FMST Student Manual - 2008 Web Edition*
UNITED STATES MARINE CORPS
Field Medical Training Battalion
Camp Lejeune
FMST 1409
Manage Respiratory Trauma
TERMINAL LEARNING OBJECTIVES
1. Given
a casualty with respiratory trauma in a combat environment and standard field
medical equipment and supplies, manage respiratory trauma to prevent further
injury or death. (FMST-HSS-1409)
ENABLING LEARNING OBJECTIVES
1. Without
the aid of references, given a description or list, identify standard
medical terminology related to the respiratory system, per the student
handout. (FMST-HSS-1409a)
2. Without
the aid of references, given a description or title, identify the anatomy of the
respiratory system, per the student handout. (FMST-HSS-1409b)
3. Without
the aid of references, given a description or list, identify treatment for an
open chest injury, per the student handout. (FMST-HSS-1409c)
4. Without
the aid of references, given a description or list, identify treatment for a
closed chest injury, per the student handout. (FMST-HSS-1409d)
5. Without
the aid of references, given a simulated casualty with an open respiratory
injury and standard field medical equipment and supplies, manage the casualty,
per the student handout. (FMST-HSS-1409e)
6. Without
the aid of references, given a description or list, identify signs and symptoms
of respiratory trauma, per the student handout. (FMST-HSS-1409f)
1.
TERMINOLOGY
Dyspnea - difficult or labored breathing.
Wheeze - a form of rhonchus, characterized by a
whistling respiratory sound. It is caused by the movement of air through a
narrowed airway.
Stridor - a harsh shrill respiratory sound.
Hyperventilation - an increase in the rate and depth
of normal respirations. Responsible for increasing oxygen levels and decreasing
carbon dioxide levels.
Tachypnea - abnormally rapid rate of respiration.
Bradypnea - an abnormally slow rate of respiration,
usually less than 8 breaths per minute.
Hypoxia - an insufficient concentration of oxygen in
the tissue in spite of an adequate blood supply.
Apnea - total cessation of breathing, also known as
respiratory arrest.
Subcutaneous Emphysema - the presence of free air or
gas in the subcutaneous tissues. The face, neck, or chest may appear swollen
with painful skin and produce a crackling sound (“rice crispies”).
Trachea - also called the windpipe, it is the main
trunk of the system of tubes by which air passes to and from the lungs. It is
located in the front of the neck, descending from the lower larynx and is
continuous with the bronchus.
Larynx - a structure superior to the trachea that
encompasses the vocal cords. Also known as “voice box.”
Epiglottis - lid like structure overhanging the larynx
that prevents food from entering the respiratory tract.
2. ANATOMY
Thorax (Chest Cavity) (see figure 1)
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Substitute Figure 1: Thorax* |
Definition - skeletal portion of
the thorax is a bony cage formed by the sternum, costal cartilages, ribs,
and the bodies of the thoracic vertebrae.
Ribs
-
Joined in the posterior with the thoracic spine and anterior with the sternum
via the costal cartilage.
- A nerve, an artery, and a vein are located along
the underside of each rib.
-
Intercostal muscles connect each rib with the one above.
Diaphragm
- The primary muscle of respiration.
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Substitute Figure 2: Pleura and
Lungs* |
Pleura (see figure 2)
Definition - thin membranes separated by a small
amount of fluid, which creates surface tension and causes them to cling
together, counteracting the lung’s natural tendency to collapse.
Parietal pleura - a thin membrane that lines the inner
side of the thoracic cavity
Visceral pleura - a thin membrane that covers the
outer surface of each lung
Lungs (see figure 3)
- Occupy
the right and left halves of the thoracic cavity
- The
left lung is divided into two lobes
- The
right lung is larger than the left lung and is divided into three lobes
-
Alveoli- the smallest components of the lungs. They are small saclike
structures through which the exchange of carbon dioxide and oxygen take place.
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Substitute Figure 3: Lungs* |
Mediastinum
Definition - area in the middle of the thoracic cavity
in which all the other organs and structures of the chest cavity lie. It
encases the:
- Heart
- Great vessels (aorta, superior/inferior vena cava)
-
Trachea (windpipe)
- Mainstem bronchi (there are two bronchi- a right and left)
- Esophagus (lies directly behind
the trachea)
3. RESPIRATORY
TRAUMA
Chest injuries are the second leading cause of trauma deaths
each year, although the vast majority of all thoracic injuries (90% of blunt
trauma and 70 to 85% of penetrating trauma) can be managed without surgery.
Traumatic chest injuries can be caused by a variety of mechanisms; however,
these injuries are usually classified as either blunt or penetrating.
Penetrating Injuries - caused by
forces distributed over a small area (i.e., gunshot wounds or stabbings). Most
often, the organs injured are those that lie along the path of the penetrating
object.
Blunt
Trauma
- caused by forces distributed over a larger area, and many injuries occur
from deceleration, bursting, or shearing forces. Conditions such as
pneumothorax, pericardial tamponade, flail chest, pulmonary contusion, and
aortic rupture should be suspected when the mechanism of injury involves
rapid deceleration, including motor vehicle collisions, falls, sport
injuries, and crush injuries.
Management of Specific Injuries
Causes - blunt trauma, crushing injuries to the chest.
Signs and Symptoms
- Pain
at the site with inhalation/exhalation
-
Shortness of breath
-
Deformity
-
Crepitus
-
Bruising to area
Treatment
- Anticipate potential complications such as tension pnuemothorax,
pericarditis, or cardiac tamponade.
-
Simple rib fractures usually require no treatment other than analgesics.
- Multiple rib fractures may require immobilization of the arm on
affected side to protect the ribs.
- Encourage coughing and deep breathing despite associated pain.
This is to prevent the collapse of the lung tissue and preventing the exchange
of CO2 and O2 (atelectasis).
- Avoid
any taping or bandaging that encircles the chest.
- Monitor and CASEVAC as necessary.
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Substitute Figure
4: Flail Chest |
Flail chest - a condition of the
chest wall due to two or more adjacent ribs being fractured in at least two or
more places. The flail segment moves paradoxically in with inspiration and out
during expiration (see figure 4)
Causes - blunt trauma to the chest wall, especially an
impact into the sternum or the lateral side of the thoracic wall.
Signs and Symptoms
-
Localized chest pain, aggravated by breathing or coughing
- Rapid
shallow respirations
-
Tenderness and/or bony crepitus with palpation
- Paradoxical chest wall movement (during inspiration, the flail
segment of the rib cage moves inward (instead of outward), which results in
reduced air intake.
Treatment
-
Immobilize flail segments upon inhalation using strips of tape
- If you suspect respiratory failure, give positive pressure
ventilation using a bag valve mask.
- Administer analgesics (small doses of morphine can be given,
see medication appendix at end of Block 2)
-
Administer oxygen if available
-
CASEVAC to the next echelon of care
Causes
- Penetrating trauma from either chest wall injury or abdominal
injuries that cross the diaphragm.
- Blunt
trauma
-
Spontaneous (with no apparent cause)
Signs and Symptoms
-
Pleuritic chest pain
-
Tachypnea/dyspnea
-
Decreased or absent breath sounds on the injured side
-
Decreased chest wall motion
Treatment
- Place
patient in Fowler’s or Semi-Fowlers position
- Bag-valve-mask assisted breathing may be necessary if RR is
less than 8 BPM, greater than 20 BPM, or signs of hypoxia
- If
caused by a wound, apply an occlusive dressing to the site
-
Monitor for signs and symptoms of a tension pneumothorax
- CASEVAC ASAP
Tension Pneumothorax - a type of
pneumothorax in which air can enter the pleural space but cannot escape
via the route of entry. This leads to an increase of pressure in the
pleural space and eventual collapse of the lung. This pressure forces the
mediastinum to the opposite side, which results in two serious
consequences: (1) breathing becomes increasingly difficult and (2) cardiac
blood flow is severely decreased (see figure 5).
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Substitute Figure
5: Tension Pneumothorax* |
Cause - chest injuries (this is the
second leading cause of preventable death on the battlefield).
Signs and Symptoms
Early signs
-
Unilateral decreased or absent breath sounds
-
Dyspnea
-
Tachypnea
Progressive signs
-
Increased dyspnea
-
Increased tachypnea
-
Increased difficulty ventilating
Late
signs
-
Jugular vein distention (JVD)
-
Tracheal deviation
-
Signs of acute hypoxia
-
Narrowing pulse pressures
-
Signs of uncompensated shock
Treatment
- Treat
all chest injuries
-
Perform needle thoracentesis
-
Administer oxygen therapy if available
- Pain
management
- Monitor and CASEVAC to next echelon of care
Open Pneumothorax (Sucking Chest Wound)
- a collection of air or gas in the pleural space causing the lung to collapse.
An open wound allows air to enter when the intrathoracic pressure is negative
and blocks the air’s release when the intrathoracic pressure is positive;
creating a “sucking chest wound,” that has the potential to cause a tension
pneumothorax.
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Open Chest Wound |
- Place patient
on affected side
- Pain management
- Monitor and CASEVAC
Hemothorax |
Hemothorax
- the accumulation of blood in the pleural space caused by a laceration of the
great vessels within the chest that can significantly compromise respiratory
efforts by compressing the lung and preventing adequate ventilation.
Causes
- Penetrating or blunt trauma
Signs and
Symptoms
- Shortness of
breath
- Chest pain
- Tachypnea
- Signs of shock
(pallor, confusion, tachycardia, hypotension)
- Decreased
breath sounds on affected side
- Hemoptysis
(coughing up blood)
- Decreased chest
wall motion
Treatment
- Place patient
in the Fowler’s position
- Treat any chest
injuries
- Treat for shock
- Administer O2,
if available
- Pain management
- Monitor and CASEVAC
Hemopneumothorax - often with
penetrating trauma, a pneumothorax is associated with a hemothorax, and an
accumulation of air, blood, and fluid within the pleural cavity.
Causes
- penetrating trauma to the chest wall, the great vessels, or the lung.
Signs and Symptoms
-
Tachypnea
-
Decreased breath sounds
- Signs
of shock
Treatment
- Place
patient in Fowler’s position (sitting up)
- Perform needle thoracentesis to relieve pressure. If blood is
withdrawn, immediately remove needle and catheter.
-
Administer oxygen, if available
- Treat
for shock
-
Monitor and CASEVAC
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CASUALTY ASSESSMENT AND RESPIRATORY TRAUMA |
|
Care Under Fire Phase: In the absence of
life-threatening hemorrhage from the respiratory system, the material
in this section is unlikely to be addressed in Care Under Fire.
Tactical Field
Care Phase: During this phase, you will be required to assess the
quality of breathing, which will require you to expose the casualty’s
chest. Consider needle thoracentesis if warranted. Note and treat
all respiratory injuries. Complete a head to toe assessment using
DCAP-BTLS noting and treating additional injuries. Determine if
vascular access is required (see Combat Fluid Resuscitation lesson)
and give fluids if necessary. If the casualty is able to drink
fluids, they should be encouraged to do so. Consider pain medications
and give antibiotics if warranted. Reassess all care provided.
Document care given, prevent hypothermia, and CASEVAC. |
REFERENCE
Identify the appropriate treatment for a simple rib
fracture.
Identify the two serious consequences of a tension
pneumothorax.
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*The FMST Student
Manual was produced by the Field Medical Training Battalion-East, Camp Lejeune,
North Carolina. This 2008 web edition has been enhanced by the Brookside
Associates, Ltd., preserving all of the original text material, while
augmenting, modifying, eliminating or replacing some of the graphics to comply with
privacy and copyright laws, and to enhance the training value. These
enhancements are marked with a red box
□
and are C. 2008, with all rights
reserved.
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