UUu UW Health Med Flight

UW Health
Med Flight
UUu
…
Michael Abernethy, MD, FAAEM
Associate Professor –Emergency Medicine
Univ of Wisconsin School of Medicine
Chief Flight Physician –UW Health Med Flight
Fantastic Cases
Penetrating Chest Trauma
Prehospital and Emergency
Department Considerations
Mechanism
Stab vs GSW vs Blunt
Geographic Anticipation
Open Pneumothorax
• Opening in chest
cavity that allows air
to enter pleural cavity
• Causes the lung to
collapse due to
increased pressure in
pleural cavity
• Can be life
threatening and can
deteriorate rapidly
Open Pneumothorax
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothorax
Inhale
Open Pneumothorax
Exhale
Open Pneumothoarx
Inhale
Open Pnuemothorax
Inhale
S/S of Open Pneumothorax
•
•
•
•
•
Dyspnea
Sudden sharp pain
Subcutaneous Emphysema
Decreased lung sounds on affected side **
Red Bubbles on Exhalation from wound
( a.k.a. Sucking chest wound)
Subcutaneous Emphysema
• Air collects in subcutaneous fat from
pressure of air in pleural cavity
• Feels like rice crispies or bubble wrap
• Can be seen from neck to groin area
Sucking Chest Wound
Treatment for Open Pneumothorax
• ABC’s with c-spine control as indicated
• High Flow oxygen
• Listen for decreased breath sounds on
affected side
• Apply occlusive dressing to wound
• Notify Hospital and ALS unit as soon as
possible
Occlusive Dressing
Asherman Chest Seal
BLS Plus Care
• Monitor Heart Rhythm
• Establish IV Access and Draw Blood
Samples
• Airway Control that may include Intubation
• Monitor for Tension Pneumothorax
Case #1
The Deer Hunter
Details
• 50 y/o male –climbing down from tree
stand
• Slipped, Impaled R chest on ladder hook
• Managed to pull himself up and off hook
• Climbed down, rode ATV to farmhouse
• Arrived with severe SOB
• Local EMS called – arrived 10 minutes
later
• Pt pale, diaphoretic
• VS HR 115, BP 95/60 RR 28 O2 sats
95%
• Single PW just lateral to R nipple
• Decreased/absent breath sounds on right
• No other injuries
Prehospital Treatment
•
•
•
•
•
•
c/o Right sided CP
100% o2 by mask monitor
VS initially normal
Good breath sounds
Increasing SOB
Med Flight unavailable because of
weather
• Paramedic intercept
Exam 10 minutes later..
•
•
•
•
•
•
Increasing respiratory distress
Sats still 100%
Absent BS on R
BP 90/40
JVD
Trachea??
Diagnosis?
Pneumothorax
vs
Tension Pneumothorax
vs
Hemothorax
Tension Pneumothorax
• Air builds in pleural space with no where
for the air to escape
• Results in collapse of lung on affected side
that results in pressure on mediastium,the
other lung, and great vessels
S/S of Tension Pneumothorax
• Anxiety/Restlessness
• Severe Dyspnea
• Absent Breath sounds
on affected side
• Tachypnea
• Tachycardia
• Poor Color
• Accessory Muscle
Use
• JVD
• Narrowing Pulse
Pressures
• Hypotension
• Tracheal Deviation
Tension
Pneumothorax
Each time we inhale,
the lung collapses
further. There
is no place for the air to
escape..
Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax
The trachea is
pushed to
the good side
Heart is being
compressed
Treatment of Tension
Pneumothorax
•
•
•
•
ABC’s with c-spine as indicated
High Flow oxygen including BVM
Treat for S/S of Shock
Notify Hospital and ALS unit as soon as
possible
• If Open Pneumothorax and occlusive
dressing present BURP occlusive dressing
BLS Plus Care
•
•
•
•
Monitor Cardiac Rhythm
Establish IV access
Airway control including Intubation
Needle Decompression of Affected Side
Needle Thoracostomy
aka Needle Decompression
Needle Decompression
• Locate 2-3 Intercostal space midclavicular line
• Cleanse area using aseptic technique
• Insert catheter ( 14g or larger) at least 3” in
length over the top of the 3rd rib( nerve, artery,
vein lie along bottom of rib)
• Remove Stylette and listen for rush of air
• Place Flutter valve over catheter
• Reassess for Improvement
Needle Decompression
Flutter Valve
• Asherman Chest Seal
makes good Flutter
Valve .
• Also can use a Finger
from a Latex Glove
• Or A Condom works
also
Emergency Department
Treatment
Altitude Effects?
Case #2
GSW to chest
I didn’t think it was loaded
•
•
•
•
•
19 y/o male Single 25 cal GSW to R chest
Driven to ED by “friends” ( left immediately)
Injury approx 15 minutes PTA
Pt c/o SOB, R CP
VS 100/70 HR 110 RR 20 O2 sat 93%
ED Treatment
• Single small entrance wound lateral to R
nipple
• IV x 2
• O2
• Labs, type and cross
• CXR……..
Tube
Thoracostomy
aka Chest Tube
Hemothorax
Case #3
We werent doing Nuthin
Case details
•
•
•
•
•
Altercation with “Two Dudes”
Stabbed several times with ? sized knife
Loaded in friends car
Drove 10 mins
Pulled over by MPD on campus ( Park and
University) 11:45pm.
• 911 called
Times
•
•
•
•
•
•
Incident approx 11:35pm
Pulled over by MPD 11:45
MFD dispatch 11:49
MFD arrival 11:53
Left scene 11:56
Arrive UW 12:00
MFD on Scene
Pale, diaphoretic, confused
Stab wound to R neck, L chest and L
abdomen
• Interventions
• Load and go
Arrival to ED
•
•
•
•
•
•
Arrive 12:00 Pulses lost 12:04
CPR started, chest needled
Lines, blood, intubation
ED thoracotomy 12:09
Pulses regained 12:11
To OR 12:15
What just happened?
Cardiac Tamponade
• Pericardium normally contains 20-50 ml
• Rapid accumulation of as little as 150ml
can impede cardiac function but..
• As much as 1000 ml may collect gradually
over a longer period of time without
hemodynamic insult
Other than Trauma ( Blood)
• Cancer
• Infection
• Connective tissue disorders
• Renal failure
S/S of Pericardial Tamponade
•
•
•
•
•
•
•
Distended Neck Veins
Increased Heart Rate
Respiratory Rate increases
Poor skin color
Narrowing Pulse Pressures
Hypotension
Death
Pericardiocentesis
ED Thoracotomy
What is a Thoracotomy?
• In the Emergent setting:
– Surgical entry into the thoracic cavity for:
•
•
•
•
•
Open pericardiotomy
Cross-clamping of aorta
Open cardiac massage
Drainage of hemothorax / -ces
Tamponade or clamping of active hemorrhage
Indications
• Accepted Indications:
– Penetrating Thoracic Injuries
• Traumatic arrest with witnessed cardiac activity
• Refractory hypotension (SBP < 70mmHg)
– Blunt Thoracic Injuries
• Refractory hypotension (SBP < 70mmHg)
– Pericardial Tamponade
– Air Embolism
Cardiorrhaphy: Foley Catheter
• Indicated in penetrating cardiac wound
– Fill Foley with NS
– Clamp
– Insert
– Inflate balloon
– Catheter can also be used for fluid infusion
Cardiorrhaphy: Sutures
• Indicated in penetrating cardiac wound
– 3-0 nonabsorbable
– Vertical Mattress
or Horizontal
– Skin Staples also effective, but must be removed
Open Pericardiotomy
• Indicated for tamponade
(tense, no visible movement)
Thoracotomy Results
•
•
•
•
•
Tense hemopericardium
Still heart
Evac of clot
Spontaneous restart of heart
To OR
VIDEO
Operative report
• ½ cm laceration to R atrium
• Exploration of R neck wound
• Exploratory laparotomy ( negative)
Disposition
Discharged to home on DAY
FOUR!
Summary