PRE-HOSPITAL EMERGENCY CARE COURSE
www.basics.org.uk
Chest Assessment &
Management
© BASICS Education March 2016
Objectives
•
To understand the importance of oxygenation
and ventilation
•
To be able to describe a systematic process of
chest assessment
•
To recognise life-threatening chest injuries and
describe their immediate pre-hospital
management
Primary Survey
Safety
<C > -
Catastrophic haemorrhage control
A
-
Airway with cervical spine control
B
-
Breathing
C
-
Circulation
D
-
Disability
E
-
Exposure
Thoracic Examination
•
Complete exposure vital
•
Apex extends above
clavicle
•
Diaphragm can reach as
high as 4th rib space on
expiration
Examination of the neck
W -
Wounds
E -
Emphysema (surgical)
T
Trachea
-
Examination of the chest
R -
Rate
I
Inspection
-
P -
Palpation
P -
Percussion
A -
Auscultation
RIPPA
•
Rate
•
Depth
•
Effort
•
Other features of work of
breathing e.g. indrawing,
nasal flaring in children
Then apply high flow oxygen
Causes of abnormal rates
< 10 breaths per min
> 30 breaths per min
•
Drugs
•
Chest injury
•
Alcohol
•
Airway compromise
•
Head injury
•
Circulatory shock
•
Medical causes
•
Respiratory conditions
•
Athlete at rest
•
Pain, anxiety, fear
•
Exercise
RIPPA
Inspect the chest for signs of:
•
Pattern bruising
•
Wounds (penetrating or
sucking)
•
Symmetry of chest
movement
•
Paradoxical movement
•
Effort of breathing
•
Inspect front, sides and
back wherever possible
RIPPA
Palpate the chest for:
•
Expansion
•
Surgical emphysema
•
Tenderness
•
Bony crepitus
•
Flail segment
•
Check gloves for
blood after feeling
back
RIPPA
Percussion
•
Can be difficult on scene or
in transit
•
Assess percussion bilaterally
•
Apex, Base, Axilla
•
Vital to assess as far
posteriorly [gravity
dependent] as possible
•
Hyper-resonance suggests air
•
Dullness suggests fluid
RIPPA
Auscultation:
•
Can be difficult on scene
or in transit
•
Auscultate bilaterally
•
Apex, Base, Axilla
•
Vital to assess as far
posteriorly [gravity
dependent] as possible
•
Air entry normal,
decreased or absent ?
•
Added sounds ?
Management of chest injuries
Life-threatening injuries
BL
Blast lung
A
Airway obstruction / disruption
T
Tension pneumothorax
O
Open pneumothorax
M
Massive haemothorax
F
Flail segment / multiple rib fractures
C
Cardiac tamponade
Blast lung
•
Causes impaired oxygen exchange
•
Also causes other lung injuries
•
Pre-hospital management is supportive
•
High flow oxygen
•
Urgent transfer
•
Clear handover is vital
Airway obstruction / disruption
•
Abnormal respiratory rate and failure to ventilate
may be due to airway compromise
•
Reassess if needed
Tension pneumothorx
Speed of onset can vary
•
Raised respiratory rate, effort
•
Affected side of chest:
•
Hyper-expanded
•
Hyper-resonant to percussion
•
Decreased breath sounds
•
Tracheal deviation is a late sign
•
High flow oxygen
•
Immediate decompression
•
Urgent transfer
Tension pneumothorax
•
Wide-bore cannula or purpose-made device
+/- syringe
•
2nd intercostal space, just above 3rd rib in
mid-clavicular line
•
Alternative site 4th intercostal space, just
above 5th rib in anterior axillary line
“triangle of safety”
•
Insert perpendicular to skin, then secure
upright
•
Reassess ABC
•
Transfer urgently
Tension pneumothorax
•
Open thorocostomy if expertise is available
•
4th intercostal space, just above 5th rib in
anterior axillary line
•
Leave open if mechanically ventilating
patient
•
Chest seal in self ventilating patient OR
•
Chest drain through thorocostomy (NICE)
•
Reassess ABC
•
Transfer urgently
Open pneumothorax
A careful search for a penetrating
sucking wound is vital
•
High flow oxygen
•
Cover wound
•
Valved chest seal
•
Occlusive dressing
(observe for tension)
•
Transfer
•
Careful handover
Massive haemothorax
•
Raised respiratory rate
•
Affected side of chest
•
Decreased expansion
•
Dull to percussion
•
Decreased breath sounds
•
Circulatory shock
•
High flow oxygen
•
Manage circulation
•
Urgent transfer with pre-alert
Flail chest / multiple rib
fractures
Flail segment
Flail chest
•
≥ 2 consecutive ribs
broken in ≥ 2 places
•
Involves whole chest
with many ribs broken
•
Causes pain and
hypoxia
•
•
Give high flow oxygen,
analgesia, splint
Causes inability to
oxygenate or ventilate
by negative pressure
•
Requires assisted /
positive pressure
ventilation
Cardiac tamponade
•
Chest injuries may affect
organs other than lungs
•
Diagnosis is difficult to
make without ultrasound
•
Pre-hospital management
is supportive
•
High flow oxygen
•
Urgent transfer
Pulse oximetry
•
Can provide additional information
regarding patient’s oxygenation
•
Can be unreliable in pre-hospital
•
•
Vibration / movement / transfer
•
Bright light
•
Nail varnish
•
Carbon monoxide poisoning
Good saturation does not
necessarily mean good
oxygenation
Capnography
•
Assesses ventilation with breath-bybreath measurement of expired
carbon dioxide
•
Good capnography implies:
•
•
Patent airway
•
Adequate oxygenation
•
Adequate circulation
•
Good ventilation
Preferable to pulse oximetry:
•
More information given
•
Dynamic monitoring with earlier warning
of respiratory compromise
Assisted ventilation
•
No absolute criteria, use clinical judgment
•
Always manage underlying condition first
where possible
•
Consider when there is
•
Poor oxygenation
•
Poor ventilation
•
Severe respiratory distress
•
rate <10 or >30 bpm
CHEST ASSESSMENT & MANAGEMENT
Questions ?
Summary
Full systematic chest examination is essential
Identify and manage life-threatening chest
injuries promptly
Reassess often
Give high flow oxygen and transfer urgently