Page 97 - PJ MED OPS Handbook 8th Ed

Occult Chest Injury

1. Hemoptysis can range in severity from occasional blood-tinged sputum to enough blood to com-
promise the airway.
2. Uncharacteristic dyspnea with exertion or any dyspnea at rest can be lung injury or evidence of
shock.
3. Chest pressure, tightness, or pain with respirations can be lung injury or myocardial ischemia
from air embolism.
4. Asymmetrical breath sounds, inspiratory crackles in any lobe(s), expiratory wheezing, prolonged
expiratory phase.
5. Abnormal pulse oximetry without other explanation is likely pulmonary contusion (i.e., primary
blast lung injury).
6. Any localized infarction syndrome of brain, eye, heart, spine, bowel, skin, or distal extremity due
to air embolism.
Management:
1. Careful inspection for penetrating trauma
2. Allow casualty to assume position for best breathing; avoid any physical exertion by casualty if at
all possible.
3. Provide supplemental oxygen if needed and available; avoid positive-pressure ventilation (PPV)
if at all possible, unless pulse oximetry <75% on ambient air; if PPV necessary, try to keep peak
airway pressures ≤35 and PEEP ≤10 cmH2O.
4. Management of arterial gas embolism (AGE) discussed in TMEP on barotrauma; transport to
hyperbaric chamber.
DISPOSITION:
1. Urgent evacuation for any hemodynamic abnormality at any time; necessity for airway
control, chest decompression, or positive-pressure ventilation (PPV); evidence of stroke,
visual deficit, myocardial ischemia or infarction, or spinal injury.
2. Priority evacuation for dyspnea or pulse oximetry <90% on ambient air; evidence of pneu-
mothorax on clinical examination; hemoptysis not compromising airway.
3. Routine evacuation for stable pulse oximetry 5–10% less than baseline at given altitude.

Chapter 8. Tactical Medical Emergency Protocols (TMEPs) n 95