Management of pneumo/haemothorax:
Multiple management considerations need to be taken when dealing with a patient suffering a pneumo/haemothorax.
Simple pneumothorax – On identifying a simple pneumothorax, supportive care is needed to help manage the patient. Depending on the circumstances and observations they may require management of primary survey deficits and supportive care, such as oxygen and analgesia. In a simple pneumothorax a needle thoracocentesis is not required. Continual monitoring and assessment are required to identify if the pneumothorax develops into a tension pneumothorax.
Tension pneumothorax – A needle thoracocentesis is required to alleviate the pressure build up in a tension-pneumothorax. Different Ambulance Services have varying devices to do this, mainly structured around a large bore cannula or similar device which is inserted in the mid-clavicular second intercostal space. On insertion, the build up of air can be released, allowing for the re-inflation of the lung and alleviation of pressure and compression on the mediastinum and other lung. The patient will likely require management of primary survey deficits and further supportive care depending on the situation, such as oxygen and analgesia. Further specialist support may be required for a finger thoracostomy procedure. Finger thoracostomy allows a greater release of air build up when compared to needle thoracocentesis. This is especially important where a patient is being positively ventilated and the ventilated air is greater than the amount of air released by the needle thoracocentesis, meaning a further tension pneumothorax could develop through positive ventilation.
Haemothorax – Within the thoracic space a large amount of blood can collect. The main overall treatment for a haemothorax is a surgical chest drain done at hospital. This means in a pre-hospital setting, there is limitations on what can be achieved and an emphasis on rapid transport. Supportive treatment will be required for the patient and management of any primary survey deficits. Some advanced clinicians and specialist services may be able to provide treatment roadside.
Open pneumothorax/sucking chest wound – Where a sucking chest wound is present, air is entering the pleural cavity from the outside. A non-occlusive dressing is required to help manage this. Different Ambulance Services have different equipment available, usually consisting of a patch with a one-way valve allowing air our of the pleural cavity but not in. The patient will likely require management of primary survey deficits and further supportive care depending on the situation, such as oxygen and analgesia.
With all traumas where a pneumo/haemothorax is suspected, the patient may have numerous other injuries due to the forces and MOI involved. A full primary survey rectifying any deficits found will be needed to help manage patient stability. Further advanced care could also be considered for specialist support and skills.
Ruptured blood vessels/organs:
Within the mediastinum of the chest are several important organs and vessels. These include the heart, great vessels (aorta, vena cava, etc), trachea, right and left bronchi, oesophagus, lymph nodes, lymph vessels, and nerves. Any significant trauma affecting this area could have severe and rapid consequences. Penetrating trauma could easily rupture or damage any of the organs and/or vessels causing massive haemorrhage and the patient to exsanguinate quickly. It could also affect the air supply into the lungs causing respiratory difficulty and arrest. Blunt trauma could also be equally as severe, causing the shearing of vessels and organs, and again massive internal haemorrhage.
The outcome of a patient with such injuries will depend on the MOI, the forces involved, and what organs are affected. Managing a patient with potential ruptured blood vessels and/or organs will require a review of the primary survey, management of any deficits, and identification of signs of hypovolaemic shock. The clinician can consider use of medications within their guidelines to try and manage any internal bleeding, such as Tranexamic Acid, oxygen administration for major trauma, and depending on the blood pressure, some fluid therapy. A targeted systolic of 60 mmHg or central carotid pulse should be aimed for in penetrating torso trauma, and systolic of 90 mmHg or peripheral radial pulse in blunt trauma or penetrating limb trauma. Consideration for specialist back up and support can be made for the utilisation of advanced skills. The clinician must also consider the time on scene and benefits of a rapid extrication to hospital.
The make up of the heart consists of 3 layers, the pericardium (outer layer), the myocardium (middle layer), and the endocardium (inner layer). Between the pericardium and myocardium, there is a pericardial space containing pericardial fluid. There is around 20 ml of pericardial fluid contained in this space. This stops any friction forming when the heart pumps and moves. The pericardium is inelastic and doesn’t stretch. During cardiac tamponade, the fluid within the pericardial space increases, either through traumatic or medical cause. As the pericardium is inelastic and doesn’t stretch, this pressure builds and puts compression on the valves and chambers of the heart. This starts to cause significant cardiovascular compromise as the heart is unable to effectively fill and pump blood around the body.
A clinician needs to consider multiple factors which may indicate the patient is having a tamponade, including the MOI and surrounding factors, the patients’ observations and signs/symptoms, and what injuries are present. Beck’s triad can be used to help identify cardiac tamponade and includes hypotension, distended neck veins, and muffled heart sounds. Hypotension due to the poor ability of the heart to pump blood and maintain blood pressure, distended neck veins due to the back fill of the vena cava, and muffled sounds due to the greater volume of fluid surrounding the heart.
Management of a patient will include the primary survey and rectification of any deficits found, further consideration for injury due to the MOI involved, oxygen administration for major trauma, and analgesia for pain. The clinician will have to quickly extricate the patient to hospital for ultimate pericardiocentesis treatment.