Over the past few months we have covered hemorrhage control in great depth. We have kept the subject matter and treatment in line with the equipment supplied in our blowout kit that we learned about as well in those previous articles. All of the tools in our blowout kit that pertained to hemorrhage control were covered along with their uses and applications. Now it is time to move to our next set of tools located within our blowout kit. Keeping on track with Tactical Combat Casualty Care (TCCC) we must now move on to the next important treatment phase after controlling the bleeding, airway management and treatment of wounds associated with trauma to the airway. As I mentioned before, the body can only go without oxygen for up to four minutes before serious damage to body organs and death will occur. We must act quickly to correct any airway problems as soon as we ensure all life threatening bleeding is controlled. The tools available to us in our blowout kit for airway trauma are as follows:
- Chest seals (2)
- Plastic packaging from chest seals.
- The eight pieces of Duct Tape that you attached to the packaging in the blowout kit.
- Nasopharyngeal Airway (NPA)
- 14g Catheter Needles
- Occlusive dressings
- OP Airway (oropharyngeal airway)
Chest injuries are the second leading cause of trauma deaths each year, although the vast majority of all thoracic injuries (90% of blunt trauma and 70% to 85% of penetrating trauma) can be managed without surgery. Traumatic chest injuries can be caused by a variety of mechanisms, including motor vehicle collisions, falls, sports injuries, crush injuries, stab wounds, and gunshot wounds.
- Penetrating Injuries – Caused by forces distributed over a small area as in gunshot wounds or stabbings. Most often, the organs injured are those that lie along the path of the penetrating object.
- Blunt Trauma – Forces are distributed over a larger area, and many injuries occur from deceleration, bursting, or shearing forces. Conditions such as pneumothorax, pericardial tamponade, flail chest, pulmonary contusion, and aortic rupture should be suspected when the mechanism of injury involves rapid deceleration.
- Dyspnea – Difficult or labored breathing.
- Wheeze – Characterized by a whistling respiratory sound. It is caused by movement of air through a narrowed airway.
- Stridor – A harsh shrill respiratory sound.
- Hyperventilation – An increase In the rate and depth of normal respirations. Responsible for increasing oxygen levels and decreasing carbon dioxide levels.
- Tachypnea – Abnormally rapid rate of respirations.
- Bradypnea – An abnormally slow rate of respiration, usually less than 8 breaths per minute.
- Hypoxia – An insufficient concentration of oxygen in the tissue in spite of an adequate blood supply.
- Apnea – Total cessation of breathing, also known as respiratory arrest.
- Thorax (Chest Cavity).
- The skeletal portion of the thorax is a bony cage formed by the sternum, costal cartilages, ribs, and the bodies of the thoracic vertebrae.
- Ribs articulate posteriorly with the thoracic spine and anteriorly with the sternum via the costal cartilage.
- A nerve, an artery, and a vein are located along the underside of each rib.
- Intercostal muscles connect each rib with the one above.
- The diaphragm is the primary muscle of respiration.
- Thin membrane consisting of two distinct pleura.
- The parietal pleura lines the inner side of the thoracic cavity.
- The visceral pleura covers the outer surface of each lung.
- A small amount of fluid is present between these two membranes which creates surface tension and causes them to cling together, counteracting the lungs natural tendency to collapse on themselves.
- If a hole develops in the thoracic wall or the lung, this space fills with air and the lungs collapse.
- Occupy the right and left halves of the thoracic cavity.
- The right lung is larger than the left lung and is subdivided into three lobes.
- The left lung is smaller than the right lung and is subdivided into two lobes.
- The smallest components of the lungs are called Alveoli (small saclike structures through whose walls the exchange of carbon dioxide and oxygen takes place).
- The Mediastinum.
- Great vessels (aorta, superior/inferior vena cava).
- Trachea (also known as the windpipe).
- Main stem bronchi (right and left).
- Esophagus (lies directly behind the trachea).
Now that we have some basic terminology and anatomy behind us, let’s talk about some specific injuries and how we treat them in the field with the equipment we mentioned in our blowout kit. We will break this down over the next few articles so we can cover as much detail as possible.
- Open Pneumothorax (Sucking Chest Wound).
- Definition – A collection of air or gas in the plural space causing the lung to collapse, most commonly introduced in a surgical opening of the chest or as a result of a stab or gunshot wound. Many small wounds will seal themselves. Some large wounds will be completely open, allowing air to enter when the intrathoracic pressure is negative and block the release when the intrathoracic pressure is positive. In simpler terms, letting air in when we breath in and trapping it when we breath out; hence the term “sucking chest wound.” These wounds are of particular concern because of their potential to cause a tension pneumothorax. We will cover a tension pneumothorax in detail next month.
- Causes – Most often the result of gunshot wounds, but they can also occur from impalement objects, motor vehicle accidents, and falls.
- Signs and Symptoms:
- Pain at the injury site
- Shortness of breath (tachypnea)
- Decreased chest wall motion (rising and fall on one side only or very shallow respirations).
- May hear a moist sucking or bubbling sound as air moves in and out of the chest wall defect.
- Cover the wound with an occlusive dressing. Tape the dressing on four sides to temporarily seal the wound and prevent the occurrence of a tension pneumothorax. Let’s take a moment to reflect back on our equipment we have in our blowout kit. We have two chest seals designed specifically for this type of wound. Wipe the wound to get excessive blood out of the way of your wound site so that your chest seal will adhere to the skin better. Place the chest seal directly over the wound centering the hole in the chest wall in the middle of your chest seal. Some manufactured chest seals will have a flapper valve or valve in the center that allows the wound to self-burp itself. Center this valve over the wound opening when placing your chest seal. Remember to always check for an exit wound, that’s why we carry two chest seals, and cover the exit wound in the exact same manner.
- If you do not have two manufactured chest seals don’t worry. That is why we have the eight strips of duct tape in our kit as well. Get any type of plastic wrap or packaging and place it over the wound and use your duct tape to tape down all four sides. Do the same on the exit wound if present. Petroleum gauze (4”x4”) are great to use for chest seals as well and can be purchased at any store with a pharmacy or over the counter supplies. If EMS response is delayed for several minutes after placing your chest seal, simply raise one corner of the chest seal to burp the wound (let trapped air escape) every 15-20 minutes. This helps eliminate the pressure build up in the chest cavity from any free air that may find its way past your dressing.
- Assess for associated penetrating torso trauma.
- Monitor for signs and symptoms of tension pneumothorax (covered next month).
- Administer oxygen if available.
- If licensed and trained, administer low dose analgesics.
- Transport to a higher level of care if EMS is not available.
Well, this gets us on a good path of covering all we need to cover in the realm of respiratory trauma. I hope you enjoyed this month’s article, and we will carry on with more chest injuries and treatment next month. Until then, remember firearm safety is paramount and always be aware of target backstop and beyond. Lead from the front and set the example for all to follow. Happy shooting and be safe. Until next month this is “Doc” McBryde and I’m Oscar Mike.
Other articles in this series can be found here: