downwards • Cover the wound site with some air tight material (e.g. polythene). • This dressing needs to be taped on three sides with the bottom edge left free. This will stop air being sucked in but will allow trapped air to escape • Provide supplemental oxygen if able • Continuously monitor and reassure the victim • If the victim becomes unconscious, conduct a Primary Survey and take appropriate action 40
  41. 41. Clinical Pharmacy VI: First Aid abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi PhD CDM CDE

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