II. Precautions

  1. Primary goal of initial chest evaluation and management is the prevention of Hypoxia

III. Assessment

  1. See Rapid ABC Assessment
  2. Focus: Breathing, Ventilation, Oxygenation
  3. Precautions
    1. Tachypnea and acidosis are the two most important respiratory markers of Critical Illness
  4. Evaluate respiratory status
    1. Oxygen Saturation
    2. Work of breathing and Respiratory Rate
    3. Lung auscultation (asymmetry, Wheezes, rales, rhonchi, Stridor)
    4. Arterial Blood Gas or Venous Blood Gas
    5. Chest XRay
    6. Bedside Lung Ultrasound in Emergency (Blue Protocol)
  5. Evaluate for Chest Trauma and secondary findings
    1. Jugular Venous Distention
    2. Tracheal deviation
    3. Palpate for chest wall injury

IV. Management

  1. Awake with spontaneous breathing
    1. Supplemental Oxygen delivery to maintain Oxygen Saturations 93-97%
  2. Conscious with Respiratory Failure
    1. Bag Valve Mask with 100% Oxygen
    2. Ventilation rate
      1. Adult: 12 breaths per minute (every 5 seconds)
      2. Child: 15 breaths per minute (every 4 seconds)
      3. Infant: 20 breaths per minute (every 3 seconds)
    3. Avoid Hyperventilation
      1. No longer recommended due to Barotrauma risks
      2. Previously used to corrects acidosis and possibly lower Intracranial Pressure
        1. Goals: PaCO2 22-29, or 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
      2. Tidal Volume: 6-8 ml/kg based on Predicted Body Weight for Height
        1. (2000) N Engl J Med 342(18): 1301-8 [PubMed]
    4. Ventilator patient in Cardiac Arrest
      1. Disconnect Ventilator
      2. Respiratory therapist (or similarly skilled) manually ventilates patient with Bag Valve Mask
        1. Maintain consistent ventilations at 6-8 seconds and avoid Hyperventilation
      3. Ventilator may be continued if settings are appropriately adjusted to account for Chest Compressions
        1. Increase peak airway pressure to 100 cm H2O (during Cardiac Arrest only)
          1. Over-rides Ventilator interpretation of Chest Compressions as chest pressure
          2. Prevents breath delivery
        2. Adult Ventilator settings during Cardiac Arrest (example)
          1. Assist Control
          2. Peak Pressure: 100 cm H2O
          3. Tidal Volume: 550 ml (or 8 ml/kg plus 50 cc tube dead space)
          4. Respiratory Rate: 12/minute
          5. FIO2: 100%
      4. References
        1. Weingart and Orman in Herbert (2014) EM:Rap 14(1): 9-10

V. Pitfalls: Trauma

  1. Pneumothorax
    1. See Tension Pneumothorax, Open Pneumothorax and Massive Hemothorax
    2. Consider in all dyspneic and tachypneic patients
      1. Initial interventions may worsen respiratory distress in Pneumothorax
        1. Exercise caution with Advanced Airway, Positive Pressure Ventilation
      2. Pneumothorax may be unmasked by initial airway and breathing management
      3. ABC Reassessment is key after each intervention
      4. Consider serial Extended FAST Exams or repeat Chest XRays
  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
      1. High risk injury associated with Hypoxia
  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
        2. Tension Pneumothorax risk when wound occluded
  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

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