ChestandAbdominalTraumaCaseStudiesCase#1

Scenario:EMSisdispatchedtoa2-carMVCwithheadoncollision.Thepostedspeedlimitismarkedat40MPH.UponEMSarrivaltothesceneanunrestrainedadultdriverisfoundinsidethevehiclewithnoted+steeringwheeldeformity.ThepatientisA&OX3butappearsrestlessandagitated.

Onassessmentthefollowingisnoted:

Airway: Patent

Breathing: RR:fast;laboredwithasymmetricchestexpansionanduseofaccessorymusclesbutnoparadoxicalmovement; left side appears hyperinflated and does not move. Breath sounds absent on left,diminishedonright;noadventitioussounds.Noopenwounds;tracheamidline.SpO286%,EtCO227.

Circulation: JVDpresent; radialpulsesabsent; carotidpulses fast,weakand thready;equalbilaterally. C /Oseverechestpain&difficultybreathing

Disability/LOC: Eyesopenspontaneously,ptisawake,alert&orientedtovoice&isabletomoveallextremitiestocommand;PERL,EMSnotesanabrasiontoLanteriorchest;theptisA&Obutrestless&agitated.

Pain: 9/10

VS: BP84/60,P116,R24

Questions Answers

1. Whattwoimmediatelife-threatsshouldbesuspectedbasedonthispresentation?

2. Whichoneismostlikelybasedonthemechanismofinjury?Whatisthepathophysiologyandtheclassicclinicalfindingsofthisinjury?

3. Whatisthemechanismofdeathinthisinjury?

4. Whattemporizinglife-savingproceduremustbeperformedimmediately?

5. Whatequipmentwillyouneed?

6. Whatlandmarksmustyoufind?

7. Atwhatangleisinsertionperformed?

Ifyouhitbone,shouldyougooverorunder?Why?

8. Whatshouldhappenafterpenetrationintothepleuralspace?

9. Willthisprocedurere-expandthecollapsedlung?Whyorwhynot?

10. Whatisthedifferencebetweenasimplepneumothoraxandatensionpneumothorax?

Chest and Abdominal Trauma Case Studies Page 2 NWC EMSS CE November 2015

Case#2Scenario:EMSisdispatchedforanadultwhofell.Uponarrivaltothescene,aneighborgreetsyouandstatesthattheysawthepersoncleaningguttersearlier.EMSseesanadultpt(50M)lyingoncementdrivewaysupineoutsidehome.Uponscenesizeupaladderisfoundonthegroundoutsidea2story(~20ft.)familyhome;bushesinfrontappeardamaged.Uponarrivaltothept,EMSfindsapersonasstatedwithbleedingfromleftforehead;10”diamofbloodongroundandappearsindistressmoaningandlocalizespain.

Onprimaryassessmentyounotethefollowing:

Airway: Gurglingsoundsnotedinairwayw/bloodysecretions

Breathing: Breathingfasterthannormal,shallowandlaboredeffort(diminishedBSonLside).

Circulation: Pulseisfastandregular;butradialsareweak.Capillaryrefillis3seconds.Neckveinsareflatandskinisdusky,coolandmoisttothetouch.

Disability/LOC: Eyesareopentopain,incomprehensiblesoundsmade&localizestopainfulstimuli. PupilsPERL;bloodglucoselevelis86.

Pain: 8/10

Secondaryassessment:VS: BP94/64,P116,R24Head: airwayclearw/suctioning;nobruisingtoface.Pupils: PERLNeck: JVD,tracheamidlineChest: abrasion&tendernessLlatarea;+distress;+crepitustopalpw/paradoxicalmovementAbdomen: abrasionnotedtotheLUQ/Lflankarea;ptmoanstopalpationPelvis: unremarkableExt: LLEw/deformity;otherwise+movementx4

Questions Answers

1. What3chestinjuriesshouldbesuspectedbasedonthispresentationandmechanismofinjury?

2. Whatisthemostlikelychestinjurybasedonthemechanismofinjuryandptpresentation?

3. Whatisthedefinitionforthatinjury?

4. Whataretheotherinjuryconcernsbasedonptpresentation?

5. WhatcriteriaisneededforthepttobeplacedonCPAP?

6. OncetreatmentincludesCPAP,whatareaofre-assessmentifkey?

7. Whereshouldthisptbetransportedbasedonpresentationandinjury?

Chest and Abdominal Trauma Case Studies Page 3 NWC EMSS CE November 2015

Case#3Scenario:. EMSiscalledtoahouseforanadultwithchestpainfromapenetratinginjury.PDisonscenestatingthatthesceneissafeandthattherewasanattemptedhomeburglaryinwhichtheburglarstabbedthehomeownerinanattempttoescapescene.Uponenteringthehouse,theptissittingonthesofaholdinghischestindistress.Thet-shirtisnotedtohaveaminoramountofbrightredbloodinacircularfashiontotheslightLoflateralpositionmidchest. Hestatesthathischestfeels likethere isaburningsensationandis inrespiratorydistress. Nopenetratingobjectsremain.

Onprimaryassessmentyounotethefollowing:

Airway: PatentBreathing: Dyspneic;RRrapid,shallowandlaboredwithnomovementofLlateralchestwall;breathsounds

absentbilaterally.RASpO289%;EtCO230

Circulation: Radialpulsesbecomingnon-palpw/inspiration,carotidsfast,weakandthready.Skinisdusky,cool

&clammy.Nouncontrolledhemorrhagebut+bubblingtochestwound,+JVDLOC: eyesopenspontaneously;voiceisorientedandmovesextremitiestocommands.PupilsarePERL.

SecondaryassessmentVS: BP:96/72;P:136;RR:32shallowandlabored.Ptstates“Ican’tcatchmybreath.”HEENT: airwayremainsopen;noDCAP-BTLS-TICPMStoheadorneckNeck: Tracheaismidline;jugularveinsflatChest: 1½”openingoverleftmedialchestwall;painonpalpationwithbloodbubblyw/resps. Heartsoundsmuffled.Abdomen: Softandnon-tender.Skin: Duskynailbeds;circumoralcyanosis.Cool,pale,diaphoretic.Neuro: GCS15;PERL;SMVintactX4Pain: 10/10

Questions Answers

1. What2chestinjuriesshouldbesuspectedbasedonthispresentationandmechanismofinjury?

2. Whataretheclassicclinicalfindingsoftheseinjuries?

3. Identifythelifethreat?

4. Howshouldthispatientbetreated?Whatlifesavingtreatmentshouldbedonefortheseinjuries?

5. Whatequipmentisneededtoperformthistreatment?

6. Whatistheongoingdangertotheptfromthisinjury?Whatisthemechanismofdeath?

7. WhatshouldbedoneifaftertreatmentwithBPrising,thentheptagainbecomeshypotensive?

8. Whereshouldthisptbetransportedbasedonpresentationandinjury?

Chest and Abdominal Trauma Case Studies Page 4 NWC EMSS CE November 2015

Case#4Scenario:YouarecalledtoarestraineddriverinaMVConexpressway.Thereis15-20inchesofmetalintrusioninatthe dashboard due to a frontal impact. The windshield is broken and the steering wheel is bent. The patient iscomplainingofseveresubsternalchestpain.Heisholdinghisarmagainsthischesttosplintwhenhebreathes.

Onprimaryassessmentyounotethefollowing:

Airway: PatentBreathing: Dyspneic; RR rapid, shallow and labored with redness and abrasions to the chest wall; no

paradoxicalmovement,SpO290%;Breathsoundspresentbutdiminishedbilaterally.Circulation: Radialpulsesequal;rapid,weakandthready.Skinpale,cool,clammy.LOC: Awake;respondstoverbalstimuliSecondaryassessment:

VS: BP:92/50;P:116;RR:26andshallowHEENT: AllWNLNeck: Tracheaismidline;jugularveinsflatChest: Contusionoversternumonchestwall;painnotedonpalpation. ECG:STwithmulti-focalPVCsAbdomen: Softandnon-tender.Skin: Cool,pale,diaphoretic.Neuro: GCS14;PERL;SMVintactX4Pain: 9/10

Questions Answers

1. Whatchestinjuriesshouldbesuspectedbasedonthismechanismofinjury?

2. Whichonewouldbemostlikely?Why?

3. Howshouldthisptbemonitored?

4. Howshouldyoutreatthispatient?

5. What2treatmentmodalitiesareindicatediftheptbecomes/remainshypotensive?

6. Whereshouldthisptbetransportedbasedonpresentationandinjury?

Chest and Abdominal Trauma Case Studies Page 5 NWC EMSS CE November 2015

Case#5Scenario:A50y/orestraineddriverofasinglevehiclecrashwhodroveofftheroadandlaterallyhitintoatreeat40mph on the drivers side. Upon arrival, assessment reveals the car to be a vintage model with only the lap beltavailable.Thereforethepatientisslumpedsidewaysintothecenterofthevehicle,moaning.

Onprimaryassessmentyounotethefollowing:

Airway: patentBreathing: labored;rapidrate.Breathsoundsnormalandequalbilaterally.Circulation: Radialpulsesrapidandweak;skinpaleandcooltotouch.LOC: Eyesclosed;respondstoverbalstimulibymoaning;notmovingextremitiestocommand. Pupils

PERL,sluggishtorespond.

Secondaryassessment:

VS: BP:88/54;P:110;RR:24.HEENT: Multipleabrasionstothelateralaspectsofthept’sheadwithlactoLforeheadandbleeding.Pupils

asnotedabove;bleedingcomingfrommouthwithlooseteeth.Neck: Tracheamidline;jugularveinsflat.Chest: No injury noted to chest with equal chest expansion; no paradoxicalmovements. EKG: ST with

PVCs.Abdomen: abdominal exam with point tenderness to palpation to R and LLQ with positive guarding and

tendernesstopalpation(moansandlocalizespain).Extremities: multipleabrasionsbutnoentrapmentorextricationneeded.

Questions Answers

1. Whatabdominalinjuriesshouldbesuspectedbasedonthispresentationandmechanismofinjury?

2. Whichabdominalinjuryisthepatientatgreatestrisk?

3. Why?Doesthisinjurytotheabdomencreateanimmediatelife-threat?

4. Howshouldyoutreatthispatient?

5. Whatistheongoingdangertothepatientfromthisinjury?

6. Identify3internalorgansintheLQsthatcouldbeinjuredfromalowlyinglapbelt?

7. Identify3internalorgansintheUQsthatcouldbeinjuredfromahighlyinglapbelt?

8. Whereshouldthisptbetransportedbasedonpresentationandinjury?

Chest and Abdominal Trauma Case Studies Page 6 NWC EMSS CE November 2015

ThoracicTraumaaswrittenfortheNWCEMSSParamedicEducationProgram

ConnieJ.Mattera,M.S.,R.N.,EMT-P

I. EpidemiologyofchesttraumaA. Incidence

1. Chestinjuriesarecommonoccurrencesfollowingbluntandpenetratingtrauma.2. Isolated chest trauma is uncommon; themajority of these patientswill have additional

injuries.3. Preventioneffortsamajorkey4. Thoracictraumaaccountsfor⅓alltraumaadmits5. Thoracicinjurymayinvolve:

a. Chestwallb. Thoracicgreatvesselsc. Heart,lungs,pleurad. Diaphragm,esophaguse. Tracheaandbronchus

6. Bluntchesttraumaa. Occursinbothruralandurbansettingsb. Motorvehiclecrashesareresponsiblefor70-80%ofbluntthoracictraumaplus

falls,sportsandcrushinjuries7. Penetratingchesttrauma

a. Usuallyassociatedwithanurbansettingb. Commonlyduetogunshotwoundsandknifewounds

(1) Low velocity gunshotwounds: Hand guns - 12-25%mortality. Sterile,woundonlyalongtrackofmissile.

(2) High velocity gunshot wounds: Military and hunting rifles. Cavitationmaycreatetissuedamage15timesthediameterofthebullet.Allthesewoundswillrequireoperativedebridementatthehospital.

(3) Shot gunwounds: Result in varyingwound typesdependingonpelletsize,choke,anddistancefromthevictim.

(4) Stabwounds:75%ofpenetratingchestwounds resulting fromknives,icepicks,sticks,arrows,portionsofautomobilesorotherprojectiles.

(5) Impalementinjuries8. Isolated chest trauma is uncommon (16%); 84% of these patients will have additional

injuriesB. Morbidityandmortality

1. Thoracicinjuriesarethesecondleadingcauseoftraumamortalityoccurringin15-25%ofalltrauma-relateddeaths(about12,000peryearintheU.S.).Mostdeathsaresecondaryto heart and great vessel trauma causing exsanguinating hemorrhage and respiratoryfailure.

2. Thoracicinjuriesaresecondonlytoheadtraumainmortalityrates.Overallmortalityrateis3%to18%.

3. Chest injuries are often associated with abdominal injuries and are a significantcontributor to fatal outcomes in an additional 25%-50% of cases. They are the leadingcauseofpreventabletraumadeath.

4. Mechanismsofinjurycausingdeathfromthoracictraumaa. MVC

(1) Accountforlargestnumberoftraumadeaths(2) Over50%haveoneormoredriverslegallyintoxicated(3) Motorcycledeathratemorethan15timesgreaterthenautocrash

b. Falls:Morethan½inelderlyc. Penetratinginjuries;seenmorefrequentlyinurbanareasduetoviolentcrimed. Crushinjuries

Chest and Abdominal Trauma Case Studies Page 7 NWC EMSS CE November 2015

C. Mechanisms of injury: Deceleration, shearing, acceleration, acceleration-deceleration,

compression1. Acceleration-deceleration: Skeletal body starts or stops moving more quickly than the

internal organs. This type ofmotion frequently causesmore damage to relatively fixedstructures,(aorta),thantonon-fixedorgans,suchastheheartandlungs.

2. Compression:Occurswhentheexternalforceappliedisgreaterthantheresistanceoftheskeletalbody.

D. Basicapproachtomajorthoracictraumaremainsunchanged,butthetreatmentofseveralinjurieshaveundergoneanevolutionintherecentpast:1. Pericardialtamponade2. Aortictransection3. Bluntcardiacinjury4. Pulmonarycontusionandflailchest

E. Preventioneffortshavethepotentialtoreducetheincidenceofthoracicinjuries:1. Firearmsafety2. Sportstraining3. Seatbeltuse,passiverestraintsystems4. Decreasedspeedlimits5. Community/legalactivityregardingdrunkdriving,etc.6. Violencepreventioneducationi.e.,conflictresolutionskills

II. ReviewthoracicanatomyfromRespiratoryA&PandCardiacA&PlecturesIII. Generalpathophysiologyofchestinjuries

A. Impairmentsinventilatoryefficiency1. Painrestrictingchestexcursion2. Airorbloodenteringthepleuralspace3. Chestwallfailstomoveinunison4. Ineffectivediaphragmaticcontraction

B. Impairmentsingasexchange1. Hypoxia:ResultsfrominadequateO2deliverytotissues2. Pulmonaryventilation/perfusionmismatch:i.e.-contusion,hematoma,alveolarcollapse3. Changes in intrathoracic pressure relationships: tension/open pneumothorax or severe

hemothorax4. Atelectasis5. Contusedlungtissue6. Respiratoryacidosis,hypercarbia:mostoftenresultsfrominadequateventilationcaused

bychangesinintra-thoracicpressurerelationshipsanddepressedlevelofconsciousnessC. DisruptionofrespiratorytractD. Impairmentsincardiacoutput

1. Hypovolemia:Inadequateintravascularvolumeduetobloodloss2. Increasedintrapleuralpressuresreducevenousreturn3. Bloodinpericardialsacreducespreload4. Decreasedstrokevolumeduetobluntcardiacinjury5. Myocardialvalvedamage6. Vasculardisruption7. Metabolicacidosis:causedbyhypoperfusiontotissues

IV. PrimaryassessmentpearlsA. Clinically evident, immediately life-threatening injuries should be considered, found and

resuscitatedassoonasadeficitisdiscovered.AVOIDHYPOXICINJURY.B. Ifagitationoralteredmentalstatus ispresent,assumethatthepatienthasanairway,breathing,

and/or perfusion problem especially if objective criteria support these findings, e.g., decreasedoxygen saturation, change in capnogram, or pulse deficits. Do not initially attribute abnormalfindingtodrugsorethanolabuseuntillife-threateningproblemshavebeenruledout.

C. Ifcervicalspinestatus isunclear,spinemotionrestrictionmustbemaintained ifamechanismofinjurysuggestspotentialc-spineinjury.

D. Etiologyofinadequateventilations/impairedgasexchange1. Ventilationdeficiencies:Pulmonary,musculoskeletal,orneurologic

Chest and Abdominal Trauma Case Studies Page 8 NWC EMSS CE November 2015

2. Diffusiondeficiencies:Pulmonarycontusion,previousdiseaseE. Inspection

1. Visuallyinspectthethoraxforappearance,contour,symmetryofexcursion,andanygrossabnormalities, i.e., deformity, contusions, abrasions, penetrating wounds, bruising,lacerations, subcutaneous or tissue edema, paradoxical movements, retractions, orimpaledobjects,etc.

2. Determineadequacyofventilationsa. Generalrespiratoryrate,depth;andeffort(tachypnea,bradypnea)b. Workofbreathing;useofaccessorymuscles;nasalflaringc. Capnographynumberandwaveform

3. Determineoxygenationstatusa. Clinical presentation i.e. mental status, skin color (cyanosis of the lips or nail

beds)etc.b. Pulseoximetry(SpO2)

4. Neckveinsa. Normalanatomiclocationofneckveins

(1) External jugulars are above the clavicle and cross over thesternocleidomastoidmuscles.

(2) Internal jugulars run parallel to the sternocleidomastoidmuscles nearthecarotidarteries.

(3) If apatient ispositionedata45° angle, thevenouspulses shouldnotascendmorethanonetotwocmabovetheclavicle.

b. Markedly distended neck veins occur when blood cannot drain into the rightatria. Inthepresenceofchesttrauma,JVDmayindicatetensionpneumothoraxorcardiactamponade.

5. Observeforthetype,amount,andnatureofsecretionsF. Palpation

1. Pointtenderness2. Lossofchestwallintegrity;instability3. Crepitus;subcutaneousemphysema4. Edema5. Trachealposition:Deviationisdifficulttoappreciateclinically

G. Percussion1. Hyperresonance/tympany(pneumothorax)2. Dullorflattone(hemothorax)

H. Listenwithout a stethoscope for noisy ventilatory efforts, air being sucked in or out of an openchestwound.

I. Auscultateimmediatelyifinventilatorydistress;Listenposteriorly,laterally,andanteriorly1. Breathsoundspresentorabsent;unilateralorbilateraldeficits2. Ifdecreased,attempttodiscernetiology;treatappropriately3. Adventitioussounds:treatduringfocusedexamphase4. Presenceofbowelsoundsinthechest-maysignifyaruptureddiaphragm

V. InjuriesthatmustbefoundatB(Breathing)astheyjeopardizeventilationsand/orgasexchangeA. Tensionpneumothorax

1. Etiologya. Results from any of the causes of a simple

pneumothoraxb. Damage to lung parenchyma (tissue) usually from

blunttraumac. In ventilated patients, it may occur secondary to

positivepressure ventilations resulting in a suddenincreaseinintrapulmonarypressure(barotrauma).

d. Penetrationofpleurabyribfracturee. Tracheobronchialtreeinjuriesfromshearforces

2. Pathophysiologya. Mostcommonlyoccursfromblunttrauma.b. Startswithasimplepneumothorax

Chest and Abdominal Trauma Case Studies Page 9 NWC EMSS CE November 2015

c. Aclosedpneumothoraxprogressivelyaccumulatesairwithinthepleuralspaceoninspirationthatcannotescapeonexpiration,creatingaone-wayvalve.

d. This accumulation produces an increase in intrapleural pressure (tension) thatcollapsesthelungontheaffectedsideanddepressesthediaphragm.

e. Whenpressureinthepleuralspaceexceedspressureintheatriaandvenacavae,theycollapse.Thiscreatesamechanicalobstructionofbloodreturntotherightheart resulting in markedly decreased preload and cardiac output –OBSTRUCTIVESHOCK

f. Then…Rising intrathoracic pressure depresses diaphragm& shiftsmediastinumawayfromaffectedside,furthercompressingvenacavae&compromisingintactlungsooppositesidebecomespressuredaswell

g. Hemodynamicdysfunctionproduceshypoxiaandobstructiveshock.h. Life-threatening emergency due to cardiovascular compromise. Must be

suspectedclinicallyassoonaspossible.3. Assessment–classicfindings

a. Inspection(1) Complaintofseverepainwithbreathing(pleuriticchestpain)(2) Restlessness,severeanxiety,agitation(3) Dyspnea,tachypnea,retractionsandothersignsofrespiratorydistress(4) Asymmetric chest movement, hyperdistended hemithorax on the

affectedside,bulgingofintercostalmuscles(5) JVD:Collapseofthesuperiorvenacavaandrightatriumpreventsblood

fromreturningtotherightsideoftheheartproducingincreasedcentralvenouspressure.HypovolemiawillpreventJVD.

(6) Desaturationandcyanosis(latesign)b. Palpation

(1) Tachycardia,weak,threadypulsesreflectreducedcardiacoutput(2) Subcutaneousemphysemainface,neckandupperchest(3) Trachealdeviation(latesign)–Tracheaissolidlytetheredanddoesnot

moveeasilyabovesternalnotch.Hardtodetectwithoutachestx-ray.c. Percussforhyperresonanceonaffectedsided. Auscultation

(1) Absentordecreasedbreathsoundsonaffectedside(2) Distantheartsounds(ifmediastinalshifttoright)(3) Displacementofapicalimpulsetoleftlateralchestwallifshifttotheleft(4) Hypotension(narrowedpulsepressure)

4. Emergencyinterventions-seelabmanuala. Applyoxygen12-15L/NRMb. Needlepleuraldecompressionisatemporizing

measure(1) Equipment needed: 10 g IV catheter

or use s commercial device;Chlorhexidinewipe.

(2) Proceduralsteps:Insertneedleata90degreeangletothechestwall inthe2ndor3rd ICS inthemidclavicularlinetoreleaseairunderpressureinpleuralspace.USEEXTREMECAREinselecting the correct site and inserting the needle using the correctanglesoitpenetratesintothepleuralspace.

Analternatesiteofneedleinsertioninthe4th-5thintercostalspaceinthemidaxillarylineisNOTapprovedintheNWCEMSSduetothepossibilityofdiaphragmandliver/spleenpenetrationbyblindneedleinsertioninasupinepatient.

(3) Iftheneedlehitsarib,gentlygooverthetopoftheribtoavoidinjurytotheneuralvascularbundlerunningundereachrib.

(4) Once in place, remove the needle and leave only the catheter in thechest.A retainedneedlehas thepotential topenetrate theheartoraventilatedlung.

(5) Release of pressurized air should relieve the patient’s acute distress,improve ventilations, and re-establish venous return (and thus

Chest and Abdominal Trauma Case Studies Page 10 NWC EMSS CE November 2015

peripheralpulses)butitwillnotre-expandthelung(breathsoundswillstill be absent).Will need a chest tube at the hospital to expand thelung.

(6) Frequently reassess catheter patency.May need to repeat procedurewithadditionalneedle.

c. Venousaccess;IVNSupto1Ld. Time-sensitivepatient–needsexpeditioustransporttoaLevelItraumacenter

5. Complicationsa. Pneumothoraxifmisdiagnosedpriortoprocedureb. Hemothoraxifapulmonary,internalmammaryorintercostalvesselistransectedc. Lunglacerationd. If tensionpneumothoraxpresentsunrecognizedand thereforenot treated, the

patient's condition may deteriorate to pulseless electrical activity (PEA) andrespiratory-cardiacarrest

6. How can you tell the difference between a pneumothorax & tension pneumothorax(bothhaveabsentbreathsounds)?

7. Howcanyoutellthedifferencebetweenahemothorax&tensionpneumothoraxwhenbothhaveunequalBS&lowBP?

B. Openpneumothorax(suckingchestwound)1. Etiology: Usually caused by penetrating chest trauma secondary to gun shot or stab

wound,butcanalsobecausedbyanimpaledobject.2. Pathophysiology

a. Penetrating trauma through the chest wallcreates an opening allowing air to enter theintrathoraciccavitythatdependsonnegativepressures and intact pleural membranes toallow inspiration through thetracheobronchialtree.(1) Sincechestwallandpleuralintegrity

is lost, the involved lungparadoxically collapses oninspirationandexpandsminimallyduringexpirationmovingair in andoutofthedefect,producinga"sucking"sound.

(2) Criticaldiameter:Airisgas,soitflowsalongthepathofleastresistance(high→lowpressure).Ifthewoundapproximates2/3thediameterofthetrachea,resistancetoairflowthroughtherespiratorytractmaybegreater than through the open wound, so air preferentially movesthrough the chest wall defect into the pleural space instead of thetrachea to equalize intrathoracic and atmospheric pressure duringventilatoryattempts.

(3) Increased intrapleural pressure leads to lung collapse on the affectedsidewithpossiblemediastinalshift

(4) Ventilation/perfusionmismatch(a) Shunting(b) Hypoventilation(c) Hypoxia(d) Largefunctionaldeadspace

(5) Air may exit the wound during the exhalation phase producing afrothingorbubblingatthesite

b. Aone-wayflapvalvemayallowairinbutnotoutresultinginanaccumulationofpressureinthepleuralspace

c. Directlunginjurymaybepresent3. Morbidity/mortality:Patientdiesfrominadequateventilationandimpairedgasexchange4. Assessment

a. Inspect(1) Visiblechestwalldefect;suckingsoundoninhalation(2) Complaintofpainwithbreathing

Chest and Abdominal Trauma Case Studies Page 11 NWC EMSS CE November 2015

(3) Restlessness,dyspnea,tachypneaandothersignsofventilatorydistress,hypoxia,andhypercarbia

(4) Asymmetricalchestexpansion,subcutaneousemphysema(5) Cyanosis(latesign)(6) Aphasia: Patient cannot speak if they are unable tomove air through

thetrachea.b. Palpateforsubcutaneousemphysemainneckandupperchest;tachycardiac. Auscultateforabsentordecreasedbreathsoundsonaffectedside(orbothsides

withsignificantinjury).5. Emergencyinterventions

a. TheSMITHPAPYRUS,writtensometimearound3,000B.C.,containstheearliestrecognized reference to "thoracic trauma".Work describes 58 patients (2 hadthoracic injuries). Recommended treatment for penetrating injury was freshmeat poultice the first day, followed by grease, honey and lint on subsequentdays

b. If detectable, there is an immediate life-threat. Convert to a closedpneumothorax.Immediatelycoverwithglovedhand.Then…(1) Askacooperativepatienttomaximallyexhaleorcough(2) Immediately apply occlusive dressing (Vaseline gauze, plastic wrap,

defib pad or commercial device). Dressings should be at least 3 or 4timesthesizeofthedefect.

(3) Maytapeon3sidestocreatefluttervalve(4) MonitorVS,ventilatory/circulatorystatus,jugularveinsafterapplication

ofocclusivedressing.c. Intubateifnecessaryandmonitorventilationsd. Oxygen 12-15 L/NRM; assist with BVM as necessary. Use positive pressure

ventilationswith caution inpatientswhohavepenetrating chestwounds.Highventilatory pressuresmay force air from an injured bronchus into an adjacentopenpulmonaryvein,producingsystemicairemboli.Thismayaccountformanyof the dysrhythmias and sudden deaths that occur in patients with severepenetratingchestwounds.

e. AdministersedativescautiouslyperOLMCtoallowforcontrolofventilationsf. Tension pneumothorax usually does not occur in the presence of an open

pneumothorax but may develop ifpenetratingwoundhasaone-way flapor issealedwithanocclusivedressing.If patient becomes dyspneic and BPdrops, assess for tensionpneumothorax and temporarily lift orremovedressingtoreleasepressure.

g. Assess need for needle pleuraldecompression if no improvementfollowingremovalofdressing

h. Noprobingofwounds(1) Givesnoinformation(2) Maycreateafalsepassage(3) Precipitateshemorrhage(4) Mayconvertaclosedtoanopenpneumothorax

C. Flailchest1. Mostsevereformofbluntchestwallinjury.2. Mechanismofinjury:usuallyduetobluntchesttrauma

a. HighspeedMVCb. Fallsc. Auto-pedestriantraumad. Motorcycletraumae. Severecompressiontrauma

3. Pathophysiology

Chest and Abdominal Trauma Case Studies Page 12 NWC EMSS CE November 2015

a. Flailchestoccurswhentwoormoreadjacentribsand/orcartilagesonbothsidesof an impact point are broken at two points resulting in a freely mobile or"floating"segment.

b. Maybeidentifiedbylocationorsize(1) Anterior,posterior,orlateral(2) Separationof thesternumfromadjacentbrokenribsorcostochondral

joints:sternalflailchestc. Freesegmentmovesseparatelyand intheoppositedirection (paradoxically) to

the rest of the thoracic wallduringtheventilatorycycle.

d. Paradoxicalmotionoftheflail

segment interferes with thenormal inspiratory/expiratorycycle due to the lack of bonysupport and changes inintrathoracicpressures.

e. Subatmospheric intrathoracic pressure during inspiration pulls the segmentinward. Positive intrathoracic pressures during expiration move the segmentoutward.

f. The most significant life-threat accompanying flail chest is the insult to lungparenchymathatcreatesapulmonarycontusion.Contusedlungproducesmorethan the normal amount of interstitial and intra-alveolar fluid resulting inimpaired gas exchange. Pulmonary contusion occurs in 30-75% of all bluntthoracictrauma(East,2006)andisthemajorcauseofrespiratorycompromise.

g. Localeffects(1) Lacerationtolungtissue(2) Hemorrhage-filledalveoli(3) Reducedcomplianceleadingtoreducedventilation(4) Increased shunt fracture with decrease in pO2 and increase in AaDO2

(alveolar-arterialoxygendifference)(5) Increasedpulmonaryvascularresistance(6) Decreasedpulmonarybloodflow(7) Injuredanduninjuredlung(ipsilateralandcontralateral(EAST,2006)

h. Pain from multiple rib fractures discourages breathing effort. Even if madeinitially, fatigue, CNS depression, or increased tracheobronchial secretions willeventuallyoutweighanypatientefforts.

i. Hypoventilation,impairedoxygendiffusion,pulmonaryphysiologicshuntingandvenous admixture results in a decreased PaO2, decreased lung compliance,decreased tidal volume and vital capacity, and decreased venous return withventilation/perfusion (VA/Q) mismatch. CO2 retention results in hypercarbia.Impairedcoughresultsinatelectasis.

4. Morbidity/mortalitya. Forces sufficient to produce a flail chest, are also sufficient to cause

pneumothoraxandseriousinjurytotheunderlyinglung.b. Mortality rates of 10% to 20% are typically accompanied by a significant

pulmonarycontusion.Mortality:5-50%duetoassociatedinjuriesc. Mortalityincreasedwith

(1) Advancedage:makeupabout10%ofthecasesbutconsume30%oftheclinicalresources(East,2006)

(2) Sevenormoreribfractures(3) Threeormoreassociatedinjuries(4) Shock(5) Headtrauma

5. Assessmenta. Inspect: Unclothed chestmustbe viewed fromanterior, posterior, and lateral

anglestodetectpresenceofaflailsegment.

Bledsoe, 2006

Chest and Abdominal Trauma Case Studies Page 13 NWC EMSS CE November 2015

(1) Evidence of chest wall trauma to soft tissues (abrasion, laceration orecchymosis)

(2) Complaintofseverepleuriticchestpainatfracturesites,splinting(3) Dyspnea, altered RR (>35 or < 8 min), cough, and other signs of

respiratorydistress(4) Paradoxical chest movements - Not always apparent in an awake

patient with muscle spasms, shallow respirations, and splintingsecondarytopain.Seenaspatienttires,usuallywithinfirst24hours.

(5) Poortidalvolume(shallowbreathing),pulseoximetrydesaturation,andcyanosis(latesign)

b. Palpate (orauscultate) for subcutaneousemphysema inneckandupper chest,tenderness,crepitus,andpainatfracturesites,tachycardia.

c. Auscultate forabsentordecreasedbreathsoundsonaffectedside, respiratorystridor.

6. Interventionsa. Goalsoftherapy

(1) Promoteoxygenationandgasexchange.(2) Achieveandmaintainadequatepaincontrol.(3) Achieveandmaintaineuvolemia.

b. Gainairwaycontrol;suction.(1) Intubation andmechanical ventilation should be avoided (East, 2006).

Mechanical ventilation should beused to correct abnormalities of gasexchangeratherthantoovercomeinstabilityofthechestwall.

(2) Clinical signs of progressive fatigue and deterioration should promptintubationandmechanicalventilations.(a) Respiratoryrate>35or<8breaths/min(b) PaO2<60mmHgatFiO2>50%(c) PaCO2>50mmHgatFiO2>50%

c. CPAP:AtrialofmaskCPAPshouldbeconsideredinalert,compliantpatientswithmarginal respiratory status regimen (EAST, 2006). No external mechanicalstabilizationorsplintingoftheflailsegmentisindicated.(1) WhyisCPAPhelpful?

(a) ProlongsO2diffusiontimeby50%(b) Improvesgasexchange(c) ↓workofbreathing(d) ↓respiratorymusclefatigue(e) ↑functionalreservecapacity(f) ↑cardiacoutput

(2) ContraindicationsforCPAP:(a) DecreasedLOC(b) Unabletomaintainpatentairway(c) Aspirationrisk;inabilitytoclearsecretions(d) Needforimmediateintubation(e) Needforventilatoryassistance(f) ECGinstability(g) Evidenceofpneumothorax(h) Gastricdistention(i) ↑ICP(j) Facial trauma/burns or recent surgery to face/mouth that

wouldcomplicatemaskseal(k) Epistaxis(l) Ptunabletotoleratemaskorpressure

(3) CriteriatodiscontinueCPAPinthefield(a) Inabilitytotoleratemask(b) Needfortrachealintubationorassistedventilations(c) ↓BP(SBP<90;DBP<60)(MAP<65)

d. Needearlyventilatorysupport

Chest and Abdominal Trauma Case Studies Page 14 NWC EMSS CE November 2015

(1) Presenceofshock(2) Associatedsevereheadinjury(3) Associatedinjuryrequiringsurgery(4) Previouspulmonarydisease(5) Age>65years(6) Fractureofeightormoreribs

e. MonitorECGf. IVFasnecessarywithNS tomaintain signsof adequate tissueperfusion. (East,

2006).Donotoverhydrate.g. Painmanagement isessential topromoteventilationand topreventuntoward

effectsofpaini.e.,splinting,atelectasis,andhypoventilation.Somepatientsmaydesaturate purely from inadequate pain management. Use of narcotic agentsmaydecreasetherespiratorydrive,worsenhypoxia,andcause↓BPandshouldbeusedwithextremecautioninthepresenceofchesttrauma.Balanceriskwithbenefit in the field. Alternative pain interventions are used at the hospital likeepiduralanalgesiaandlocalnerveblocks.

h. Noexternalsplintingindicatedi. If patient suffers a cardiac arrest: an impedance thresholddevice (ResQPod) is

contraindicated7. Complications

a. **Flail chest servesas a red flag for significantunderlying intrathoracic injury,usually pulmonary contusion. Also suspect intrathoracic injuries such ashemothoraxandpneumothorax.SuspectifSpO2remains<90despite15LO2.

b. Pneumoniamay occur secondary to a combination of factors: hypoventilation,intubation,aspiration,inadequatepainmanagement,atelectasis,andpoolingofsecretions.

c. Prolonged tracheal intubation can lead to associated complications such astrachealstenosis,vocalcordparalysis,andvocalcordulceration.

d. Long-termsymptomsincludecomplaintsofdyspneaandchestpain.VI. C:Circulation=Injuriesthatjeopardizecirculation/perfusion

A. Assessforhemodynamicstability1. Mental status: Restlessness, progressive agitation, mental confusion and irrational or

uncooperativebehavior2. Pulses:Presence/absence,rate(generallyfastorslow),quality(full/thready),rhythmicity

(regular/irregular), location (carotid, femoral, or radial), symmetry, deficit, or loss oninhalation (pulsusparadoxus). Tachycardia isnot specific toonecause,butmaygiveanindicationofshock.

3. Skinperfusion:Color/temperature/moisture.Lookforpale,cool,diaphoreticskinduetosympatheticnervoussystemresponse.

4. Evaluateneckveins5. MonitorECGrhythm1. Hearttones

a. Heartsoundsarebestnotedoverthefollowingareas:(1) Mitralvalve:5thleftintercostalspace(LICS)inthemidclavicularline(2) Tricuspidvalve:lowerleftsternalborderatthe4thintercostalspace(3) Aorticvalve:2ndrightintercostalspaceatthesternalborder(4) Pulmonicvalve:2ndleftintercostalspaceatthesternalborder

a. Heart sounds are often difficult to assess while examining the multiplytraumatized patient. However,muffled or distant heart tones are noteworthybecausethisfindingmayindicatecardiactamponadeoratensionpneumothoraxwithsignificantmediastinalshift.

6. ShiftofapicalimpulseB. Because many of the organs in the chest are so vascular, hemorrhagic shock is a common

complication. The lungsarea lowpressure system.Continuoushemorrhage indicates ruptureofmajorvessel.1. Chest trauma patients in shock had a mortality of 7%. If respiratory distress was also

present,alongwithshock,themortalityincreasedto73%.

Chest and Abdominal Trauma Case Studies Page 15 NWC EMSS CE November 2015

2. Mostfrequentsourcesofbleedingcausingshockinthoracictraumaa. Bluntchesttrauma

(1) Pelvicorextremityfractures (59%)(2) Intraabdominalinjuries (41%)(3) Intrathoracicbleeding (26%)

In addition, 15% hadmyocardial contusion and 7% had SCIwhich can contribute to hypotension from decreasedmyocardialcontractilityanddiminishedsympathetictone.

b. Penetratingchesttrauma(1) Intrathoracicbleeding(74%)oftenfrommultiplesites:

(a) Lung(36%)(b) Cardiac,usuallywithtamponade(25%)(c) Greatvessel(14%)(d) Intercostal/internalmammaryarteries(10%)

(2) Othercontributingsources:40%C. Pericardialtamponade

1. Definition: Tamponade comes from the French word, "tampon", meaning "to plug".Pericardialtamponadeliterallymeansapluginthepericardialsac.Itpracticallymeansanaccumulation of blood and/or clot in the pericardium causing an increase inintrapericardialpressure.

2. Etiology: Can occur with blunt or penetrating trauma, however, penetrating is morecommon from small projectiles (ice pick or stilettoknife).Becauseblunttraumacausessuchalargetear,the patient generally exsanguinates before the lesioncansealover.

3. Epidemiologya. Incidence

(1) Occurs in less than 2% of chesttrauma

(2) Tamponade occurs in 10% ofpatients with blunt chest trauma(Yamamotoetal,2005).

(3) Approximately80-90%ofpatientswithstabwoundstotheheartshowevidenceoftamponade.

Occursin93%ofallrightventricularwounds;43%ofleftventricularwounds(Chappell,p.14)(4) CanoccurwithacuteMIandmyocardialrupture(5) Rare–CPR

b. Morbidity/mortality(1) Estimatedmortality15-60%(2) Gunshotwoundscarryhighermortalitythanstabwounds(3) Lowermortalityifisolatedtamponadeispresent(4) Clinical severity depends on pericardial compliance, rate of fluid

accumulationandamountoffluidinpericardium4. Anatomicalconsiderations

a. Thepericardiumisatough,fibroussac,enclosingtheheartandattachingtothegreatvesselsatthebaseastheyleavetheheart

b. Visceralandparietal layersservetoanchortheheart, restrictingexcessmotionduringaccelerationorrepositioningofthebody.Theyalsopreventkinkingofthegreatvessels.

c. Thespacebetweenthelayersisa“potentialspace”d. Parietal,fibrousportionisnon-distensible.Spaceisnormallyfilledwith30-50ml

of straw-colored fluid secreted by the visceral pericardium. Fluid provideslubrication,lymphaticdrainageandimmunologicprotectionfortheheart.

5. Pathogenesisofpericardialtamponadea. Bleeding from the myocardium or

coronary arteries accumulates in thepericardialsac.Thepericardiumhasanon-linear pressure compliance curve. In

Chest and Abdominal Trauma Case Studies Page 16 NWC EMSS CE November 2015

chronicdisease,theremaybeaslow,progressiveaccumulationoffluidthatmaydistendthesacfrom1000-1500mLyetmaintainadequateoutput.

b. Intraumaticinjury,rapidlyaccumulatingamountsof>50mLcanoveraperiodofminutes to hours increases intrapericardial pressure and overcomes thecompliancecurveasthereisnotimeforthetissuestostretchandaccommodatefor theexcess fluid.Themostcompressible structureswithin thesaccollapse -atria,greatveins.

c. The combinationof pressure and vascular collapsedecreases venous return totherightsideoftheheart (preload),restrictsdiastolicexpansionandfillingandreducesstrokevolume.

d. Initially, mechanisms such as an increased heart rate, increased myocardialcontractility, and an increase in ventricular filling pressure are used tocompensateforthedecreaseinstrokevolume(CO=SVXHR).

e. Once the limits of compensation are reached, further increases in pericardialvolumecauseasevereimpairmentofcardiacfunctioning.

f. Myocardialperfusiondecreasesduetopressureeffectsonthewallsoftheheartanddecreaseddiastolicpressures.

g. Ischemicdysfunctionmayresultininfarctionh. Becauseofthedynamicsofthepressurecompliancecurve,removalofaslittleas

20to50mlofbloodmaydrasticallyimprovecardiacoutputi. Samemechanism of death as a tension pneumothorax = Inadequate venous

returnanddecreasedCO.6. Assessment

a. Clinicalpresentationdependsontheinteractionbetweenpericardialcompliance,rateoffluidaccumulation,andtheamountoffluidpresentinthepericardium.

b. Beck'striad:advancedstagesseeninonly30%ofpatients(1) JVD(firstsign):Kussmaul’ssign(neckveinsfillduringinspiration,empty

duringexpiration)(2) Decreased arterial pressure (Systolic BP less than100mmHg); pulsus

paradoxusandnarrowedpulsepressure(3) Muffled(subjective)heartsounds

c. Evidenceofshock/hypoxemia(1) Thready/absentperipheralpulses (PEA):peripheralpulse0 (absent)or

1+ (thready of a 4+ scale). Cardiac arrest may occur secondarily tounrecognizedpericardial tamponade. Patientswhosurvivearrestmaysustain other complications such as sepsis, anoxic encephalopathy, orischemicbowelifthearrestisprolonged

(2) Diaphoresis(3) Dyspneaandothersignsofrespiratorydistress;cyanosisofupperhalfof

body(4) Alteredmentalstatus,agitation(5) Tachycardia,tachypnea(6) Pulsusparadoxus:SystolicBPdecreases>10mmHgwithinspiration

d. ContinuousECGmonitoring–assessandrecordtracingse. Maybedifficulttodifferentiatebetweenatensionpneumothoraxandpericardial

tamponadeinthefieldastheysharemanyofthesamesignsandsymptoms.7. Emergencyinterventions

a. Gainairwaycontrol;12-15Loxygenb. IVNStoachieveaminimumSBPof80.c. MonitorforPEA:TreatperTraumaticArrestSOPwhileenroute.d. Pericardiocentesis is a controversial temporizing interventiondue to the riskof

possiblecardiacdamage.Itmayelicitmarkedimprovementinthepatientwhoishemodynamicallycompromisedifenoughbloodisremovedfromthepericardialsac to allow right heart filling again. This procedure is NOT done in the NWCEMSS.

e. PrepareresuscitativeequipmentD. Massivehemothorax

Chest and Abdominal Trauma Case Studies Page 17 NWC EMSS CE November 2015

1. Definition: Accumulationof 1500mLormoreblood in thepleural space (Class III or IVhemorrhage).Pleuralspacescanholdtheentirebloodvolume.

2. Etiology:Bluntorpenetratinginjurywithtraumatosystemicorpulmonaryvessels,lung,orhearta. Bleedingsourcesonleftside,indecreasingorderoffrequency

(1) Ribfracture(2) Pulmonaryparenchyma(3) Aorticisthmus(4) Spleen(5) Heart(6) Intercostalartery:Caneasilybleed50ml/min(7) Supra-aorticvessel(8) Majorpulmonaryvessel(9) Diaphragm

b. Bleedingsourcesonrightsideindecreasingorderoffrequency(1) Ribfracture(2) Pulmonaryparenchyma(3) Liver(4) Intercostal/internalmammaryartery(5) Supra-aorticvessel(6) Pulmonaryvessel(7) Aorticisthmus(8) Heart(9) Diaphragm

3. Morbidity/mortalitya. Life-threateninginjurythatfrequentlyneedsurgentchesttubeinsertionand/or

surgeryatthehospitalb. Hemothoraxassociatedwithgreatvesselorcardiacinjury

(1) 50%willdieimmediately(2) 25%livefivetotenminutes(3) 25%maylive30minutesorlonger

4. Pathophysiologya. Bloodaccumulatesinpleuralspacecausingpartialortotal

lungcollapsewithpossiblemediastinalshiftandimpairedvenousreturn

b. Patientpresents inhypovolemicshockandinrespiratorydistress. Cause of death = exsanguination leading tocardiacarrest.

c. Ventilatoryinsufficiencydependsontheamountofbloodinpleuralspace5. Assessment

a. Inspection(1) Signsofhypovolemicshock(pale,cool,moistskin)(2) Dyspnea, tachypnea, and other signs of respiratory distress;

desaturationonpulseoximeter(3) Asymmetric chest expansion, complaint of chest tightness, pleuritic

chestpain(4) Ecchymosesoveraffectedlung(5) Hemoptysisorbloodysputum(6) Neckveinsshouldbeflat

b. Palpation(1) Tracheashouldnotbedeviated(2) Diminishedpulsequality,tachycardia

c. Percussfordullnessonaffectedsided. Auscultate for decreased or absent lung sounds on affected side; BP for

hypotension,narrowedpulsepressure6. Emergencyinterventions

a. Gainairwaycontrol

Chest and Abdominal Trauma Case Studies Page 18 NWC EMSS CE November 2015

b. 12-15Loxygen;assistventilationsasnecessaryc. InsertlargeboreperipheralIVlined. AdministerNStocorrecthypotensiontominimumacceptablelevels(SBP80with

penetratingtraumaand90withblunttrauma).Ifhypotensionlastslessthan30minutes,mortalitymayonlybe11%.Ifhypotensionisprolonged:mortalityrisesto40%-50%.Ifpatienthasunderlyingdisease& is 65 years or older, the mortality withhypotension for > 30 minutes may be over90%.

e. Hospitals will insert chest tubes, perhapsautotransfuse the patient and determine ifrapidoperativeinterventionisnecessary.

E. Myocardialrupture1. Associatedwith immediate traumaordelayed for2-3

weeks2. Associated with blunt trauma as the heart is compressed between the sternum and

vertebrae3. Penetratingtrauma:Rib,missile,sternalbone4. Historyoftraumawithapresentationof

a. Heartfailureb. Cardiactamponade

5. Immediateonsetofheartfailurefollowingtraumaa. Ruptureofcardiacvalvesb. Intraventricularseptalrupture

6. ManagementissupportiveF. Commotiocordis:Blowtothechestthatproducescardiacarrest.Thismaybemorecommonthan

once thought.Anyblow to thechest, regardlessof its intensityorvelocityor force is capableofproducing cardiac arrest, especially in younger children whose rib cages are narrow and haveunderdeveloped chest muscles. Patients have experienced death due to a blow from softballs,baseballs,hollowtoybaseballbats, snowballs, chestblowsduringshadowboxing,playingwithafamilydogortryingtoremedyhiccups(Cooke,2002).

G. Traumaticasphyxia1. Pathophysiology

a. Suddencompressionalforcesqueezesthechestb. Vascularpressureincreasesinthehead,neck,andkidneysc. Jugularveinsengorge,capillariesrupture

2. Clinicalpresentationa. Inspection

(1) Bluntchesttrauma,mayhaveflail(2) Profoundshock(3) Cyanosisofface,neck,andshoulder(4) Swellingorhemorrhageof the conjunctiva;mayexhibit exophthalmos

(protrudingeyes)(5) Swollen,cyanotictongueandlips(6) JVD(7) Skinbelowarearemainspink(8) Bloodyvomiting(hematemesis)

b. Auscultation:Hypotensionwhenpressureisreleased3. Emergencyinterventions

a. Gainairwaycontrolb. 12-15LoxygenviaBVMortransportventilator.c. Spinemotionrestrictiononalongspineboardd. Timesensitivepatient;beginexpeditioustransporte. Venousaccessenroute;fluidadministrationperITC

VII. SecondaryassessmentA. Once the initial assessment is completedand life-threatening injurieshave received resuscitative

intervention, proceed with focused history and exam.With chest trauma, any negative change

Chest and Abdominal Trauma Case Studies Page 19 NWC EMSS CE November 2015

fromtheinitialassessmentisasignofpossibletrouble.B. Fullsetofvitalsigns

1. Pulse:Rate,quality,rhythmicity,deficits2. Bloodpressure

a. Narrowedpulsepressureb. Hypertensionc. Hypotensiond. Pulsusparadoxus

3. Respirations:Rate,pattern,depthC. SAMPLE–history

1. Symptoms2. Allergies3. Medications4. Pastmedicalhistory5. Lastoralintake/LMP6. Eventssurroundingtheincident–mechanismofinjury

D. Continue to use maneuvers of inspection, palpation, percussion and auscultation to detectadditionalinjuries.1. Chest wall injuries are characterized by pain, ineffective ventilation, and secretion

retention2. Injuries to the lung includepulmonarycontusionsandhematomas.Bothcausebleeding

intothealveoliwhichimpairsgasexchange.3. Pleuralspaceinjuries:pneumothoraces,hemothorax,andtracheobronchialtears

E. Injuriestosuspect/findnow1. Aortictransection2. Penetratingwoundsofthegreatvessels3. Bronchialdisruption4. Esophagealinjury;traumaticdiaphragmatichernia5. Bluntcardiacinjury(myocardialcontusion)6. Pulmonarycontusion7. Simplepneumothorax8. Hemopneumothorax9. Fracturedribs10. Sternalfracture

F. Thoracicaortadissection/transection1. Etiology

a. Mostcommonlyinjuredfromblunttrauma;usuallyhighspeedMVCswithlateralimpactsandsometimesfallsfromaheight.

b. Produces15%ofallblunttraumadeaths.c. Penetrating injuries may occur at any point and usually result in massive

hemorrhage. Patients do not respond to CPR or volume replacement untilcontinuinglossiscontrolled.

2. Morbidity/mortalitya. 80-85%dieatsceneb. Ofthosewhosurvive,10-15%survivetoarrivalathospitalc. 33%diewithinsixhoursd. 33%diewithin24hourse. 33%survivethreedaysorlonger

3. Pathogenesisa. Impactproducesincreasedintraluminalpressuresb. Pointsofattachment

(1) Isthmusatligamentumarteriosum 85%(2) Aorticannulus 9%(3) Diaphragm 3%(4) Other 3%

c. Whenthebodyisinmotionandcomestoasuddenhalt,shearingforcesorstresson fixation points cause tears of the intimal layer at points of attachment or

Chest and Abdominal Trauma Case Studies Page 20 NWC EMSS CE November 2015

thinningwhichallowsittoseparatefromthemedia.d. Mediaandadventitiaaremoreelasticandmaynottearinitiallye. Blood dissects between the two layers causing a bulge on the vessel (false

aneurysm).4. Assessment

a. In those who are not immediately exsanguinating, the physical exam may beunremarkable. There are no specific symptoms… patients present with a vastspectrumofclinicalfindings.Maintainahighindexofsuspicion.

b. Inspection(1) Complaintofretrosternalchestorinterscapularpain(80%)(2) Ischemicpainoftheextremities(3) Signsofhypovolemicshock;pallor(4) Severedyspnea,stridor(5) Decreasinglevelofconsciousness,restlessness,apprehensiveness(6) Dysphagia(fromhematoma-inducedesophagealcompression)(7) Hoarseness(fromhematoma-inducedlaryngealcompression)

c. Palpation(1) Pulsedifferentialbetweenarmsorgreaterpulseamplitudeinarmsthan

in legs (may reflect ruptured descending aorta), decreased or absentfemoralpulses

(2) Trachealshift(3) Tachycardia.

d. Auscultation(1) Hypotension-25%duetoleakageandhypovolemia(2) Hypertension-25%duetostretchingofsympatheticnervesintheaorta

neartheligamentumarteriosum(3) Pressuredifferentialbetweenrightandleftarms(mayreflectruptured

subclavianarteryonsidewithlowerpressure)(4) Harshsystolicmurmuroverprecordiumor interscapular regiondueto

turbulenceasthebloodexitstheheartandpassesthedisruptedbloodvesselwall.

e. Besuspiciousif:(1) +physicalexam;decreasedBPtolowerlimbs;(2) 1st-2ndribfracture;(3) sternalfracture;or(4) significantdeceleration>35mph.

5. ClinicalS&Sa. Respiratorydistressb. Signsofpericardialtamponadec. Physicalevidenceofmajorchesttraumae.g.,steeringwheelimprintonchestd. Pulse differential between arms or between upper and lower extremities:

decreasedorabsentfemoralpulsese. UpperextremityhypertensionorBPdifferentialbetweenarmsf. Enlarginghematomaatthethoracicoutletg. Interscapularmurmurh. Palpablefracturesofsternumand/orthoracicspinesi. Traumawhichmaybesuspiciousforoccultinjuriesj. Scapulafracturek. Multipleleftribfracturesl. Flailchestm. Claviclefractureinthemulti-systeminjuredpatientn. Firstribfracture

6. Emergencyinterventionsa. Airwaycontrolb. Monitorforsignsofdecreasedtissueperfusion/hypovolemicshockc. IVFtoachieveBPjustupto80-90mmHg.Donothydratetooquickly-raisingthe

BP may complete the separation or rupture the remaining vascular walls.

Chest and Abdominal Trauma Case Studies Page 21 NWC EMSS CE November 2015

Permissivehypotensionispreferred.d. Monitorthepatient'sresponsetofluidadministration;VSe. Monitorfordysrhythmiasandalterationsinconsciousnessf. Time sensitive patient. They need immediate surgical intervention. Transport

ASAPtoahospitalwithcardiothoracicsurgerycapabilities.7. Complications

a. Paraplegia:vascularsupplytocorddisruptedinthoracicsegmentsb. Bowelischemiac. Renalfailured. Anoxiae. Braininjuryf. Leftventricularfailure

G. Penetratingwoundsofthegreatvessels1. Usuallyinvolve

a. Chestb. Abdomenc. Neck

2. Woundsareaccompaniedbya. Massivehemothoraxb. Hypovolemicshockc. Cardiactamponaded. Enlarginghematomas

3. Hematomasmaycausecompressionofanystructurea. Venacavaeb. Tracheac. Esophagusd. Greatvesselse. Heart

4. Emergencyinterventionsa. Managehypovolemiab. Reliefoftamponadeifpresentc. Time-sensitivepatient;expeditioustransport

H. Bluntcardiacinjury(oldmyocardialcontusion)1. Mostcontroversialofallinjuries2. Incidence: 13-75% of trauma patients experience blunt cardiac trauma. Disparity

explainedduetolackofa"goldstandard"diagnostictestatthehospital.Itoccursmorefrequentlyinyoungerpatients.

3. Morbidity: Rarely fatal alone, but may cause significant morbidity. Mortality: 8-20%;deaths secondary to dysrhythmias or ventricular failure. May be the most commonunsuspectedvisceralinjuryfoundafterfatalcrashes.

4. Mechanismofinjurya. 90%occurduetoMVCs.Speedsof20-35mphcancausecontusionw/oexternal

chesttraumab. Extent of injury is related to themagnitude of the force, duration overwhich

forceisapplied,andtherateofchangeovertime.c. Forces: Compression (RV absorbs impact against sternum ("clapper against a

bell"),acceleration/deceleration, intra-abdominalcavitycompressedandkineticenergydirectedupward(hydraulicrameffect).

5. Associatedinjuriescausingincreasedindexofsuspiciona. Sternalfracturesb. Anteriorflailsc. Aortictransectiond. Pelvicfracturese. Cardiogenicshockifcontusion>40%ofventricularsurface

6. Pathophysiologya. Areasofdamagearewelldemarcatedb. Hemorrhagewithedemaandfragmentedmyocardialfibers

Chest and Abdominal Trauma Case Studies Page 22 NWC EMSS CE November 2015

c. Cellularinjuryd. Vasculardamagemayoccure. Pericardial tamponade: hemopericardium from lacerated epicardium or

endocardiumf. Decreasedventricularfunction

(1) RVmostfrequentlyinjuredduetoproximitytochestwall(2) LVdysfunction secondary to increase inRVafterloadwith subsequent

shift of the intraventricular septum to the left - causing decreased LVcomplianceandstrokevolume.

g. Dysrhythmiasecondaryto(1) activationofectopicpacemakers;(2) re-entrypathways;(3) hypoxia/ischemia;or(4) alcoholingestion.

7. Sequelae(complications)ofbluntcardiactrauma–muchlikeAMIa. Dysrhythmiasusuallyabsentinchildren.Thelocationoftheinjuryinfluencesthe

typeofdysrhythmiathatoccurs.b. VSD:ventricularseptaldefectc. Valvulardisruptiond. Coronaryarteryocclusione. Ventricularaneurysmandmyocardialrupturef. Fibrinousreactionatcontusionsitemayleadtodelayedpericardialrupturewith

cardiacherniation8. Clinicalpresentation

a. Chiefcomplaint isoftenretrosternalchestpainorshortnessofbreath:typicallysharp and well localized but may mimic ischemic pain. Often difficult todistinguishfromchestwallpain.

b. Inspect forecchymosisonanteriorchest,complaintof retrosternalangina,andsigns of hemodynamic instability and cardiogenic shock (but be aware thatpatientmaybeasymptomatic).

c. Palpateforpointtenderness,crepitusoversternumorribsd. Auscultateforcrackles,hearttonesandforapericardialfrictionrub;S3gallope. ECGs: Abnormal in 40%-80% of contusions, but abnormal in 50% of patients

withoutcontusionswithchesttrauma.(1) Cardiac injury causes alterations in cardiac depolarization and

repolarizationandcardiacischemia.ECGchangesareoftennotedwithin24 hours and return to normal in a much shorter time than thoseproduced by myocardial infarction. Most resolve spontaneously,without treatment. One of the limitations of the conventional ECG isthat the recordings are dominated by the larger mass of the leftventricle,while themore anteriorly placed RV is themore commonlyinjured chamber. The ECG is therefore not a sensitive or specificindicator ofMC. Use only to increase index of suspicion. There is notypicalECGpatternforcardiaccontusion.

(2) Dysrhythmias: 90% present at impact. Should revert to normal in 3-4months.(a) Persistenttachycardia(b) DeathinfieldcausedbyVTorVF(c) Atrialflutter/fib(d) PACs,PVCs-frequentlyresolvebyarrivalathospital

(3) Conductionabnormalities:trendtowardoverdiagnosis(a) RBBB(b) AVblocks(c) ShortPRsyndrome(d) Leftorrightatrialenlargement(e) Non-specificST-Twavechanges-80%.Mustproveitwaspre-

existentorassumeitwascausedbyinjury

Chest and Abdominal Trauma Case Studies Page 23 NWC EMSS CE November 2015

(f) ProlongedQTinterval

Chest and Abdominal Trauma Case Studies Page 24 NWC EMSS CE November 2015

9. Emergencyinterventions

a. Gainairwaycontrolb. Oxygentherapybasedonclinicalpresentationc. MonitorHR,andperipheralpulses,andBP.Notifymedicalcontrolof

(1) changesinmentalstatus,(2) systolicBPbelow100mmHg,(3) absentorthreadyperipheralpulses.

d. Continuallyassesspatientforsignsof(1) pulsusparadoxus,(2) neckveindistention,(3) muffledheartsounds,and/or(4) hypotension.

e. AdministerIVFtomaintainBPat90f. Pressoragentssuchasdopamineinhighdosesforhypotension:Befamiliarwith

dose and administration calculations prior to the time the patient requirespressorsupport.

g. AntidysrhythmicagentsasneededI. Pulmonarycontusion:seeflailchest

1. Incidence:Presentin30to75percentofpatientswithsignificantbluntchesttrauma2. Mechanismofinjury

a. Commonlyassociatedwithribfractureb. Highvelocitymissilewithblasteffectc. Highenergyshockwavesfromexplosiond. Rapiddeceleratione. Lowvelocity:projectileslikeanicepick

3. Mortalityandmorbiditya. Missedduetohighincidenceofotherassociatedinjuriesb. Mortalitybetween14-20%

4. Pathophysiologya. Threephysicalmechanisms

(1) Implosioneffect(a) Overexpansion of air in lungs secondary to positive-pressure

concussivewave(b) Rapidexcessivestretchingandtearingofalveoli

(2) InertialeffectStripsalveolifromheavierbronchialstructureswhenacceleratedatvaryingratesbyconcussivewave

(3) Spaldingeffect(a) Liquid-gasinterfaceisdisruptedbyshock-wave(b) Wavereleasesenergy(c) Differentialtransmissionofenergycausesdisruptionoftissue

b. Alveolarandcapillarydamagec. WBCandplateletaggregationinpulmonaryvesselsleadstoreleaseofvasoactive

substancesd. Loss of pulmonary capillary integrity with increased membrane permeability;

movement ofwater andplasmaproteins into alveolar and interstitial spaces =interstitialedemaandcongestiveatelectasis

e. Surfactantdilutionresultsindecreasedlungcompliancef. The amount of oxygen delivered across the pulmonary capillary bed in the

injured segment is decreased resulting in hypoxemia and carbon dioxideretention.

g. Hypoxiacausesreflexthickeningofmucoussecretions(1) Bronchiolarobstruction(2) Atelectasis

h. If the contusion is large, thebody compensatesby vasoconstrictingpulmonaryblood flow and increasing cardiac output to shunt blood around the area ofminimaloxygenation.There isdeceased functional reservecapacitydue to this

Chest and Abdominal Trauma Case Studies Page 25 NWC EMSS CE November 2015

pulmonary shunting which causes mixed venous blood to be returned to theheartresultinginfurtherhypoxemia.

5. Assessmenta. The adverse effects of pulmonary contusion usually do not become clinically

evidentuntil24hoursafterinjury.b. Inspection

(1) Signs of respiratory distress, dyspnea, tachypnea, restlessness,apprehension

(2) Ineffectivecough(3) Hemoptysis(4) Possiblechestwallabrasionsorcontusions(5) Increased pulmonary secretions, decreased pulmonary compliance,

desaturationonpulseoximeter,andcyanosisc. Palpateforpossibletendernessoverchestwall,tachycardiad. Auscultateforcracklesandwheezes,areasofdecreasedbreathsounds

6. Emergencyinterventionsa. Gainairwaycontrolb. 15Loxygen;assistventilationsasnecessaryc. RestrictIVfluidsunlesshypovolemicd. Analgesicsasindicated

J. Tracheobronchialinjuries1. Epidemiology

a. Incidence:Rare:lessthan3%ofchesttraumab. Trachealinjuriesareusuallycausedbypenetratingtraumac. Bronchialinjuriesareusuallycausedbydeceleration(blunt)mechanismsd. Morbidity/mortality: High mortality rate: greater than 30% due to associated

airway obstruction. Majority of the patients die at the scene secondary toasphyxia.

2. Pathophysiologya. Siteofinjury

(1) Tearcanoccuranywherealongtracheal/bronchialtree(2) Transverseruptureisthemostcommontypeoftrachealinjury(3) >80%occurwithin2.5cmofthecarina(pointoffixation)

b. Rapidmovementofairintopleuralspacec. Tensionpneumothoraxrefractorytoneedledecompressiond. Continuousflowofairfromneedledecompressionsitee. Severehypoxiaf. Associated injuries: Esophageal,greatvessels, lung,cardiac,andcervical spine

injuries are noted because of anatomical location andmechanism.Mechanismcanalsoaccountforassociatedheadinjuriesandfacialinjuries.

3. Clinicalpresentationa. Variability in presentation: ranging from asymptomatic to severe

dyspnea/cyanosisb. Inspection:Hoarseness,dyspnea,tachypnea,ventilatorydistress,hemoptysisc. Palpation:Massivesubcutaneousemphysemad. Auscultation

(1) Decreasedorabsentbreathsoundsassociatedwithpneumothorax(2) Hamman's sign may be present (crunching sound noted with heart

auscultation)e. S&Stensionpneumothorax

4. Emergencyinterventiona. Gainairwaycontrolb. 15 L oxygen; do not use high pressures without preparing for needle

decompressionc. Vascularaccess,prepareresuscitationequipment

(1) Tracheobronchial rupture/tear via blunt trauma occurs secondary tocrushing or compressive injury that causes a sudden decrease in

Chest and Abdominal Trauma Case Studies Page 26 NWC EMSS CE November 2015

anterior/posterior diameter and increase in lateral diameter (i.e., lapbelt across the throat inMVC). Since the lungsmaymove laterally inresponse to the force, the trachea/bronchimay transect secondary toexceededstretch.

(2) Thecricoidringandcarinaserveasfixedpointsforthetrachea.Whenthere is an acute acceleration/deceleration force, a shearing force isproducedatthesefixedpointsandcreatesatrachealinjury.

(3) Directinsulttoahyperextendedcervicaltracheamaycauserupture,e.g.strikingthedashboard,steeringwheel.

(4) Rapid increase in intrathoracic pressures concomitant with a closedglottis may produce a "blowout" injury to the trachea with a linearrupture.(Similartomechanismprecipitatingclosedpneumothorax.)

K. Sternalfracture1. Epidemiology

a. Incidence:5-8%ofallthoracicinjuriesb. Mechanism of injury is anterior blunt chest trauma at or below the

manubriosternal junction. Classic example is when the chest hits the steeringwheelordashboardinanMVC.Otherinjurymechanismsincludedirectblowtothesternumorcompressionofthesternumassociatedwithhyperflexionsternalinjury

c. Potential lifethreatening injuries includemyocardialcontusion,cardiacrupture,cardiactamponade,orseverepulmonaryinsult

d. Morbidity/mortality(1) 25-45%mortality(2) Highassociationwithmyocardialorlunginjury

(a) Myocardialcontusion(b) Myocardialrupture(c) Pulmonarycontusion

2. Pathophysiologya. Severeimpactasareaiswellsupportedbytheribsandclaviclesb. Associatedinjuriescausemorbidityandmortality

(1) Pulmonaryandmyocardialcontusion(2) Flailchestifribattachmentsaredisruptedonbothsides(3) Vasculardisruptionofthoracicvessels(4) Intraabdominalinjuries(5) Headtrauma

c. Rarelyisfracturedisplacedposteriorlytodirectlyimpingeonheartorvessels,butitdoesoccur

3. Clinicalfindingsa. Inspect for anterior chest pain, sternal deformity, contusion, localized pain,

tachypnea,ECGchangesassociatedwithmyocardialcontusionb. Palpatefortenderness,instability,crepitusoversternumc. Unstablefracturesmayresultinaflailchestd. ECGchanges

4. Emergencyinterventionsa. Gainairwaycontrolb. Oxygenbasedonclinicalpresentationc. Restrictfluidsifpulmonarycontusionispresentd. Provideanalgesicsperlocalprotocolse. Allowchestwallself-splinting

VIII. OtherchestinjuriesA. Simplepneumothorax

1. Epidemiologya. Incidence

(1) 10-40%ofallbluntchesttrauma(checkcurrentdata)(2) Almost100%inpenetratingchesttrauma

b. Morbidity/mortality:Dependsonextentofatelectasisandassociatedinjuries

Chest and Abdominal Trauma Case Studies Page 27 NWC EMSS CE November 2015

c. Classificationofpneumothoraxisdeterminedbythedegreeofcollapse:(1) Small:15%orlessoccupationofthepleuralcavity(2) Moderate:15%-60%occupationofthepleuralcavity(3) Large:60%orgreateroccupationofthepleuralcavity

2. Pathophysiologya. Lungis1-3cmawayfromthechestwall.Pneumothoraxresultsfromaone-time

leakofastableamountofairintothepleuralspace.b. Disruptionofpleuralintegritymayresultfromalacerationcausedbyafractured

rib,penetratingmissile,orbarotraumaasseeninthe“paperbagsyndrome”ormayoccurspontaneouslyfollowingstrenuousexercise,severecoughingepisodes(particularlyinpatientswithCOPD),afterairtravel,orinpatientswithMarfan’sSyndrome.

c. Lossofintrapulmonary/intrapleuralsubatmosphericpressured. Elastic recoil of lung tissue allows it to collapse when pleural integrity is

disrupted.e. Pulmonaryfunctionmaybegoodinahealthypersonf. Smalltearsmayself-seal;largeronesmayprogressg. Respiratorycompromisedependsonthedegreeofcollapseandtheamountof

pulmonaryreserve.LargerpneumothoracesproduceadecreasedareaforVA/Qmatchingresultinginaphysiologicshuntinthelungsandhypoxemia

3. Clinicalpresentationa. Inspectfordyspnea,tachypnea,ventilatorydistress;sudden,pleuriticchestpain

thatmayrefertoshoulderorarmonaffectedside;mayhavealteredchestwallmovementand/orventilationperfusionmismatchandsignsofhypoxia

b. Percuss:Hyperresonanceonaffectedsidec. Palpate: Tachycardia; trachea may tug towards affected side; difficult to

appreciatewithaclinicalexamd. Auscultate:Decreasedor absent breath soundson affected side. If upright, air

will accumulate in the apices. Assess there first for altered breath sounds. Ifsupine,airaccumulatesintheanteriorchest.

4. Emergencyinterventionsa. Optimizeventilationsandgasexchangewith12-15LO2;situpb. Monitorforsignsoftensionpneumothoraxc. PeripheralvenousaccessandadministerNSorLR

B. Ribfractures1. Epidemiology

a. Incidenceandsignificance(1) Most common thoracic injury; seen in more than 50% of cases with

significant blunt chest trauma. Significant chiefly because the paininvolvedinhibitsthepatientfromtakingadequatebreaths.

(2) Pediatric patients have cartilaginous ribs that bend easily. Theyexperiencedecreasedincidenceoffractures,butincreasedincidenceofpulmonaryinjury.

(3) Geriatricpatientshavecalcifiedribsthatarelessflexibleandmoreeasilyfractured. Also tend to have increased morbidity due to co-morbidconditionsanddecreasedpulmonaryreserves.

b. Etiology(1) Causedbydirectblowstothechest:Mechanismusuallyassociatedwith

age-relatedinjuries:(a) Sports/recreationalinjuriesinadolescents(b) MVC/assaultsinadults(c) Fallsinthegeriatricpopulation

(2) Occurs at the point of impact or along the border of the object thatimpactsthechest.Mayalsooccurataweakenedpointwheretheribsflex(posteriorangle).

(3) Ribs 4 through 9 aremost commonly fractured as they are the leastprotected.The first three ribsare relativelyprotectedby the shoulder

Chest and Abdominal Trauma Case Studies Page 28 NWC EMSS CE November 2015

girdleandthelowestribs(the“floatingribs”)arelessexposedandmoremobile,soarealsorelativelyprotected.

(4) Morbidityincreaseswiththenumberoffractures,extremesofage,andassociated chronic respiratory or cardiac conditions - especially in theelderly. Two or more rib fractures are associated with an increasedincidenceofinternalinjury

2. Pathophysiologya. Becausetheribsarepartofaring,whenaribbreaks…b. Decreasedminuteventilationduetosplintingfrompainc. Whenever a person breathes shallowly, for any reason, the alveoli do not get

fullyinflated;littlebylittle,theybegintocollapseandtheprogressiveatelectasismakes the lungs more vulnerable to pneumonia. Additionally, there may bedecreased surfactant production that normally lowers surface tension andfacilitates alveolar opening. This results in shunting of blood to nonventilatedalveoli that can lead to arterial hypoxemia, plugging of proximal airways,segmentalandlobarcollapse,pneumonia,andbronchiectasis.

3. Concomitantinjuriesa. 1st through 3rd ribs take great force to fracture. Assoc. w/ fractures of neck,

clavicle, scapula, and great vessel injury (subclavian artery/vein, aortic injury)severe intrathoracic injury (tracheobronchial injury, aortic rupture, and othervascularinjuries,especiallyifmultipleribsareinvolved.

b. Fractures of the ninth, tenth, and eleventh ribs are associated withintraabdominal injury: lower left rib fractures: splenic injury; lower right ribfractures:liverinjury.

c. Sternal fracturesareassociatedwithpulmonarycontusionand/orbluntcardiacinjury

4. Cartilaginousinjuriesaresimilar,butoftenmorepainfulandtakelongertoheal5. Clinicalpresentation

a. Inspection(1) Chestwallpain localized to the siteof injuryaggravatedbybreathing,

coughing,ormovement(2) Mayhaveoverlyingchestwallcontusionordeformity(3) Subcutaneousemphysemaimplies…(4) Shallowventilatoryeffortandreducedchestwallexcursion

(a) Hypoxia(b) Hypoventilation–atelectasis(c) Musclespasmatfracturesite

(5) Splinting:Patientwilloftenleantowardthefracturetorelievemusculartensiononthesite

(6) Inadequatecoughb. Palpation

(1) Pointtendernesstopalpation;maybeunstable(2) Deformity,crepitus(gratingsensation)atfracturesite

6. Complicationsa. Pneumo/hemothoraxduetolacerationofbronchiorintercostalarteriesb. Pneumomediastinumc. Tensionpneumothoraxd. Non-unionoffracture;Costochondralseparatione. Pneumonia(largeprobleminelderly)f. Neurologicdeficitsiflacerationofintercostalnervesg. Pitfall: Do not underestimate the severe pathophysiology of rib fractures,

especiallyinelderlypatients.7. Emergencyinterventions

a. Optimizeventilations topreventatelectasis andpneumonia. Encouragepatienttocoughanddeepbreathe.Splintchestwithpillow.

b. Administeranalgesicstofacilitatechestwallmotion.CJM:S10;S15

Chest and Abdominal Trauma Case Studies Page 29 NWC EMSS CE November 2015

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