PRE-HOSPITAL EMERGENCY CARE COURSE www.basics.org.uk
Chest Assessment & Management BASICS Education March 2016
Objectives To understand the importance of oxygenation and ventilation To be able to describe a systematic process of chest assessment To recognise life-threatening chest injuries and describe their immediate pre-hospital management
Primary Survey Safety <C > - Catastrophic haemorrhage control A - Airway with cervical spine control B - Breathing C - Circulation D - Disability E - Exposure
Thoracic Examination Complete exposure vital Apex extends above clavicle Diaphragm can reach as high as 4th rib space on expiration
Examination of the neck W - E - Wounds Emphysema (surgical) T - Trachea
Examination of the chest R - Rate I - Inspection P - Palpation P - Percussion A - Auscultation
RIPPA Rate Depth Effort Other features of work of breathing e.g. indrawing, nasal flaring in children Then apply high flow oxygen
Causes of abnormal rates < 10 breaths per min Drugs Alcohol Head injury Medical causes Athlete at rest > 30 breaths per min Chest injury Airway compromise Circulatory shock Respiratory conditions Pain, anxiety, fear Exercise
RIPPA Inspect the chest for signs of: Pattern bruising Wounds (penetrating or sucking) Symmetry of chest movement Paradoxical movement Effort of breathing Inspect front, sides and back wherever possible
RIPPA Palpate the chest for: Expansion Surgical emphysema Tenderness Bony crepitus Flail segment Check gloves for blood after feeling back
RIPPA Percussion Can be difficult on scene or in transit Assess percussion bilaterally Apex, Base, Axilla Vital to assess as far posteriorly [gravity dependent] as possible Hyper-resonance suggests air Dullness suggests fluid
RIPPA Auscultation: Can be difficult on scene or in transit Auscultate bilaterally Apex, Base, Axilla Vital to assess as far posteriorly [gravity dependent] as possible Air entry normal, decreased or absent? Added sounds?
Management of chest injuries
Life-threatening injuries BL Blast lung A T O M Airway obstruction / disruption Tension pneumothorax Open pneumothorax Massive haemothorax F C Flail segment / multiple rib fractures Cardiac tamponade
Blast lung Causes impaired oxygen exchange Also causes other lung injuries Pre-hospital management is supportive High flow oxygen Urgent transfer Clear handover is vital
Airway obstruction / disruption Abnormal respiratory rate and failure to ventilate may be due to airway compromise Reassess if needed
Tension pneumothorx Speed of onset can vary Raised respiratory rate, effort Affected side of chest: Hyper-expanded Hyper-resonant to percussion Decreased breath sounds Tracheal deviation is a late sign High flow oxygen Immediate decompression Urgent transfer
Tension pneumothorax Wide-bore cannula or purpose-made device +/- syringe 2nd intercostal space, just above 3rd rib in mid-clavicular line Alternative site 4th intercostal space, just above 5th rib in anterior axillary line triangle of safety Insert perpendicular to skin, then secure upright Reassess ABC Transfer urgently
Tension pneumothorax Open thorocostomy if expertise is available 4th intercostal space, just above 5th rib in anterior axillary line Leave open if mechanically ventilating patient Chest seal in self ventilating patient OR Chest drain through thorocostomy (NICE) Reassess ABC Transfer urgently
Open pneumothorax A careful search for a penetrating sucking wound is vital High flow oxygen Cover wound Valved chest seal Occlusive dressing (observe for tension) Transfer Careful handover
Massive haemothorax Raised respiratory rate Affected side of chest Decreased expansion Dull to percussion Decreased breath sounds Circulatory shock High flow oxygen Manage circulation Urgent transfer with pre-alert
Flail chest / multiple rib fractures Flail segment 2 consecutive ribs broken in 2 places Causes pain and hypoxia Give high flow oxygen, analgesia, splint Flail chest Involves whole chest with many ribs broken Causes inability to oxygenate or ventilate by negative pressure Requires assisted / positive pressure ventilation
Cardiac tamponade Chest injuries may affect organs other than lungs Diagnosis is difficult to make without ultrasound Pre-hospital management is supportive High flow oxygen Urgent transfer
Pulse oximetry Can provide additional information regarding patient s oxygenation Can be unreliable in pre-hospital Vibration / movement / transfer Bright light Nail varnish Carbon monoxide poisoning Good saturation does not necessarily mean good oxygenation
Capnography Assesses ventilation with breath-bybreath measurement of expired carbon dioxide Good capnography implies: Patent airway Adequate oxygenation Adequate circulation Good ventilation Preferable to pulse oximetry: More information given Dynamic monitoring with earlier warning of respiratory compromise
Assisted ventilation No absolute criteria, use clinical judgment Always manage underlying condition first where possible Consider when there is Poor oxygenation Poor ventilation Severe respiratory distress rate <10 or >30 bpm
CHEST ASSESSMENT & MANAGEMENT Questions?
Summary Full systematic chest examination is essential Identify and manage life-threatening chest injuries promptly Reassess often Give high flow oxygen and transfer urgently