Chapter 35 Chest Trauma

Part 1 While you are working as a paramedic for a local aeromedical service, your helicopter is requested by a nearby township to assist with a motor vehicle crash. After lifting off from the helipad, you are informed that you are en route to a head-on collision on a major highway. Two people have already been pronounced dead at the scene.

Part 1 (cont’d) You arrive to find an 18-year-old male passenger who was partially ejected from the vehicle; he was not wearing a seatbelt. Fire department personnel have extricated the patient from the vehicle, applied full spinal precautions, and are currently assisting the patient’s ventilations with a bag-mask device.

Part 1 (cont’d) Primary AssessmentRecording Time: 0 minutes Appearance Secured to a long backboard Level of Consciousness U (Unresponsive) Airway Patent with an oropharyngeal airway inserted Breathing Assisted ventilations with 100% supplemental oxygen Circulation Pale skin

Part 1 (cont’d) 1.What will your initial priorities be when assessing and managing this patient? 2.Given the mechanism of injury for an unrestrained passenger in a car and this patient’s vital signs, what kinds of injuries should you think about during your assessment?

Part 2 As you assume patient care, you begin by reassessing the patient’s airway. As the bag-mask ventilations continue, you find the patient has a patent airway. His mental status remains unresponsive with a Glasgow Coma Scale (GCS) score of 5 and some decorticate posturing. You and your partner decide to manage the patient’s airway with endotracheal intubation, while still maintaining manual in-line immobilization of the cervical spine.

Part 2 (cont’d) The patient is intubated without difficulty, the placement of the endotracheal tube is confirmed by multiple methods, and assisted ventilation is continued. You prepare for transport, as your partner starts an IV to administer a fluid bolus of lactated Ringer’s solution. After moving the patient, you reassess his ventilation and note that his breath sounds are absent on the right side. His neck reveals jugular vein distention (JVD), and you are not really sure if the trachea is deviated to the left side.

Part 2 (cont’d) Vital SignsRecording Time: 10 minutes Level of consciousness Unresponsive, with a Glasgow Coma Scale score of 5 Pulse Radial pulse, 128 beats/min Blood pressure 70/38 mm Hg Respirations Intubated; ventilating with 100% supplemental oxygen Skin Cool, pale, and diaphoretic SaO 2 88% on room air

Part 2 (cont’d) 3.Why does the patient remain hypoxic despite confirmed airway patency and the effective delivery of high-concentration oxygen? 4.Do his vital signs and physical examination suggest any threats to his breathing that may be correctable?

Part 2 (cont’d) 5.What further injuries within the thorax could account for the patient’s persistent hypotension and tachycardia? 6.Are there interventions you can provide in the field if such injuries are identified?

Part 3 After determining the patient has a tension pneumothorax, you perform a needle decompression. You hear a rapid “rush” of air as the catheter enters the thoracic cavity. You place the patient on a cardiac monitor, and reassess the vital signs.

Part 3 (cont’d) ReassessmentRecording Time: 15 minutes Skin Pale, cool, diaphoretic extremities with a pinker core Pulse 114 beats/min, somewhat irregular Blood pressure 98/54 mm Hg Respirations Intubated; ventilating with 100% supplemental oxygen SaO 2 95% ECG Sinus tachycardia with occasional premature ventricular contractions and premature atrial contractions

Part 4 An assessment of the patient’s circulation reveals no evidence of muffled heart tones, jugular vein distention (JVD), dullness to chest percussion, or evidence of traumatic asphyxia. After loading the patient into the helicopter, you complete a detailed physical exam, establish a second IV line, and continue fluid resuscitation. Your physical exam reveals crepitus and palpable deformity over the ninth and tenth ribs on the left, as well as a rigid abdomen. Deformity of the left lower leg is evident, and the patient has multiple soft-tissue injuries on all extremities.

Part 4 (cont’d) ReassessmentRecording Time: 20 minutes Skin Pale, cool extremities with a pink core Pulse 108 beats/min Blood pressure 104/58 mm Hg Respirations Intubated; ventilating with 100% supplemental oxygen SaO 2 98% ECG Sinus tachycardia without further ectopy

Part 4 (cont’d) 7.What additional injuries might your physical findings suggest? 8.What additional treatments may be needed for this patient?

Part 5 The patient’s vital signs are monitored en route to the hospital with no further deterioration. You administer IV fluids to maintain perfusion. You and your partner care for the patient’s injuries en route to the trauma center. When you arrive at the trauma center, the trauma team takes over the patient’s care. You and your partner provide a concise, complete report to the team, including the mechanism of injury, the deaths of two other passengers, your initial physical assessment, the interventions you performed, and the patient’s response to those treatments.

Part 5 (cont’d) During the emergency department evaluation, the patient is found to have a right-sided pneumothorax, a left-sided pulmonary contusion, fractures of left ribs 8 through 11, a lacerated spleen, a fractured left tibia and fibula, and multiple soft-tissue injuries. A tube thoracotomy is performed in the emergency department. The patient is taken to surgery for repair of his abdominal and orthopedic injuries and, after a 15-day hospitalization, is discharged home with no permanent disability.