Treating Open and Treating Open and Closed Chest WoundsClosed Chest Wounds

OBJECTIVES:OBJECTIVES:

-What is an Open Chest wound? How do we -What is an Open Chest wound? How do we treat it?treat it?

-What is a Closed Chest wound? How do we -What is a Closed Chest wound? How do we treat it?treat it?

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

Signs and Symptoms of a Sucking Signs and Symptoms of a Sucking Chest WoundChest Wound

Sucking or Hissing sounds coming from the Chest Sucking or Hissing sounds coming from the Chest woundwound

Casualty coughing up bloodCasualty coughing up blood Frothy blood coming from the wound siteFrothy blood coming from the wound site Shortness of breath; Difficulty breathingShortness of breath; Difficulty breathing Chest not rising normally when casualty inhalesChest not rising normally when casualty inhales Pain in shoulder or anywhere that increases with Pain in shoulder or anywhere that increases with

breathingbreathing Bluish tint of lips, inside mouth, fingertips or nail Bluish tint of lips, inside mouth, fingertips or nail

bedsbeds Rapid and weak heartbeatRapid and weak heartbeat

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Air in between Lung Air in between Lung “bag” and rib cage.“bag” and rib cage.

Decompression allows Decompression allows the escape of this airthe escape of this airWill not re-inflate Will not re-inflate lung, but will relieve lung, but will relieve tension and pressure tension and pressure

in chest area.in chest area.

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

Open PneumothoraxOpen Pneumothorax

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

Management:Management: Ensure an open airwayEnsure an open airway Seal the wound. Both entrance and Seal the wound. Both entrance and exitexit with with

an occlusive dressing, petrolatum gauze or an occlusive dressing, petrolatum gauze or Asherman Chest SealAsherman Chest Seal® ® (LOOK FOR THE EXIT (LOOK FOR THE EXIT HOLE)HOLE)

Real world: Place the casualty in their Real world: Place the casualty in their position of comfort. Test=injured sideposition of comfort. Test=injured side

Monitor respirations after an occlusive Monitor respirations after an occlusive dressing is applied. Consider doing a NCD if dressing is applied. Consider doing a NCD if respirations become labored. respirations become labored.

Open PneumothoraxOpen Pneumothorax Petroleum Gauze can also be used to seal Petroleum Gauze can also be used to seal a sucking chest wounda sucking chest wound..

"Asherman Chest Seal"Asherman Chest Seal""

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

For multiple injuries to the chest For multiple injuries to the chest ( e.g. casualty exposed to shrapnel ( e.g. casualty exposed to shrapnel from a mortar or an IED), You can from a mortar or an IED), You can

use use TegadermTegaderm ( ( IV OP SitesIV OP Sites) to ) to cover multiple areas. cover multiple areas.

The Goal is to seal the Chest area The Goal is to seal the Chest area immediatelyimmediately

Treating Open and Closed Treating Open and Closed Chest Wounds (Cont’d)Chest Wounds (Cont’d)

Demonstration of sealing an Open Chest Demonstration of sealing an Open Chest Wound, and discussion of various Wound, and discussion of various materials that can be used in this materials that can be used in this

process. process.

Demonstrate how to create a “Flutter Demonstrate how to create a “Flutter Valve” and the need for one. Valve” and the need for one.

Demonstrate how to seal an Open Chest Demonstrate how to seal an Open Chest wound with an impaled Objectwound with an impaled Object

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Closed Chest Wounds / Tension Closed Chest Wounds / Tension PneumothoraxPneumothorax

Signs and SymptomsSigns and Symptoms

Anxiety, agitation, and apprehensionAnxiety, agitation, and apprehension Diminished or absent breath soundsDiminished or absent breath sounds Increasing difficulty in breathing with Increasing difficulty in breathing with

cyanosis (bluish tint around lips, nail cyanosis (bluish tint around lips, nail beds, inside mouth)beds, inside mouth)

Rapid shallow breathingRapid shallow breathing Abnormally Low Blood Pressure ( NO Abnormally Low Blood Pressure ( NO

RADIAL PULSE IS PRESENT)RADIAL PULSE IS PRESENT)

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Signs and Symptoms of a Tension Signs and Symptoms of a Tension Pneumothorax (Cont’d)Pneumothorax (Cont’d)

Distended Neck veins Distended Neck veins Cool clammy skinCool clammy skin Decreased Level of ConsciousnessDecreased Level of Consciousness Visible deterioration of casualties Visible deterioration of casualties

conditioncondition Tracheal deviation (Shifting of the Tracheal deviation (Shifting of the

windpipe to the left or right) [ windpipe to the left or right) [ A late A late sign, and probably will not be observedsign, and probably will not be observed]. ].

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Air pushes over heart and collapses lung

Heart compressed not able to pump well

Air outside lung from wound

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Management:Management: Ensure an open airwayEnsure an open airway Decompress the affected sideDecompress the affected side

Indications:Indications:– Any chest trauma with progressive Any chest trauma with progressive

respiratory distress. respiratory distress.

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Procedure:Procedure: Identify the second ICS on the Identify the second ICS on the

anterior chest wall, MCL:anterior chest wall, MCL:

Needle Chest Needle Chest DecompressionDecompression

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Insert a 14 ga. Catheter at a 90Insert a 14 ga. Catheter at a 90 angle angle over the top of the 3over the top of the 3rdrd rib, into the 2 rib, into the 2ndnd ICS at the MCL.ICS at the MCL.

Needle must be long enough to enter Needle must be long enough to enter the chest cavity (3 1/4 – 3 1/2 inches). the chest cavity (3 1/4 – 3 1/2 inches). Per the Army Surgeon Generals Per the Army Surgeon Generals guidance.guidance.

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

If a tension pneumothorax is present, a If a tension pneumothorax is present, a “hiss of air” may be heard escaping from “hiss of air” may be heard escaping from the chest cavity.the chest cavity.

Remove the needle, leave the catheter in Remove the needle, leave the catheter in place.place.

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Tape the catheter hub to the chest wall.Tape the catheter hub to the chest wall. The casualty's condition should rapidly The casualty's condition should rapidly

improve.improve. If the catheter is removed accidentally, If the catheter is removed accidentally,

just re-insert another 14 gauge needle just re-insert another 14 gauge needle next to the former one.next to the former one.

Evacuate ASAPEvacuate ASAP Make sure Flight Medic KNOWS he has a Make sure Flight Medic KNOWS he has a

catheter in his chest.catheter in his chest.

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Questions:Questions: Why “up and over”andWhy “up and over”andNever “down and under”Never “down and under”

What if casualty doesn't have a tension What if casualty doesn't have a tension pneumothorax and you perform NCD?pneumothorax and you perform NCD?

• May already have hole(s) in chestMay already have hole(s) in chest• Probably larger than diameter of 14 ga. needleProbably larger than diameter of 14 ga. needle• No additional damageNo additional damage

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Questions:Questions: Will lung re-inflate after pressure is released Will lung re-inflate after pressure is released

from chest cavity? Example: The Three Kings from chest cavity? Example: The Three Kings moviemovie

No. To re-inflate the lung you must have a No. To re-inflate the lung you must have a chest tube with suction and or positive chest tube with suction and or positive pressure ventilation.pressure ventilation.

NCD merely releases the tension and built up NCD merely releases the tension and built up pressure which will ultimately suffocate the pressure which will ultimately suffocate the casualty.casualty.

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Complications:Complications: Insertion of the needle over the top of Insertion of the needle over the top of

the rib prevents laceration of the the rib prevents laceration of the intercostal vessels or nerve which can intercostal vessels or nerve which can cause hemorrhage or nerve damage.cause hemorrhage or nerve damage.

““Up and over” NEVER “down and Up and over” NEVER “down and under”under”

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

Injuries to the chest are fewer in Injuries to the chest are fewer in nature secondary to modern body nature secondary to modern body armor, however it doesn't protect armor, however it doesn't protect 100%.100%.

Wounds to the chest can be rapidly Wounds to the chest can be rapidly fatal if not identified early and fatal if not identified early and treated appropriatelytreated appropriately..

Treating Open and Closed Chest Treating Open and Closed Chest Wounds (Cont’d)Wounds (Cont’d)

QUESTIONS?QUESTIONS?

Demonstration of NDC on a Demonstration of NDC on a mannequinmannequin