CONDELL MEDICAL CENTER EMS CONTINUING EDUCATION APRIL, 2003

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CONDELL MEDICAL CENTER EMSCONTINUING
EDUCATIONAPRIL, 2003

• TRAUMA IDENTIFICATION INTERVENTIONS CHEST
  TRAUMA
• Kathi Knop, RN, PHRN
• EMS Educator, Good Shepherd Hospital

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Incidence of Chest Trauma

• Cause of 1 in every 4 trauma deaths in US
• 12,000/yr. (25 of MVC deaths)
• Divided into Blunt Penetrating
• Proper emergency care resuscitation integral
  parts of management of these patients

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Anatomical Structures

• Structures damaged/involved in trauma to the
  Chest
• Heart
• Lungs
• Aorta
• Esophagus
• Venacava
• Bronchi
• Trachea

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PENETRATING CHEST TRAUMA

• Wounds where an object penetrates chest wall
  creates opening into thoracic cavity
• Gunshot stab wounds most common
• Stab wounds historically most common
• Increase in crime criminal activity means
  number of gunshot wounds is on the rise
• Knowledge of type of weapon (guns) is useful
• Unbalanced/hollow point can cause extensive
  internal destruction with small entrance wounds

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Stab Wound To Left Ventricle
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ENERGY OF WOUNDS

• Low energy wounds caused by arrows, knives, and
  other slow moving objects
• High-energy wounds caused by hunting military
  rifles that create a missile of high velocity and
  high kinetic energy.
• Create extensive tissue damage by shock wave,
  tissue movement larger temporary cavity.

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GUNSHOT TO HEAD
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GUNSHOT WOUND TO CHEST
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BULLET THROUGH COKE CAN
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BULLET FRAGMENTS (SKULL)
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SUICIDE BY GUNSHOT
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BLUNT CHEST TRAUMA

• A force propelled onto the chest wall that does
  not leave an open wound
• MVCs account for almost 90 of all blunt chest
  trauma
• Risk is reduced by shoulder/lap belt and air bags
  (frontal crashes)

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FRONTAL IMPACT!
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Other Causes of Blunt Chest Injuries

• Falls
• Sports Injuries
• Crush Injuries
• Acts of Violence

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CATEGORIES OF BLUNT CHEST TRAUMA

• Acceleration Increase in rate of speed or
  velocity of a moving object
• Deceleration Decrease in rate of speed or
  velocity (MVC)
• Shearing Stretching forces applied at a
  90-degree angle
• Compression Direct Blow to Chest

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DEADLY THREATS

• IMMEDIATE LIFE THREATS
• AIRWAY OBSTRUCTION
• TENSION PNEUMOTHORAX
• OPEN PNEUMOTHORAX
• FLAIL CHEST
• CARDIAC TAMPONADE

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Causes of Tension Pneumothorax

• Injury to the chest wall, lung or bronchus.
• Open injury to the chest wall allowing air to
  enter but not escape.(sucking chest wound.)
• Air continuously leaks out of the lung into the
  pleural space
• Pressures in cavity rise/collapsed lung presses
  against heart lung on opposite side

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MORE ON TENSION

• Remaining uninjured lung is compressed
• Rising pressure may exceed normal pressure of
  blood in veins returning to heart which cannot
  travel to heart
• DEATH CAN FOLLOW RAPIDLY
• May develop after sealing an open chest wound

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Stages of Tension Pneumothorax Development

• Early signs
• Unilateral decreased air entry, increase in
  dyspnea in spite of treatment.
• Progressive signs
• Increased respirations, with subcutaneous
  emphysema. Difficulty in ventilating.
• Late signs
• Jugular venous distention, tracheal
  deviation, acute hypoxia, narrowing pulse
  pressure, increased respirations and
  decompensated shock.

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Treatment of Tension Pneumothorax

• Scene safety, as well as personal safety.
• Airway Open, maintain and protect. Decompress
  chest.(Anteriorly- 2nd or 3rd intercostal space.
• Assist ventilations if required, with 100 O2.
• Vital signs and ECG monitoring.
• Administer large amounts of fluid to compensate
  for shock.
• Treat associated injuries and anticipate spinal
  injuries.

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TENSION PNEUMO ON FILM
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NEEDLE DECOMPRESSION

• Use Standard Precautions.
• Recognize indications for procedure.
• Prepare equipment. Apply flutter valve.
• Palpate site at 2nd or 3rd intercostal space,
  mid-clavicular line.

• Clean site appropriately.
• Insert 3 12 or 14 gauge needle along the
  superior border of 3rd to 4th rib until air
  released.
• Remove stylet.
• Check for improvement in clinical status.
• Secure catheter/flutter valve.
• Reassess ventilations/patient status.

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TENSION PNEUMO
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OPEN PNEUMOTHORAX

• Open sucking chest wound allows free passage of
  air into out of pleural space
• If opening is 2/3 diameter of trachea (pts.
  pinky) air passes through chest defect with
  respiratory effort (path of least resistance)

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AND.

• Effective Ventilation is impaired leading to
  hypoxia
• Air replaces lung tissue/ lung collapses leaving
  dead space
• Frothy blood may be around opening
• CAN DEVELOP TENSION IF IMPROPERLY SEALED!

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SIGNS AND SYMPTOMS

• Obvious Wound with sucking sound on inspiration
• Dyspnea
• Decreased/absent breath sounds on affected side
• Frothy blood at opening

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SUCKING CHEST WOUND
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TREATMENT

• 100 O2
• Promptly close wound with sterile occlusive
  dressing taped on three sides only
• Rapid transport for definitive treatment (chest
  tube-surgery?)
• Watch closely, may have to Burp to prevent
  Tension

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THREE SIDED SEAL
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FLAIL CHEST

• Segment of chest that does not have continuity
  with the rest
• Free to move with pressure changes of breathing
• Caused by 3 or more adjacent rib fractures in 2
  or more places

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FLAIL
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SIGNS/SYMPTOMS

• Dyspnea
• Paradoxical chest wall movement
  (asymmetrical/uncoordinated)
• Poor air movement
• Crepitus of ribs
• Hypoxia
• Cyanosis

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TREATMENT (PER BTLS)

• High Flow Oxygen
• Fluid resuscitation if hypotensive
• Pain management (Morphine)
• Intubation with positive pressure ventilations
  may be necessary to stabilize flail section
• Rapid transport to appropriate facility

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HOW IT WORKS.
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CARDIAC TAMPONADE

• More prevalent with penetrating trauma
• Blood enters pericardial sac, which doesnt
  stretch and normally holds 20-35 cc fluid to
  cushion
• Exerts pressure on the heart increases venous
  pressure (JVD)

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AND..

• Decreases cardiac outputs causing hypotension
• Immediate danger is from compression of heart
  muscle which decreases CO
• Common mechanisms rapid horizontal deceleration
  (MVC)

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AS WELL AS..

• Rapid vertical Deceleration (falls from heights)
• Significant impact to chest wall
  (sporting/recreational accidents)
• The slower the bleeding, the longer the patient
  can tolerate this.

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Signs and Symptoms of Cardiac Tamponade

• Becks Triad Muffled heart sounds, Increased JVD
  and decreased blood pressure.
• Tachycardia and hypovolemic shock.
• Diminished QRS complexes.

• Narrowing pulse pressure (difference between
  systolic and diastolic, lt15mm Hg is critical)
• Pulsus paradoxus (loss of peripheral pulses
  during inspiration). Very difficult to detect in
  the field

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OTHER HINTS.

• PEA may be the cause of cardiac arrest
• Conduction of heart intact but mechanics have
  failed
• Sometimes confused with tension pneumo- MOI the
  same but
• BREATH SOUNDS WILL BE EQUAL INSTEAD OF ABSENT IN
  TENSION

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Treatment of Pericardial Tamponade

• Scene safety and safety to yourself.
• Airway Open, maintain and protect, maintain
  cervical spine control.
• Assist ventilations with 100 O2.
• I.V fluid replacement, large amounts of fluid to
  be done enroute to hospital.(Frank Starlings
  Law).
• Keep BP between 90-100mmHg.
• Rx associated injuries with complete spinal
  immobilization even though this patient has a
  very weak prognosis.

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OTHER FACTS TO KNOW

• Definitive care in ER is pericardiocentesis
  (Needle inserted below xyphoid process into sac)
• Even a small amount of blood withdrawn makes a
  dramatic improvement in condition
• Pericardial sac is self-sealing afterwards
• Mortality rate is 50
• Keep a high index of suspicion!

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POTENTIAL LIFE THREATS- The Rest of the Deadly
Threats

• Simple pneumo/hemothorax
• Aortic Rupture
• Tracheobronchial Rupture
• Blunt Cardiac Injury
• Diaphragmatic Rupture

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MASSIVE HEMOTHORAX

• Rapid accumulation of blood in the pleural space
  (gt1500 CCs)

• Causes
• Blunt trauma (deceleration injury)
• Rib Fractures
• Lung laceration
• Laceration of great vessels

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AND

• Bleeding is rapid.
• Each side of thorax can hold 3000 ml (l/2 total
  blood volume.
• Tidal vol. is reduced.

• Hypovolemia ensures.
• Mortality rate is 75.
• Most patients die at the scene.

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SIGNS AND SYMPTOMS

• Dyspnea
• Chest pain
• Dullness on affected side

• Decreased breath sounds on affected side (may
  sound distant)
• Tracheal shift
• Signs/symptoms of shock

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TREATMENT

• Aggressive fluid infusion through large bore
  IVs.
• Pleural decompression.
• Rapid transport to definitive care (CHEST TUBE
  WITH DRAINAGE OF THE PLEURAL CAVITY).

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MASSIVE HEMOTHORAX
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AORTIC INJURIES

• Most common cause of death after blunt chest
  trauma
• Usually die at the scene. 15-20 may survive to
  arrive at the ER
• Deceleration forces cause shearing within vessel
  compression of the vessel against spinal column

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COMMON LOCATIONS

• Aortic isthmus distal to ligamentum arteriosum
• Ascending aorta where aorta leaves pericardial
  sac
• Lower part of the aorta above diaphragm
• Junction of innominate artery with aortic arch

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MOST OCCUR AT THE ISTHMUS
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SIGNS/SYMPTOMS

• Suspect rupture in high speed MVC or falls from
  heights
• Presence of sternal/1st rib fractures highly
  suggestive of aortic injury due to the profound
  force it takes to fracture

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LOOK FOR..

• Hypotension
• Decreased LOC
• Isolated upper arm hypertension/variation right
  to left
• Absent/weakened lower extremity pulses
• Dyspnea/respiratory distress
• Chest wall ecchymosis
• Crepitus of ribs (1st,2nd,3rd) on left side.

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ALL YOU CAN DO.

• High flow oxygen
• Fluid Resuscitation
• Rapid Transport for surgery
• If complete rupture occurs during transport,
  there is nothing the medical crew can do to
  prevent death

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SOMETHING DIFFERENT
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ADULT IV CONSCIOUS SEDATION THE DRUGS

• Head Injury Lidocaine 1.5 mg/kg IVP to manage
  ICP
• Pain Morphine 2 mg slow IVP, titrate in 2 mg
  increments to 10 mg maximum
• If gag reflex present Benzocaine spray or
  equivalent to posterior pharynx

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AND OF COURSE, VERSED!

• Dose
• 2 mg slow IVP
• If not sedated in 60 seconds
• 2 mg slow IVP every 60 seconds until sedated up
  to 10 mg maximum

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ASPIRATION PNEUMONIA

• Primarily caused by impaired airway protection
  which occurs in patients with altered LOC
• Extent severity depends on volume acidity of
  aspirated material
• Even small volume of acidic material may cause
  severe pneumonitis

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SIGNS AND SYMPTOMS

• May occur without knowledge of EMS
• Rales
• Cough
• Cyanosis
• Wheezing
• Fever

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THOSE AT RISK

• Anyone with decreased LOC
• Patients requiring assistance with respirations
  (BVM)
• Patients requiring intubation (especially with
  conscious sedation)
• Signs/symptoms may not be apparent until patient
  arrives at hospital

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WAYS TO PREVENT ASPIRATION

• Position Pt. HOB at 30 degrees if no trauma
  involved
• Turn patient to side.
• Suction, Suction, Suction
• Check blink to assess for gag reflex

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PREVENTION

• Any patient requiring assisted ventilation or
  intubation should receive cricoid pressure
  (Sellicks maneuver)
• Maneuver described by Brian A. Sellick,
  anesthesiologist in London in early 1960s
• Initiate during pre-oxygenation (BVM)

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DONT LET GO!!!!

• Cricoid Pressure should not be released until the
  patient has been successfully intubated and the
  cuff is inflated
• The primary purpose of this maneuver is to
  prevent aspiration
• Use it when bagging patient that is not intubated

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THIS PRACTICE

• Prevents regurgitation of gastric contents
• Assists with visualization of cords (secondary
  function)
• Reduces gastric distension (which promotes
  regurgitation)
• Controversy over whether to release in presence
  of active vomiting

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TECHNIQUE

• Find prominent thyroid cartilage (Adams apple)
• Find soft depression below Adams apple
• Find hard prominence below soft depression
• Apply firm pressure while pinching with thumb and
  index finger toward back and head

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HOW IT WORKS

• CRICOID PRESSURE PUSHES THE TRACHEAL ORIFICE
  BACKWARD AND MORE INTO THE VISUAL FIELD OF THE
  PERSON INTUBATING
• RELEASE PRESSURE ONLY WHEN PROPER TUBE PLACEMENT
  IS CONFIRMED AND THE TUBE CUFF IS INFLATED

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ANY QUESTIONS????
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