Page 35 - 2021 Advanced Ranger First Responder Handbook

Thoracic Management
Thoracic Trauma
Penetrating and blunt chest trauma remains a threat regardless of the use of body armor. Hemorrhage remains the
number one cause of death in thoracic trauma. Still, the primary preventable life threat is tension pneumothorax. Always
consider both hemorrhagic shock and tension pneumothorax when progressively worsening respiratory distress devel-
ops in a casualty with a known or suspected torso trauma. The late signs of decreased breath sounds, tracheal devia-
tion, 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 pneumothorax. The management of
an open chest wound with an occlusive dressing, which seals the wound, may lead to development of a pneumothorax.
Once sealed, patients must be monitored for development of tension pneumothorax. Continued assessment for hemo-
thorax should follow management of tension pneumothorax.

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 14G, 3.25-inch needle/catheter
inserted in the fifth intercostal space, anterior axillary line, or second intercostal space, midclavicular line. 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 a vented occlusive dressing to cover the defect and securing it
in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. Casualties with evi-
dence of torso trauma and no vital signs should have bilateral needle decompression or finger thoracostomy performed
to ensure they do not have a tension pneumothorax prior to all resuscitation efforts being halted. Hemorrhage remains
the number one cause of death, and aggressive blood product resuscitation should be initiated.
Tactical Evacuation: Consider finger thoracostomy if multiple needle decompressions, no improvement, life- threatening
complications, and/or long transport is anticipated. Most combat casualties do not require supplemental oxygen, but R
administration of oxygen may be of benefit for the following types of casualties: low oxygen saturation, injuries associ-
ated with impaired oxygenation, casualties with traumatic brain injury (TBI) (maintain oxygen saturation > 95%), casual-
ties in shock, and casualties at altitude.
Extended Care
Reassess patient for development of tension pneumothorax. Consider finger thoracostomy if: patient requires multiple
needle decompressions OR no improvement with needle decompression OR evacuation time is prolonged (> 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% for TBI). 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. Al-
ways use a PEEP valve when bagging. If sufficient supply of chest seals is available, consider removing seals, “burping”
wounds, and resealing with a new occlusive dressing. Manage resuscitation fluids only to maintain a systolic pressure
of 90–100, radial pulse, and/or mentation.
Flail Chest Management: Monitor for developing hypoxia secondary to lung contusions. Casualty may require positive
pressure ventilation. Ensure adequate analgesia or procedural sedation as required. These casualties frequently fatigue
and require definitive surgical airway.
Hemothorax: Identification of hemothorax is difficult to assess in the field. Mechanism of Injury (MOI), reduced breath
sounds, difficulty breathing, and unexplained shock should lead to suspicion of hemothorax. Rapid evacuation to surgi-
cal capability, ventilation support, aggressive blood transfusion, and finger thoracostomy is indicated for hemothorax.
Accompanying Abdominal Injuries: Any injury between the nipple and the navel may be assumed to be a thoraco-
abdominal injury. Consider the use of vented occlusive dressings over these wounds if concerned for tension pneumo-
thorax. Subsequently, assess patient for development of tension pneumothorax pathophysiology. Diaphragmatic rupture
or injuries may occur and have a significant effect on respiratory effort. Control any visible hemorrhage from bowel using
an approved hemostatic agent or gauze. Irrigate gross debris off of exposed bowel. Attempt to gently reduce bowel
back into abdominal 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.

2021 ADVANCED RANGER FIRST RESPONDER HANDBOOK 25