11/10/2015

Chest and The Saving of the President Case Studies Produced by: Frank Kavanaugh, MD

NWC EMSS November 2015 Continuing Education Susan Wood, RN Paramedic

Goals for Today Before going any farther…

Review of: Write down one question that still remains • Different etiologies of shock specifically how it unclear for your individual practice when relates to chest & abdominal trauma encountering trauma patients, whether related • Immediate life threats surrounding pts to chest and abdominal or generally sustaining chest & abdominal trauma speaking. • Identify injury based on blunt vs.

What is so shocking? Shock…what’s the issue? Shock is classified by its primary etiology, All forms of shock are due to failure of one or even though multiple dysfunctions often more of the 3 separate but related factors occur in response to the primary insult. necessary to maintain perfusion.

Pump Volume Individuals must have: – Adequate pump Container Obstruction – Circulating blood volume (with oxygen carrying capacity)

– Intact vascular container

1 11/10/2015

Pump Container Deceleration injury

Blunt cardiac Ruptured injury aorta

Large vessel injury

Obstructive shock is commonly seen Volume in association with… Chest trauma

Jeopardy question: What other mechanism can results in obstructive shock? Pulmonary Embolus

In which part of the assessment should these be found?

Primary • Blunt What is the B=Breathing • Penetrating mechanism? • Compression

2 11/10/2015

What is the common complaint with Unchanging Priorities any ? Airway patency Breathing/gas exchange Circulation/cardiac status Respiratory Disability – neuro life threat distress Environment/expose Avoid HYPOXIC injury

Deceleration injury A deceleration injury causing a ruptured large vessel quickly leads to a volume issue Vessels running through the chest are the largest in the Before EMS body is ever on These are the pts the scene that are in arrest upon EMS arrival

Pump Often in trauma pts Volume cardiac monitoring is an Hemothorax after thought which is >1500 mL blood in pleural space not acceptable practice Pleural space can hold entire blood volume SOP: ITC p. 37 Conduction deficit from Permissive hypotension contusions to maintain perfusion

Blunt vs. MUST be on a cardiac Penetrating monitor

3 11/10/2015

Kine-what? Trauma: “Transference of energy from some external force to the human body which exceeds the tensile force/resiliency of the body causing a structural or physiologic alteration” (Halpern, 1989).

Kinematics: Both are Relationship between speed, mass, vector direction & physical injury traumatic the study of motion exclusive of the influence of but…. mass & force

Case 1:

Dispatched to a 2-car MVC

with head on collision (posted speed 40 MPH)

Case Studies • Unrestrained driver / + steering wheel deformity • A & O X 3 but restless & agitated • C / O severe chest pain & difficulty breathing

Identify life threats found in Assessment

A: Patent primary assessment & treat B: RR fast; labored w/ asymmetric expansion + accessory muscle use; no paradoxical movement BS absent on L, diminished on R Patent airway No open ; trachea midline Respiratory distress RA SpO2 86%; EtCO2 27 Perfusion status altered; no palp radial pulse C: No radial pulse; carotids fast, weak & thready + JVD D: E=spont, V=oriented, M=to command; PERL, *Mental status remains intact to L chest

4 11/10/2015

What MOI is responsible for Blunt ~70-80% of blunt chest trauma? Direct compression

Fracture of solid organs MVC Blowout of hollow organs

Followed by: Deceleration forces Falls Tearing of organs and blood vessels Sports related injury

• Results from energy Blunt exchange between an WHICH IS MOST LIKELY SUSPICION object & human body BASED ON PRESENTATION? • Occurs when a body area is struck by, or strikes, an object • Higher mortality – Injury often hidden; evidence of injury Tension Pneumothorax very subtle or absent Why?

Classic clinical findings? What information is needed Chest pain

Extreme dyspnea; ↑ WOB to confirm suspicion? Anxiety, tachypnea, hypoxia ↓ BS on affected side ↑ HR; ↓ MAP; narrowed PP Resistance to BVM ventilations + JVD (- hypovolemia) Vital Signs

5 11/10/2015

Tension pneumothorax Why?

How can you tell the difference between a pneumothorax & tension pneumothorax ?

(both have absent breath sounds) It starts with a simple pneumothorax

Simple Pneumothorax But it doesn’t stop there… Defect in chest wall acts as Collection of air one-way valve into the pleural space through an Air is allowed to enter upon injury to the inspiration, but not escape on chest wall exhalation

Many underlying Each breath further deflates etiology – the & collapses medical and trauma *Tension PTX is often caused by care provider over/hyperventilating*

Why so much pressure? Secondary Assessment

VS: BP 84/60, P 116, R 24

https://www.youtube.com/watc Head to toe h?v=i-sZzZ4TMnY

After identification and treatment of life threat

6 11/10/2015

Pleural needle decompression… So, what intervention should be done after identification of a life Only 3 were done in the field this threat? last year, all with proper indication

Low frequency high stress situation Let’s review PBPI stats

What landmarks must you find?

As intrathoracic pressure ↑, it depresses the diaphragm pushing mediastinum If left Why? toward unaffected side Chain reaction: unrecognized, Mechanical obstruction ↓ preload of blood flow to R what is the end results in significant ↓ stroke volume result? ↓ in preload & CO ↓ CO Cardiovascular collapse is evidenced by ↓ BP hypotension Opposite lung also affected DEATH & obstructive shock

This is obstructive shock!

7 11/10/2015

What should happen after the Release pressure (tension) needle Relieve acute distress penetrates the Improve ventilations pleural space? Re-establish venous return (CO, pulses, BP)

What if there is no improvement? What are the risks and complications associated with procedure?

Why is the mid-axillary site discouraged? • Neighbor sees pt (50 M) lying Case 2 Diaphragm can rise to 4th or 5th ICS when on cement driveway supine Dispatched for pt is supine outside home, calls EMS an adult who • Ladder on ground outside 2 story (~20 ft.) family home; fell bushes in front appear damaged • Upon arrival, EMS finds a person as stated with blood from L forehead; 10” diam of blood on ground Needle may penetrate • Moaning; localizes pain & liver or spleen appears in distress

8 11/10/2015

Assessment What is the concern? A: Gurgling sounds noted in airway w/ bloody secretions Multi-system trauma B: Breathing faster than normal, shallow and yes; but also breathing is affected labored effort (diminished BS on L side) Any add’l info does EMS obtain in 1° survey? C: + fast, reg pulse; radials are weak. Cap – Capnography (28, square) refill 3 sec – SpO2 (91%) D: Eyes open to pain, incomprehensible – Will move all extremities to command except L sounds made and localizes to painful foot (a deformity is noted) stimuli. Pupils PERRL; bG 86

Identify life What • Suction & maintain threats interventions airway have been done? • Breathing issue (↓ BS on L) The purpose of the – Determine need for oxygen 1° survey is to identify those • Alteration in injuries that are life perfusion (faint threats radial pulse) – Consider IVFs after

VS

The eye does not Secondary assessment Now VS: BP 94/64, P 116, R 24 see and the hand Head to toe what? does not feel what Head: airway clear w/ suctioning the mind does not Pupils: PERL, no bruising to face think of… Neck: - JVD, trachea midline Chest: abrasion & tenderness L lat area; + distress; + crepitus to palp w/paradoxical mvt Abdomen: abr. LUQ/L flank area; moans to palp Pelvis: unremarkable Ext: L LE w/deformity; otherwise + movement x 4

9 11/10/2015

True or False What ALL is going on?

Individuals who sustain blunt chest trauma do • Multi-system trauma not usually have to be admitted to the hospital? • Head injury

False: Accounts for 1/3 of all trauma admits Closed chest injury Often associated with multi-system injury • Flail • Assessment findings: paradoxical movement

By definition, a flail consists of… Possible injury Anterior, posterior, or lateral location? Fracture of 3 or Separation of sternum from adjacent broken ribs or more adjacent costochondral joints: sternal flail Free floating ribs in 2 or more chest chest places = mobile wall segment segment palpated or observed as paradoxical movement

When should a flail be recognized? Treatment? Primary assessment Assist with breathing

What causes fatigue with a flail How? chest? CPAP (if pt capable of following instructions) Muscle tightening Increased effort to breathe BVM (if altered mental status)

10 11/10/2015

The significance…

Flail chest, the most severe form of blunt chest wall injury with mortality rates of 10-20% occurs in 30-75% of blunt thoracic trauma

The Eastern Association of the of Trauma, 2006 EAST guidelines

Flail Goal CPAP Ensure oxygenation

Prevent hypercarbia

“Obligatory should be https://www.youtube .com/watch?v=LU1ek avoided…and C-PAP should be considered in A-cBjY alert pts with good ventilatory effort (East, 2006)

Let’s Review Contraindications Positive pressure (CPAP) “splints” lower airways & keeps alveoli open Pneumothorax Prevents alveolar collapse (atelectasis) Less energy used to Only going to be recognized through proper open them with assessment next breath MUST listen for breath sounds throughout Stops fluid movement into secondary and ongoing assessments alveoli MUST reassess VS frequently checking for hypotension (SBP<90)

11 11/10/2015

BREAK Case 3 • EMS is called to a house for an adult with Hang in chest pain from a penetrating injury. there… • PD is on scene stating that the scene is safe and that there was an attempted home burglary in which the burglar stabbed the homeowner in an attempt to escape scene. • Pt states that his chest feels like a burning sensation and respiratory distress.

Assessment Open chest injury A: Patent, able to speak B: RR faster than nl; shallow & labored How can a chest be “open?” BS diminished B; + open to slightly L of • An object can pass through the wall from the center of chest; trachea midline outside or a fractured and displaced rib can RA SpO2 89%; EtCO2 30 penetrate the chest wall from within C: faint radial pulse becoming non-palp w/ inspiration; carotids fast, weak & thready • Injury can occur to the heart, or great + JVD; skin dusky, cool & moist. No uncontrolled vessels when penetration to the chest wall hemorrhage but + bubbling to chest wound occurs D: E=spont, V=oriented, M=to command; PERL, abrasion to L chest

Assessment Treatment

EMS finding a wound to the chest wall What ultimately needs to be done for an in which there may (or may not) be a open pneumothorax? characteristic “sucking” sound Maintain adequate ventilation w/ open associated airway How is this accomplished? Apply an occlusive dressing to seal the The pt may be SOB or gasping for air wound Administer oxygen as needed Identify treatment modalities Identify shock Transport decision

12 11/10/2015

Why can breath sounds be absent on both Penetrating sides?

Air enters thoracic cavity Direct trauma to organ and through wound – must have negative pressures vasculature & intact pleural membranes to cause gas movement through Energy transmitted from mass tracheobronchial tree and velocity

What makes this happen? Remember… Ventilation/perfusion mismatch Air may exit wound If wound during exhalation approximates ⅔ producing frothing or tracheal bubbling at the site diameter,

Air may be allowed in but most air will not out increasing Patient dies from move through pressure in pleural space inadequate chest wall defect, -possible mediastinal shift ventilation and NOT through NO GAS EXCHANGE Direct lung injury possible trachea

On to…what is next? What needs to be done? Secondary assessment Pt c/o “not being able to catch his breath” Needle BP: 96/72, P: 136, R: 26 and labored decompression? SpO2: 88% RA; EtCO2: 30 Airway remains open, no DCAP-BTLS-TIC PMS to head or neck How about closing the hole that’s already there Chest w/ an open wound, blood bubbly w/resps while allowing the air to escape that has Abdomen and pelvis unremarkable already started to collect?

13 11/10/2015

How is this IF S & S of tension PTX: temporarily lift side of dressing Convert open pneumothorax to done? closed to allow air release Apply an occlusive dressing recover wound • vaseline gauze • defib pad • commerical device Assess need to Monitor VS, ventilatory & Decompress only circulatory status IF NO improvement Assess for JVD after application following removal Continue with ITC of dressing SOP p 41

Because this was on the L chest close to midline, what Small penetrations in pericardium seal from additional finding is this pt at risk fatty tissues or for? formation of clots Once sealed, blood continues to collect in sac putting pressure on vena cavae & RA What if the BP showed a narrow PP & muffled heart tones?

Classic clinical findings? Case 4 Restrained driver MVC Beck’s triad • EMS is called to the expressway for a frontal ■ narrowed PP impact MVC ■ JVD • 15-20” metal intrusion in at dash ■ muffled heart • w/s broken & steering wheel bent sounds • Awake, responding to verbal stimuli & Looks like cardiogenic guarding chest, splinting when he breathes shock BS present (unless other accompanying injury

14 11/10/2015

Assessment Injury from direct blow to the • A: patent, able to speak • B: Dyspneic; RR rapid, shallow & labored chest w/redness & abrasions to chest

SpO2 90%, capnography 34 • C: + equal radial pulse, rapid & thready. Skin pale, cool & clammy. No external Whatever the bleeding noted MOI • D: GCS = 14. Pupils PERL 3 mm; responding to verbal stimuli

CC: retrosternal chest pain or Blunt cardiac SOB typically sharp, well injury Assessment localized may mimic ischemic pain Mortality 8-20% Hard to distinguish from chest MVC: 20-35 MPH can wall pain cause cardiac injury w/o Inspect for ecchymosis on obvious chest wall injury anterior chest Forces: Compression, S/S hemodynamic acceleration/deceleration, intra- instability abdominal cavity compression & cardiogenic shock May be asymptomatic

Dysrhythmias: 90% present at impact Assessment should include Death in field caused by VT or VF Anticipate: ST, PVCs, VF, AF, A-flutter; PEA may be  Changes in mental status present  SBP < 100 mmHg Frequently resolve by hospital arrival  Absent/thready peripheral pulses May have  CO  Pulsus paradoxus  JVD  Muffled heart sounds

15 11/10/2015

What’s indicated? Organs caught between frontal force impact and O2 based on need vertebrae may rupture ECG monitoring: 12-L IVF to maintain BP to what in accordance w/ SOP? How should hypotension be treated? What should be given if dysrhythmias occur?

VS: Secondary BP 92/50, P116, RR 26 & Chest Trauma Pneumothorax shallow Simple HEENT: Assessment Open unremarkable; trachea midline, no JVD Tension Chest: Hemothorax contusion over sternum on wall w/ pain; ECG ST w/ multi-focal PVCs Cardiac Abdomen: tamponade soft & non-tender Skin: Pale, cool, diaphoretic Whatever the Neuro: problem…find it GCS 14; PERL; SMV intact x 4 and stabilize it! w/ pain 9/10

Abdominal injuries In what year was it deemed mandatory to have automatic restraint systems in cars?

Restraints include: seat belts, shoulder straps, child safety seats, and airbags. 1990

Jeopardy question

16 11/10/2015

Frequent cause Blunt abdominal trauma of preventable Assume w/ SUBTLE deceleration death MOI & Mortality < 46% penetrating High (75%) incidence of torso wounds other injuries Solid organs more likely High index of to be injured suspicion for Contributes to 25% of abdominal trauma deaths injury

Blunt vs. penetrating RUQ Liver Name that Colon Appendix Blunt injury is the usual MOI ~60% of the time Gallbladder Ureter quadrant! except in urban situations in which penetrating Duodenum Kidney Ovary LUQ reigns at 60-80% Adrenal glands Pancreas Liver RLQ Spleen Pancreas Appendix Colon Spleen Ureter Gallbladder Colon Kidney Duodenum Adrenal glands Ovary Uterus (if LLQ enlarged) Colon Kidney Fallopian tube Uterus Ovary Adrenal glands Fallopian tube Colon

Intraperitoneal

Cross section of the upper abdomen at the level of the pancreas

17 11/10/2015

Retroperitoneal Held in place by mesentery organs

Interconnected relationship Assessment Goals Identify clinically evident life threats Discover subtle signs of trauma through careful observation, continuous monitoring, serial exams

Potential for great injury

Primary Case 5 Assessment 50 restrained driver single vehicle crash drove A: patent off the road & laterally hit into a tree B: labored; rapid rate. BS normal & equal B posted speed 40 MPH C: Radial pulses rapid & weak; skin pale & cool to touch Vintage car w/ lap belt only; patient found D: eyes closed; responds to verbal stimuli by slumped sideways in moaning, not moving extremities to to center of the vehicle, pt. command. Pupils PERL, sluggish to moaning respond

18 11/10/2015

Secondary Greatest concerns for injury? Assessment Head VS: BP 88/54, P 110, R 24 HEENT: Multiple abrasions to lateral head w/ Spine lac to L forehead-bleeding. Mouth B LQ abdomen w/loose teeth; bleeding. Trachea midline; No JVD. Chest: no injury noted w/ = expansion; no Primary concern? paradoxical mvt. ECG: ST w/ PVCs Abdomen: point tenderness to palp to B LQs; + Poor perfusion guarding Hypotension Ext: mult. abrasions; no entrapment or ext. needed Internal injury not seen!

Treatment Plan If an adult is hypotensive with , how Transport decision? much IVF should be Level One TC infused? Why? GCS < 13 and hemodynamically Just enough to unstable maintain SBP

of 90 unless Ultimate Goal head trauma Manage hypotension to maintain adequate perfusion

Signs and Symptoms of Abdominal Chest and abdominal injuries Injury coughing up blood/vomiting blood, nausea, In relation to traumatic injury, is often vomiting associated with multisystem injury. rapid/shallow breathing The significance of MOI helps to predict patterns distended abdomen, tender of injury. diffuse pain Never under-estimate the need for complete & rapid pulse thorough assessments. low blood pressure shock You will never find what you never think to look prefers to lie still with legs for when assessing injury in trauma patients.

19 11/10/2015

Did we answer your Thank you for questions listening~ today?

20