HIGH YIELD THORACIC INJURIES
Some of the most common traumatic injuries are chest wounds. Many chest wounds are managed in a manner similar to other forms of trauma, detailed attention to the ABCs and a thorough secondary patient assessment. However, there are two specific injuries that require specialized treatment from all members of a team, from EMR to paramedic; sucking chest wounds and Impaled objects.
Sucking Chest Wounds
Sucking chest wounds are named after the sucking sound that emanates from it. These injuries involve the entire depth of the chest wall, go through the pleura of the chest cavity, and may even involve the lung itself. The "sucking" or "gurgling" noise comes from blood and air being sucked into the chest cavity together each time the patient takes a breath and the diaphragm creates negative pressure in the chest.
These wounds are dangerous, not only due to blood loss, but the risk of blood and/or air filling the chest cavity, creating a pneumothorax, hemothorax, or worse; tension pneumothorax. These complications all prevent the lung on the affected side from expanding. A tension pneumothorax actually pressurizes the affected chest cavity above atmospheric pressure, compressing the heart and opposite lung.
The key signs and symptoms of these complications are tracheal deviation, shortness of breath, reduced lung sounds, low SPO2%, and hypotension.
When evaluating patients who have a sucking chest wound, ensure that you evaluate the whole patient. While the chest wound may be alarming there are often other hidden injuries that may contribute to the patient's overall condition. Any area of the ABC's can be affected by even a relatively minor chest wound.
- Always consider if the mechanism of injury has a high risk of spinal trauma and apply C-Spine precautions as required.
- Complete a full secondary survey, examining all skin surfaces for wounds.
To Manage a patient with a sucking chest wound you must close off the defect int he chest wall while allowing any accumulated blood and air to exit. At the EMR level, management of these wounds focuses around wound occlusion, rapid transport, and regular reassessment.
- Place patients in the position that causes them the least discomfort
- Acquire an airtight (occlusive) dressing for the wound; these may be called "occlusive," "one-way," or "3-sided" dressings.
- Tape this dressing over the wound on 3-sides, ensuring air can escape from one side. This 3-way dressing allows built-up air pressure (and ideally blood) to escape while preventing further air from entering the wound. The open side is the lowermost (or dependent) side, so that gravity can assist blood exiting the wound and it won't fill the pouch-effect like having the open side on the top would.
- Transport the patient at best possible speed to the nearest trauma center.
- Re-assess the patient at regular intervals, even with the placement of occlusive dressings and administration of oxygen, these patients can suddenly and dramatically deteriorate.
IMPALED OBJECTS: Impaled objects in the chest are dramatic and can present in many ways. Some patients will be clinically unstable and close to death, while others will be able to walk around and converse normally with medical providers. Regardless of the patient presentation, management is the same.
- Do not attempt to remove the object UNLESS the patient requires cardiopulmonary resuscitation and it directly interferes with chest compressions or the airway.
- Expose the skin around the wound to the best of your ability, (i.e. ensure the wound area is well visualized).
- Hold the object in place manually until you can apply a "bulky dressing" to the object and wound.
- Arrange for emergent transport for further medical care, consider specialty trauma centers as appropriate based on patient presentation.
WARNING: The only time you should remove an impaled object is when it interferes with obtaining a patent airway or it interferes with compressions being performed. Removing an impaled object places the patient at risk for further bleeding and injury to underlying structures in the body. The bulky dressing is intended to both hold the object in place and seal the space between the object and skin, preventing further external loss of blood or ingress of air.