Transcript FIELD MEDICAL SUSTAINMENT TRAINING - NH-TEMS

FIELD MEDICAL SUSTAINMENT
TRAINING
Terminal Learning Objectives
Reacquaint Corpsmen with basic triage
and lifesaving skills.
 Recognize potential life threatening
injuries, treat and prevent shock.
 In a field environment treat and asses
combat casualties and prepare for
MEDEVAC.
 Properly insert and secure an intravenous
catheter.

TRAIN HARD, FIGHT
EASY… AND WIN.
TRAIN EASY, FIGHT
HARD AND DIE.
SHOCK

DEFINITION – A state of inadequate
tissue perfusion, which causes cellular
metabolic oxygen demands to exceed the
supply
HYPOVOLEMIC SHOCK

DEFINITION – A type of shock
characterized by an inadequate perfusion
of the body due to volume loss within the
circulatory system. This is the most
common form of shock seen in the combat
/ field / tactical environment.
CAUSES:
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External loss of whole blood – i.e. hemorrhage
Loss of plasma – i.e. severe burns
Loss of extra cellular fluids – i.e. gastrointestinal
fluids lost through vomiting or diarrhea
Internal hemorrhage
Third Space losses – fluid moves from vascular
system into the tissues, i.e. edema
SIGNS / SYMPTOMS

Signs and symptoms seen with hypovolemic shock are usually linked
with the amount of fluid lost. However, these parameters are only
guidelines and should not be taken as absolute amounts.
Class I – Initial Stage
1) The circulatory blood volume is decreased but not enough to
cause serious effects.
2) Blood volume reduction up to 10% or
3) Clinical Findings
(a) No clinical findings
approximately 500 cc’s
Class II – Compensatory Stage
Although the circulating blood volume is
reduced, compensatory mechanisms are
able to maintain blood pressure and tissue
perfusion at a level sufficient to prevent
cellular damage
 Blood volume reduction from 15 – 25% or
approximately 750 – 1250 cc’s

Clinical Findings
Minimal tachycardia (heart rate up to 100
– 105)
 Slight decrease in blood pressure
 Mild evidence of peripheral
vasoconstriction with cool hands and feet

Class III – Progressive Stage or
Decompensated Shock
At this point, unfavorable signs begin to
appear. The body’s compensatory
systems can no longer maintain adequate
perfusion with the continued blood loss.
 Blood volume reduction from 25 – 35 % or
approximately 1250 - 1750 cc’s

Clinical Findings:
Tachycardia (heart rate 105 – 120 beats
per minute)
 Decrease in pulse pressure
 Systolic pressure, 70 – 100 mm Hg
 Restlessness
 Increased Sweating
 Pallor
 Oliguria (decreased urine output)

Class IV – Irreversible Stage
Even though the blood volume may be
restored and vital signs stabilized, death is
imminent
 Blood volume reduction from 35 to 50%
or approximately 1750 – 2500 cc’s

Clinical Findings
Tachycardia over 120 beats per minute
 Blood pressure below 60 mmHg systolic
and frequently unobtainable by cuff
 Mental stupor
 Extreme pallor
 Cold extremities
 Anuria (no urine output)
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TREATMENT:
Identify the source of the fluid loss and
correct the problem
 Control gross bleeding – direct pressure,
pressure bandaging, pressure points,
tourniquets
 Anti-emetics to control vomiting
 Anti-diarrhea medications to control
diarrhea

TREATMENT:
Restore intravascular volume
 Fluid and electrolyte replacement (3 cc’s of a
crystalloid fluid (LR, NS) for every 1 cc of blood
lost) – available at the BAS.
 Whole blood replacement – 1 cc of whole blood
for every 1 cc of blood lost)
 Blood Substitute Product replacement – i.e.
Hespan. Dosing is 250 - 500 cc’s at a time.
Maximum allowable in 24 hours is 1500 cc’s.
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TREATMENT
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Elevate lower extremities
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Trendelenburg positioning
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Keep the patient warm
BURNS
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Thermal burns are not an uncommon
injury on the modern battlefield. They can
result from exposure to flame weapons
and devices (napalm and white
phosphorous), or from explosions from
fuel sources (gasoline, diesel, and jet
fuel).
BURNS
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The severity of the burns experienced by
the patient will vary greatly, depending on
the source of the burn, the amount of
time the patient was exposed to the
agent, and the location of the burn.
CLASSIFICATIONS OF BURNS

Burns can be categorized by two methods:
1) The depth of the burn
2) Total Body Surface Area (TBSA)
affected by the burn
First Degree Burn / Superficial Burn
 Definition
– a burn that involves only
the epidermis
Sign / Symptoms

Skin is dry and erythematous
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Pain to site
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The burned area blanches with pressure
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Edema (if present) will be minimal
Second Degree Burn / Partial
Thickness Burns
 Definition
– a burn in which the
epidermis is burned through and the
dermis is damaged
Sign / Symptoms
Deep, intense pain
 Skin is moist
 Skin will be hyperemic in color
 Blister formation
 Edema will be moderate
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Third Degree Burn / Full Thickness
Burn
 Definition
– a burn in which all the
layers of the skin are damaged
Sign / Symptoms
Skin has a dry, leathery appearance
 The skin can range in color from pale
yellow to cherry red, brown, or carbon
black
 Severe pain around periphery of burn, but
little to no pain near center of burn
 Will see First and Second Degree burns
surrounding the Third Degree Burn
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Total Body Surface Area (TBSA)
affected by the burn
Burns can be categorized by the
percentage of body surface damaged by
the burn
 Two Methods for Estimating the Total Body
Surface Area (TBSA) affected by Burns:
RULE OF NINES and RULE OF PALMS

Rule of Nines (RON)
The Rule of Nines divides the TBSA into
areas compromising 9% or multiples of
9%, except for the peritoneum which is
equal to 1% TBSA.
 The Rule of Nines is an estimate and is
most useful for adults and children over
the age of 10
 The Rule of Nine’s is helpful for estimating
the TBSA of large or regularly shaped
burns

Rule of Palm’s (ROP)
The Rule of Palm’s assumes that the palm
size of the patient represents
approximately 1% of the TBSA. TBSA is
then estimated by approximating the
number of “palms” it would take to
completely cover the burn
 The rule of Palm’s is helpful for estimating
the TBSA of small or irregularly formed
burns
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TYPES OF BURNS
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INHALATION BURNS
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THERMAL BURNS
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INDUSTRIAL OR CHEMICAL BURNS
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ELECTRICAL BURNS
INHALATION BURNS
Definition – burns in the upper and lower
airways, caused by the inspiration of heat,
toxic, chemicals, smoke, or other gases
 Cause:
1. Heat inhalation
2. Inhalation of toxic chemicals or smoke
3. Inhalation of carbon monoxide gas
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Signs / Symptoms
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Dyspnea
Tachypnea
Coughing
Stridor
Hoarseness
Sooty Sputum
Abnormal Lung Sounds – crackles,
wheezes, or rhonchi may be present
Signs / Symptoms
Burns to the oral and/or pharyngeal
mucous membranes
 Singed nasal hairs
 Facial burns
 Tachycardia
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Treatment
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Maintain the patient’s ABC’s
Adjunctive airways may be used if respiratory
distress occurs
Endotracheal intubation for severe respiratory
distress
Emergency cricothyroidotomy if edema causes
airway obstruction
Administer humidified oxygen if available
Place the patient in an upright position
Evacuate
THERMAL BURNS
Definition – tissue injury caused by
exposure to extreme radiant heat
 Causes
1. Scalding liquids
2. Steam or other hot gases
3. Contact with hot objects
4. Fire
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Sign / Symptoms
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Signs and symptoms with thermal burns
are the same as for First, Second, and
Third degree burns
Treatment
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Remove the patient from the source of injury
Maintain the patient’s ABC’s
Remove any material that could continue the
burning process (oils, burned clothing, etc.)
First degree burns – immersion in cool water or
the application of cool compresses
Second degree burns – initially, place in cool
water or apply cool compresses. Dry, bulky
dressing can be applied later.
Administer oxygen therapy if available
Protect the patient from heat loss and possible
hypothermia
Treat for shock
INDUSTRIAL OR CHEMICAL BURNS
Definition – occur when the patient comes
in direct contact with caustic chemical
agents
 Cause:
Acids /Alkalies
Petroleum Based Products
 Military Causes:
Napalm
White Phosphorous
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Sign / Symptoms
Sign / Symptoms are influenced by the
length of contact, the concentration of the
chemical, and the amount of chemical
 Erythema
 Edema
 Blisters
 Tissue necrosis
 Pain at exposure site
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Treatment
Irrigate burned area with copious amounts
of water
 Burns due to concrete or lime should not
be irrigated with water. The mixture of
these powders with water creates a
corrosive substance that will further burn
the patient. Brush the powder off the
patient instead.
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Treatment
Burns due to phenol (carbolic acid) should
not be irrigated with water since phenol is
not water soluble. Instead, irrigate with a
lipid-soluble solvent (i.e. polyethylene
glycol)
 Hydrofluoric acid burns (used in glass
etching, dental laboratories, industry, and
electronic plants) are potentially life
threatening. Evacuate the patient as
quickly as possible
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White Phosphorous
Ignites with air contact – therefore, cover
wound with a wet dressing
 A solution of sodium bicarbonate may be
used to rinse the wound to help neutralize
the resulting phosphoric acid
 White phosphorous wounds may be
identified by using a fluorescent blue light
– the white phosphorous will fluoresce and
glow bright white
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ELECTRICAL BURNS
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Definition – electrical current, including
lightning, can cause severe damage to the
body. The skin is burned where the
energy enters the body and where it flows
into a ground. Along the path of this flow,
tissues are damaged due to heat
ELECTRICAL BURNS
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Cause
1. Exposure to electrical current
(either AC or DC)
2. Lightning Strike
Sign / Symptom
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Burns where the energy enters and exits the
body
Difficulty breathing or respiratory arrest
Irregular heartbeat or cardiac arrest
Muscle tenderness
Fasiculations
Convulsions
Fractured bones
Visual difficulties
Treatment
Maintain the patient’s ABC’s
 Care for shock
 Administration of oxygen therapy if
available
 Application of cool compresses to burn
areas
 Dry, sterile dressings to burns
 Evacuate
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TREATMENT OF BURNS (GENERAL
PRINCIPLES)
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Maintaining the patient’s ABC’s always
takes precedence.
Remove the patient from the
environment where the burn occurred
Remove any substance which will
continue to burn the patient
Initially, most burns can be irrigated with
cool water.
Cover with a dry, sterile, bulky dressing
Evacuate Immediately
st
1
Degree Burn
nd
2
Degree Burn
rd
3
Degree
Heat Injuries
HEAT INJURIES
Heat Cramps
Definition – slow, painful, skeletal muscle
cramps and spasms usually in the muscles
most heavily used, and last for 1 to 3
minutes
 Cause – Salt depletion that occurs when
fluid losses are replaced by water alone
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Signs / Symptoms
The muscles are tender
 The skin is usually moist
 Core temperature may be normal or
slightly elevated
 There is always a history of vigorous
activity preceding the onset of symptoms
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Treatment
Rest in a cool environment
 Drink an oral saline solution (0.9% Normal
Saline solution, Gatorade)
 Rest for 2 –3 days with no exertional
activities
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Heat Syncope
Definition – a sudden episode of
unconsciousness resulting from cutaneous
vasodilation and subsequent hypotension.
 Cause: Cutaneous vasodilation
Hypotension
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Signs / Symptoms
Systolic blood pressure usually less than
100 mm Hg
 Pulse is weak
 Skin is cool and moist
 Core temperature is normal or mildly
elevated
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Treatment
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Place patient in a recumbant position
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Rest in a cool place
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Administration of fluids either by mouth or
intravenously
Heat Exhaustion
Definition – A systemic reaction to
prolonged heat exposure (hours to days)
and is due to sodium depletion and
dehydration
 Cause: Salt depletion through intense
sweating.
Prolonged heat exposure.
Replacement of body fluids with
water and not electrolytes.
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Signs / Symptoms
Thirst
 Fatigue
 Nausea
 Oliguria
 Giddiness
 Delirium
 Gastrointestinal flu like symptoms
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Signs / Symptoms
The skin is moist, flushed
 Rectal temperature is usually over 37.8
degrees C (100 degrees F)
 Heart rate is elevated
 Signs of heat syncope and heat cramps
may accompany heat exhaustion
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Treatment
Rest in a cool environment
 Provide adequate fluid hydration, either
orally or intravenously
 Salt replacement
 Restriction of activities for the next few
days
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Heatstroke
Definition – a severe, life-threatening
failure of thermoregulatory mechanisms,
resulting in an excessive rise in body
temperature
 Cause: Impaired heat loss mechanisms
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Signs / Symptoms
Core body temperature greater than 41
degrees C (105.8 degrees F)
 Absence of sweating
 Loss of consciousness
 Dizziness
 Weakness
 Emotional lability
 Nausea and vomiting
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Signs / Symptoms
Confusion
 Delirium
 Blurred vision
 Convulsions
 Coma
 Skin is hot, flushed, and dry
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Treatment
Maintain an adequate airway and
ventilation
 Rapidly reducing the body core
temperature
 Care must be taken that the cooling
methods used do not produce
vasoconstriction or shivering which would
decrease the cooling rate and increase
heat production
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METHODS OF COOLING THE BODY
DIRECT COOLING
 Items are placed around the body to assist
in the dissipation of excess heat
 Examples include:
Applying ice bags to vascular areas of the
body (axilla, groin, scalp, and neck
regions)
Wrapping the body in a cooling blanket
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IMMERSION
Immerse the patient in a bathtub filled
with cool room temperature water. Do not
immerse the extremities
 Requires constant monitoring of the
patient during the procedure
 This method is slow (10-40 minutes).
 May cause hypothermia if the patient is
left in the water for too long
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IMMERSION
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The use of cold water must be avoided
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It could cause vasoconstriction, which
would impede the rate of heat loss
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It could cause shivering, which would
increase heat production
ROOM TEMPERATURE WATER
MISTING
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Spray or mist a semi-nude heat casualty
on a mesh hammock applying a film of
water on skin
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A fan may also be utilized to increase the
effectiveness of this method
Advantages
Method is fast (3-10 minutes)
 Requires minimal monitoring of patient.
 This method does not require cold or ice
water. Ambient air temperature water is
all that is required.
 Can treat multiple casualties
simultaneously.

EVACUATION
Heat stroke patients in a field environment
must be medically evacuated to a medical
treatment facility. During medevac, douse
the patient with water and maintain free
movement of air over the wet casualty
 In an ambulance, leave doors and
windows open to promote circulation. In
a helicopter, fly at cooler altitudes and
leave doors open, if possible
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EVACUATION
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Sedative drugs should be avoided because
they disrupt an already malfunctioning
heat regulating mechanism. If convulsion
occurs, Valium may be administered
intravenously
RESPIRATORY TRAUMA
AND DISORDERS
Rib Fractures
Definition – a break in the integrity of any
of the rib bones
 Causes:
Blunt trauma to the rib cage
Crushing injuries to the chest

Signs / Symptoms
Pain at the site
 Pain with inspiration / exhalation
 Shortness of breath
 Deformity
 Crepitus
 Subcutaneous emphysema
 Ecchymosis
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Treatment
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Place patient on affected side
Pain medications
Simple fractures of 1 to 2 ribs usually require no
more treatment
Multiple fractures can be immobilized with a
sling and swathe.
Oxygen therapy if available
Encourage coughing and deep breathing to
prevent atelectasis
Flail Chest

Definition – when many ribs are fractured,
especially at multiple sites, a portion of
the chest wall may become mechanically
unstable. When negative intrathoracic
pressure is developed during inspiration,
the unstable (flail) segment moves inward
and reduced the amount of air taken in
Causes
Blunt trauma to the chest wall
 Signs / Symptoms
 Pain with respirations
 Paradoxical chest wall movement
 Dyspnea or respiratory distress
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Treatment
Administer oxygen if available
 Endotracheal intubation – if respiratory
condition deteriorates
 Administer analgesics (morphine may be
given for this condition)
 External chest wall supports (taping,
binding) are not required and may be
harmful to the patient

Pneumothorax
Definition – a collection of air in the
pleural space which causes the lung to
collapse
 Causes:
Penetrating trauma – from either chest
wall injury or abdominal injuries that cross
the diaphragm
Blunt trauma
Spontaneous causes

Signs / Symptoms
Sudden, sharp chest pain
 Difficulty breathing
 Decreased chest wall motion
 Tachypnea
 Tachycardia
 Diaphoresis
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Signs / Symptoms
Hypotension
 Hyper-resonance with percussion on
affected side
 Absent or diminished breath sounds on
affected side
 Pallor or Cyanosis
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Treatment
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Place patient in Fowler’s position
Administer oxygen if available
Analgesics
Needle thoracentesis if symptoms are
severe
If caused by a wound, applying an
occlusive dressing to the site
Evacuation
Hemothorax
Definition – an accumulation of blood and
fluid in the pleural cavity, between the
visceral and parietal pleura
 Causes:
Penetrating trauma to the chest wall,
great vessels, or the lung
Blunt trauma (less common)
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Signs / Symptoms
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Chest pain
Difficulty breathing
Decreased chest wall motion
Tachypnea
Tachycardia
Hypotension
Dullness on percussion to affected side
Diminished or absent breath sounds on affected
side
Treatment
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Place patient in Fowler’s position
Administer oxygen if available
Analgesics (aspirin and motrin should be avoided
because of their anti-thrombolytic actions)
Chest tube insertion to remove the accumulated
blood (if at BAS or higher echelon of care)
Insertion of two large bore IV’s
Evacuation
Hemopneumothorax
Definition – an accumulation of air, blood,
and fluid with in the pleural cavity, causing
the lung to collapse.
 Causes:
Penetrating trauma to the chest wall,
the great vessels, or the lung
Signs / Symptoms – same as for
hemothorax and pneumothorax
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Treatment
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Place patient in Fowler’s position
Administer oxygen if available
Analgesics
Endotracheal intubate if signs/symptoms
become severe
Chest tube insertion to remove accumulated air,
blood, and fluids (if at BAS or echelon of care)
Two large bore IV’s
Evacuation
Tension Pneumothorax
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Definition – is a life threatening lung
injury. Air enters the pleural space on
inspiration, but the air cannot escape on
expiration. Rising intrathoracic pressure
collapses the lung on the affected side
causing a mediastinal shift that
compresses the heart, great vessels,
trachea, and ultimately, the uninjured
lung. Venous return is impeded, cardiac
output falls, and hypotension results.
Causes
Open chest injuries
 Closed chest injuries
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Signs / Symptoms
Signs of pneumothorax with worsening
symptoms
 Distended neck veins
 Tracheal deviation – a shift towards the
unaffected side
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Treatment
Cover the open wound with an occlusive
dressing sealed on three sides
 Needle thoracentesis
 Administer oxygen therapy if available
 Administer analgesics
 Two large bore IV’s
 Chest tube insertion (if at a BAS or higher
echelon of care)
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Open Pneumothorax or “Sucking
Chest Wound”
Definition – a pneumothorax resulting
from a wound through the chest wall. Air
enters the pleural space both through the
wound and the trachea.
 Causes:
Large, penetrating trauma to the chest
wall
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Signs / Symptoms
Sudden chest pain
 Dyspnea
 Difficulty breathing
 Decreased chest wall motion
 Hypotension
 Tachycardia
 Tachypnea
 Open sucking wound on inspiration
 Diminished or absent lung sounds on
affected side
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Treatment
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Cover the wound with an occlusive
dressing.
Needle thoracentesis may be indicated to
correct the pneumothorax if signs or
symptoms are severe.
Administer oxygen if available.
Administer analgesics
Two large bore IV’s
Evacuation
EMERGENCY
CRICOTHYROIDOTOMY

DEFINITION – An emergency surgical
procedure where an incision is made
through the skin and cricothyroid
membrane which allows for the placement
of an endotracheal tube into the trachea
when airway control is not possible by
other methods
INDICATIONS FOR EMERGENCY
CRICOTHYROIDOTOMY
Obstructed airway – an obstructed object
will usually prevent the passage of an
endotracheal tube through the airway.
Therefore, a surgical airway distal to the
obstruction is required. Causes of an
obstructed airway include
 Trauma to the head and neck which would
preclude the use of an ambu-bag,
oropharyngeal airway, nasopharyngeal
airway, and endotracheal tube insertion

CONTRAINDICATIONS FOR
CRICOTHYROIDOTOMY
Massive trauma to the larynx or cricoid
cartilage – damage to the affected
structures will make it impossible to
perform the procedure properly
 Contraindicated if another means of
establishing an airway have not been
attempted (i.e. nasotracheal or orotracheal
intubations)

COMPLICATIONS ASSOCIATED
WITH CRICOTHYROIDOTOMY
HEMORRHAGE
 ESOPHAGEAL PERFORATION OR TRACHEOESOPHAGEAL
FISTULA
 Definition – the creation of a hole between the
esophagus and trachea
 Causes:
 Creating an incision too deep through the cricothyroid
membrane
 Forcing the endotracheal tube through the cricothyroid
membrane and into the esophagus
 Treatment requires surgical repair at higher echelon of
care
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