Page 39 - 2025 Ranger Medic Handbook

Thoracic Trauma Management
Thoracic Trauma
Penetrating and blunt chest trauma remains a threat regardless of the use of body armor. The primary life-threat that is
preventable is tension pneumothorax. Always consider presumptive diagnosis of tension pneumothorax when progres-
sively worsening respiratory distress develops in a casualty with a known or suspected torso trauma. The late signs of
decreased breath sounds, tracheal deviation, and jugular vein distention may not always be present and may be difficult
to assess on the battlefield. Relief of tension pneumothorax requires release of air under pressure within the chest cavity.
Constant reassessment of patients with chest trauma is imperative to identify progression or reemergence of tension SECTION 2
pneumothorax. The management of an open chest wound with an occlusive dressing sealing the wound may lead to the
development of a pneumothorax. Once sealed, patients must be monitored for development of tension pneumothorax.
Continued assessment for hemothorax, flail segments, or cardiac tamponade should follow management of tension.
TCCC Application
Care Under Fire: No specific action.
Tactical Field Care: In a casualty with progressive respiratory distress and known or suspected torso trauma, consider
a tension pneumothorax and decompress the chest on the side of the injury with at least a 14-G, 3.25-inch needle/
catheter inserted in the 5 th intercostal space, anterior axillary line (preferred), or second intercostal space, mid clavicular
line (secondary site). Ensure that the needle entry into the chest is not medial to the nipple line and is not directed toward
the heart. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to
cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension
pneumothorax. Casualties with evidence of torso trauma and no vital signs should have bilateral needle decompression
or finger thoracostomy (preferred) performed to ensure they do not have a tension pneumothorax prior to all resuscita-
tion efforts being halted.
Tactical Evacuation: Consider finger thoracostomy or chest tube insertion if multiple needle decompressions, no im-
provement, life-threatening complications and/or long transport is anticipated. Most combat casualties do not require
supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties: low oxygen
saturation, injuries associated with impaired oxygenation, casualties with TBI (maintain oxygen saturation > 95%), cas-
ualties in shock, and casualties at altitude.
Extended Care
Reassess patient for development of tension pneumothorax. Consider finger thoracostomy or chest tube if: patient
requires multiple needle decompressions OR no improvement with needle decompression OR evacuation time is pro-
longed (> 1 hour) OR evacuation requires transport at high altitude in unpressurized aircraft. If available, provide oxygen
as needed to maintain O 2 saturation > 90% (> 95% and < 100% for TBI). Apply negative pressure to chest tube if avail-
able, not exceeding –20cm H 2 O. Consider rib blocks for pain management. If patient is being ventilated, maintain strict
bagging cycles (1 breath every 5 seconds) and a tidal volume of approximately 500mL to allow for complete exhalation
and avoid stacking breaths. Always use a PEEP valve when bagging. Consider the use of a ventilator if available and add
physiologic PEEP (3–5cm H 2 O). Consider sedation for casualties requiring prolonged intubation/ventilation if no shock
or hypotension. If a sufficient supply of chest seals are available, then consider removing seals, “burping” wounds, and
resealing with a new occlusive dressing. Resuscitative fluids should be managed very conservatively unless there is
significant blood lost from other injuries. Regardless, manage resuscitation fluids only to maintain a systolic pressure of
90–100mmHg, radial pulse, and/or mentation.
Flail Chest Management: Casualties with flail chest can present with tachypnea and eventual hypoxia due to shallow
breaths. The primary treatment for flail chest is PAIN CONTROL to allow the casualty enough relief for sufficient inspira-
tion and oxygenation. This will prevent respiratory fatigue. If unable to improve vitals with pain management, consider
alternate etiology for symptoms (pneumothorax, hemorrhagic shock, hemothorax etc). If alternate etiologies for respira-
tory distress have been ruled out and/or treated, and casualty continues to demonstrate signs of severe fatigue, consider
systemic analgesic and sedation, placement of a surgical airway, and mechanical ventilation.
Hemothorax: Identification of hemothorax is difficult to assess in the field. MOI, reduced breath sounds, difficulty
breathing, and unexplained shock should lead to suspicion of hemothorax. Rapid evacuation to surgical capability, ven-
tilation support, judicious fluid therapy, and chest tube are indicated for hemothorax. If continuous output from the chest
tube is > 200–250cc/hr over the first 4 hours, there is a very high likelihood of intrathoracic vascular injury that requires
surgical intervention. If evacuation capabilities are significantly delayed or blood products are limited, high output chest
tube drainage may require re-triage of casualty and consideration for transition to expectant/palliative care.
Cardiac Tamponade: Bleeding or fluid collection into the pericardium may often be expected from hard frontal trauma
to the chest or small puncture wounds creating compression on the heart. Little can be accomplished in the field if this
injury is suspected. The suspicion of this injury should elevate the urgency of evacuation and should be communicated
to receiving facility if possible. If properly trained, a pericardiocentesis may be performed in extremis situations.
Cardiac Dysrhythmias: If patient is being monitored with ECG capability, cardiac dysrhythmias with chest trauma (es-
pecially blunt trauma) may occur. Manage any such dysrhythmias as with any such cardiac patient IAW ACLS guidelines.
Accompanying Abdominal Injuries: Any injury between the nipple and the navel may be assumed to be a thoraco-
abdominal injury. Consider the use of occlusive dressings over these wounds if concerned for tension pneumothorax.
Subsequently, assess patient for development of tension pneumothorax physiology. Diaphragmatic rupture or injuries
may occur and have a significant effect on respiratory effort. Control any visible hemorrhage from bowel using approved
hemostatic agent or gauze. Irrigate gross debris off of exposed bowel. Attempt to gently reduce bowel back into ab-
dominal cavity. If bowel is reduced, approximate skin (sutures or staples) and cover abdominal wound with an occlusive
dressing. If bowel is unable to be reduced, cover bowel with moist dressing.
2025 RANGER MEDIC HANDBOOK 25