TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
081-86A-0049
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
081-86A-0050
PEFORM NEEDLE CHEST DECOMPRESSION
081-86A-3007
Purpose: This Training Support Package provides the instructor with a standardized lesson plan
for presenting an introduction on the procedures for treating a casualty with chest wounds to the
ANA Medical Company.
Collective: Treat Unit Casualties
References Number Title Date Additional Information:
ANA STP 8-86C-E4-5-SM-TG, Soldier's Manual and Trainer's Guide MOS 86C, Mar 2008
ANA 4-02.2, Medical Evacuation, Feb 2009
STP 8-68W13-SM-TG
STP 8-91W15-SM-TG
Instructor Requirements:
1:20, MoD Defense Personnel, Contractor, ANA Personnel
Instructional Guidance
NOTE: Before presenting this lesson, instructors must thoroughly prepare by studying this lesson
and identified reference material.
Before class- This LESSON PLAN has practical exercises built throughout to check on learning or
generate discussion among the group members. You may add any questions you deem
necessary to bring a point across to the group or expand on any matter discussed.
 You must know the information in this LESSON PLAN well enough to teach from it, not
read from it.
SECTION II. INTRODUCTION
Method of Instruction: Conference / Discussion or Practical/Hands on
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio is: 1:20
Motivator
Many casualties with multiple injuries will have an associated chest injury. Severe thoracic
injuries may result from vehicle accidents, falls, gunshot wounds, crush injuries, stab wounds,
and/or burn injuries. Penetrating chest wounds are a frequent cause of mortality on the battlefield.
The soldier medic must be familiar with the proper treatment, stabilization and evacuation of
soldiers with associated chest trauma.
Terminal Learning Objective
NOTE: Inform the students of the following Terminal Learning Objective requirements.
At the completion of this lesson, you [the student] will:
ACTION: Perform appropriate trauma assessment and emergency care for the traumatic chest
wall injury and provide treatment for a casualty with progressive respiratory distress.
CONDITIONS: Given a casualty with a suspected chest injury under simulated combat conditions
and an M-5 medical aid bag stocked with a basic load.
STANDARDS: Treat a chest wound without causing additional injury to the casualty.
A. ENABLING LEARNING OBJECTIVE
ACTION: Treat a Casualty with a Closed Chest Wound
CONDITIONS: All other more serious injuries have been treated. Necessary materials and
equipment: cravats, field jacket, poncho, blanket, or similar material, and oxygen.
STANDARDS: Treat a closed chest wound, minimizing the effects of the injury, without causing
additional injury to the casualty.
Learning Step / Activity 1.Medical personnel
Method of Instruction: Conference / Discussion
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio: 1:20
Time of Instruction: 4 hr
B. ENABLING LEARNING OBJECTIVE
ACTION: Treat a Casualty with an Open Chest Wound
CONDITIONS: All other more serious injuries have been treated. Necessary materials and
equipment: scissors, adhesive tape, field dressings, padding, ace bandage, and cravats.
STANDARDS: Treated an open chest wound, minimizing the effects of the injury. Sealed the
entry and exit wounds.
Learning Step / Activity 2.Medical personnel
Method of Instruction: Conference / Discussion
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio: 1:20
Time of Instruction: 4 hr
C. ENABLING LEARNING OBJECTIVE
ACTION: Perform Needle Chest Decompression
CONDITIONS: You have a conscious, breathing casualty with chest trauma who requires needle
chest decompression. Necessary materials and equipment: stethoscope, large bore needle (10 to
14 gauge), 35 to 60 cc Luer-Lock syringe with 3-way stopcock, povidone-iodine swab, sterile
gloves, and an ANA Form 1380 (Field Medical Card).
STANDARDS: Completed all the steps necessary to perform a needle chest decompression in
order, without causing unnecessary injury to the casualty.
Learning Step / Activity 3. Medical personnel
Method of Instruction: Conference / Discussion
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio: 1:20
Time of Instruction: 4 hr
Instructional Lead-In
Knowledge of the anatomy of the thoracic cavity is essential when planning for chest trauma. You
must recognize the clinical presentation of major thoracic injuries and provide appropriate care.
Open thoracic injuries can be the result of a penetrating or blunt trauma and, unless treated
rapidly and appropriately, these injuries can result in severe morbidity and mortality on the
battlefield. This lesson is an overview of the principles and techniques of managing these injuries.
SHOW SLIDE 1
SHOW SLIDE 2, 3
LEARNING OBJECTIVE
AT THE END OF THIS LESSON YOU WILL BE ABLE TO:
CONDITIONS: You have a casualty with a chest injury. All other more serious
injuries have been assessed and treated. You will need scissors, adhesive
tape, field dressings, padding, ace wrap, cravats, field jacket, poncho, blanket,
or similar material, oxygen and an ANA Form 1380 (Field Medical Card).
STANDARDS: Treat a chest wound without causing additional injury to the
casualty.
Briefly detail the task, condition and standard to the students. Explain that this is performance
based and that the students will be tested on this following this block of instruction.
SHOW SLIDE 4
CHEST WOUNDS
The chest is also called the thorax. The thoracic (chest) cavity is the body cavity
located between the neck and the diaphragm. It is surrounded by the rib cage.
The thoracic cavity contains the lungs, the heart, and many major blood vessels.
Any injury to the chest can be serious. A penetrating object, for example, can
puncture a lung, an artery or vein, or the heart itself.
Chest injuries are of major importance because they are a common cause of death. Fifty percent
of the people who expire from chest injuries die on the way to the hospital. The common causes
of penetrating and non-penetrating chest injuries include automobile accidents, falls and blows,
gunshot wounds, stab wounds, and crushing injuries. In a chest injury, there is a possibility of
internal bleeding and/or direct injury to the heart or lungs; therefore, any chest injury may be
serious. Chest decompressions, field functions, and other procedures may be used to save the
casualty's life if they are performed correctly and in a timely manner. With specialized training and
prescribed methods of treatment for various chest traumas, your ability to recognize and react
quickly in each situation is an important factor in regard to whether the casualty survives.
The chest is also called the thorax. The thoracic (chest) cavity is the body cavity located between
the neck and the diaphragm. It is surrounded by the rib cage. The thoracic cavity contains the
lungs, the heart, and many major blood vessels. Any injury to the chest can be serious. A
penetrating object, for example, can puncture a lung, an artery or vein, or the heart itself.
SHOW SLIDE 5, 6
CHEST WOUNDS
Organs within the Chest
Lungs - The body has two lungs. Each lung is enclosed in a pleural cavity,
which is an airtight area within the chest. Each pleural cavity is separate and
independent of the other pleural cavity.
–)
If an object punctures the chest wall and allows air to enter one pleural cavity,
the lung within that cavity begins to collapse (not fully). The other lung,
however, will not collapse. Any degree of collapse, though, interferes with the
ability to inhale a sufficient amount of air. A buildup of pressure from air or blood
around the collapsed lung can also cause compression of the heart and the
other lung.
–
CHEST WOUNDS
Organs within the Chest
Heart - The heart is located in the pericardial cavity. The pericardial cavity is
located between the lungs in a space called the mediastinum. In addition to the
heart, the mediastinum contains the lower part of the trachea, part of the
esophagus, large blood vessels, and the thymus.
-
Organs within the Chest
Lungs - The body has two lungs. Each lung is enclosed in a pleural cavity, which is an airtight
area within the chest. Each pleural cavity is separate and independent of the other pleural cavity.
If an object punctures the chest wall and allows air to enter one pleural cavity, the lung within that
cavity begins to collapse (not expand fully). The other lung, however, will not collapse. Any
degree of collapse, though, interferes with the ability to inhale a sufficient amount of air. A buildup
of pressure from air or blood around the collapsed lung can also cause compression of the heart
and the other lung.
Heart - The heart is located in the pericardial cavity. The pericardial cavity is located between the
lungs in a space called the mediastinum. In addition to the heart, the mediastinum contains the
lower part of the trachea, part of the esophagus, large blood vessels, and the thymus.
SHOW SLIDE 7
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
081-833-0049
)
-
-
ACTION: Treat a Casualty with a Closed Chest Wound
CONDITIONS: All other more serious injuries have been treated. Necessary
materials and equipment: cravats, field jacket, poncho, blanket, or similar
material, and oxygen.
STANDARDS: Treated a closed chest wound, minimizing the effects of the
injury, without causing additional injury to the casualty.
Briefly detail the task, condition and standard to the students. Explain that this is performance
based and that the students will be tested on this following this block of instruction.
In a closed chest injury, the chest is injured but there is no break in the skin. A closed chest injury
can be caused by a blow to the chest by a blunt instrument, a fall, a cave-in, or a vehicle
accident. The following 2 slides show the performance steps for signs and symptoms of a closed
chest injury.
SHOW SLIDE 8, 9
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
Performance Steps
1. Check casualty for signs and symptoms of closed chest injuries.
a. Pleuritic pain that is increased by or occurs with respirations and is
localized around the injury site.
b. Labored or difficult breathing.
c. Diminished or absent breath sounds.
d. Cyanotic lips, fingertips, or fingernails.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
1. Check casualty for signs and symptoms of closed chest injuries continued.
e. Rapid, weak pulse and low blood pressure.
f. Coughing up blood or bloody sputum.
g. Failure of one or both sides of the chest to expand normally upon
inhalation.
h. Paradoxical breathing--the motion of the injured segment of a flail chest,
opposite to the normal motion of the chest wall.
--
Performance Steps
Check the casualty for signs and symptoms of closed chest injuries.
Pleuritic pain that is increased by or occurs with respirations and is localized around the injury
site.
Labored or difficult breathing.
Diminished or absent breath sounds.
Cyanotic lips, fingertips, or fingernails.
Rapid, weak pulse and low blood pressure.
Coughing up blood or bloody sputum.
Failure of one or both sides of the chest to expand normally upon inhalation.
SHOW SLIDE 10, 11
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
1. Check casualty for signs and symptoms of closed chest injuries continued.
i. Enlarged neck veins.
j. Bulging tissue between the ribs and above the clavicles.
k. Tracheal deviation--shift of the trachea from the midline toward the
unaffected side due to pressure buildup on the injured side.
–
l. Mediastinal shift--shift of the heart, great vessels, trachea, and esophagus
from the midline to the unaffected side due to pressure buildup on the
injured side.
–
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
1. Check casualty for signs and symptoms of closed chest injuries continued.
WARNING: Evidence of mediastinal shift indicates excessive pressure within
the chest cavity. Compression of the heart and great vessels will impair blood
flow through the heart. Immediate relief of the pressure (chest decompression)
must be accomplished by trained medical personnel or death will result.
Paradoxical breathing--the motion of the injured segment of a flail chest, opposite to the normal
motion of the chest wall.
Enlarged neck veins.
Bulging tissue between the ribs and above the clavicles.
Tracheal deviation--shift of the trachea from the midline toward the unaffected side due to
pressure buildup on the injured side.
Mediastinal shift--shift of the heart, great vessels, trachea, and esophagus from the midline to the
unaffected side due to pressure buildup on the injured side.
WARNING: Evidence of mediastinal shift indicates excessive pressure within the chest cavity.
Compression of the heart and great vessels will impair blood flow through the heart. Immediate
relief of the pressure (chest decompression) must be accomplished by trained medical personnel
or death will result.
SHOW SLIDE 12, 13
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury.
a. Rib fracture generally caused by a direct blow to the chest or compression
of the chest. Severe coughing can also cause rib fracture.
(1) Signs and symptoms.
(
(a) Pain is aggravated by respirations and coughing.
(b) Crepitus is present.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(c) The casualty will take a defensive posture to protect the injury.
(2) Complications.
(a) Internal bleeding (hemothorax).
(b) Shock.
Determine the type of injury
Rib fracture generally caused by a direct blow to the chest or compression of the chest. Severe
coughing can also cause rib fracture.
Signs and symptoms
Pain is aggravated by respirations and coughing.
Crepitus is present.
The casualty will take a defensive posture to protect the injury.
Complications.
Internal bleeding (hemothorax).
Shock.
A simple fracture of a rib is usually caused by a direct blow to the chest or by compression of the
chest. The casualty usually has local pain at the site of the fracture and the pain is usually
aggravated when he breathes or moves. There may be a bruise or swelling at the fracture site.
The most common fracture sites are the fifth to the tenth pair of ribs. The upper pairs of ribs are
protected by the bones of the shoulders. The lower (eleventh and twelfth) pairs of ribs are not
attached to the sternum and have greater flexibility.
SHOW SLIDE 14
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(3) Treatment.
(a) Use a sling and swathe to immobilize the affected side.
(b) Administer oxygen as necessary.
NOTE: The broken rib may puncture the lung or the skin.
WARNING: Do not tape, strap, or bind the chest.
Treatment.
Use a sling and swathe to immobilize the affected side.
Administer oxygen as necessary.
NOTE: The broken rib may puncture the lung or the skin.
WARNING: Do not tape, strap, or bind the chest.
Immobilize the Fracture. Make the casualty comfortable and keep him as still as possible. Apply a
sling and swathe to the arm on the injured side. The sling and swathe help to immobilize the
injured side as much as possible. There is a danger the rib may be broken in two places. If so, a
rib segment is free of the sternum and spine and the segment may "float." The sharp end of the
rib segment could puncture the lung or damage the heart or major blood vessels.
SHOW SLIDE 15, 16
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
b. Flail chest involves three or more ribs fractured in two or more places or
fractured sternum.
–
(1) Signs and symptoms.
(a) Sever pain at the site.
(b) Rapid shallow breathing.
(c) Paradoxical respirations.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(2) Complications.
(a) Respiratory insufficiency.
(b) Traumatic asphyxia.
Flail chest involves three or more ribs fractured in two or more places or a fractured
sternum.Signs and symptoms.
Sever pain at the site.
Rapid shallow breathing.
Paradoxical respirations.
Complications.
Respiratory insufficiency.
Traumatic asphyxia.
A flail chest results when three or more ribs are broken in two or more places, allowing rib
segments to "float". The sternum may also be fractured. Floating rib segments may damage a
lung, major blood vessels, or the heart. Lung tissue lying under the flail segment is usually
damaged, resulting in internal bleeding and swelling which interferes with respiratory function.
The floating rib segments do not follow the normal chest movements. Their movement is
paradoxical (opposite normal) in that the floating rib segments move in when the casualty inhales
and out when the casualty exhales.
Other indications of a flail chest include a lack of lung expansion resulting in loss of effective lung
volume. The casualty usually tries to breathe deeply to offset the decrease in lung efficiency.
Severe hypoxia and cyanosis can occur quickly in spite of the casualty's efforts.
SHOW SLIDE 17, 18
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(3) Treatment.
(a) Establish and maintain an airway.
(b) Administer oxygen.
(c) Assist the casualty's respirations, if necessary.
(d) Monitor the casualty for signs of hemothorax or tension
pneumothorax, as necessary.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(e) Stabilize the flail segment using one of the following
1) Apply manual pressure.
(
2) Tape a pillow, folded blanket, field jacket, or poncho in place.
3) Place the casualty on the injured side.
Treatment.
Establish and maintain an airway.
Administer oxygen.
Assist the casualty's respirations, if necessary.
Monitor the casualty for signs of hemothorax or tension pneumothorax, as necessary.
Stabilize the flail segment using one of the following methods:
Apply manual pressure.
Tape a pillow, folded blanket, field jacket, or poncho in place.
Place the casualty on the injured side.
Immobilize the Fracture - Tape a pillow, folded blanket, field jacket, or poncho in place over the
fractures to act as a splint. Have the casualty lie on his injured side. The ground acts like a splint
to help restrict movement. This position also helps to reduce pain.
WARNING: Do not wrap the casualty's chest with tape. This will interfere with the casualty's ability to
breathe. Monitor the casualty's respirations, if signs of progressive respiratory distress reappear,
the catheter may have become plugged by blood or tissue. Attempt to irrigate; if unsuccessful,
place a second catheter next to the first.
SHOW SLIDE 19, 20
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
c. Hemothorax is caused by the bleeding from lacerated blood vessels in the
chest cavity and/or lungs. It results in the accumulation of blood in the chest
cavity but outside the lungs.
(1) Signs and symptoms.
(a) Hypotension due to blood loss.
(b) Shock.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(c) Cyanosis.
(d) Tightness in the chest.
(e) Mediastinal shift may produce deviated trachea away from
the affected side.
(f) Coughing up frothy red blood.
Hemothorax is caused by the bleeding from lacerated blood vessels in the chest cavity and/or
lungs. It results in the accumulation of blood in the chest cavity but outside the lungs.
Signs and symptoms.
Hypotension due to blood loss.
Shock.
Cyanosis.
Tightness in the chest.
Mediastinal shift may produce deviated trachea away from the affected side.
Coughing up frothy red blood.
A Hemothorax is a condition in which blood enters the pleural cavity outside the lung and
becomes trapped. As more and more blood becomes trapped, the increased pressure causes the
lung in the affected pleural cavity to collapse. Hemothorax can be caused by any chest injury. It
can result from lacerated blood vessels in the chest wall, lacerated major blood vessels within the
chest, or laceration of the lung. Signs and symptoms of tension pneumothorax also apply to
hemothorax. In addition, hemothorax may result in hypovolemic shock. Tension pneumothorax
and hemothorax may be present together.
SHOW SLIDE 21, 22
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(2) Complications.
(a) Possibility of hypovolemic shock.
(b) Frequently accompanies a pneumothorax.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(3) Treatment.
(a) Establish and maintain an airway.
(b) Administer oxygen.
(c) Assist the casualty's breathing, as necessary.
Complications
Possibility of hypovolemic shock.
Frequently accompanies a pneumothorax.
Treatment.
Establish and maintain an airway.
Administer oxygen.
Assist the casualty's breathing, as necessary.
A hemothorax is more likely to cause significant hypovolemia before tension could be built up.
The left and right lung spaces and the mediastinum can hold more than three liters of fluid (over
half of the circulating blood volume).
As the pressure increases and the injured (right) lung collapses, the trachea and heart will be
pushed more and more toward the casualty's uninjured (left) side. The shift will compress the
heart and the uninjured (left) lung. This is a late sign of these conditions.
This casualty needs to be evacuated immediately.
SHOW SLIDE 23, 24
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
d. Injuries to the back of the chest can result from a direct blow on the back
of the chest. Contusions or rib fractures may occur and spinal injury should
be suspected.
(1) Signs and symptoms.
(a) Rib fracture.
(b) Lacerations on the back.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(c) Muscle strain.
(d) Fractured scapula.
(e) Spinal injury.
(f) Respiratory distress.
Injuries to the back of the chest can result from a direct blow on the back of the chest.
Contusions or rib fractures may occur and spinal injury should be suspected.
Signs and symptoms.
Rib fracture.
Lacerations on the back.
Muscle strain.
Fractured scapula.
Spinal injury.
Respiratory distress.
Check for injury to the back of the chest. The most important is injury to the spine. Other injuries
include lacerations, muscle strain, and fractures of bones associated with the chest (such as the
scapula).
SHOW SLIDE 25, 26
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(2) Complications.
(a) Spinal injury.
(b) Hemothorax.
(c) Pneumothorax.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(3) Treatment. (The main concern with this injury is the spine).
a) Establish and maintain an airway.
NOTE: Use the jaw thrust technique if a spinal injury is suspected.
(b) Administer oxygen.
(c) Assist the casualty's respirations, if necessary.
Complications.
Spinal injury.
Hemothorax.
Pneumothorax.
Treatment. (The main concern with this injury is the spine).
Establish and maintain an airway.
NOTE: Use the jaw thrust technique if a spinal injury is suspected.
Administer oxygen.
Assist the casualty's respirations, if necessary.
Treat suspected spinal injuries.
Maintain an open airway and assist with respirations, if needed. Keep the casualty as still as
possible if a spinal injury is suspected.
SHOW SLIDE 27, 28, 29
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(d) Treat suspected spinal injuries.
e. Tension pneumothorax.
(1) Condition in which air enters the chest cavity (pleural space) through a
hole in the lung(s), expanding the space with every breath the casualty
takes.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(2) The air becomes trapped and cannot escape.
(3) Increased pressure in the chest causes the lung(s) to collapse.
(4) May result from the laceration of the lung by a broken rib or by
spontaneous rupture of a bleb or lesion on the lung.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(5) Position the casualty for evacuation.
(a) Conscious--in a comfortable position.
–
(b) Unconscious--on the injured side.
–
Tension pneumothorax.
Condition in which air enters the chest cavity (pleural space) through a hole in the lung(s),
expanding the space with every breath the casualty takes.
The air becomes trapped and cannot escape.
Increased pressure in the chest causes the lung(s) to collapse.
May result from the laceration of the lung by a broken rib or by spontaneous rupture of a bleb or
lesion on the lung.
Position the casualty for evacuation.
Conscious--in a comfortable position.
Unconscious--on the injured side.
Tension pneumothorax is a condition in which air enters the pleural cavity outside the lung and
becomes trapped. As more and more air becomes trapped, the increased pressure causes the
lung in the affected pleural cavity to collapse. Tension pneumothorax can be caused by an open
chest wound, but it can also result from a closed chest injury.
Signs of tension pneumothorax include increased difficulty in breathing, shortness of breath,
absent or diminished breath sounds on the effected side, subcutaneous emphysema, distended
neck veins, bulging chest tissues, weak pulse, and cyanosis.
SHOW SLIDE 30, 31
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
2. Determine the type of injury continued.
(6) Treatment.
(a) Establish and maintain an airway.
(b) Administer oxygen.
(c) Assist the casualty's respirations, as necessary.
(d) Monitor the casualty for evidence of a mediastinal shift.
TREAT A CASUALTY WITH A
CLOSED CHEST WOUND
3. Treat the casualty for shock.
4. Record the care provided on the appropriate form.
5. Evacuate the casualty.
NOTE: Continue to assess the casualty, if necessary.
Treatment.
Establish and maintain an airway.
Administer oxygen.
Assist the casualty's respirations, as necessary.
Monitor the casualty for evidence of a mediastinal shift.
Treat the casualty for shock.
Record the care provided on the appropriate form.
Evacuate the casualty.
NOTE: Continue to assess the casualty, if necessary.
A casualty with tension pneumothorax resulting from a closed chest injury should be treated as
soon as possible. A chest needle decompression should be performed. Maintain an open airway
and assist with respiration if needed. Administer oxygen if available. Monitor the casualty for
tracheal deviation or mediastinal shift.
SHOW SLIDE 32
Briefly detail the task, condition and standard to the students. Explain that this is performance
based and that the students will be tested on this following this block of instruction.
SHOW SLIDE 33, 34
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
Performance Steps
1. Check the casualty for signs and symptoms of an open chest wound.
a. A "sucking" or "hissing" sound when the casualty inhales.
b. Difficulty breathing.
c. A puncture wound of the chest.
d. An impaled object protruding from the chest.
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
1. Check the casualty for signs and symptoms of an open chest wound.
e. Froth or bubbles around the injury.
f. Coughing up blood or blood tinged sputum.
g. Pain in the chest or shoulder.
An open chest wound is a wound in which the skin and the chest wall are penetrated. An open
chest wound can be caused by a bullet, knife blade, shrapnel, or other object.
Signs and symptoms of an open chest wound are:.
Sucking or hissing sounds coming from chest wound. When a casualty with an open chest wound
inhales, air goes in the wound. When he exhales, air escapes from the wound. This airflow
sometimes causes a "sucking" or "hissing" sound.
Because of this distinct sound, an open chest wound is often called a "sucking chest wound."
Difficulty in breathing (dyspnea).
Visible puncture wound in the chest (front or back). If you are not sure if a wound has penetrated
the chest wall completely, treat the wound as though it were an open chest wound.
Impaled object protruding from the chest.
Frothy blood or air bubbles in the blood around the wound site.
Bright red or frothy blood being coughed up.
Sputum containing blood
Chest not rising normally during inhalation.
Pain in the shoulder or chest area. The pain usually increases with breathing]
Bluish tint (cyanosis) of the lips, inside of the mouth, the fingertips, or nail beds. This color change
is caused by the decreased amount of oxygen in the blood.
SHOW SLIDE 35
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
2. Expose the wound.
a. Cut or unfasten the clothing that covers the wound.
b. Disrupt the wound as little as possible.
NOTE: Do not remove clothing stuck to the wound.
3. Check for an exit wound.
a. Feel and/or look at the casualty's chest and back.
b. Remove the casualty's clothing, if necessary.
Expose the Wound
Expose the area around the open chest wound by removing, unfastening, cutting, or tearing the
clothing covering the wound. Do not disrupt the wound any more than is necessary. Do not try to
clean the wound or remove debris from the wound.
Stuck Material - If clothing or other material is stuck to the wound area, do not remove the stuck
material since removing it might cause additional damage to the wound. Cut around the material
so the seal and dressing can be applied on top of the stuck material.
Protruding Object - If an impaled object is protruding from the wound, do not remove the object.
Check for an exit wound. Look for a pool of blood under the casualty's back. Carefully palpate
and visually examine the casualty's chest, back, and axillaries (armpits) for other open chest
wounds. Remove clothing, as needed, to expose other wounds if you are not in a chemical
environment. If there is more than one open chest wound, treat the most serious (largest or
heaviest bleeding) wound first. Then seal and dress the other open chest wounds. Any wound
from the chin to the umbilicus (navel) has the potential to enter the chest cavity and requires the
use of an occlusive dressing.
SHOW SLIDE 36, 37
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
4. Seal the wound(s), covering the larger wound first.
NOTE: All penetrating chest wounds should be treated as if they were sucking
chest wounds.
a. Cut the dressing wrapper on one long and two short sides and remove
the dressing.
NOTE: In an emergency, any airtight material can be used. It must be large
enough so it is not sucked into the chest cavity.
b. Apply the inner surface of the wrapper to the wound when the casualty
exhales.
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
4. Seal the wound(s), covering the larger wound first.
c. Ensure that the covering extends at least 2 inches beyond the edges of
the wound.
d. Seal by applying overlapping strips of tape to three sides of the plastic
covering to provide a flutter-type valve.
e. Cover the exit wound in the same way, if applicable.
One of the objectives in treating an open chest wound is to keep air from entering the chest cavity
through the wound. Stopping air from entering the wound helps to keep the lung from collapsing
or, at least, slows down the collapse. Since air can pass through a field dressing, airtight sealing
material must be placed between the wound and the dressing to keep air from entering the
wound.
Obtain an Asherman chest seal or other appropriate manufactured chest seal device from your
aid bag.
Use the included gauze to dry the area surrounding the wound as well as possible to increase
adhesion with the dressing.
If available apply tincture of benzoin around the wound area to increase adhesion of the dressing.
If the patient has excessive chest hair, the area may need to be shaved to allow proper adhesion
of the dressing.
Remove the backing and expose the adhesive dressing.
Tell the casualty to exhale and hold his breath. This forces some of the trapped air out of the
chest cavity. The more air forced out of the chest cavity before the wound is dressed, the better
the casualty will be able to breathe.
NOTE: If the casualty is unconscious or cannot hold his breath, place the adhesive dressing over
the wound after his chest falls but before it rises again.
Apply the adhesive dressing over the wound so that it adheres to the casualty's chest and the
one-way valve is over the penetrating wound. The one-way valve lets air and blood escape while
preventing their re-entry. The clear pad design allows you to visually inspect the wound.
If you do not have a manufactured seal available, you can improvise a seal using airtight
material, such as the plastic envelope from a field dressing or a petroleum gauze packet. The
following steps give procedures for sealing an open chest wound using a plastic envelope.
Obtain a field dressing package. If the casualty is carrying a field dressing, use his dressing.
Otherwise, obtain a field dressing from your aid bag.
Open the plastic dressing envelope.
Remove the bandage scissors from your aid bag.
Cut one of the short ends of the plastic envelope and remove the inner packet (dressing wrapped
in paper). Cut the envelope so as little as possible is cut off the main part of the envelope. Drop or
place the inner packet where it will not become contaminated. You may place the packet on the
casualty's abdomen, for example.
Cut the other short end of the plastic envelope and one of the long sides. You now have a
rectangular piece of airtight plastic which can be used to seal the open chest wound.
CAUTION: Avoid touching the inside surface of the plastic envelope. The inner surface will be
applied directly to the wound and should be kept as free from contamination as possible.
Have the casualty exhale.
If the casualty is conscious, tell him to exhale and hold his breath. This forces some of the
trapped air out of the chest cavity. The more air forced out of the chest cavity before the wound is
dressed, the better the casualty will be able to breathe.
If the casualty is unconscious or cannot hold his breath, place the plastic envelope over the
wound after his chest falls but before it rises again.
If the envelope is not large enough or is torn, use foil, material cut from a poncho, cellophane, a
plastic MRE (meal ready-to-eat) package, or similar airtight material to form the seal.
CAUTION: If an impaled object is protruding from the chest wound, place airtight material around
the object to form as airtight a seal as possible.
Tape sealing material in place. Use the tape from your aid bag to tape down three edges of the
plastic envelope. When the casualty inhales, the plastic is sucked against the wound and air
cannot enter the wound. Make sure that the edge not sealed is towards the ground to let the
blood drain out.
SHOW SLIDE 38, 39
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
4. Seal the wound(s), covering the larger wound first continued.
NOTE: Assess the effectiveness of the flutter valve when the casualty
breathes. When the casualty inhales, the plastic should be sucked against the
wound, preventing the entry of air. When the casualty exhales, trapped air
should be able to escape from the wound and out the untaped side of the
dressing.
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
5. Dress the wound.
a. Place the field first aid dressing over the seal and tie the ends directly
over the wound.
b. Use padding material and another dressing for additional pressure and
stability, if required.
c. Dress the exit wound in the same way, if applicable.
CAUTION: Ensure that the dressings are not tied so tightly that they interfere
with the breathing process or the flutter-type valve.
Apply a dressing to secure and protect the seal and to absorb secretions. Secure the dressing
with a bandage. The following steps are for applying a field dressing to an improvised occlusive
dressing.
Apply the Field Dressing
Pick up the packet containing the dressing.
Grasp the packet with both hands and twist until the paper wrapper breaks.
Remove the dressing from the wrapper and discard the wrapper.Avoid touching the white, sterile
dressing pad and keep the pad as free from contamination as possible.
Grasp the folded tails of the dressing with both hands, hold the dressing above the wound with
the sterile pad toward the wound, and pull the tails so the dressing opens and flattens.
Place the sterile dressing pad on top of the sealing material.
CAUTION: If an impaled object is protruding from the chest wound, apply a bulky dressing to the
wound without covering or moving the object. Then stabilize the object by placing bulky dressings
made from the cleanest material available around the protruding object.
Secure the Dressing - Secure the dressing using the attached bandages. The bandages must
be tight enough to ensure the dressing will not slip, but not tight enough to interfere with the
casualty's breathing. If the casualty is able, have him hold the dressing in place while you secure
it. If he cannot help, hold the dressing in place while securing it
Grasp one tail, slide it under the casualty, bring it up the other side of the casualty, and bring it
back over the dressing.
Wrap the other tail around the casualty in the opposite direction and bring it back over the
dressing.
Tell the casualty to exhale and hold his breath. If the casualty is unconscious or cannot hold his
breath, tie the knot after his chest falls and before the chest rises again.
Tighten the tails and tie them with a non-slip knot over the center of the dressing. Tying the knot
over the middle of the dressing directly over the wound will provide additional pressure to the
wound and will help to ensure a good seal against the influx of air.
If there is more than one open chest wound, seal and dress the other wound(s) using the same
procedures. If improvised dressings and bandages are needed, make dressings from the
cleanest material available and use material torn from a shirt or other material as bandages.
SHOW SLIDE 40, 41
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
6. Place the casualty on the injured side.
7. Monitor the casualty.
a. Monitor breathing and the wound seal.
b. Assess the effectiveness of the flutter valve.
c. Check vital signs.
d. Observe for signs of shock.
TREAT A CASUALTY WITH AN
OPEN CHEST WOUND
8. Record the treatment on the appropriate form.
NOTE: Continue to assess the casualty, if necessary. The casualty should be
evacuated by the most expedient means.
After the open chest wounds have been sealed and dressed, continue your evaluation and
administer any other needed care, including procedures to control shock.
The casualty should be placed on his side, treatment recorded on ANA Form 1380, and
evacuated by the most expedient means.
SHOW SLIDE 42
Briefly detail the task, condition and standard to the students. Explain that this is performance
based and that the students will be tested on this following this block of instruction.
SHOW SLIDE 43
PERFORM NEEDLE CHEST DECOMPRESSION
PNEUMOTHORAX
Pneumothorax is defined as the presence of air within the pleural space. Air
may enter the pleural cavity either from the lungs through a rupture, laceration,
or from the outside through a sucking chest wound. Trapped air in the pleural
space compresses the lung beneath it.
Unrelieved pressure will push the contents of the mediastinum in the opposite
direction, away from the side of the tension pneumothorax. This, in turn, will
compromise venous return to the heart and interfere with respiration.
Pneumothorax is defined as the presence of air within the pleural space. Air may enter the pleural
cavity either from the lungs through a rupture, laceration, or from the outside through a sucking
chest wound. Trapped air in the pleural space compresses the lung beneath it.
Unrelieved pressure will push the contents of the mediastinum in the opposite direction, away
from the side of the tension pneumothorax. This, in turn, will compromise venous return to the
heart and interfere with respiration.
If signs of tension pneumothorax are present, perform a chest needle decompression. On the
battlefield, unilateral penetrating chest trauma with progressive increases in difficulty breathing is
an indication to perform chest needle decompression since other methods of assessment may be
unavailable or impossible to assess.
SHOW SLIDE 44, 45
PERFORM NEEDLE CHEST DECOMPRESSION
1. Verify the presence of tension pneumothorax by checking for indications of
the condition.
WARNING: Correct assessment is essential. Insertion of a needle into the
pleural space of a non affected person will result in pneumothorax.
a. Question a conscious casualty about difficulty in breathing, pain on the
affected side, or coughing up blood.
b. Observe a bared anterior chest and upper abdomen for respiratory rate
and depth.
PERFORM NEEDLE CHEST DECOMPRESSION
1. Verify the presence of tension pneumothorax by checking for indications of
the condition.
c. Look for mediastinal shift manifested as a tracheal deviation and/or jugular
distension.
-
d. Look and listen for gasping for air (dyspnea) and progressive respiratory
distress.
NOTE: Dyspnea may be, but is not always, an indication of pneumothorax.
e. Look at and feel the patient's chest for signs of subcutaneous
emphysema.
Signs of tension pneumothorax include increased difficulty in breathing, shortness of breath,
cyanosis, and the trachea moving from its normal position toward the uninjured side of the chest.
Question a conscious casualty about difficulty in breathing, pain on the affected side, or coughing
up blood.
Observe a bared anterior chest and upper abdomen for respiratory rate and depth.
Look for mediastinal shift manifested as a tracheal deviation and/or jugular distension.
Look and listen for gasping for air (dyspnea) and progressive respiratory distress.
NOTE: Dyspnea may be, but is not always, an indication of pneumothorax.
Look at and feel the patient's chest for signs of subcutaneous emphysema
SHOW SLIDE 46, 47
PERFORM NEEDLE CHEST DECOMPRESSION
1. Verify the presence of tension pneumothorax by checking for indications of
the condition.
f. Check for lack of chest excursion.
(1) Observe the rising and falling of the chest on respiration.
(
(2) Compare chest excursion bilaterally.
g. Look for unilateral distension.
PERFORM NEEDLE CHEST DECOMPRESSION
1. Verify the presence of tension pneumothorax by checking for indications of
the condition.
(1) Place one hand on the affected side.
(2) Place the other hand on the unaffected side.
(3) Observe the height of each hand.
(4) Determine if the height of the hand on the affected side is greater
during expiration than the height of the hand on the unaffected side.
Check for lack of chest excursion.
Observe the rising and falling of the chest on respiration.
Compare chest excursion bilaterally.
Look for unilateral distension.
Place one hand on the affected side.
Place the other hand on the unaffected side.
Observe the height of each hand.
Determine if the height of the hand on the affected side is greater during expiration than the
height of the hand on the unaffected side.
SHOW SLIDE 48, 49
PERFORM NEEDLE CHEST DECOMPRESSION
1. Verify the presence of tension pneumothorax by checking for indications of
the condition.
h. Use a stethoscope to listen to breath sounds.
(1) Compare the sides for equality.
(2) Auscultate both sides of the chest.
(3) If breath sounds are unequal, percuss both sides to determine the
difference in tone.
PERFORM NEEDLE CHEST DECOMPRESSION
1. Verify the presence of tension pneumothorax by checking for indications of
the condition.
NOTE: Breath sounds will be diminished or absent on the affected side.
i. Check for progressive distension of the abdomen that is not relieved by
gastric aspiration and endotracheal intubation.
j. Look for deep cyanosis.
k. Look for signs and symptoms of shock.
Use a stethoscope to listen to breath sounds.
Compare the sides for equality.
Auscultate both sides of the chest.
If breath sounds are unequal, percuss both sides to determine the difference in tone.
NOTE: Breath sounds will be diminished or absent on the affected side.
Check for progressive distension of the abdomen that is not relieved by gastric aspiration and
endotracheal intubation.
Look for deep cyanosis.
Look for signs and symptoms of shock.
SHOW SLIDE 50
NEEDLE CHEST DECOMPRESSION
Tension pneumothorax is a condition in which air enters the pleural cavity outside the lung and
becomes trapped. As more and more air becomes trapped, the increased pressure causes the
lung in the affected pleural cavity to collapse. Tension pneumothorax can be caused by an open
chest wound, but it can also result from a closed chest injury. This slide shows a tension
pneumothorax resulting from air that has escaped from a lung injured by floating rib segments.
Tension pneumothorax can also result from damage to the bronchi (air tubes) leading to the
lungs. Air in the pleural cavity that results from disease rather than trauma to the lung is referred
to as spontaneous pneumothorax. Complete collapse of the lung may be followed by tracheal
deviation and mediastinal shift.
SHOW SLIDE 51
TRACHEAL DEVIATION AND JVD
)
–
JVD
The trachea is shifted away
from the collapsed lung
Tracheal Deviation
The jugular veins become
engorged from restricted
blood return to heart
)
LATE SIGNS!
The trachea is shifted away from the collapsed lung. The jugular veins become engorged from
restricted blood return to heart. These are LATE SIGNS.
SHOW SLIDE 52
TENSION PNEUMOTHORAX – CLOSED INJURY
-
)
This slide shows the signs and symptoms of tension pneumothorax on a casualty with a closed
chest wound.
SHOW SLIDE 53, 54, 55
PERFORM NEEDLE CHEST DECOMPRESSION
2. Locate the insertion site.
a. Locate the second intercostal space (between the second and third ribs)
at the midclavicular line (approximately in line with the nipple) on the
affected side of the patient's chest.
3. Thoroughly cleanse a three - four inch area around the insertion site.
a. Begin in the center and work outward using a circular motion.
PERFORM NEEDLE CHEST DECOMPRESSION
4. Insert a large bore (10 to 14 gauge) needle with attached syringe.
a. Place the needle tip, bevel up, on the insertion site (2nd intercostal
space, midclavicular line).
b. Lower the proximal end of the needle to permit the tip to enter the skin just
above the third rib margin.
c. Firmly insert the needle into the skin over the third rib, until the pleura
has been penetrated, as evidenced by feeling a "pop" as the needle enters
the pleural space.
PERFORM NEEDLE CHEST DECOMPRESSION
4. Insert a large bore (10 to 14 gauge) needle with attached syringe.
WARNING: Proper positioning of the needle is essential to avoid puncturing
blood vessels and/or nerves.
Obtain a 14 gauge needle from your aid bag. The needle should be two to three and a fourth
inches in length to ensure it penetrates deep enough into the chest cavity. A catheter covers most
of the needle, but does not cover the needle point
Locate the second intercostal space (between second and third rib) on the mid-clavicular line on
the injured side of the chest.
Prepare the area with anti-microbial scrub if time permits. Thoroughly cleanse a three - four inch
area around the insertion site. Begin in the center and work outward using a circular motion.
Insert the needle point at a 90 degree angle over the top of the third rib into the second intercostal
space Stop advancing the needle once a hiss of air is heard You should feel a “pop” as the
needle enters the chest cavity or you aspirate air (if using a syringe/needle combination).
WARNING: Proper positioning of the needle is essential to avoid puncturing blood vessels and/or
nerves.
SHOW SLIDE 56
PERFORM NEEDLE CHEST DECOMPRESSION
2. Locate the insertion site.
2. Locate the insertion site.
This slide depicts how to properly locate the second intercostal space (between second and third
rib) on the mid-clavicular line on the injured side of the chest.
SHOW SLIDE 57
PERFORM NEEDLE CHEST DECOMPRESSION
3. Thoroughly cleanse a three - four inch
area around the insertion site.
4. Insert a large bore (10 to 14 gauge) needle
with attached syringe.
)
-
This slide displays how to thoroughly cleanse a three - four inch area around the insertion site
and Insert a large bore (10 to 14 gauge) needle with attached syringe.
SHOW SLIDE 58, 59
PERFORM NEEDLE CHEST DECOMPRESSION
5. Decompress the affected side by aspirating as much air as is necessary to
relieve the patient's acute symptoms.
.
NOTES:
1. If you are using a catheter-over-needle, hold the needle still and push the
catheter into the plural space until resistance is felt. Withdraw the needle along
the angle of insertion while holding the catheter still.
2. If you are using a three-way stopcock, additional air can be aspirated from
the plural cavity by turning the stopcock lever to allow expulsion of the air from
the syringe.
PERFORM NEEDLE CHEST DECOMPRESSION
6. Initiate use of Underwater seal drainage.
7. If an underwater seal drainage is not available, use a commercial one-way
flutter valve (Asherman Chest Seal) or improvise one.
–
a. Cut a finger casing from a sterile glove.
b. Cut off the finger tip.
c. Tie or tape the finger casing to the needle hub.
.
Decompress the affected side by aspirating as much air as is necessary to relieve the patient's
acute symptoms.
NOTES:
1. If you are using a catheter-over-needle, hold the needle still and push the catheter into the
plural space until resistance is felt. Withdraw the needle along the angle of insertion while holding
the catheter still.
2. If you are using a three-way stopcock, additional air can be aspirated from the plural cavity by
turning the stopcock lever to allow expulsion of the air from the syringe.
Initiate use of Underwater seal drainage.
If an underwater seal drainage is not available, use a commercial one-way flutter valve
(Asherman Chest Seal) or improvise one.
Cut a finger casing from a sterile glove.
Cut off the finger tip.
Tie or tape the finger casing to the needle hub.
SHOW SLIDE 60, 61
PERFORM NEEDLE CHEST DECOMPRESSION
7. Commercial one-way flutter valve (Asherman Chest Seal) or improvise one
continued.
d. Check the operation of the improvised flutter valve.
(1) Ensure that air passes through the needle-valve assembly and
improvised flutter valve on expiration.
(2) Ensure that the flutter valve collapses against itself on inspiration.
NOTE: This will prevent air from entering the pleural cavity.
PERFORM NEEDLE CHEST DECOMPRESSION
8. Secure the needle or catheter to the chest.
9. Record the treatment on the Field Medical Card.
Check the operation of the improvised flutter valve.
Ensure that air passes through the needle-valve assembly and improvised flutter valve on
expiration.
Ensure that the flutter valve collapses against itself on inspiration.
NOTE: This will prevent air from entering the pleural cavity.
Secure the needle or catheter to the chest.
Record the treatment on the Field Medical Card.
SHOW SLIDE 62
CHEST WOUNDS
SUMMARY
In a closed chest injury, the chest is injured but there is no break in the skin. A
closed chest injury can be caused by a blow to the chest by a blunt instrument,
a fall, a cave-in, or a vehicle accident
An open chest wound is a wound in which the skin and the chest wall are
penetrated. An open chest wound can be caused by a bullet, knife blade,
shrapnel, or other object
SHOW SLIDE 63
CHEST WOUNDS
One of the objectives in treating an open chest wound is to keep air from
entering the chest cavity through the wound. Stopping air from entering the
wound helps to keep the lung from collapsing or, at least, slows down the
collapse. Since air can pass through a field dressing, airtight sealing material
must be placed between the wound and the dressing to keep air from entering
the wound.
QUESTIONS
SUMMARY
In a closed chest injury, the chest is injured but there is no break in the skin. A closed
chest injury can be caused by a blow to the chest by a blunt instrument, a fall, a cave-in,
or a vehicle accident
An open chest wound is a wound in which the skin and the chest wall are penetrated. An
open chest wound can be caused by a bullet, knife blade, shrapnel, or other object
One of the objectives in treating an open chest wound is to keep air from entering the
chest cavity through the wound. Stopping air from entering the wound helps to keep the
lung from collapsing or, at least, slows down the collapse. Since air can pass through a
field dressing, airtight sealing material must be placed between the wound and the
dressing to keep air from entering the wound.
Tension pneumothorax is a condition in which air continues to accumulate in the pleural
cavity and increases pressure on the injured lung. Signs of tension pneumothorax
include increased difficulty in breathing, shortness of breath, cyanosis, and the trachea
moving from its normal position toward the uninjured side of the chest.
Injuries to the chest are fewer in nature, often due to the advent of modern body armor; however,
it doesn't protect you 100%. Penetrating wounds to the chest can be rapidly fatal if not identified
early and treated appropriately. In multiple trauma casualties, chest injuries are common and
many times are considered life-threatening. You must have the ability to identify and appropriately
treat the injury to salvage the casualty on the battlefield QUESTIONS