An Open Question

Scene

At 1532 you respond with an engine company and law enforcement to a residence for a "suicide attempt." You find a 23-year-old male on the floor, alert but pale and short of breath. There is an entrance wound to his right anterior chest and a larger exit wound that has resulted in a scapular fracture with moderate bleeding. Police inform you that he used a jacketed .38-caliber round.

Treatment

A quick baseline exam reveals that radial pulses are absent bilaterally, the patient's skin is cool and his capillary refill time is five seconds. The wounds in his chest are "sucking," and as he pleads with you for help, he is unable to speak more than one or two words at a time. Covering the entrance wound with your gloved hand, you immobilize him on an LSB and provide 15 lpm/O2 via NRB. His left chest is clear and moving well, and his heart sounds are normal. His neck veins are flat.

As the patient is secured for transport, you place an occlusive dressing over both wounds, but his dyspnea worsens, and he will not tolerate the oxygen mask. Initial vitals are HR 142, BP 74/46, RR 36 and SaO2 86%. His trachea is at the midline, but you feel it tugging toward the left as he gasps for air. Attempting to "burp" the dressing does not improve his respirations, and right-side breath sounds are absent. You decompress his right side with a 14-gauge needle in the third intercostal space at the midclavicular line; this is accompanied by a rush of air. Unfortunately, the oxygen saturations do not measurably improve, and the patient remains extremely dyspneic and cyanotic.

Your partner has already established IV access with a 16-gauge in the right arm and has NS infusing wide-open after a 500cc bolus. Using a rapid-sequence protocol, the patient is orally intubated with 5mg Versed, 125mg Anectine and 5mg Norcuron. His saturations increase to 95%, and BVM compliance is good. Vitals upon arrival at the ED are HR 128, BP 97/53, SaO2 96% and respirations performed with BVM at 14.

Hospital

The trauma team is waiting to assume care, and a surgeon quickly places a right-side chest tube and evacuates almost 400cc of blood. Two liters of warmed saline are rapid-infused and O-negative blood is hung as the patient is prepared for the OR. During surgery, he is found to have a hemopneumothorax, lacerated pulmonary vein and fractured scapula. He recovers well and is discharged five days later.

Summary

The lungs are surrounded by the pleural membranes. The visceral pleura directly covers the lung and is separated from the parietal pleura by a layer of surfactant, which reduces friction during respiratory movement. A potential space exists between these two layers, and they may become separated by fluid or air. A lung can collapse to the size of a fist under pressure from either.

Standard treatment in the field for an open chest wound is an occlusive dressing. The first thing that can be used to occlude the wound is a gloved hand. After placing the dressing, evaluate the breath sounds and determine if they have improved. The dressing should be taped down on three sides, leaving one side open to relieve the pressure during exhalation (one-way valve). "Burping" the dressing involves lifting one side to make sure any pressure buildup is relieved, as occasionally the dressing can become adhered to the skin, which may lead to a tension pneumothorax.

If, after ensuring the occlusive dressing is properly in place, the respiratory rate increases, distress level worsens, oxygen saturations fall and breath sounds decrease, then needle decompression is required. A neurovascular bundle is located underneath each rib, and it is important to avoid damage to that bundle by performing a decompression over the top of a rib. If the patient is intubated before the development of a tension pneumothorax, carefully evaluate the breath sounds (especially if the left-side sounds are diminished) to determine if the ET tube needs to be withdrawn a centimeter. The rescuer performing ventilation will usually recognize a tension pneumothorax by the difficulty in bagging the patient. Remember, when you perform a needle thoracentesis, you are creating an open chest wound.

Early signs and symptoms of a tension pneumothorax include diminished or absent breath sounds, severe dyspnea, narrowing pulse pressure, tachycardia and restlessness. Neck veins may be distended, but this can be a normal finding in a supine patient. The classic sign is a deviated trachea; the trachea shifts toward the "good" lung as the buildup of pressure collapses the "bad" lung. This is a late sign and suggests the tension pneumothorax has been developing for some time.

One sign that does not normally accompany a plain pneumothorax is hypotension. In this case, the persistent low BP, combined with cool, mottled skin and a delayed capillary refill time, led providers to suspect that a hemothorax was developing as well. With endotracheal intubation and pleural decompression, the positive-pressure ventilations allowed the affected right lung to inflate more fully, utilize more of the available alveolar space and "bag out" some of the blood pooling at the base. The patient's vital signs and saturation improved. He needed surgical treatment and removal of the blood in the pleural space before ventilation and oxygenation could normalize.

INITIAL ASSESSMENT

A 23-year-old male with a GSW to the right side of his chest; an exit wound is found on his back. He is pale and cool, with gasping respirations and absent radial pulses. Moderate bleeding is associated with the exit wound.

HEAD-TO-TOE ASSESSMENT

Head: Airway patent; circumoral cyanosis.
Neck: No JVD; tracheal tugging.
Chest: Entrance wound to right anterior wall; diminished breath sounds on right side. Left lung clear with good expansion. Normal heart sounds.
Abdomen: Soft, flat, no evidence of trauma.
Pelvis: Stable.
Extremities: Cool and mottled; absent distal pulses.
Back: Exit wound found with scapular fracture, moderate bleeding.
Neuro: Alert and anxious.

VITAL SIGNS