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Chest Injuries (CPG A0802)

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Assessment

  • Respiratory status

  • Type of injury

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Action - general

  • O2 as per CPG A0001

  • Analgesia as per CPG A0501​

  • Position upright if possible

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Action - Flail segment/rib fractures

  • May require ventilatory support if decreased VT

  • ​Pain associated with rib fractures may lead to hypoventilation. In these instances, prioritise carefultitration of analgesia.

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Action - Open chest wound

  • Do not occlude an open pneumothorax

  • Occlusive dressing only required if haemorrhage is apparent

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Action - Simple pneumothorax

  • If unequal breath sounds in spontaneously ventilating Pt, or SpO2 <92% on room air, or subcutaneous emphysema, monitor for development of TPT

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Assessment - TPT

  • If signs of simple pneumothorax and any of the following:

    • ​↑ respiratory distress in awake Pt ↓ SpO2 to <92% despite O2

    • ↓ conscious state

    • ↑ HR +/- + BP

    • ↑ peak inspiratory pressure/stiff bag

    • ↓ EtCO2

    • ↑ JVP

    • Tracheal shift

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Action - Cardiac arrest imminent

  • GCS 10 and BP < 70 mmHg:

    • Immediate chest decompression

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Action - Cardiac arrest not imminent

  • Monitor closely for deterioration

  • Chest injury patients receiving IPPV have a high risk of developing a TPT. Bilateral chest
    decompression is appropriate prior to managing decreased perfusion.

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Advanced Paramedic

  • Suspected TPT with GCS >10​

    • Prepare Lignocaine 50 mg in 5 mL (1%) in a 10 mL syringe and attach a 23g or 21g needle.

    • Infiltrate chest wall with up to 5 mL Lignocaine 1%

    • Insert an intercostal catheter, ARS device or long 14g cannula in the mid-clavicular line of the 2nd interspace.

    • If air escapes, or air and blood bubble through the cannula / intercostal catheter, or no air / blood
      detected, leave in situ and secure.

    • If no air escapes but copious blood flows through the cannula / intercostal catheter then a major
      haemothorax is present. Remove, then cover the insertion site.

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Notes

  • In awake, spontaneously ventilating Pt, TPT is likely if generic symptoms of pneumothorax are present and Pt has increasing respiratory distress and/or decreasing conscious state.

  • Low BP is a late sign In the ventilated Pt, TPT is likely to develop rapidly with a sudden decrease in SpO2 and BP.

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Flow Chart - General

Chest Injuries Flow Chart.jpg
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Flow Chart - Tension Pneumothorax

TPT Flowchart.jpg
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