ENVIRONMENTAL EMERGENCIES Signs of Poisonous Snakebites

• Pain in the bites area that keeps getting worse

Emergency
• An emergency can be defined as a medical or surgical • Swelling of the bite area or ecchymotic in the site.
condition requiring immediate or timely intervention to • Nausea, vomiting, sweating, and weakness
prevent permanent disability or death. • Pit viper venom produces both proteolytic (pertaining
to any substances that promotes the breakdown of
Topics Covered protein ) and hemotoxic effects
A. Bites and Stings
B. Heat-Related Emergencies
C. Cold-Related Emergencies
D. Poison Emergencies
A. BITES AND STINGS
1. Animal and Human Bites
2. Snakebites
3. Insect, Bee, and Spider Bites and Stings
4. Tick
1. Animal and Human Bites
• Although many bites are minor, some may break the Emergency Management
skin. Objectives: To remove as much venom as possible and
• When a bite breaks the skin , the wound can bleed and retard the spread of venom:
may become infected from the germs in the biter’s Venom may be neurotoxin (effect on nerves and nerve
mouth. Bites that do not break the skin are not usually cells ) or hemotoxic.
serious. 1. Make patient lie down as soon as possible.
• Be sure to stay away from an animal that is acting 2. Remove constrictive items such as rings.
Strangely 3. Provide warmth
Management 4. Clean the wound, cover with a light sterile dressing
• Make sure the scene is safe. Get the first aid kit. Wear 5. Immobilized the injured body part below the level of
PPE. the heart
• For animal bites, phone or send someone to phone your Initial evaluation in the ED is performed quickly and
emergency response number. (ABTC) includes information about the following:
• Clean the wound with aid a lot of running water (and a. Whether the snake was venomous or non venomous; if
soap, if available) the snake is dead, it should be transported to the ED
• Stop any bleeding with pressure and dressings. with the patient for identification.
• For all bites that break the skin, call a healthcare b. Where and when the bite occurred and the
provider. circumstances of the bite.
• If there is a bruise or swelling, place a bag of ice and c. Sequence of events, signs and symptoms (fang
water wrapped in a tower on the bite for up to 20 punctures, pain, edema, and erythema of the bite and
minute near by tissue).
Important d. Severity
• Animals that carry rabies: e. Vital signs
– Cat, dog, skunk, raccoon, fox, bat or other wild animal f. Circumference of the bitten extremity or area at several
– Human points; the circumference of the extremity that was
bitten is compared to the circumference of the
2. SNAKEBITES
opposite extremity.
• If a snake bites someone, it is helpful to be able to
g. Laboratory data( CBC, urinalysis and clotting studies)
identify the kind of snake. Sometimes you can identify
the snake from its bite mark. If you aren’t sure whether Note: Ice, tourniquets, heparin and corticosteriods are
a snake is poisonous, assume that it is not used during the acute stage. It is contraindicated in
the first 6-8 hrs. ( they may depress antibody production
Snake Bites- the most frequent poisonous snake bite
and hinder the action of antivenin= antitoxin
occurs from pit vipers. Upper extremities is the most
manufactured from the snake venom and used to treat
snake bites)
Administration of Anti-venin (anti toxin) over the bite or sting area for up to 20 minutes
Most effective administration is within • Watch the person for at least 30 minutes for signs of an
twelve(12) hours after the snake bites (for allergic reaction
envenomated cases) should be given after
Initial Emergency Management
skin test by intravenous infusion.
1. Wound care with soap and water
Important 2. Avoid scratching, it results to histamine response
• When making sure the scene is safe, be very careful 3. Apply ice to reduced swelling and decreases venom
around a wounded snake absorption
• Back away and go around the snake 4. Administer oral antihistamine and analgesic to
• If a snake has been killed or hurt by accident, leave it decrease the pain and itchiness
alone. A snake might bite even when severely hurt or
Emergency Management If in case of anaphylactic
close to death. shock
• If the snake needs to be moved, use a long-handled 1. Give Epinephrine Hydrochloride (adrenalin) 0.5-1 ml of
shovel. If you don’t need to move it, leave it alone 1:1000 solution (subcutaneously) and the site is massage
3. INSECT, BEE & SPIDER BITES and STINGS to hasten absorption.
• Facts: 2. The patient is assessed for signs and symptoms of
– Usually insect and spider bites and stings cause only anaphylactic reaction
mild pain, itching, and swelling at the bite. 3. Patient and family education is an important measure
– Some insect bites can be serious and even fatal if in preventing exposure to stinging insects
• The person bitten has a severe allergic reaction to
the bite or sting Early signs and symptoms of impending potentially
• Poison (venom) is injected into the person (for fatal respiratory failure
example, from a black widow spider or brown On inspection:
recluse spider • Skin may display well-circumscribed, discrete cutaneous
wheals with erythematous , raised, indented borders
Clinical Manifestations
and blanced centers.
1. Generalized urticaria
• giant hives.
2. Itching
• Angioedema
3. Malaise
• lump in the throat
4. Anxiety due to laryngeal edema due to severe
bronchospasm Respiratory symptoms:
5. Shock and death • Wheezing
• Dyspnea
Note: Generally, the shorter the time between the sting
• Chest tightness suggest bronchial obstruction
and the onset of severe symptoms, the worsen the
• Stridor secondary to laryngeal edema
prognosis
GI and Genitourinary Symptoms:
Management • Severe stomach cramps
• Make sure the scene is safe. Get the first aid kit. Wear
• Nausea
PPE.
• Diarrhea
• Phone or send someone to phone your emergency
• Urinary urgency incontinence
response number (or 911) and get the first aid kit if
– The person has signs of a severe allergic reaction Neurologic Symptoms:
– The person tells you that she has a severe allergic • Dizziness
reaction to insect bites or stings. Get the person’s • Drowsiness
epinephrine pen if she has one. • Headache
• Restlessness
• If a bee stung the person • Seizures
– Look for the stinger. Bees are the only insects that
may leave their stingers behind. Cardiovascular Symptoms:
– Scrape away the stinger and venom sac by using • Hypotension
something with a dull edge, such as a credit card. • Shock
• Wash the bite or sting area with a lot of running water • Cardiac arrhythmias – can precipitate to vascular
(and soap, if possible) Collapse
• Put a bag of ice and water wrapped in a towel or cloth
Emergency Management
Treatment focuses on maintaining the ff: 5. TICKS
• a patent airway • Ticks are found on animals and in wooded areas. They
• ensuring adequate oxygenation attach themselves to exposed body parts.
• restoring vascular volume and • Many ticks are harmless. Some carry serious diseases.
• controlling and counteracting the effects of the • If you find a tick, remove it as soon as possible. The
chemical longer the tick stays attached to a person, the greater
• mediators released. the person’s chance of catching a disease.
Treatment includes: Management for Tick Bites
1. Immediate administration of epinephrine (adrenaline) • Make sure the scene is safe, Get the first aid kit. Weak
1:1,000 aqueous solution PPE
• Grab the tick by its mouth and head as close to the skin
INTRAMUSCULAR- to reverse broncho constriction and
as possible with tweezers or a tick-removing device.
cause vasoconstriction ( repeat after 5 to 10 minutes if no
• Lift the tick straight out without twisting or squeezing
improvement is seen).
its body. If you lift the tick until the person’s skin tents
SUBCUTANEOUS – if the patient hasn’t lost consciousness and wait for several seconds, the tick may let go.
• Wash the bite with running water (and soap if available.)
INTRAVENOUS – if the reaction is severe, life-threatening
• See a healthcare provider if you are in an area where
situation ( repeating dosage every 5 minutes. If patient is
tick- borne-disease occur. If possible, place the tick in a
in cardiac arrest , give high dose IV push and repeat every
plastic bag and give it to the healthcare provider
3 to 5 minutes)
B. HEAT-RELATED EMERGENCIES
2. Longer-acting epinephrine, corticosteroids, and
• HEAT CRAMPS
diphenhydramine (Benadryl) and Famotidine (Pepcid)
• HEAT EXHAUSTION
- histamine blockers to decrease circulating histamine
• HEAT STROKE
levels to reduce the allergic response (long term
management). 1. HEAT CRAMPS
3. Albuterol (Proventil) nebulizer treatment • Heat cramps are painful muscle spasms, most often in
4. Aminophylline (Theophylline) to treat bronchospasm the calves, arms, stomach muscles
5. Volume expanders to maintain and restore Signs of Heat Cramps
circulating plasma volume. • Muscle cramps
6. IV vasopressors such as norepinephrine (Levophed) • Sweating
and dopamine to stabilize blood pressure. • Headache
7. CPR to treat cardiac arrest
Management
4. Poisonous Spider & Scorpion Bites and Stings • Make sure the scene is safe. Get the first aid kit.
• Signs Wear PPE
– Severe pain at the site of the bite or sting • Have the person with heat cramps rest and cool off
– Muscle cramps • Have the person drink something that contains sugar
– Headache and electrolytes, such as juice or a sports drink, or water
– Fever – Vomiting if the others aren’t available
– Breathing problems
– Seizures Important
– Lack of response • Mild heat-related signs are a warning that the person’s
condition may get worse unless you take action.
Management • Symptoms of heat-related emergencies often increase
• Make sure the scene is safe. Get the first aid kit. if left untreated
Wear PPE.
• Phone your emergency response number (or 911) 2. HEAT EXHAUSTION
• Wash the bite with a lot of running water (and soap, if • Is a serious condition that often
available) turns into heat stroke. It often
• Put a bag of ice and water wrapped in a towel or cloth occurs when someone exercises
on the bite in the heat and sweat a lot
• See if the person needs CPR. If he does, give CPR, if you
don’t know how, give Hands-Only CPR
 Signs of Heat Exhaustion Signs of Heat Stroke
• Sweating • Confusion
• Nausea • Passing out
• Dizziness • Dizziness
• Vomiting • Seizures
• Muscle cramps • Other signs includes
• Feeling faint – Nausea
• Fatigue – Vomiting
Management – Muscle cramps
• Make sure the scene is safe. Get the first aid kit. – Feeling faint
Wear PPE – fatigue
• Phone or ask someone to phone your emergency Clinical Manifestations
response number (or 911) 1. Profound central nervous system dysfunction
• Have a person lie down in a cool place manifested by confusion, delirium, bizarre behavior,
• Remove as much of the person’s clothing as possible coma.
• Cool the person with a cool water spray 2. Elevated body temp.(40.6 degree Celsius or higher).
• If cool water spray is not available, place cool damp 3. Hot, dry skin
cloths on the neck, armpit, and groin area 4. Anhidrosis (absence of sweating).
• Have the person drink something that contains sugar 5. Tachypnea
and electrolytes, such as juice or a sports drink, or water 6. Tachycardia
if the others aren’t available 7. Hypotension
Management for Heat Stroke
• Make sure the sin is safe. Get the first aid kit and AED.
Wear PPE
• Phone or ask someone to phone your emergency
response number (or 911)
• Put the person in cool water, up to her neck if possible
• See if the person needs CPR. If he does, give CPR, If you
don’t know how, give Hands-only CPR
3. HEAT STROKE Important
- is an acute medical emergency caused by failure of the • Begin cooling the person immediately. Ever minute
heat regulating mechanism of the body. counts
-It usually occurs during extended heat waves, especially • If you can’t put the person in cool water up to neck,
accompanied by high humidity. cool her with a cool water spray
- occurs to health individual during sports or walk • Stop cooling the person once her behavior is normal
activities. Example exercising in extreme heat and again. Continued cooling could lead to low body
humidity temperature (hypothermia)
• Only put water on the person’s skin
People at risk are: • If the person can drink, give her something to drink,
• those not acclimatized to heat sports drinks ar the best
• elderly and very young people • If the person can’t drink, wait for someone with more
• those unable to care for themselves
• those with chronic and debilitating diseases ASSESSMENT
• those taking certain medications such as major 1. Assess the patient’s ABC’s and initiate emergency
tranquilizer, and anticholinergies, and beta-adrenergic resuscitative measures.
blocking agents. (impairs thermo regulation) 2. Assess oxygen saturation and administer supplemental
oxygen.
- It can cause thermal injury at the cellular level, 3. Monitor the patient’s vital signs continuously,
resulting in widespread damage to the heart, liver, especially core body temperature.
kidney, and blood coagulation 4. Assess neurologic and cardiac status close
Emergency Management: C. COLD-RELATED EMERGENCIES
1. Reduce body temperature as quickly as possible by
1. FROSBITE
the ff. methods:
2. HYPOTHERMIA (Low Body temperature)
a. Provide cool sheets and towels or do continuous
3. NEAR DROWNING
sponging with cool water or provide cooling blankets.
b. Apply ice to the neck, groin, chest, axillae while 1. FROSTBITE
spraying with tepid water. • A cold injury to part of the body
c. Perform ice saline lavage of the stomach and colon • is a trauma from exposure to freezing temperature and
( if does not decrease) actual freezing of the tissue fluids in the cell and
d. Emerge the patient in a cold water bath if possible. intracellular spaces.
2. Massage body and extremities to maintain circulation • It results in cellular and vascular damage
and cutaneous vasodilation Most Common Body parts affected by Frostbite
3. Start intravenous infusion therapy of normal saline or • includes the feet, hands, nose, cheeks and ears.
lactated ringer solution to replace fluid losses and • It ranges from 1st degree (redness and erythema) to 4th
maintain adequate circulation. degree (full depth tissue destruction)
Give slowly because of danger of pulmonary edema
and myocardial injury ( from increase body temp and Signs of Frosbite
poor renal function ) • The skin over the frostbitten area is white, waxy, or
4. Give valium or chlorpromazine to suppress or control grayish-yellow
shivering /seizure activities • A frostbitten area is cold and numb
5. Give additional supportive measure like • A frozen extremity may be hard, cold, and insensitive to
- oxygen therapy touch and may appear white or mottled blue-white.
- central venous pressure and pulmonary artery wedge • Skin doesn’t move when you push it
pressure monitoring. Emergency Management:
- ET intubation if necessary. The goal of management is to restore normal body
- potassium chloride for hypokalemia temperature.
- NAHCO3 to correct metabolic acidosis 1. Do not allow patient to ambulate if the lower
5. Measure urine output – acute tubular necrosis is a extremities are involved.
complication of heart stroke from rhabdomyolysis 2. Remove all constrictive clothing and jewelry that could
(myoglobin in the urine) impair circulation.
7. Advice patient to avoid immediate re-exposure to high 3. Rewarm extremity rapidly by immersing at 37C to 40C
heat between 10am-2pm. circulating bath for30-40 minutes span. 4. Give
Note: Permanent liver, cardiac and CNS damage may analgesic for pain. ( rewarming method is very painful )
Occur 5. Sterile gauze or cotton is placed between affected
fingers or toes to prevent macerations. Observed strict
Diagnostic Test
No single diagnostic test confirms heat stroke aseptic technique
1. ABG results may reveal respiratory alkalosis and 6. Give tetanus prophylaxis if ulceration has occurred.
hypoxemia. 7. Place patient on bed rest with foot cradle if feet are
3. CBC may reveal leukocytosis and increased Hct involved.
secondary to hemoconcentration. 3. Electrolyte levels a. Elevate the affected parts to help control swelling.
may show hypokalemia. Other blood studies may b. Avoid pressure or friction on extremity. Affected
reveal elevated BUN level, increased bleeding and area should be handled gently to avoid further
clotting times. mechanical injury. Massage is contraindicated
4. Urinalysis may show concentrated urine with elevated 8. Give prophylactic antibiotic and anti inflammatory
protein levels, tubular casts and myoglobinuria. therapy.
9. Instruct patient to avoid subsequent exposure to cold.
10.Encourage patient to avoid tobacco or caffeine
because of the vasoconstriction effects which further
reduce the already deficient blood supply to injured
tissues
Additional Measures:
• Whirlpool bath for the affected extremity to aid
circulation, debride necrotic tissue and help prevent
infection. * dilated pupils
• Escharotomy (incision through the eschar) to prevent * rigor mortis-like state
further tissue damage, allow for normal circulation and * ventricular fibrillation
permit joint motion. * loss of deep tendon reflexes
• Fasciotomy to treat compartment syndrome
Emergency Management
2. HYPOTHERMIA
Management is consisting of specific rewarming methods
• is a condition in which the core (internal) temperature
and supportive measures.
is 34.4 c or below as a result of exposure to cold.
• It occurs when the patient loses the ability to maintain 1. Assess the patient’s ABC and initiate CPR
body temperature 2. Administer supplemental oxygen and prepare for ET
Causes intubation and mechanical ventilation with positive
1. Results from near drowning in cold water end expiratory pressure (PEEP) to maintain tissue
2. Prolonged exposure to cold temperature oxygenation
3. Disease or debility that alters homeostasis 3. Initiate continuous cardiac monitoring. Defibrillation of
4. Administration of large amounts of cold blood or ventricular fibrillation (because cold induced
blood products myocardial irritability leads to conduction disturbances
especially ventricular fibrillation and cardio-vascular
Candidates collapse if blood is returned too rapidly to a cold heart.)
The risk of serious cold injury is higher in patients who are: 4. Administration of NaHCO3 to correct metabolic
• Young acidosis.
• Elderly 5. Administration of anti-arrhythmic drugs
• Lacking in insulating body fat 6. Insertion of indwelling catheter to monitor fluid status
• Wearing wet or inadequate clothing
• Abusing drugs or alcohol or smoking B. Rewarming methods - this includes active core
• Suffering from cardiac disease (internal) rewarming, active external rewarming and
• Fatigued passive rewarming.
• Malnourished with a depletion of calorie reserves. 1. Active core (internal) rewarming
a. Infusing warmed IV fluids
ASSESSMENT b. Providing heated, humidified supplemental oxygen.
Obtaining the history of a patient with a cold injury may c. performing warm fluid lavage (peritoneal, gastric,
reveal: bladder or colonic lavage). d. Performing continuous
• cause of hypothermia arteriovenous rewarming (CAVR), hemodialysis or
• Temperature to which the patient was exposed cardiopulmonary by pass
• Length of exposure 2. Passive External Rewarming
STAGES OF HYPOTHERMIA When the patient rewarms on his own
1. Mild Hypothermia a. Removing wet clothing
2. Moderate Hypothermia b. Covering the client with warm blankets.
3. Severe Hypothermia c. Placing the client in a warm room.
Clinical Manifestations: 3. Active External Rewarming
a. Immersing the patient in a warm bath (104F or 40C).
Mild Hypothermia (32.0-35 C)
b. Placing the patient on a heating blanket.
* Severe shivering
c. Placing radiant lamps or heat over the patient.
* Slurred speech
d. Heated objects such as water
* Amnesia
3. NEAR-DROWNING
Moderate Hypothermia (30-32 c)
Near drowning is survival for at least 24 hours after
* unresponsiveness
submersion
* peripheral cyanosis
• The most common consequence is HYPOXEMIA ( an
* muscle rigidity
abnormal deficiency in the concentration of oxygen in
* signs of shock (if the patient was improperly rewarmed)
arterial blood ) and followed by METABOLIC ACIDOSIS
Severe Hypothermia (25 to 30 C) • Is the third most common cause of unintentional death
* absences of palpable pulses and leading cause of unintentional death in children
* no audible heart sounds under 14 years of age
Factors Associated w/ Drowning or Near Drowning 1. ABG analysis shows decreased O2 content, low
1. Heavy drinking before swimming bicarbonate levels, and low pH.
2. Inability to swim or swimmers in panic 2. Electrolyte levels may be elevated or decreased,
3. Diving injuries depending on the type of water aspirated.
4. Hypothermia 3. CBC- leukocytosis may occur
5. Exhaustion 4. ECG shows arrhythmias and waveform changes.
6. A boating accident 5. Assess core body temperature and institute rewarming
7. Heart attack as necessary.
8. Suicide attempt 6. Start IV lines and insert indwelling urinary catheter to
Forms of Near drowning measure urine output.
DRY – the victim doesn’t aspirate fluid but suffers 7. If the patient’s abdomen is distended, Nasogastric tube
respiratory obstruction or asphyxia (10% to 15% patients) are used to decompress the stomach and to prevent
WET – the victim aspirates fluid and suffers from asphyxia aspiration of gastric contents.
or secondary changes due to fluid aspiration.(85% 8. Give medications (Drug treatment)
patients) Sodium Bicarbonate – for acidosis
SECONDARY – the victim suffers a recurrence of Corticosteroids and osmotic diuretics – for cerebral
respiratory distress (usually aspiration pneumonia or edema
pulmonary edema within minutes or 1 to 2 days after a Antibiotics – to prevent infection
near drowning incident Bronchodilators – to ease bronchospasms
9. Observe for pulmonary complications and signs of
CLINICAL MANIFESTATION delayed drowning (confusion, substernal pain,
Victims can display a host of clinical problems adventitious breath sounds)
• Fever Suction often. Pulmonary artery catheters may be use
• Confusion for cardiopulmonary status
• Unconsciousness
• Irritability D. POISON EMERGENCIES
• Lethargy 1. SWALLOWED POISONS ( Ingested)
• Restlessness 2. INHALED POISONS (Carbon Monoxide)
• Substernal chest pain 3. SKIN CONTAMINATION POISONS (Chemical Burns)
• Shallow or gasping respirations 4. FOOD POISONING
• Cough that produces a pink, frothy fluid POISONING
• Vomiting • refers to inhalation, ingestion, and injection of, or
• Abdominal distention skin contamination from, any harmful substance
• Apnea • Poison is any substance which when ingested, inhaled,
• Asystole absorbed, applied to the skin or produced within the
• Bradycardia body in relatively small amounts, injures to the body by
• Tachycardia its chemical reaction
Emergency Management: Children are the most common poison victims usually
Treatment Goal is Prevention of Hypoxia from accidental ingestion of salicylates ( aspirin) ,
1. Ensuring adequate airway and respiration. Initiate CPR cleaning agents, insecticides, paints, cosmetics, and
and 100% O2 plants.
2. Use of endotracheal intubations with positive pressure is the 4th leading cause of death in children.
ventilation- to improve oxygenation and prevent Adults poisoning is common among chemical company
aspiration. employees particularly those in companies that use
- If the patient breath spontaneously O2 can be chlorine, carbon dioxide, hydrogen sulfide, nitrogen
administered by mask. dioxide, and ammonia
3. Arterial blood gas analyses-to evaluate oxygen, carbon
• Improper cooking, canning, and storage of food;
dioxide, bicarbonate levels and pH ( determine the type
ingestion of or skin contamination from plants.
of ventilatory support needed) pulse oximeter
Example dieffenbachia, mistletoe, azalea, and
DIAGNOSTIC TEST philodendron.
Diagnosis requires a history of near drowning, including • Accidental or intentional drug overdose of barbiturates
the type of water aspirated, characteristic features and or chemical ingestion
auscultation of crackles and rhonchi.
• Poison depends on the substance that’s inhaled or c. Syrup of Ipecac for alert patient
ingested. The extent of damage depends on the pH of the d. Gastric lavage ( gastric aspirate is saved and sent to
substance, the amount ingested, its form (solid or liquid) lab for toxicology screening) after Administer activated
and the length of exposure to it charcoal
Emergency Treatment is Initiated with the ff. Goals e. Cathartic when appropriate
1. Remove or inactivate the poison before it is absorbed f. Do not take more than 5 minutes to induce emesis
2. Provide supportive care in maintaining vital organ • Carry out gastric lavage-to remove any unabsorbed
system poison.
3. Administer a specific antidote to neutralize a specific Nursing alert:
poison • This procedure is not done if corrosive or hydrocarbon
4. Implement treatment that hastens the elimination of solvents has been ingested (gasoline, liquid wax,
the absorbed poison kerosene)
1. SWALLOWED POISONS ( Ingested) • Instruct family to bring unused poison to hospital for
• Swallowed poisoning may be corrosive. Identification
• It includes alkaline and acid agents that can cause Diagnostic Test
tissue destruction after coming in contact with mucus 1. Toxicology Studies including drug screen of
membranes poison levels in the mouth, vomitus, urine, stool or
General Nursing Management blood or on the victim’s hands or clothing.
1. Maintain airway, ventilation and oxygenation. 2. CBC and electrolyte, BUN, creatinine, and ABG levels -
2. Treat shock (administer with whole blood) which evaluate the patient’s renal status and acid-base
results from the cardio depressant action of the balance as well as his blood oxygen ventilation status.
substance ingested, from venous pooling in lower 3. Urinalysis – can evaluate the patient’s renal status
extremities, or from reduced circulating blood volume because many toxic and caustic substances can be
resulting from increased capillary permeability . excreted through the kidneys.
3. Support the patient having convulsions. Many poisons 4. Chest xray – may reveal mediastinitis, pleural effusion,
excite the central nervous system or the patient pneumoperitoneum and aspiration pneumonia
convulses due to O2 deprivation. 5. Abdominal xray – may reveal pneumoperitoneum or
a. Give intravenous phenobarbital (or other ascitis
anticonvulsant until specific therapy can be instituted Corrosive Poisons
b. Give positive pressure respiration if 02 is necessary Clinical Manifestations (What to look for)
4.Give analgesic for pain. 1. Severe pain, burning sensation in mouth and throat
5. Watch for fluid imbalance or acidosis 2. Nausea and Vomiting
6.Give specific therapy 3. Destruction of oral mucosa
Administer special chemical antidotes or 4. Drooling in children, painful swallowing or inability to
special pharmacological antagonist (e.g. nalaxone swallow.
hydrochloride (Narcan) as early as possible 5. Abdominal pain or guarding
Note: If measures ineffective 6. airway obstruction
• Administer multiple doses of charcoal 7. Altered mental status
• Diuresis for substances excreted by the kidneys, 8. Diarrhea
• Dialysis 9. Respiratory distress
• Hemoperfusion Types of Corrosive Poisons
7. If due to suicidal attempt, psychiatric consultation is 1. Acid and acid like corrosives
needed before discharge. Common acid-containing sources include:
8. Health teaching a. toilet bowl cleaning products
b. automotive battery liquid
Measures to remove poison from patient's stomach
immediately by inducing vomiting. c. rust-removal products
a. Give 3-4 glassful of milk or water to drink to dilute d. metal-cleaning products
poison. e. cement-cleaning products
b. Induce vomiting by giving syrup of ipecac or inserting f. drain-cleaning products
the index finger or blunt end of the spoon at g. soldering flux containing zinc chloride
the back of the patient's throat.
• Acidic cleaners such as chlorinated household cleaners, symptoms of CNS damage
undergo oxygenation reactions and form hydrochloric a. Psychosis
acid, which causes gastric injury if ingested. b. Spastic paralysis
c. Visual disturbances
• These agents cause coagulation necrosis, a process in
d. Deterioration of mental status and behavior
which a protective layer forms at the site of the injury
8. If suicidal attempt, psychiatric consultation is needed.
and limits its depth
9. Health department should be informed for inspection
2. Alkaline Corrosive
Clinical Manifestations
Common alkaline-containing sources include:
1. Headache
a. drain-cleaning products
2. Muscular weakness
b. ammonia-containing products
3. Palpitation
c. oven-cleaning products
4. Dizziness
d. swimming pool-cleaning products
5. Confusion-coma
e. automatic dishwasher detergent
f. hair relaxers 3. SKIN CONTAMINATION POISONS (Chemical Burns)
g. clinitest tablets • It occur from direct contact with the chemical or
h. bleaches splashing onto skin or eyes.
i. cement • They are generally associated with acidic or alkaline
solutions such as bleach, drain or toilet bowl cleaners or
• Alkaline cleaners, such as drain cleaner, are generally
metal cleaners
tasteless and odorless, allowing larger amounts to be
ingested. These substances tend to cause injury to the Emergency Management
mucosa and submucosa of the esophagus. 1. Drenched skin immediately with running water
(shower, hose, faucet)
• Alkaline substances cause liquification necrosis, a
2. Apply continuous stream of water on skin while
process in which necrosis continues from the superficial
removing clothing
layers into the deeper tissue
3. Cleanse skin thoroughly with water. Rapidity in
Test to evaluate washing is the most important in reducing external
1. pH testing of saliva determination whether the Injury
substance is an acid or base; however, a neutral pH can’t
Nursing Alert
rule out ingestion of a caustic substance.
Water should not be applied to burn from lye or white
• A pH of less than 2.0 (acidic substance) or greater than phosphorus because of the potential for an
12.5 (alkaline substance) indicates the potential for explosion or for deepening the burn. Treatment
severe tissue damage 1. Antimicrobial treatment
2. INHALED POISONS (Carbon Monoxide) 2. Debridement
3. Tetanus prophylaxis
• May occur as an industrial or household accident or as 4. If required, plastic surgery for further wound
attempted suicide. management
• CO exerts its toxic effects by binding to circulating Hg.
And there by reducing the O2 carrying capacity of the 4. FOOD POISONING
blood. Hg. Food Poisoning- is a sudden explosive
• Absorbs CO 200x more readily than it absorbs O2. CO illness that may occur after ingestion of contaminate food
bound Hg. called CARBOXYHEMOGLOBIN, does not or drink.
transport O2 Botulism is a serious form of food poisoning that requires
continual surveillance.
Emergency Management
1. Carry patient to fresh air immediately, open all doors Emergency Management
and windows 1. Induce vomiting
2. Loosen all tight clothing a. Have a patient drink warm water, stimulate back of
3. Initiate CPR if required. Give 100% O2 by mask. the pharynx with finger or blunt end of the spoon to
4. Prevent chilling, wrap the patient with blankets induce vomiting
5. Do not give alcohol in any form b. Save vomitus for possible laboratory analysis ( food,
6. Keep the patient as quiet as possible gastric contents, vomitus, serum and feces)
7. Observe patient continuously for there may permanent
2. Monitor vital signs on a continuing basis
a. Assess respiration, blood pressure, sensorium,
central venous pressure, and muscular activity.
b. Weigh
3. Determine source and type of food poisoning.
a. Bring suspected food to medical facility for
identification.
b. Determine
• How soon after eating did the symptoms occur?
Immediate onset suggests chemical, plant or animal
poisoning.
• What was eaten in the previous meal? Did the food
have any unusual odor or taste?
• Did vomiting occur? What was the appearance of
the vomitus
• Did diarrhea occur? Usually absent with botulism,
shellfish or other fish poisoning.
• Are any neurologic symptoms present? Occur
in botulism, chemical plant and animal poisoning.
• Does the patient have fever? (It is a characteristic in
salmonella, ingestion of fava beans and some fish
poisoning
4. Support respiratory system-death from respiratory
paralysis occurs with botulism, fish poisoning and
other food poisoning.
4. Maintain fluid and electrolyte balance.
6. Control nausea. Give anti-emetic medication if can't
tolerate orally.
7. Control diarrhea. Give anti-diarrheal drug-to
absorb the toxins
FOREIGN BODY AIRWAY OBSTRUCTION • The patient may go silent and hold or point to their
INTRODUCTION throat (Universal Sign of Choking).
Foreign-body airway obstruction (FBAO) (choking) is a ASSESSMENT OF FBAO
life-threatening emergency. In England and Wales in 2016, If FBAO is suspected, it is important to assess its severity
252 deaths from choking were reported, with almost 30% and always ask the patient “are you choking?”. Their
of these in people aged 80 years and over. Alarmingly, response will help distinguish between a mild or severe
over 60% of deaths from choking in 2016 occurred in obstructive airway.
hospitals and other healthcare settings (Office for
National Statistics, 2017). In the Philippines, FBAO ranks
as one of the major cause of mortalities.
Nurses must be able to recognise and effectively treat
FBAO. As most FBAO events are associated with eating,
they are often witnessed, thereby providing an
opportunity for early intervention while the patient is still
conscious.
Back blows (slaps), chest thrusts and abdominal thrusts
are manoeuvres that can increase intra-thoracic pressure
and expel foreign bodies from the airway. In 50% of FBAO
episodes, back blows alone are effective at relieving the
obstruction; however, in 50% of cases more than one
SEVERITY OF AIRWAY OBSTRUCTION
technique is needed to relieve the obstruction (Perkins et
Mild airway obstruction (effective cough): patient able
al, 2017).
to talk and has an effective cough
CAUSES OF FBAO Severe airway obstruction (ineffective cough): typically,
Choking usually occurs while the person is eating or patient responds “yes” by nodding their head without
drinking and can be associated with muscle, neurological speaking; unable to cough effectively
or cerebral impairment (Pavitt et al, 2017). Most deaths
MILD AIRWAY OBSTRUCTION
from choking are caused by food (87%), while small
Coughing generates high and sustained airway pressures
objects – a particular problem in children – are the cause
and may expel a foreign body, so it is important to
of 13% of choking-related deaths (ONS, 2017).
encourage the patient to cough. A patient with mild
People at increased risk of FBAO include those with any airway obstruction should remain under continuous
of the following conditions or characteristics: observation until they improve as a severe obstruction
• Altered level of consciousness may subsequently develop. Aggressive treatment with
• Drug and/or alcohol intoxication back blows and chest and abdominal thrusts at this stage
• Neurological impairment, with reduced swallowing and is unnecessary – it may cause harm and could exacerbate
cough reflexes (for example, stroke) the airway obstruction. These interventions should only
• Respiratory disease be used if the patient shows signs of severe airway
• Mental impairment obstruction.
• Dementia SEVERE AIRWAY OBSTRUCTION
• Poor dentition If the patient shows signs of severe airway obstruction:
• Geriatrics • Call for help/pull the emergency buzzer immediately
• Use of Metered Dose Inhalers and encourage the patient to cough;
SIGNS OF FBAO • Stand at the patient’s side, slightly behind them;
Recognising the signs of FBAO is the key to early and • Support the patient’s chest with one hand and lean
effective intervention. The context may provide them forward – if this dislodges the foreign body, it will
important clues – for example, choking is common at hopefully fall out of the mouth instead of slipping
mealtimes or a child may have been playing with small further down the airway
objects. • If symptoms continue, deliver up to five back blows
• A cough (slaps) between the scapulae using the heel of the hand.
• Struggling to breathe or talk • Following each back blow, check to see if the
• Cyanosis obstruction has been dislodged; If the back blows fail,
• Grasping or reaching for the throat. proceed to abdominal thrusts.
• Stand behind the patient, placing both arms around the AFTERCARE AND REFERRAL
upper abdomen; Following successful treatment for an FBAO, a foreign
• Lean the patient forward; body may still be present in the airways; if someone has
• Place a clenched fist between the patient’s umbilicus dysphagia, a persistent cough or complains of having
and the ribcage, and clasp it with the other hand; something stuck in their throat, they should seek medical
• Deliver up to five sharp thrusts to the abdomen, advice.
inwards and upwards; Performing abdominal thrusts and chest compressions
• Take care not to apply pressure to the xiphoid process has the potential to cause serious internal injury,
or the lower ribcage as this may cause abdominal including ruptures or laceration of abdominal or thoracic
trauma; viscera, so patients must be examined for injuries.
• If the obstruction remains, alternate up to five back USE OF AIRWAY CLEARANCE DEVICES
blows with up to five abdominal thrusts. Although there are several airway clearing devices for the
treatment of FBAO currently available, their routine use is
not recommended. However, appropriately trained
health professionals can use advanced techniques – such
as suction or laryngoscopy and forceps – to remove a
foreign body from the airway.
CONCLUSION
FBAO is a life-threatening emergency that nurses must be
able to recognize and effectively treat.

IF THE PATIENT LOSES CONSCIOUSNESS YOU

SHOULD:
• Carefully support them to the ground;
• If you have not done so already, summon help following
local protocols – call for an ambulance or contact your
cardiac arrest team;
• Start cardiopulmonary resuscitation (CPR) – do 30 chest
compressions first as these may relieve the obstruction;
• After 30 compressions, attempt two ventilations, then
continue CPR until the patient recovers and starts to
breathe normally.
ABDOMINAL THRUSTS IN AN OBESE OR PREGNANT
PATIENT
It may be difficult to carry out abdominal thrusts on a
patient who is obese or pregnant. If you cannot encircle
their abdomen, stand behind the patient, position your
hands over the lower end of the sternum and pull hard
into the chest with quick thrusts (chest thrusts)
Foreign Body Airway Obstruction in Children • Geriatrics
INTRODUCTION • Use of Metered Dose Inhaler
Between 2014 and 2016 there were 30 deaths from SIGNS OF FBAO
choking in infants and children aged <14 years in England Recognizing the signs of FBAO is the key to early and
and Wales (Of ice for National Statistics, 2017). The effective intervention. The context may provide
causes of foreign-body airway obstruction (FBAO) are important clues – for example, choking is common at
split equally between food and small objects mealtimes or a child may have been playing with small
objects
A quick response can prevent death from choking, so
• A cough
nurses should be able to recognise and respond to FBAO.
• Struggling to breathe or talk
Those working with families should also ensure parents
• Cyanosis
know how to prevent, recognize and respond to it.
• Grasping or reaching for the throat.
CHOKING • The patient may go silent and hold or point to their
Choking is a life-threatening emergency that nurses must throat (Universal Sign of Choking).
be able to recognize and treat
ASSESSMENT OF FBAO
FBAO If FBAO is suspected, it is important to assess its severity
Is clinical emergency that may be life threatening. Nurses and always ask the patient “are you choking?”. Their
should be confident in assessing the severity of airway response will help distinguish between a mild or severe
obstruction, delivering interventions to relieve the airway obstructive airway
obstruction and knowing when to call for assistance.
SEVERITY OF AIRWAY OBSTRUCTION
SIGNS OF FBAO
Mild obstruction (effective cough)
Recognizing the signs of FBAO in infants and children is
: patient able to talk and has an effective cough
the key to early, effective intervention. The context may
The infant/child:
provide important clues – for example, choking is
• Is crying/able to verbally respond to questions
common at mealtimes, or a child may have been playing
• Has a loud cough
with small objects that easily fit into the mouth. The most
• Is able to take a breath before coughing and is fully
common signs and symptoms of choking are:
responsive
• A cough;
• Struggling to breathe or talk (cry in infants); Severe obstruction (inef ective cough)
• Gagging – the infant/child may go silent and hold or : typically, patient responds “yes” by nodding their head
point to their throat. without speaking; unable to cough effectively
• If the obstruction is only partial, the child may be able Typically the infant/child:
to vocalize/cry, cough and breathe • Is unable to vocalise
• Is quiet
CAUSES OF FBAO
• Has a silent cough
Other causes of airway obstruction in children – including
• Is unable to breathe
laryngitis and epiglottitis – present with similar symptoms.
• Shows signs of cyanosis and decreasing levels of
The presence of a foreign body should be suspected if the
consciousness
symptoms have a sudden onset and there are no other
systemic signs of illness such as pyrexia.. If FBAO is
suspected, it is important to assess the severity by
establishing whether the infant/child has an effective or
ineffective cough. In older children it is useful to ask “are
you choking?”; their response will help distinguish
between a mild or severe obstructive airway
• Altered level of consciousness
• Drug and/or alcohol intoxication
• Neurological impairment, with reduced swallowing and
cough reflexes (for example, stroke)
• Respiratory disease
• Mental impairment
• Dementia
• Poor dentition
BACK SLAPS IN INFANT Place the infant in a prone position (usually over the lap)
with the head downwards to enable gravity to help
remove the foreign body;
Stabilize the infant’s (floppy) head: place the thumb of
one hand at the angle of the lower jaw and one or two
fingers on the opposite side of the jaw (take care not to
compress the soft tissues under the infant’s jaw, as this
could exacerbate the obstruction of the airway);
Deliver up to five sharp back blows (slaps) with the heel
CHOKING IN INFANTS AND CHILDREN of one hand in the middle of the back between the
Nurses should advise parents to: shoulder blades. Following each back blow, check to see
• Always cut up food: infants and young children can whether it has relieved the obstruction
choke on small, sticky or slippery foods If back blows fail to dislodge the object and the infant is
• Keep small objects out of reach: infants and small still conscious, deliver up to five chest thrust
children examine objects by putting them in their
Turn the infant supine with head in a downwards position,
mouths. Ensure small toys/objects such as building
using your arm to support the infant’s back and your
bricks, button batteries, coins and marbles are stored
hand to support the head. Your thigh can provide
out of reach
additional support;
• Sit children down to eat
• Always supervise infants and young children Locate the ‘landmark’ for chest compressions – this is the
lower sternum approximately a finger-width above the
MILD AIRWAY OBSTRUCTION
xiphisternum;
Coughing generates high and sustained airway pressures
and may expel a foreign body, so it is important to Perform up to five chest thrusts – these are like chest
encourage the patient to cough. A patient with mild compressions, but sharper in nature and delivered at a
airway obstruction should remain under continuous slower rate;
observation until they improve as a severe obstruction
Following each chest thrust, check to see whether the
may subsequently develop.
obstruction has been dislodged;
Aggressive treatment with back blows and chest and
If the obstruction remains, continue alternating up to five
abdominal thrusts at this stage is unnecessary – it may
back blows with up to five chest thrusts
cause harm and could exacerbate the airway obstruction.
These interventions should only be used if the patient
shows signs of severe airway obstruction
Coughing generates high and sustained airway pressures,
and may expel a foreign body, so it is important to
encourage the child to cough. Children with an effective
cough will be able to cry or verbally respond to questions.
In these situations, no external manoeuvres – such as
back blows – are needed but close observation is
required until the infant/child improves, as severe airway
obstruction may develop.
SEVERE AIRWAY OBSTRUCTION S EVE R E AI RWAY
Ineffective Cough (Infants Less than 1 year) O B S T RU C T I O N ( I N E F F E C T IVE
If the patient shows signs of severe airway obstruction: C O U G H ) I N C H I L D R E N ( > 1 Y EAR )
• Call for help/pull the emergency buzzer immediately If a child shows signs of severe airway obstruction:
and encourage the patient to cough; • Call for help/pull the emergency buzzer immediately if
• Deliver up to five back blows (slaps) using the following in the hospital;
procedure: • Deliver up to five back (slaps)
Deliver up to five sharp back blows (slaps) with the heel
of one hand in the middle of the back between the
shoulder blades (Fig 4). Following each back blow, check chest compressions immediately. It is advised for a lone
to see whether the obstruction has been dislodged. rescuer to perform cardiopulmonary resuscitation for one
minute before summoning assistance;
Before repeating ventilations, check the mouth for the
presence of an object and remove it if this is possible (see
above) (Maconochie et al, 2017)
AFTERCARE AND REFERRAL
After successful treatment for a FBAO, the foreign body
may still be present in the airways and can cause
complications. Advise parents/carers that they should
seek medical advice if the infant/child has dysphagia or a
Position the child with their head down (a small child may persistent cough, or complains of having something stuck
be placed over the lap, as described above). If this is not in their throat.
feasible, support the child into the leaning-forward As chest/abdominal thrusts and chest compressions can
position recommended for adults (Fig 5); cause serious internal injury, patients must be examined
If back blows fail to dislodge the object and the child is for injuries after these interventions have been
still conscious, deliver up to five abdominal thrusts performed (Perkins et al, 2017).
(Fig 5) using the following procedure: CONCLUSION
Professional responsibilities – These procedures should
Position yourself behind the child either standing or be undertaken only after approved training, supervised
kneeling. Place your arms under the child’s arms; practice and competency assessment, and carried out in
Place a clenched fist between the umbilicus and accordance with local policies and protocols
xiphisternum;
Hold the clenched fist with your other hand; pull sharply
inwards and upwards;
Deliver up to five abdominal thrusts. Following each
abdominal thrust, check to see whether the obstruction
has been dislodged;
Take care not to apply pressure to the xiphoid process or
the lower rib cage as this may cause abdominal trauma;
If the obstruction remains, continue alternating up to five
back blows with up to five abdominal thrusts

IF THE PATIENT LOSES CONSCIOUSNESS YOU

SHOULD:
Open the airway and attempt five ventilations. Determine
the ef ectiveness of each ventilation – if the chest fails to
rise, reposition the head;
If the infant/child remains unresponsive, commence
Thoracic and vascular assessment
in Trauma

Introduction to Thoracic Injury

Vital Structures
- Heart, Great Vessels, Esophagus,
Tracheobronchial Tree, & Lungs
25% of MVC deaths are due to
thoracic trauma
- 12,000 annually in US
Abdominal injuries are common with
chest trauma.
Prevention Focus Thoracic Skeleton
Gun Control Legislation ➢ Topographical Thoracic Reference
Improved motor vehicle Lines
restraint systems ○ Midclavicular line
- Passive Restraint ○ Anterior axillary line
Systems ○ Mid-axillary line
- Airbags ○ Posterior axillary line
Intercostal space
Anatomy and Physiology of the Thorax ➢ Artery, Vein and Nerve on inferior
Thoracic Skeleton margin of each rib
➢ 12 Pair of C-shaped ribs Thoracic Inlet
○ Ribs 1-7: Join at sternum ➢ Superior opening of the thorax
with cartilage end-points ➢ Curvature of 1st rib with associated
○ Ribs 8-10: Join sternum with structures
combined cartilage at 7th rib Thoracic Outlet
○ Ribs 11-12: No anterior ➢ Inferior opening of the thorax
attachment ➢ 12th rib and associated structures &
Sternum Xiphisternal joint
➢ Manubrium Diaphragm
○ Joins to clavicle and 1st rib ➢ Muscular, dome-like structure
○ Jugular Notch ➢ Separates abdomen from the
Body thoracic cavity
➢ Sternal angle (Angle of Louis) ➢ Affixed to the lower border of the rib
○ Junction of the manubrium cage
with the sternal body ➢ Central and superior margin extends
○ Attachment of 2nd rib to the level of the 4th rib anteriorly
Xiphoid process and 6th rib posteriorly
➢ Distal portion of sternum ➢ Major muscle of respiration
○ Draws downward during
inspiration
 ○ Moves upward during ➢ Exhalation
exhalation ○ Musculature relaxes
Associated Musculature ○ Diaphragm & intercostals
➢ Shoulder girdle return to normal
➢ Muscles of respiration ■ Greater internal
○ Diaphragm pressure than
○ Intercostal muscles atmospheric
■ Contract to elevate the ribs ■ Air exits lungs
and increase thoracic
diameter Trachea, Bronchi & Lungs
■ Increase depth of respiration ➢ Pleura
■ Sternocleidomastoid ○ Visceral Pleura
○ Raise upper rib and ○ Cover lungs
sternum ➢ Parietal Pleura
○ Lines inside of thoracic cavity
➢ Pleural Space
○ POTENTIAL SPACE
■ Air in Space =
PNEUMOTHORAX
■ Blood in Space =
HEMOTHORAX
➢ Serous (pleural) fluid within
○ Lubricates & permits ease of
expansion
Mediastinum
Physiology of Respiration ➢ Central space within thoracic cavity
➢ Changing pressure assists: ➢ Boundaries
○ Venous return to heart ○ Lateral: Lungs
○ Pumping blood to systemic ○ Inferior: Diaphragm
circulation ○ Superior: Thoracic outlet
➢ Structures
➢ Inhalation ○ Heart
○ Diaphragm contracts and ○ Great Vessels
flattens ○ Esophagus
○ Intercostals contract ○ Trachea
expanding ribcage ○ Nerves
○ Thorax volume increases ■ Vagus
■ Less internal ■ Phrenic
pressure than ➢ Thoracic Duct
atmospheric ➢ Great Vessels
■ Air enters lungs ○ Aorta
■ Fixed at three sites
● Annulus
○ Attaches to heart
 ■ Internal structures
- Ligamentum Arteriosum continue in motion
- Near bifurcation of ■ Ligamentum
pulmonary artery Arteriosum shears
- Aortic hiatus aorta
- Passes through diaphragm ➢ Age Factors
➢ Superior Vena Cava - Pediatric Thorax: More
➢ Inferior Vena Cava cartilage = Absorbs forces
➢ Pulmonary Arteries - Geriatric Thorax:
Calcification & osteoporosis
Pulmonary Veins = More fractures
➢ Esophagus ➢ Penetrating Trauma
○ Enters at thoracic inlet - Low Energy
○ Posterior to trachea = Arrows, knives, handguns
○ Exits at esophageal hiatus = Injury caused by direct
contact and cavitation
Pathophysiology of Thoracic Trauma - High Energy
= Military, hunting rifles &
Blunt Trauma high powered hand guns
➢ Results from kinetic energy = Extensive injury due to high
forces pressure cavitation
➢ Subdivision Mechanisms ➢ Shotgun
A. Blast - Injury severity based upon the
■ Pressure wave distance between the victim and
causes tissue shotgun & caliber of shot
disruption Type I: >7 meters from the weapon
■ Tear blood vessels & Soft tissue injury
disrupt alveolar tissue Type II: 3-7 meters from weapon
■ Disruption of Penetration into deep fascia and
tracheobronchial tree some internal organs
■ Traumatic diaphragm Type III: <3 meters from weapon
rupture Massive tissue destruction
- Crush (Compression)
■ Body is compressed Injuries Associated with Penetrating
between an object Thoracic Trauma
and a hard surface ● Closed pneumothorax
■ Direct injury of chest ● Open pneumothorax (including
wall and internal sucking chest wound)
structures ● Tension pneumothorax
B. Deceleration ● Pneumomediastinum
■ Body in motion strikes ● Hemothorax
a fixed object ● Hemopneumothorax
■ Blunt trauma to chest ● Laceration of vascular structures
wall
 ● Tracheobronchial tree lacerations
● Esophageal lacerations
● Penetrating cardiac injuries
● Pericardial tamponade
● Spinal cord injuries
● Diaphragm trauma
● Intra-abdominal penetration with
associated organ injury

Pathophysiology of Thoracic Trauma

Chest Wall Injuries Sternal Fracture & Dislocation
Associated with severe blunt anterior
Contusion trauma
- Most Common result of blunt injury Typical MOI
- Signs & Symptoms - Direct Blow (i.e. Steering
Erythema wheel)
Ecchymosis Incidence: 5-8%
DYSPNEA Mortality: 25-45%
PAIN on breathing - Myocardial contusion
Limited breath sounds - Pericardial tamponade
HYPOVENTILATION BIGGEST - Cardiac rupture
CONCERN = “HURTS TO - Pulmonary contusion
BREATHE” Dislocation uncommon but same
Crepitus MOI as fracture
Paradoxical chest wall motion - Tracheal depression if
Rib Fractures posterior
Flail Chest
>50% of significant chest trauma
cases due to blunt trauma Segment of the chest that becomes
free to move with the pressure
Compressional forces flex and
changes of respiration
fracture ribs at weakest points
Three or more adjacent rib fracture
Ribs 1-3 requires great force to
in two or more places
fracture
Serious chest wall injury with
Possible underlying lung injury
underlying pulmonary injury
Ribs 4-9 are most commonly
- Reduces volume of
fractured
respiration
Ribs 9-12 less likely to be fractured - Adds to increased mortality
Transmit energy of trauma to internal Paradoxical flail segment movement
organs
Positive pressure ventilation can
If fractured, suspect liver and spleen restore tidal volume
injury
Hypoventilation is COMMON due to
PAIN
Pathophysiology of Thoracic Trauma - Excessive pressure reduces
Pulmonary Injuries Pneumothorax effectiveness of respiration
- Air is unable to escape from inside
Simple Pneumothorax the pleural space
● AKA: Closed Pneumothorax - Progression of Simple or Open
- Progresses into Tension Pneumothorax
Pneumothorax
● Occurs when lung tissue is disrupted Pathophysiology of Thoracic Trauma
and air leaks into the pleural space Pulmonary Injuries Tension
● Progressive Pathology Pneumothorax Signs & Symptoms
- Air accumulates in pleural
space ● Dyspnea
- Lung collapses ○ Tachypnea at first
- Alveoli collapse (atelectasis) ● Progressive ventilation/perfusion
- Reduced oxygen and carbon mismatch
dioxide exchange ○ Atelectasis on uninjured side
- Ventilation/Perfusion ● Hypoxemia
Mismatch ● Hyperinflation of injured side of
■ Increased ventilation chest
but no alveolar ● Hyperresonance of injured side of
perfusion chest
■ Reduced respiratory ● Diminished then absent breath
efficiency results in sounds on injured side
HYPOXIA ● Cyanosis
● Typical MOI: “Paper Bag Syndrome” ● Diaphoresis
● AMS
Open Pneumothorax ● JVD
- Free passage of air between ● Hypotension
atmosphere and pleural space ● Hypovolemia
- Air replaces lung tissue ● Tracheal Shifting
- Mediastinum shifts to uninjured side ○ LATE SIGN
- Air will be drawn through wound if Pathophysiology of Thoracic Trauma
wound is 2/3 diameter of the trachea Pulmonary Injuries Tension Hemothorax
or larger
- Signs & Symptoms Hemothorax
Penetrating chest trauma - Accumulation of blood in the pleural
Sucking chest wound space
Frothy blood at wound site - Serious hemorrhage may
Severe Dyspnea accumulate 1,500 mL of blood
Hypovolemia - Mortality rate of 75%
- Each side of thorax may hold
Tension Pneumothorax up to 3,000 mL
- Buildup of air under pressure in the - Blood loss in thorax causes a
thorax. decrease in tidal volume
 - Ventilation/Perfusion Pathophysiology of Thoracic Trauma
Mismatch & Shock Cardiovascular Injuries
- Typically accompanies pneumothorax
- Hemopneumothorax
Myocardial Contusion
Pathophysiology of Thoracic Trauma - Occurs in 76% of patients with
Pulmonary Injuries I Hemothorax Signs severe blunt chest trauma
& Symptoms - Right Atrium and Ventricle is
commonly injured
● Blunt or penetrating chest trauma - Injury may reduce strength of
● Shock cardiac contractions
○ Dyspnea - Reduced cardiac output
○ Tachycardia - Electrical Disturbances due to
○ Tachypnea irritability of damaged myocardial
○ Diaphoresis cells
○ Hypotension - Progressive Problems:
● Dull to percussion over injured side Hematoma
Hemoperitoneum
Pathophysiology of Thoracic Trauma Myocardial necrosis
Pulmonary Injuries Dysrhythmias
CHF & or Cardiogenic shock
Pulmonary Contusion
- Soft tissue contusion of the lung Pathophysiology of Thoracic Trauma
- 30-75% of patients with significant Cardiovascular Injuries I Myocardial
blunt chest trauma Contusion Signs & Symptoms
- Frequently associated with rib ● Bruising of chest wall
fracture ● Tachycardia and/or irregular rhythm
- Typical MOI ● Retrosternal pain similar to MI
- Deceleration ● Associated injuries
- Chest impact on - Rib/Sternal fractures
steering wheel ● Chest pain unrelieved by oxygen
- Bullet Cavitation ○ May be relieved with rest
- High velocity ○ THIS IS TRAUMA-RELATED
ammunition PAIN (Similar signs and
- Microhemorrhage may account for symptoms of medical chest
1- 1 ½ L of blood loss in alveolar pain)
tissue
- Progressive deterioration of Pathophysiology of Thoracic Trauma
ventilatory status Cardiovascular Injuries
- Hemoptysis typically present
Pericardial Tamponade
➢ Restriction to cardiac filling caused
by blood or other fluid within the
pericardium
 ➢ Occurs in <2% of all serious chest Pathophysiology of Thoracic Trauma
trauma Cardiovascular Injuries
- However, very high mortality
➢ Results from tear in the coronary Myocardial Aneurysm or Rupture
artery or penetration of myocardium ● Occurs almost exclusively with
- Blood seeps into pericardium extreme blunt thoracic trauma
and is unable to escape ● Secondary due to necrosis resulting
- 200-300 ml of blood can from MI
restrict effectiveness of ● Signs & Symptoms:
cardiac contractions - Severe rib or sternal fracture
(Removing as little as 20 ml - Possible signs and
can provide relief) symptoms of cardiac
tamponade
Pathophysiology of Thoracic Trauma - If affects valves only (Signs &
Cardiovascular Injuries I Pericardial symptoms of right or left
Tamponade Signs & Symptoms heart failure)
- Absence of vital signs
● Dyspnea
● Possible cyanosis Traumatic Aneurysm or Aortic Rupture
● Beck’s Triad ● Aorta most commonly injured in
○ JVD severe blunt or penetrating trauma
○ Distant heart tones - 85-95% mortality
○ Hypotension or narrowing ● Typically patients will survive the
pulse pressure initial injury insult
● Weak, thready pulse - 30% mortality in 6 hrs
● Shock - 50% mortality in 24 hrs
● Kussmaul’s sign - 70% mortality in 1 week
○ Decrease or absence of JVD ● Injury may be confined to areas of
during inspiration aorta attachment
● Pulsus Paradoxus ● Signs & Symptoms
○ Drop in SBP >10 during - Rapid and deterioration of
inspiration vitals
○ Due to increase in CO2 - Pulse deficit between right
during inspiration and left upper or lower
● Electrical Alterans extremities
○ P, QRS, & T amplitude -
changes in every other Other Vascular Injuries
cardiac cycle ● Rupture or laceration
● PEA ○ Superior Vena Cava
○ Inferior Vena Cava
○ General Thoracic
Vasculature
● Blood Localizing in Mediastinum
○ Compression of:
 - Great vessels Traumatic Asphyxia
- Myocardium ● Results from severe compressive
- Esophagus forces applied to the thorax
● General Signs & Symptoms ● Causes backwards flow of blood
○ Penetrating Trauma from right side of heart into superior
○ Hypovolemia & Shock vena cava and the upper extremities
○ Hemothorax or ● Signs & Symptoms:
hemomediastinum ○ Head & Neck become
engorged with blood
Pathophysiology of Thoracic Trauma - Skin becomes deep
Other Thoracic Injuries red, purple, or blue
- NOT RESPIRATORY
Traumatic Esophageal Rupture RELATED
● Rare complication of blunt thoracic ○ JVD
trauma ○ Hypotension, Hypoxemia,
● 30% mortality Shock
● Contents in esophagus/stomach ○ Face and tongue swollen
may move into mediastinum ○ Bulging eyes with
- Serious Infection occurs conjunctival hemorrhage
- Chemical irritation
- Damage to mediastinal Assessment of the Thoracic Trauma
structures Patient
- Air enters mediastinum
● Subcutaneous emphysema and ● Scene Size-up
penetrating trauma present ● Initial Assessment
Tracheobronchial Injury ● Rapid Trauma Assessment
● MOI ○ Observe
○ Blunt trauma - JVD, SQ Emphysema,
○ Penetrating trauma Expansion of chest
● 50% of patients with injury die within ○ Question
1 hr of injury ○ Palpate
● Disruption can occur anywhere in ○ Auscultate
tracheobronchial tree ○ Percuss
● Signs & Symptoms: ○ Blunt Trauma Assessment
○ Dyspnea ○ Penetrating Trauma
○ Cyanosis Assessment
○ Hemoptysis ● Ongoing Assessment
○ Massive subcutaneous
emphysema Management of the Chest Injury Patient
○ Suspect/Evaluate for other General Management
closed chest trauma
● Ensure ABC’s
○ High flow O2 via NRB
○ Intubate if indicated
 ○ Consider RSI - Dress with bulky bandage against
○ Consider overdrive flail segment (Stabilizes fracture site)
ventilation - High flow O2 (Consider PPV or ET if
■ If tidal volume less decreasing respiratory status)
than 6,000 mL - DO NOT USE SANDBAGS TO
■ BVM at a rate of STABILIZE FX
12-16 Open Pneumothorax
- May be beneficial - High flow O2
for chest contusion - Cover site with sterile occlusive
and rib fractures dressing taped on three sides
- Promotes oxygen - Progressive airway management if
perfusion of alveoli indicated
and prevents Tension Pneumothorax
atelectasis ● Confirmation
● Anticipate Myocardial Compromise ○ Auscultation & Percussion
● Shock Management ● Pleural Decompression
○ Consider PASG ○ 2nd intercostal space in
- Only in blunt chest mid-clavicular line
trauma with SP <60 - TOP OF RIB
mm Hg ○ Consider multiple
○ Fluid Bolus: 20 mL/kg decompression sites if
○ AUSCULTATE! patient remains symptomatic
AUSCULATE! ○ Large over the needle
AUSCULATE! catheter: 14ga
○ Create a one-way-valve:
Management of the Chest Injury Patient Glove tip or Heimlich valve
Hemothorax
Rib Fractures ● High flow O2
- Consider analgesics for pain and to ● 2 large bore IV’s
improve chest excursion ○ Maintain SBP of 90-100
- Versed ○ EVALUATE BREATH
- Morphine Sulfate SOUNDS for fluid overload
CONTRAINDICATION: Myocardial Contusion
Nitrous Oxide (May migrate into pleural or ● Monitor ECG
mediastinal space and worsen condition) ○ Alert for dysrhythmias
Sternoclavicular Dislocation ● IV if antidysrhythmics are needed
- Supportive O2 therapy Pericardial Tamponade
- Evaluate for concomitant injury ● High flow O2
Flail Chest ● IV therapy
- Place patient on side of injury ● Consider pericardiocentesis; rapidly
(ONLY if spinal injury is NOT deteriorating patient
suspected) Aortic Aneurysm
- Expose injury site ● AVOID jarring or rough handling
● Initiate IV therapy enroute
 ○ Mild hypotension may be
protective
○ Rapid fluid bolus if aneurysm
ruptures
● Keep patient calm
Tracheobronchial Injury
● Support therapy
○ Keep airway clear
○ Administer high flow O2
○ Consider intubation if unable
to maintain patient airway
○ Observe for development of
tension pneumothorax and
SQ emphysema
Traumatic Asphyxia
● Support airway
○ Provide O2
○ PPV with BVM to assure
adequate ventilation
● 2 large bore IV’s
● Evaluate and treat for concomitant
injuries
● If entrapment > 20 min with chest
compression
● Consider 1mEq/kg of Sodium
Bicarbonate