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After completing this lesson, you should be able to:
4-1. Identify the possible effects of an open chest wound.
4-2. Identify the signs and symptoms of an open chest wound.
4-3. Identify the procedures for sealing an open chest wound.
4-4. Identify the possible effects of a tension pneumothorax.
4-5. Identify the signs and symptoms of tension pneumothorax.
4-6. Identify the procedures for performing needle chest decompression.
REFERENCES
STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.
FM 4-25.11, First Aid.
Training Support Package 071-D-2317 / First Aid 2 (Manage the Airway)
LESSON 4
TREATING PENETRATING CHEST TRAUMA AND DECOMPRESSING
TENSION PNEUMOTHORAX
Section I. TREATING AN OPEN CHEST WOUND
4-1. INTRODUCTION
The body has two lungs. Each lung is enclosed
in a separate airtight area within the chest. If an object punctures the
chest wall and allows air to get into one of these areas, the lung within
that area begins to collapse. In order for both lungs to collapse, both
sides of the chest would have to be punctured. Any degree of collapse,
however, interferes with the casualty's ability to breathe and reduces the
amount of oxygen available for the body to use. Figure 4-1 shows a normal
chest and lungs. Figure 4-2 shows a chest and lungs with a penetrating
(open) chest wound that has allowed one of the lungs to collapse.
Figure 4-1. Normal chest cavity and lungs.
Figure 4-2. Collapsed lung.
4-2. SIGNS AND SYMPTOMS OF AN OPEN CHEST WOUND
An open chest wound can be caused by the
chest wall being penetrated by a bullet, knife blade, shrapnel, or other
object. If you are not sure if the wound has penetrated the chest wall
completely, treat the wound as though it were an open chest wound. Some of
the signs and symptoms of an open chest wound are given below.
a.
Sucking or hissing sounds coming from chest wound. (When a casualty with an
open chest wound breathes, air goes in and out of the wound. This air
sometimes causes a "sucking" sound. Because of this distinct sound, an open
chest wound is often called a "sucking chest wound.")
b.
Casualty coughing up blood (hemoptysis).
c.
Frothy blood coming from the chest wound. (The air going in and out of an
open chest wound causes bubbles in the blood coming from the wound.)
d.
Shortness of breath or difficulty in breathing.
e.
Chest not rising normally when the casualty inhales. (The casualty may have
several fractured ribs, resulting in a flail chest.)
f.
Pain in the shoulder or chest area that increases with breathing.
g.
Bluish tint of lips, inside of mouth, fingertips, or nail beds (cyanosis).
(This color change is caused by the decreased amount of oxygen in the
blood.)
h.
Signs of shock such as a rapid and weak heartbeat.
4-3. CHECKING FOR OPEN CHEST WOUNDS
Check for both entry and exit wounds. Look
for a pool of blood under the casualty's back and use your hand to feel for
wounds.
a.
If there is more than one open chest wound, treat the more serious (largest,
heaviest bleeding) wound first.
b.
If there is more than one wound to a side, such as an entrance and exit
wound, apply the flutter valve seal to the wound on the casualty's front and
a full seal (all four sides taped down) to the wound on the casualty's
back..
4-4. EXPOSING THE WOUND
Expose the area around the open chest wound
by removing, cutting, or tearing the clothing covering the wound. If
clothing is stuck to the wound, do not try to remove the stuck clothing as
this may cause additional pain and injury. Cut or tear around the stuck
clothing. Do not try to clean the wound or remove objects from the
wound.
4-5. SEALING AN OPEN CHEST WOUND
Since air can pass through dressings and
bandages, you must seal the open chest wound with plastic, cellophane, or
other nonporous, airtight material to prevent air from entering the chest
and collapsing the lung. The wrapper from an emergency bandage or a field
first aid dressing can be used. Foil or material cut from a poncho can also
be used.
NOTE:
If possible, use supplies from the casualty's first aid kit rather than your
own. You may need your supplies in case you have to administer aid to
yourself later.
a.
Prepare the Sealing Material. Cut the airtight material as needed so
that it lies flat and will extend at least two inches beyond the edges of
the wound (all directions).
b.
Have Casualty Exhale. Tell the casualty to exhale (breathe out) and
hold his breath. This forces some of the air out of the chest wound. The
more air that can be forced out of the chest before the wound is sealed, the
better the casualty will be able to breathe after the wound is sealed.
NOTE:
The casualty can resume normal breathing after the wound is sealed.
NOTE:
If the casualty is unconscious or cannot hold his breath, place the sealing
material over the wound after his chest falls but before it rises.
c. Apply and Tape the Airtight Material Over Wound.
(1) Place the cleanest side of the sealing material directly over the wound. If a plastic bandage wrapper is being used, place the inside surface of the wrapper (the side without printing) directly over the wound.
(2) Check the material to make sure that it extends at least two inches beyond the wound edges in all directions. If the material does not have a two-inch margin, it may not form an airtight seal and may even be sucked into the wound. If the sealing material is not large enough or is torn, remove it and obtain other airtight material to form the seal.
(3) Tape down three edges of the material, usually the top edge and two side edges. This creates a "flutter valve" effect. When the casualty inhales, the plastic is sucked against the wound and air cannot enter the wound. When the casualty exhales, air may be able to exit the wound through the untaped (bottom) edge of the plastic. See figure 4-3.
Figure 4-3. Flutter valve effects (inspiration and expiration).
NOTE:
If there are two wounds affecting the same lung, apply airtight material to
the back wound and tape down all four sides so that air cannot enter or
escape.
d.
Dress the Wound. Apply an emergency bandage (Lesson 5). The dressing
and bandage will help to protect the airtight material from damage and
provide pressure to the wound.
(1) Place the dressing pad directly over the plastic wrapper forming the flutter valve and secure the dressing with the bandage. The bandage should not be applied so tight that it interferes with the casualty's breathing.
(2) If the casualty is able, you can have him hold the dressing pad in place while you apply the bandage. If he cannot help, then you must hold the dressing in place while securing it.
(3) If an object is protruding from the chest wound, do not try to remove it. Place airtight material around the object to form as airtight a seal as possible. Stabilize the object by placing a bulky dressing made from the cleanest material available around the object. Apply improvised bandages to hold the sealing material and dressings in place. Do not wrap the bandages around the protruding object.
4-6. POSITIONING A CASUALTY WITH A DRESSED OPEN CHEST WOUND
Position the casualty on his side (recovery
position) with his injured side next to the ground (figure 4-4). Pressure
from contact with the ground acts somewhat like a splint to the injured side
and helps to reduce pain. (If you position the casualty with his uninjured
side toward the ground, the weight on the uninjured side might make
breathing difficult for the casualty.)
Figure 4-4. Casualty with a dressed open chest wound.
NOTE:
The casualty may wish to sit up. If he can breathe easier when sitting up
than lying on his side, allow him to sit up with his back leaning against a
tree, wall, or other support. If he becomes tired, have him lie on his
injured side again.
Section II. TREATING TENSION PNEUMOTHORAX
4-7. TENSION PNEUMOTHORAX
Tension pneumothorax occurs when there is a
buildup of air in the plural space that cannot escape. As the air pressure
outside the lung continues to increase, the affected lung continues to
collapse. In addition to causing further collapse of affected lung, the
increasing air pressure pushes the mediastinum (the mass of
material--including the heart--that separates the two plural sacs) in the
opposite direction. This movement of the mediastinum may compress the
uninjured lung, major blood vessels, and the heart. You will need to perform
a needle chest decompression to relieve the pressure.
4-8. SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX
a. Signs and symptoms of tension pneumothorax include the following:
(1) Anxiety, agitation, and apprehension.
(2) Diminished or absent breath sounds.
(3) Increasing difficulty in breathing (dyspnea) with cyanosis (bluish tint of lips, inside of mouth, fingertips, and/or nail beds)
(4) Rapid, shallow breathing (tachypnea).
(5) Distended neck veins.
(6) Abnormally low blood pressure (hypotension) evidenced by a loss of radial pulse (pulse at the wrist).
(7) Cool, clammy skin.
(8) Decreased level of consciousness (AVPU scale).
(9) Visible deterioration.
(10) Loss of consciousness.
(11) Tracheal deviation (a shift of the windpipe to the right or left).
NOTE:
Tracheal deviation is a late sign of tension pneumothorax and will probably
not be observed.
b.
The above signs and symptoms may be difficult to assess in a combat
situation. Therefore, assume that tension pneumothorax exists when:
(1) The casualty has an open chest wound and
(2) The casualty is having increasing respiratory difficulty.
4-9. NEEDLE CHEST DECOMPRESSION
CAUTION: A needle chest decompression is performed ONLY if
the casualty has a penetrating wound to the chest and increasing trouble breathing.
a.
Gather Materials. You will need the large bore needle and catheter
unit from the first aid kit. Use the supplies in the casualty's first aid
kit if possible. You will also need a strip of tape from the spool in the
kit.
NOTE: The needle is a 14 gauge needle that is three inches in length. The rigid
metal needle is covered with a flexible catheter (tube). The needle provides
rigidity needed in puncturing the chest wall. When it is removed, the
flexible catheter remains to allow air to escape the air pocket that is
causing the tension pneumothorax.
NOTE: Catheter/needle unit refers to the catheter with the needle inside.
b.
Locate the Insertion Site. The insertion site is located in the
second intercostal space (the area between the second and third ribs,
counting from the top) at the mid-clavicular line (an imaginary line
perpendicular to the ribs approximately in line with the casualty's nipple)
on the same side of the chest as the penetrating wound. Figure 4-5 shows the
location of the second intercostal space. Figure 4-6 shows the mid-clavicular
line.
Figure 4-5. Locating the second intercostal space (wound on casualty's left side).
Figure 4-6. Locating the mid-clavicular line (wound on casualty's left side).
c.
Prepare Catheter/Needle Unit. Remove the catheter/needle unit from
its packaging and then remove the protective covering.
d.
Insert the Catheter/Needle. Firmly insert the needle (with catheter
covering) into the skin above the top of the third rib into the second
intercostal space at a 90-degree angle (figure 4-6). Continue inserting the
needle until the chest cavity has been penetrated. You will feel a "pop" as
the needle enters the chest cavity. A hiss of escaping air under pressure
should be heard.
CAUTION:
Proper positioning of the needle is essential to avoid damaging blood
vessels and nerves that run along the bottom of each rib.
e.
Withdraw the Needle. Withdraw the needle from inside the catheter
while holding the catheter hub to keep the catheter in place. The catheter
will remain as a means for air trapped in the chest to escape to the
atmosphere.
f.
Secure the Catheter. Use the strip of tape to secure the catheter hub
to the chest wall. Figure 4-7 illustrates a casualty with a catheter and
flutter valve dressing in place.
g.
Monitor Casualty. By allowing trapped air to escape from the plural
area, the casualty's respirations should quickly improve. Applying airtight
material over the wound and having a catheter release trapped air permits
the affected lung to re-inflate somewhat (figure 4-7). If possible, monitor
the casualty until medical care arrives or until the casualty is evacuated
to the nearest medical facility. Be prepared to take measures to treat for
shock.
Figure 4-7. Casualty with catheter in place to relieve tension pneumothorax.
h.
Transport Casualty. If you have performed a needle chest
decompression on a casualty with a tension pneumothorax, he should be
transported injured side up rather than injured side down in order to allow
access to the catheter during transport. The casualty may also be
transported in a sitting-up position if the casualty finds that position
more comfortable.
LESSON EXERCISES: LESSON 4
INSTRUCTIONS: Answer the
following exercises by marking the letter of the response that best
answers the question or best completes the sentence or by writing the
answer in the space provided.
After you have answered all of the exercises,
check your answers against the "Solutions to Lesson Exercises" at the end of
the exercises. For each exercise answered incorrectly, reread the lesson
material referenced.
1. A soldier has been stabbed in his chest.
The blade entered the chest just above his right nipple, penetrated the
chest wall, and was withdrawn. Which of the following is most likely to
happen?
a. His right lung will begin to collapse.
b. His left lung will begin to collapse.
c. Both of his lungs will begin to collapse.
2. A soldier has suffered a wound to the chest. You are not sure if the chest wall has been penetrated. What should you do?
a. Leave the wound exposed until the medic arrives.
b. Dress and bandage the wound as you would a cut on the arm.
c. Apply airtight material over the wound and tape down three sides of the material, then dress and bandage the wound.
d. Apply airtight material over the wound and tape down all four sides of the material, then dress and bandage the wound.
3. An open chest wound is sometimes called
another name. What is the name?
______________________________________________________________
4. List three signs or symptoms other than
the sound of air passing through the wound that may indicate the casualty
has an open chest wound.
______________________________________________________________
______________________________________________________________
______________________________________________________________
5. A soldier has been shot. The bullet passed
through the left side of his chest (entrance and exit wounds). Which of the
following is the preferred method of treatment.
a. Apply airtight material over each wound and tape down all four sides of the material for each wound.
b. Apply airtight material over each wound, tape down three sides of the material for the wound on the front, and tape down all four sides of the material for the wound on the back.
c. Apply airtight material over each wound and tape down three sides of the material for each wound.
6. A casualty has a puncture wound to his chest about 1.5 inches in diameter. You have airtight material in the following sizes. You want to use the smallest material that fits the size criteria. Which piece should you use?
a. Square 2 inches by 2 inches.
b. Square 4 inches by 4 inches.
c. Square 6 inches by 6 inches.
d. Square 8 inches by 8 inches.
e. Rectangle 8 inches by 12 inches.
7. When positioning a casualty with a dressed open chest wound, he should lie:
a. On his back.
b. On his front.
c. On his side, wounded side up.
d. On his side, wounded side down.
8. Tension pneumothorax has developed in a casualty with a chest injury to his right side. The condition could result in:
a. Collapse of his right lung.
b. Compression of his left lung.
c. Compression of the heart and blood vessels.
d. Responses a and b above.
e. Responses a and c above.
f. Responses a, b, and c above.
9. A casualty with an open chest wound is showing initial signs of tension pneumothorax. You should:
a. Raise a corner of the dressing covering the untaped side of the airtight material (over the flutter valve).
b. Insert a large bore needle to decompress the plural sac.
c. Begin cardiopulmonary resuscitation.
10. Which of the following is a sign or symptom of tension pneumothorax? (More than one response may be correct.)
a. Skin becomes warmer and dry.
b. Nail beds of fingers become bluish.
c. You can no longer feel the casualty's pulse at his wrist.
d. The casualty's breathing has returned to normal.
e. The casualty is becoming agitated.
f. The veins in the casualty's neck appear to be swollen.
11. You are going to insert a catheter/needle to relieve tension pneumothorax. You should choose an insertion site that is:
a. On the top of the chest and on the injured side.
b. On the side of the chest and on the injured side.
c. On the top of the chest and on the uninjured side.
d. On the side of the chest and on the uninjured side.
e. In the middle of the chest over the sternum (breastbone).
12. The insertion site to relieve tension pneumothorax should be:
a. Slightly below the second rib.
b. Slightly above the third rib.
c. Slightly below the third rib.
d. Slightly above the fourth rib.
e. Slightly below the fourth rib.
f. Slightly above the fifth rib.
13. The insertion site to relieve tension
pneumothorax is located along the casualty's mid-clavicular line. What else
is located on or near this imaginary line?
________________________________________
14. You are inserting a catheter/needle to
relieve tension pneumothorax. How can you tell when you have penetrated the
chest wall and the tip of the needle is now in the plural space?
______________________________________________________________
15. Once you have penetrated the plural space
with a large bore needle, you should:
a. Tape the needle in place.
b. Remove the needle and tape airtight material over the injection site.
c. Remove the needle, leaving the catheter, and tape the catheter hub to the chest.
d. Remove the needle, leaving the catheter, and tape airtight material over the injection site.
16. A casualty who has a catheter from a needle chest decompression is being evacuated. How should he be positioned on the litter?
a. On his back.
b. On his stomach.
c. On his injured side (the side with the catheter).
d. On his uninjured side (the side without the catheter).
17. Using a manikin or fellow student, practice treating
an open chest wound.
18. If an appropriate manikin and appropriate supplies are
available, practice performing a needle chest decompression.
SOLUTIONS TO LESSON EXERCISES: LESSON 1 (Scroll Down)
1. a (para 4-1)
2. c (paras 4-2, 4-5)
3. Sucking chest wound (para 4-2a)
4. Any three of the following (paras 4-2 b through h)
Coughing up blood
Bubbles in blood on chest
Breathing problems (shortness of breath, etc.)
Abnormal chest actions (flail chest)
Pain that increases when inhaling
Cyanosis
Pulse rate increases, but becomes weaker
5. b (para 4-3)
6. c (para 4-5c(2)). The wound size is 1.5 inches in diameter. Two inches
beyond the wound equals 2" + 1.5" + 2" = 5.5" diameter. The 6"x6" square is
the smallest material to contain a circle with a 5.5" diameter.
7. d (para 4-6)
8. f (para 4-7)
9 b (para 4-7)
10. b, c, e, f (para 4-8a)
11. a (para 4-9b)
12. b. (paras 4-9b, d, d Caution)
13. nipple (para 4-9b, fig 4-6)
14. Feel a "pop" or Hear air escaping. (either or both) (para 4-9d)
15. c (paras 4-9e, f)
16. d (para 4-9h)
17. See checklist on the following page.
18. See second checklist.
|
TREAT AN OPEN CHEST WOUND Given: Simulated conscious casualty with open chest wound(s) indicated Appropriate airtight material for seal Tape (from first aid kit) Emergency bandage (from first aid kit) Knife or other instrument to cut/prepare sealing material |
||
| GO NO-GO | ||
| 1. | Checks casualty for entrance and exit wound. | ______ ______ |
| 2. | Exposes wound. | ______ ______ |
| 3. | Prepares airtight material that will extend at least 2 inches beyond the edge of the wound on all sides. | ______ ______ |
| 4. | Has casualty exhale and hold breath. | ______ ______ |
| 5. | Places airtight material over wound so that airtight material extends at least 2 inches beyond edges of wound. | ______ ______ |
| 6. | Tapes three sides of airtight material to chest. | ______ ______ |
| 7. | If two wounds, repeats steps 2 through 6 except that all four sides are taped to the chest. | ______ ______ |
| 8. | Dresses and bandages the wound. | ______ ______ |
| OVERALL EVALUATION (A no-go on any step will result in a no-go for the entire task) |
GO NO-GO | |
|
PERFORM A NEEDLE CHEST
DECOMPRESSION Given: Simulated casualty (manikin) with dressed chest wound Large bore needed with catheter (from first aid kit) Tape (from first aid kit) |
||
| GO NO-GO | ||
| 1. | Identifies insertion site (second intercostal space above third rib on mid-clavicular line on injured side). | ______ ______ |
| 2. | Removes catheter/needle unit from packaging and removes protective cover. | ______ ______ |
| 3. | Inserts catheter/needle unit into insertion site at approximately a 90-degree angle. | ______ ______ |
| 4. | Continues insertion until chest wall is penetrated ("pop" is felt, air heard escaping). (Instructor may need to inform student that there is a "pop" and/or sound of escaping air if the manikin is not designed to provide these clues.) | ______ ______ |
| 5. | Removes the needle, leaving the catheter in place. | ______ ______ |
| 6. | Secures the catheter hub to the chest wall using the strip of tape. | ______ ______ |
| OVERALL EVALUATION (A no-go on any step will result in a no-go for the entire task) |
GO NO-GO | |
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