Primary Survey Breathing Evaluation

1. See Also
   1. Cardiopulmonary Resuscitation
   2. Guidelines for Emergency Cardiovascular Care
2. Assessment
   1. Focus: Breathing, Ventilation, Oxygenation
   2. Evaluate
      1. Oxygen Saturation
      2. Work of breathing and Respiratory Rate
      3. Chest XRay
3. Management
   1. Awake with spontaneous breathing
      1. Supplement High Flow Oxygen delivery with nonrebreather mask with reservoir
   2. Conscious with respiratory failure
      1. Bag Valve Mask with 100% Oxygen
      2. Ventilation rate
         1. Adult: 12 breaths per minute
         2. Child: 15 breaths per minute
         3. Infant: 20 breaths per minute
      3. Consider Hyperventilating
         1. Corrects acidosis and lowers Intracranial Pressure
         2. Maintain:
            1. PaCO2 22-29 or
            2. Respiratory Rate twice normal
   3. Cardiopulmonary Resuscitation
      1. Ventilations should last 1 second per breath and demonstrate visible chest rise
      2. Place Advanced Airway when able
         1. Can maintain airway with 2 intranasal and an Oral Airway until Advanced Airway available
      3. Advanced Airway in position and confirmed
         1. Ventilations every 6-8 seconds (8-10 per minute) asynchronous to compressions
4. Pitfalls: Trauma
   1. Pneumothorax
      1. Tension Pneumothorax
      2. Open Pneumothorax
      3. Massive Hemothorax
   2. Rib Fractures
      1. High risk injury if Fractured ribs 1 through 3 (or associated Scapular Fracture)
         1. Associated with significant cardiopulmonary injury
      2. Flail Chest
         1. Manage with Positive Pressure Ventilation
         2. Assess for associated Pneumothorax of Hemothorax (requires Chest Tube)
      3. Pulmonary Contusion
   3. Open chest wounds
      1. Do not use an open chest wound as a site for Chest Tube due to contamination risk
         1. Create a new Chest Tube entry site
      2. Sucking Chest Wounds
         1. Apply three sided Occlusive Dressing for temporary stabilization until Chest Tube can be placed
         2. Chest Tube is the primary management for an open chest wound
            1. Do not completely occlude the wound until Chest Tube is in place (Tension Pneumothorax risk)
   4. Crashing trauma patient pearls
      1. Have a low threshold for placing bilateral Chest Tubes
         1. Evaluates chest for bleeding source
         2. Manages Pneumothorax, Hemothorax, Flail Chest and Sucking Chest Wound
5. References
   1. Cardiopulmonary Resuscitation Guidelines
      1. http://www.circulationaha.org
      2. (2010) Guidelines for CPR and ECC
      3. (2005) Circulation 112(Suppl 112):IV
      4. (2000) Circulation, 102(Suppl I):86-9