A.
ENABLING LEARNING OBJECTIVE D
Action:
Conditions:
Standards:
1.
Treat a simulated casualty with penetrating chest trauma, including
decompressing a tension pneumothorax as necessary.
Given a simulated conscious or unconscious casualty and a combat
lifesaver medical equipment set.
Score a GO on the performance checklist.
Learning Step / Activity 1. Treat Penetrating Chest Trauma and Decompress a Tension
Pneumothorax
Method of instruction: Conference/Discussion/Demonstration
Instructor to Student Ratio: 1:100
Time of Instruction: 2 hrs
Media: A/V
Section I. TREATING AN OPEN CHEST WOUND
1. INTRODUCTION
NOTE: Show Slide # 1
In the previous lesson, we covered restoring and maintaining the casualty's airway.
One of the greatest dangers to a casualty's ability to breathe is injury to the chest.
NOTE: Show Slide # 2-3
The body has two lungs. Each lung is enclosed in a separate airtight area within the chest. If an object
punctures the chest wall and allows air to get into one of these areas, the lung within that area begins to
collapse.
In order for both lungs to collapse, both sides of the chest would have to be punctured. However, any
degree of collapse of either lung interferes with the casualty's ability to breathe and reduces the amount
of oxygen available for use by the body.
2. SIGNS AND SYMPTOMS OF AN OPEN CHEST WOUND
NOTE: Show Slide # 5
When an object penetrates the chest wall, the injury is called an open chest wound. The penetration can
be caused by a bullet, knife blade, shrapnel, stick or small tree limb propelled by an explosion, or other
object. Anytime there is an have an open chest wound, there is danger of the lung collapsing.
Some of the signs and symptoms of an open chest wound are given below.
(1) Sucking or hissing sounds coming from chest wound. (When a casualty with an open chest
wound breathes, air goes in and out of the wound, creating a "sucking" sound. Because of this
distinct sound, an open chest wound is often called a "sucking chest wound.")
(2) Casualty coughing up blood.
(3) Frothy blood coming from the chest wound. (The air going in and out of an open chest wound
causes bubbles in the blood coming from the wound.)
(4) Shortness of breath or difficulty in breathing.
NOTE: Show Slides # 7 thru 9
(5) Chest not rising normally when the casualty inhales. (The casualty may have several fractured
ribs, resulting in a flail chest.)
(6) Pain in the shoulder or chest area that increases with breathing.
(7) Bluish tint of lips, inside of mouth, fingertips, or nail beds (cyanosis) caused by a decrease of
oxygen in the blood.
(8) Rapid and weak heartbeat (shock).
If you are not sure if the wound has penetrated the chest wall completely, treat the wound as though it
were an open chest wound.
3. CHECK FOR OPEN CHEST WOUNDS
NOTE: Show Slide # 10
You must seal the open chest wound so that air from the atmosphere will not get into the casualty's chest
and collapse the lung.
The first step is to locate the open chest wound.
Check for both entry and exit wounds. Look for a pool of blood under the casualty's back. Use your hand
to feel for wounds on the casualty's back.
If there is more than one open chest wound, treat the more serious (largest, heaviest bleeding) wound
first.
NOTE: Show Slide # 11
If the casualty has two wounds (an entrance and exit wound) affecting the same lung, apply the fluttervalve seal (three taped sides) to the wound on the front and a full seal (all four sides taped) to the wound
on the back.
4. EXPOSE THE WOUND
NOTE: Show Slide # 12
Expose the area around the open chest wound by removing, cutting, or tearing the clothing covering the
wound. Scissors from the aid bag, a knife, or a bayonet may be used.
Remind the students to not remove clothing stuck to the wound as this may cause additional pain and
injury. Cut or tear around the stuck clothing.
Remind the students to not clean the wound or remove objects stuck in the wound.
5. PREPARE SEALING MATERIAL
NOTE: Show Slide # 13
Since air can pass through dressings and bandages, you must place airtight material over the chest
wound before you dress and bandage the wound.
Plastic from a field dressing or other bandage pack is one source of airtight material.
Demonstrate preparing sealing material from a plastic field first aid dressing wrapper.
DEMONSTRATION: Preparing Sealing Material
Demonstrate cutting a plastic field dressing wrapper and other sources for use to seal an open chest
wound.
Explain what is being done as the procedure is performed.
Make sure all of the students can see.
Ask the students if they have any questions about what they have just seen before continuing the lesson.
NOTES TO INSTRUCTOR:
The steps for preparing a plastic wrapper from a field first aid dressing are given below.
(1) Cut open one end of the plastic wrapper of a field dressing.
(2) Remove the inner packet (the field dressing wrapped in paper) and put it aside.
(3) Continue to cut around the edges of the plastic wrapper until a flat surface is created. This plastic
wrapper will be used to make the airtight seal.
(4) Tell students that the inside portion (without printing) will be placed against the wound since it is
the cleanest. Tell students that the edges of the sealing material should extend at least two
inches beyond the edges of the wound.
6. SEAL AN OPEN CHEST WOUND USING A FLUTTER-VALVE SEAL
Continue from the previous demonstration. Demonstrate how to seal an open chest wound with a flutter
valve seal.
DEMONSTRATION: Sealing an Open Chest Wound (Flutter Valve Technique)
Use an appropriate manikin or assistant instructor as the simulated casualty with an open chest wound
(front). Begin with the casualty lying on his back with arms at his side and legs straight.
Demonstrate placing the sealing material over the wound, taping three sides, applying a dressing and
bandage.
Demonstrate placing the casualty in a recovery position (injured side down).
ALTERNATIVE: Have an assistant instructor perform the procedures on a manikin or another assistant
instructor while you explain what is being performed.
Explain what is being done as the procedure is performed.
Make sure all of the students can see.
Ask the students if they have any questions about what they have just seen before continuing the lesson.
NOTES TO INSTRUCTOR:
NOTE: Show Slide # 14
The steps for sealing an open chest wound are given below.
(1) Expose the wound.
(2) Tell the casualty to exhale and hold his breath.
(3) Place the inside surface of the plastic wrapper from previous demonstration (or other appropriate
prepared material) directly over the hole in the chest to seal the wound.
(4) Check the sealing material to ensure that it extends at least two inches beyond the wound edges
in all directions.
NOTE: Show Slide # 15
(5) Tape down three edges of the material (top edge and two side edges) to create a "flutter valve"
effect that lets air escape from the chest but does not allow air from the atmosphere to enter the
chest..
(6) Tell the casualty to resume normal breathing.
(7) Dressing and bandage the wound to protect the airtight material from damage and protect the
wound.
NOTE: Show Slide # 16
(8) Place casualty in a recovery position with injured side to the ground.
QUESTION: This casualty had only one open chest wound. Suppose he had both an entrance wound
and an exit wound on the same side of his body; that is, both wounds affect the same lung. What would I
do about the exit wound on his back?
ANSWER: Expose the wound. Apply airtight sealing material over the wound. Tape down all four sides.
Dress and bandage the wound.
QUESTION: Suppose there is a stick protruding from the chest wound? What would I do?
ANSWER: Do not try to remove the protruding object. Place airtight material around the object to form as
airtight a seal as possible. Stabilize the object by placing a bulky dressing made from the
cleanest material available around the object. Apply improvised bandages to hold the sealing material
and dressings in place. Do not wrap the bandages around the protruding object.
7. SEAL AN OPEN CHEST WOUND WITH AN IMPALED OBJECT
NOTE: Show Slide # 17
One problem you may encounter is an object protruding from the wound. For instance, an explosion may
have propelled a small broken tree limb with enough force to penetrate a soldier's chest.
Demonstrate how to seal an open chest wound with an impaled object.
DEMONSTRATION: Sealing an Open Chest Wound (Protruding Object)
Use an appropriate manikin or assistant instructor as the simulated casualty with an object protruding
from an open chest wound (front). Begin with the casualty lying on his back with arms at his side and legs
straight.
Demonstrate placing the sealing material over the wound, applying bulky dressing, and applying a
bandage.
ALTERNATIVE: Have an assistant instructor perform the procedures on a manikin or another assistant
instructor while you explain what is being performed.
Explain what is being done as the procedure is performed.
Make sure all of the students can see.
Ask the students if they have any questions about what they have just seen before continuing the lesson.
NOTE: Show Slide # 18
Remember, if the casualty is unconscious or cannot hold his breath, place the airtight material over the
wound after his chest falls but before it rises.
If the casualty is conscious, he may want to sit upright. If so, allow him to sit up with his back leaning
against a tree, wall, or other support. If he becomes tired, place him in the recovery position on his injured
side again.
Section II. TREATING TENSION PNEUMOTHORAX
8. TENSION PNEUMOTHORAX
Pneumothorax basically means air (pneumo) in the chest (thorax). Tension refers to pressure. Tension
pneumothorax occurs when the air in the chest continues to accumulate and cannot escape. This
condition results in increasing danger to the casualty's respiratory system.
First, the pocket of trapped air caused the affected lung to begin to collapse again.
In addition, the pocket of trapped air pushes against the heart and major blood vessels and against the
uninjured lung. This interferes with the casualty's circulatory and respiratory systems.
Tension pneumothorax can occur even if you applied a flutter valve type seal to the open chest wound.
Tension pneumothorax is potentially a fatal condition. This condition is treated by inserting a
catheter/needle into the chest and allowing the trapped air to escape.
9. SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX
NOTE: Show Slide # 19
Signs and symptoms of tension pneumothorax include the following:
(1) Anxiety, agitation, and apprehension.
(2) Diminished or absent breath sounds.
(3) Increasing difficulty in breathing with cyanosis (bluish tint of lips, inside of mouth, fingertips,
and/or nail beds)
(4) Rapid, shallow breathing.
(5) Distended neck veins.
NOTE: Show Slide # 20
(6) Abnormally low blood pressure (hypotension) evidenced by a loss of radial pulse.
(7) Cool, clammy skin.
(8) Decreased level of consciousness (AVPU scale) or loss of consciousness.
(9) Visible deterioration of the casualty's condition.
(10) Tracheal deviation (a shift of the windpipe to the right or left).
Tracheal deviation is a late sign of tension pneumothorax and will probably not be observed.
The above signs and symptoms may be difficult to assess in a combat situation. You must be alert to the
possibility of tension pneumothorax whenever a casualty has a penetrating chest wound. Therefore, the
sole criterion for treating a tension pneumothorax with needle decompression is an open chest wound
with increasing respiratory difficulty.
10. NEEDLE CHEST DECOMPRESSION
NOTE: Show Slide # 21
The buildup of trapped air in the casualty's chest can be relieved by puncturing the air pocket with a
needle and catheter unit and allowing the trapped air to escape. This is called a needle chest
decompression.
A needle chest decompression is performed ONLY if the casualty has a penetrating wound to the chest
and increasing trouble breathing.
NOTE: Show Slide # 22
Demonstrate performing a needle chest decompression.
DEMONSTRATION: Performing a Needle Chest Decompression
Use an appropriate manikin or assistant instructor as the simulated casualty with an open chest wound
(front) that has been sealed and dressed and with signs of tension pneumothorax. Begin with the casualty
lying on his back with arms at his side and legs straight.
Demonstrate locating the insertion site.
Demonstrate inserting a large bore needle to relieve tension pneumothorax.
Demonstrate securing the catheter hub with tape.
ALTERNATIVE: Have an assistant instructor perform the procedures on a manikin or another assistant
instructor while you explain what is being performed.
Explain what is being done as the procedure is performed.
Make sure all of the students can see.
Ask the students if they have any questions about what they have just seen before continuing the lesson.
NOTES TO INSTRUCTOR:
The steps for performing needle chest decompression and positioning the casualty are given below.
NOTE: Show Slide # 23
(1) Obtain a large bore needle and catheter unit and a strip of tape from your aid bag.
NOTE: Show Slide # 24
(2) Locate the insertion site--the second intercostal space just above the third rib at the midclavicular line on the same side as the open chest wound.
NOTE: Show Slide # 25
(3) Firmly insert the needle into the skin at a 90-degree angle.
NOTE: Show Slide # 26
(4) Continue inserting the needle until the chest cavity has been penetrated. You will feel a "pop" as
the needle enters the chest cavity. A hiss of escaping air under pressure should be heard.
NOTE: Show Slide # 27
(5) Withdraw the needle while holding the catheter in place.
NOTE: Show Slide # 28
(6) Use the strip of tape to secure the catheter hub to the chest wall. The catheter will remain as a
means for air trapped in the chest to escape to the atmosphere.
NOTE: CHECK ON LEARNING
QUESTION: Why should you insert the needle just above the third rib instead of just below the second
rib?
ANSWER: To avoid damaging blood vessels and nerves that run along the bottom of each rib.
11. ADDITIONAL CARE
NOTE: Show Slide # 29
By allowing trapped air to escape from the plural area, the casualty's respirations should quickly improve.
If possible, monitor the casualty until medical care arrives or until the casualty is evacuated to the nearest
medical facility.
When the casualty is evacuated, he can be positioned:
(1) On his side with the injured side up (this is the opposite of a open chest wound without needle
chest decompression).
(2) In a sitting-up position if the casualty finds that position more comfortable.
NOTE: Show Slide # 30
12. STUDENT PRACTICE
Have students practice the following.
(1) Applying a flutter-valve seal to a simulated casualty with an open chest wound (entrance wound
only, wound on front of chest).
(2) Performing needle chest decompression on a simulated casualty.
(3) Placing a casualty in the appropriate recovery position.
13. PERFORMANCE EXAMINATIONS
The performance examinations for Lesson 4 can be administered immediately following student practice
or at a later time.
14. CLOSING
In the previous lesson, we learned to open the casualty's airway and to maintain the airway using a
nasopharyngeal tube.
In this lesson, we learned to treat injuries that threaten the casualty's ability to breath by sealing any
wounds that penetrate the chest wall and by using a needle and catheter unit to relieve tension
pneumothorax should it develop.
Together, these lessons can result in you to save the life of a fellow soldier with breathing difficulties.
CHECK ON LEARNING:
Conduct a check on learning and summarize the learning activity.