ENVIRONMENTAL EMERGENCIES
• Pain in the bites area that keeps getting worse
Emergency
• An emergency can be defined as a medical or surgical
condition requiring immediate or timely intervention to
prevent permanent disability or death.
Topics Covered
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
skin.
• When a bite breaks the skin , the wound can bleed and
may become infected from the germs in the biter’s
mouth. Bites that do not break the skin are not usually
serious.
• Be sure to stay away from an animal that is acting
Strangely
Management
• Make sure the scene is safe. Get the first aid kit. Wear
PPE.
• For animal bites, phone or send someone to phone your
emergency response number. (ABTC)
• Clean the wound with aid a lot of running water (and
soap, if available)
• Stop any bleeding with pressure and dressings.
• For all bites that break the skin, call a healthcare
provider.
• If there is a bruise or swelling, place a bag of ice and
water wrapped in a tower on the bite for up to 20
minute
Important
• Animals that carry rabies:
– Cat, dog, skunk, raccoon, fox, bat or other wild animal
– Human
2. SNAKEBITES
• If a snake bites someone, it is helpful to be able to
identify the kind of snake. Sometimes you can identify
the snake from its bite mark. If you aren’t sure whether
a snake is poisonous, assume that it is
Snake Bites- the most frequent poisonous snake bite
occurs from pit vipers. Upper extremities is the most
Signs of Poisonous Snakebites
• Swelling of the bite area or ecchymotic in the site.
• Nausea, vomiting, sweating, and weakness
• Pit viper venom produces both proteolytic (pertaining
to any substances that promotes the breakdown of
protein ) and hemotoxic effects
Emergency Management
Objectives: To remove as much venom as possible and
retard the spread of venom:
Venom may be neurotoxin (effect on nerves and nerve
cells ) or hemotoxic.
1. Make patient lie down as soon as possible.
2. Remove constrictive items such as rings.
3. Provide warmth
4. Clean the wound, cover with a light sterile dressing
5. Immobilized the injured body part below the level of
the heart
Initial evaluation in the ED is performed quickly and
includes information about the following:
a. Whether the snake was venomous or non venomous; if
the snake is dead, it should be transported to the ED
with the patient for identification.
b. Where and when the bite occurred and the
circumstances of the bite.
c. Sequence of events, signs and symptoms (fang
punctures, pain, edema, and erythema of the bite and
near by tissue).
d. Severity
e. Vital signs
f. Circumference of the bitten extremity or area at several
points; the circumference of the extremity that was
bitten is compared to the circumference of the
opposite extremity.
g. Laboratory data( CBC, urinalysis and clotting studies)
Note: Ice, tourniquets, heparin and corticosteriods are
not used during the acute stage. It is contraindicated in
the first 6-8 hrs. ( they may depress antibody production
and hinder the action of antivenin= antitoxin
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:
• a patent airway
• ensuring adequate oxygenation
• restoring vascular volume and
• controlling and counteracting the effects of the
chemical
• mediators released.
Treatment includes:
1. Immediate administration of epinephrine (adrenaline)
1:1,000 aqueous solution
INTRAMUSCULAR- to reverse broncho constriction and
cause vasoconstriction ( repeat after 5 to 10 minutes if no
improvement is seen).
SUBCUTANEOUS – if the patient hasn’t lost consciousness
INTRAVENOUS – if the reaction is severe, life-threatening
situation ( repeating dosage every 5 minutes. If patient is
in cardiac arrest , give high dose IV push and repeat every
3 to 5 minutes)
2. Longer-acting epinephrine, corticosteroids, and
diphenhydramine (Benadryl) and Famotidine (Pepcid)
- histamine blockers to decrease circulating histamine
levels to reduce the allergic response (long term
management).
3. Albuterol (Proventil) nebulizer treatment
4. Aminophylline (Theophylline) to treat bronchospasm
5. Volume expanders to maintain and restore
circulating plasma volume.
6. IV vasopressors such as norepinephrine (Levophed)
and dopamine to stabilize blood pressure.
7. CPR to treat cardiac arrest
4. Poisonous Spider & Scorpion Bites and Stings
• Signs
– Severe pain at the site of the bite or sting
– Muscle cramps
– Headache
– Fever – Vomiting
– Breathing problems
– Seizures
– Lack of response
Management
• Make sure the scene is safe. Get the first aid kit.
Wear PPE.
• Phone your emergency response number (or 911)
• Wash the bite with a lot of running water (and soap, if
available)
• Put a bag of ice and water wrapped in a towel or cloth
on the bite
• See if the person needs CPR. If he does, give CPR, if you
don’t know how, give Hands-Only CPR
5. TICKS
• Ticks are found on animals and in wooded areas. They
attach themselves to exposed body parts.
• Many ticks are harmless. Some carry serious diseases.
• If you find a tick, remove it as soon as possible. The
longer the tick stays attached to a person, the greater
the person’s chance of catching a disease.
Management for Tick Bites
• Make sure the scene is safe, Get the first aid kit. Weak
PPE
• Grab the tick by its mouth and head as close to the skin
as possible with tweezers or a tick-removing device.
• Lift the tick straight out without twisting or squeezing
its body. If you lift the tick until the person’s skin tents
and wait for several seconds, the tick may let go.
• Wash the bite with running water (and soap if available.)
• See a healthcare provider if you are in an area where
tick- borne-disease occur. If possible, place the tick in a
plastic bag and give it to the healthcare provider
B. HEAT-RELATED EMERGENCIES
• HEAT CRAMPS
• HEAT EXHAUSTION
• HEAT STROKE
1. HEAT CRAMPS
• Heat cramps are painful muscle spasms, most often in
the calves, arms, stomach muscles
Signs of Heat Cramps
• Muscle cramps
• Sweating
• Headache
Management
• Make sure the scene is safe. Get the first aid kit.
Wear PPE
• Have the person with heat cramps rest and cool off
• Have the person drink something that contains sugar
and electrolytes, such as juice or a sports drink, or water
if the others aren’t available
Important
• Mild heat-related signs are a warning that the person’s
condition may get worse unless you take action.
• Symptoms of heat-related emergencies often increase
if left untreated
2. HEAT EXHAUSTION
• Is a serious condition that often
turns into heat stroke. It often
occurs when someone exercises
in the heat and sweat a lot
 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:
1. Reduce body temperature as quickly as possible by
the ff. methods:
a. Provide cool sheets and towels or do continuous
sponging with cool water or provide cooling blankets.
b. Apply ice to the neck, groin, chest, axillae while
spraying with tepid water.
c. Perform ice saline lavage of the stomach and colon
( if does not decrease)
d. Emerge the patient in a cold water bath if possible.
2. Massage body and extremities to maintain circulation
and cutaneous vasodilation
3. Start intravenous infusion therapy of normal saline or
lactated ringer solution to replace fluid losses and
maintain adequate circulation.
Give slowly because of danger of pulmonary edema
and myocardial injury ( from increase body temp and
poor renal function )
4. Give valium or chlorpromazine to suppress or control
shivering /seizure activities
5. Give additional supportive measure like
- oxygen therapy
- central venous pressure and pulmonary artery wedge
pressure monitoring.
- ET intubation if necessary.
- potassium chloride for hypokalemia
- NAHCO3 to correct metabolic acidosis
5. Measure urine output – acute tubular necrosis is a
complication of heart stroke from rhabdomyolysis
(myoglobin in the urine)
7. Advice patient to avoid immediate re-exposure to high
heat between 10am-2pm.
Note: Permanent liver, cardiac and CNS damage may
Occur
Diagnostic Test
No single diagnostic test confirms heat stroke
1. ABG results may reveal respiratory alkalosis and
hypoxemia.
3. CBC may reveal leukocytosis and increased Hct
secondary to hemoconcentration. 3. Electrolyte levels
may show hypokalemia. Other blood studies may
reveal elevated BUN level, increased bleeding and
clotting times.
4. Urinalysis may show concentrated urine with elevated
inflammatory
protein levels, tubular casts and myoglobinuria.
C. COLD-RELATED EMERGENCIES
1. FROSBITE
2. HYPOTHERMIA (Low Body temperature)
3. NEAR DROWNING
1. FROSTBITE
• A cold injury to part of the body
• is a trauma from exposure to freezing temperature and
actual freezing of the tissue fluids in the cell and
intracellular spaces.
• It results in cellular and vascular damage
Most Common Body parts affected by Frostbite
• includes the feet, hands, nose, cheeks and ears.
• It ranges from 1st degree (redness and erythema) to 4th
degree (full depth tissue destruction)
Signs of Frosbite
• The skin over the frostbitten area is white, waxy, or
grayish-yellow
• A frostbitten area is cold and numb
• A frozen extremity may be hard, cold, and insensitive to
touch and may appear white or mottled blue-white.
• Skin doesn’t move when you push it
Emergency Management:
The goal of management is to restore normal body
temperature.
1. Do not allow patient to ambulate if the lower
extremities are involved.
2. Remove all constrictive clothing and jewelry that could
impair circulation.
3. Rewarm extremity rapidly by immersing at 37C to 40C
circulating bath for30-40 minutes span. 4. Give
analgesic for pain. ( rewarming method is very painful )
5. Sterile gauze or cotton is placed between affected
fingers or toes to prevent macerations. Observed strict
aseptic technique
6. Give tetanus prophylaxis if ulceration has occurred.
7. Place patient on bed rest with foot cradle if feet are
involved.
a. Elevate the affected parts to help control swelling.
b. Avoid pressure or friction on extremity. Affected
area should be handled gently to avoid further
mechanical injury. Massage is contraindicated
8. Give prophylactic antibiotic and anti
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
ingested. The extent of damage depends on the pH of the
substance, the amount ingested, its form (solid or liquid)
and the length of exposure to it
Emergency Treatment is Initiated with the ff. Goals
1. Remove or inactivate the poison before it is absorbed
2. Provide supportive care in maintaining vital organ
system
3. Administer a specific antidote to neutralize a specific
poison
4. Implement treatment that hastens the elimination of
the absorbed poison
1. SWALLOWED POISONS ( Ingested)
• Swallowed poisoning may be corrosive.
• It includes alkaline and acid agents that can cause
tissue destruction after coming in contact with mucus
membranes
General Nursing Management
1. Maintain airway, ventilation and oxygenation.
2. Treat shock (administer with whole blood) which
results from the cardio depressant action of the
substance ingested, from venous pooling in lower
extremities, or from reduced circulating blood volume
resulting from increased capillary permeability .
3. Support the patient having convulsions. Many poisons
excite the central nervous system or the patient
convulses due to O2 deprivation.
a. Give intravenous phenobarbital (or other
anticonvulsant until specific therapy can be instituted
b. Give positive pressure respiration if 02 is necessary
4.Give analgesic for pain.
5. Watch for fluid imbalance or acidosis
6.Give specific therapy
Administer special chemical antidotes or
special pharmacological antagonist (e.g. nalaxone
hydrochloride (Narcan) as early as possible
Note: If measures ineffective
• Administer multiple doses of charcoal
• Diuresis for substances excreted by the kidneys,
• Dialysis
• Hemoperfusion
7. If due to suicidal attempt, psychiatric consultation is
needed before discharge.
8. Health teaching
Measures to remove poison from patient's stomach
immediately by inducing vomiting.
a. Give 3-4 glassful of milk or water to drink to dilute
poison.
b. Induce vomiting by giving syrup of ipecac or inserting
the index finger or blunt end of the spoon at
the back of the patient's throat.
c. Syrup of Ipecac for alert patient
d. Gastric lavage ( gastric aspirate is saved and sent to
lab for toxicology screening) after Administer activated
charcoal
e. Cathartic when appropriate
f. Do not take more than 5 minutes to induce emesis
• Carry out gastric lavage-to remove any unabsorbed
poison.
Nursing alert:
• This procedure is not done if corrosive or hydrocarbon
solvents has been ingested (gasoline, liquid wax,
kerosene)
• Instruct family to bring unused poison to hospital for
Identification
Diagnostic Test
1. Toxicology Studies including drug screen of
poison levels in the mouth, vomitus, urine, stool or
blood or on the victim’s hands or clothing.
2. CBC and electrolyte, BUN, creatinine, and ABG levels -
evaluate the patient’s renal status and acid-base
balance as well as his blood oxygen ventilation status.
3. Urinalysis – can evaluate the patient’s renal status
because many toxic and caustic substances can be
excreted through the kidneys.
4. Chest xray – may reveal mediastinitis, pleural effusion,
pneumoperitoneum and aspiration pneumonia
5. Abdominal xray – may reveal pneumoperitoneum or
ascitis
Corrosive Poisons
Clinical Manifestations (What to look for)
1. Severe pain, burning sensation in mouth and throat
2. Nausea and Vomiting
3. Destruction of oral mucosa
4. Drooling in children, painful swallowing or inability to
swallow.
5. Abdominal pain or guarding
6. airway obstruction
7. Altered mental status
8. Diarrhea
9. Respiratory distress
Types of Corrosive Poisons
1. Acid and acid like corrosives
Common acid-containing sources include:
a. toilet bowl cleaning products
b. automotive battery liquid
c. rust-removal products
d. metal-cleaning products
e. cement-cleaning products
f. drain-cleaning products
g. soldering flux containing zinc chloride
• 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
INTRODUCTION
Foreign-body airway obstruction (FBAO) (choking) is a
life-threatening emergency. In England and Wales in 2016,
252 deaths from choking were reported, with almost 30%
of these in people aged 80 years and over. Alarmingly,
over 60% of deaths from choking in 2016 occurred in
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
technique is needed to relieve the obstruction (Perkins et
al, 2017).
CAUSES OF FBAO
Choking usually occurs while the person is eating or
drinking and can be associated with muscle, neurological
or cerebral impairment (Pavitt et al, 2017). Most deaths
from choking are caused by food (87%), while small
objects – a particular problem in children – are the cause
of 13% of choking-related deaths (ONS, 2017).
People at increased risk of FBAO include those with any
of the following conditions or characteristics:
• 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
• Geriatrics
• Use of Metered Dose Inhalers
SIGNS OF FBAO
Recognising the signs of FBAO is the key to early and
effective intervention. The context may provide
important clues – for example, choking is common at
mealtimes or a child may have been playing with small
objects.
• A cough
• Struggling to breathe or talk
• Cyanosis
• Grasping or reaching for the throat.
• The patient may go silent and hold or point to their
throat (Universal Sign of Choking).
ASSESSMENT OF FBAO
If FBAO is suspected, it is important to assess its severity
and always ask the patient “are you choking?”. Their
response will help distinguish between a mild or severe
obstructive airway.
SEVERITY OF AIRWAY OBSTRUCTION
Mild airway obstruction (effective cough): patient able
to talk and has an effective cough
Severe airway obstruction (ineffective cough): typically,
patient responds “yes” by nodding their head without
speaking; unable to cough effectively
MILD AIRWAY OBSTRUCTION
Coughing generates high and sustained airway pressures
and may expel a foreign body, so it is important to
encourage the patient to cough. A patient with mild
airway obstruction should remain under continuous
observation until they improve as a severe obstruction
may subsequently develop. Aggressive treatment with
back blows and chest and abdominal thrusts at this stage
is unnecessary – it may cause harm and could exacerbate
the airway obstruction. These interventions should only
be used if the patient shows signs of severe airway
obstruction.
SEVERE AIRWAY OBSTRUCTION
If the patient shows signs of severe airway obstruction:
• Call for help/pull the emergency buzzer immediately
and encourage the patient to cough;
• Stand at the patient’s side, slightly behind them;
• Support the patient’s chest with one hand and lean
them forward – if this dislodges the foreign body, it will
hopefully fall out of the mouth instead of slipping
further down the airway
• If symptoms continue, deliver up to five back blows
(slaps) between the scapulae using the heel of the hand.
• Following each back blow, check to see if the
obstruction has been dislodged; If the back blows fail,
proceed to abdominal thrusts.
• Stand behind the patient, placing both arms around the
upper abdomen;
• Lean the patient forward;
• Place a clenched fist between the patient’s umbilicus
and the ribcage, and clasp it with the other hand;
• Deliver up to five sharp thrusts to the abdomen,
inwards and upwards;
• Take care not to apply pressure to the xiphoid process
or the lower ribcage as this may cause abdominal
trauma;
• If the obstruction remains, alternate up to five back
blows with up to five abdominal thrusts.
AFTERCARE AND REFERRAL
Following successful treatment for an FBAO, a foreign
body may still be present in the airways; if someone has
dysphagia, a persistent cough or complains of having
something stuck in their throat, they should seek medical
advice.
Performing abdominal thrusts and chest compressions
has the potential to cause serious internal injury,
including ruptures or laceration of abdominal or thoracic
viscera, so patients must be examined for injuries.
USE OF AIRWAY CLEARANCE DEVICES
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
CHOKING IN INFANTS AND CHILDREN
Nurses should advise parents to:
• Always cut up food: infants and young children can
choke on small, sticky or slippery foods
• Keep small objects out of reach: infants and small
children examine objects by putting them in their
mouths. Ensure small toys/objects such as building
bricks, button batteries, coins and marbles are stored
out of reach
• Sit children down to eat
• Always supervise infants and young children
MILD AIRWAY OBSTRUCTION
Coughing generates high and sustained airway pressures
and may expel a foreign body, so it is important to
encourage the patient to cough. A patient with mild
airway obstruction should remain under continuous
observation until they improve as a severe obstruction
may subsequently develop.
Aggressive treatment with back blows and chest and
abdominal thrusts at this stage is unnecessary – it may
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
Ineffective Cough (Infants Less than 1 year)
If the patient shows signs of severe airway obstruction:
• Call for help/pull the emergency buzzer immediately
and encourage the patient to cough;
• Deliver up to five back blows (slaps) using the following
procedure:
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
of one hand in the middle of the back between the
shoulder blades. Following each back blow, check to see
whether it has relieved the obstruction
If back blows fail to dislodge the object and the infant is
still conscious, deliver up to five chest thrust
Turn the infant supine with head in a downwards position,
using your arm to support the infant’s back and your
hand to support the head. Your thigh can provide
additional support;
Locate the ‘landmark’ for chest compressions – this is the
lower sternum approximately a finger-width above the
xiphisternum;
Perform up to five chest thrusts – these are like chest
compressions, but sharper in nature and delivered at a
slower rate;
Following each chest thrust, check to see whether the
obstruction has been dislodged;
If the obstruction remains, continue alternating up to five
back blows with up to five chest thrusts
S EVE R E AI RWAY
O B S T RU C T I O N ( I N E F F E C T IVE
C O U G H ) I N C H I L D R E N ( > 1 Y EAR )
If a child shows signs of severe airway obstruction:
• Call for help/pull the emergency buzzer immediately if
in the hospital;
• 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
to see whether the obstruction has been dislodged.
Position the child with their head down (a small child may
be placed over the lap, as described above). If this is not
feasible, support the child into the leaning-forward
position recommended for adults (Fig 5);
If back blows fail to dislodge the object and the child is
still conscious, deliver up to five abdominal thrusts
(Fig 5) using the following procedure:
Position yourself behind the child either standing or
kneeling. Place your arms under the child’s arms;
Place a clenched fist between the umbilicus and
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
chest compressions immediately. It is advised for a lone
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
persistent cough, or complains of having something stuck
in their throat.
As chest/abdominal thrusts and chest compressions can
cause serious internal injury, patients must be examined
for injuries after these interventions have been
performed (Perkins et al, 2017).
CONCLUSION
Professional responsibilities – These procedures should
be undertaken only after approved training, supervised
practice and competency assessment, and carried out in
accordance with local policies and protocols

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
Gun Control Legislation
Improved motor vehicle
restraint systems
- Passive Restraint
Systems
- Airbags
Anatomy and Physiology of the Thorax
Thoracic Skeleton
➢ 12 Pair of C-shaped ribs
○ Ribs 1-7: Join at sternum
with cartilage end-points
○ Ribs 8-10: Join sternum with
combined cartilage at 7th rib
○ Ribs 11-12: No anterior
attachment
Sternum
➢ Manubrium
○ Joins to clavicle and 1st rib
○ Jugular Notch
Body
➢ Sternal angle (Angle of Louis)
○ Junction of the manubrium
with the sternal body
○ Attachment of 2nd rib
Xiphoid process
➢ Distal portion of sternum
Thoracic Skeleton
➢ Topographical Thoracic Reference
Lines
○ Midclavicular line
○ Anterior axillary line
○ Mid-axillary line
○ Posterior axillary line
Intercostal space
➢ Artery, Vein and Nerve on inferior
margin of each rib
Thoracic Inlet
➢ Superior opening of the thorax
➢ Curvature of 1st rib with associated
structures
Thoracic Outlet
➢ Inferior opening of the thorax
➢ 12th rib and associated structures &
Xiphisternal joint
Diaphragm
➢ Muscular, dome-like structure
➢ Separates abdomen from the
thoracic cavity
➢ Affixed to the lower border of the rib
cage
➢ Central and superior margin extends
to the level of the 4th rib anteriorly
and 6th rib posteriorly
➢ 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

- Ligamentum Arteriosum
- Near bifurcation of
pulmonary artery
- Aortic hiatus
- Passes through diaphragm
➢ Superior Vena Cava
➢ Inferior Vena Cava
➢ Pulmonary Arteries
Pulmonary Veins
➢ Esophagus
○ Enters at thoracic inlet
○ Posterior to trachea
○ Exits at esophageal hiatus
Pathophysiology of Thoracic Trauma
Blunt Trauma
➢ Results from kinetic energy
forces
➢ Subdivision Mechanisms
A. Blast
■ Pressure wave
causes tissue
disruption
■ Tear blood vessels &
disrupt alveolar tissue
■ Disruption of
tracheobronchial tree
■ Traumatic diaphragm
rupture
- Crush (Compression)
■ Body is compressed Injuries Associated with Penetrating
between an object Thoracic Trauma
and a hard surface
■ Direct injury of chest
wall and internal
structures
B. Deceleration
■ Body in motion strikes
a fixed object
■ Blunt trauma to chest
wall
■ Internal structures
continue in motion
■ Ligamentum
Arteriosum shears
aorta
➢ Age Factors
- Pediatric Thorax: More
cartilage = Absorbs forces
- Geriatric Thorax:
Calcification & osteoporosis
= More fractures
➢ Penetrating Trauma
- Low Energy
= Arrows, knives, handguns
= Injury caused by direct
contact and cavitation
- High Energy
= Military, hunting rifles &
high powered hand guns
= Extensive injury due to high
pressure cavitation
➢ Shotgun
- Injury severity based upon the
distance between the victim and
shotgun & caliber of shot
Type I: >7 meters from the weapon
Soft tissue injury
Type II: 3-7 meters from weapon
Penetration into deep fascia and
some internal organs
Type III: <3 meters from weapon
Massive tissue destruction
● Closed pneumothorax
● Open pneumothorax (including
sucking chest wound)
● Tension pneumothorax
● Pneumomediastinum
● Hemothorax
● Hemopneumothorax
● Laceration of vascular structures
 ● 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
Pulmonary Injuries Pneumothorax
Simple Pneumothorax
● AKA: Closed Pneumothorax
- Progresses into Tension
Pneumothorax
● Occurs when lung tissue is disrupted
and air leaks into the pleural space
● Progressive Pathology
- Air accumulates in pleural
space
- Lung collapses
- Alveoli collapse (atelectasis)
- Reduced oxygen and carbon
dioxide exchange
- Ventilation/Perfusion
Mismatch
■ Increased ventilation
but no alveolar
perfusion
■ Reduced respiratory
efficiency results in
HYPOXIA
● Typical MOI: “Paper Bag Syndrome”
Open Pneumothorax
- Free passage of air between
atmosphere and pleural space
- Air replaces lung tissue
- Mediastinum shifts to uninjured side
- Air will be drawn through wound if
wound is 2/3 diameter of the trachea
or larger
- Signs & Symptoms
Penetrating chest trauma
Sucking chest wound
Frothy blood at wound site
Severe Dyspnea
Hypovolemia
Tension Pneumothorax
- Buildup of air under pressure in the
thorax.
- Excessive pressure reduces
effectiveness of respiration
- Air is unable to escape from inside
the pleural space
- Progression of Simple or Open
Pneumothorax
Pathophysiology of Thoracic Trauma
Pulmonary Injuries Tension
Pneumothorax Signs & Symptoms
● Dyspnea
○ Tachypnea at first
● Progressive ventilation/perfusion
mismatch
○ Atelectasis on uninjured side
● Hypoxemia
● Hyperinflation of injured side of
chest
● Hyperresonance of injured side of
chest
● Diminished then absent breath
sounds on injured side
● Cyanosis
● Diaphoresis
● AMS
● JVD
● Hypotension
● Hypovolemia
● Tracheal Shifting
○ LATE SIGN
Pathophysiology of Thoracic Trauma
Pulmonary Injuries Tension Hemothorax
Hemothorax
- Accumulation of blood in the pleural
space
- Serious hemorrhage may
accumulate 1,500 mL of blood
- Mortality rate of 75%
- Each side of thorax may hold
up to 3,000 mL
- Blood loss in thorax causes a
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
trauma
- However, very high mortality
➢ Results from tear in the coronary
artery or penetration of myocardium
- Blood seeps into pericardium
and is unable to escape
- 200-300 ml of blood can
restrict effectiveness of
cardiac contractions
(Removing as little as 20 ml
can provide relief)
Pathophysiology of Thoracic Trauma
Cardiovascular Injuries I Pericardial
Tamponade Signs & Symptoms
● Dyspnea
● Possible cyanosis
● Beck’s Triad
○ JVD
○ Distant heart tones
○ Hypotension or narrowing
pulse pressure
● Weak, thready pulse
● Shock
● Kussmaul’s sign
○ Decrease or absence of JVD
during inspiration
● Pulsus Paradoxus
○ Drop in SBP >10 during
inspiration
○ Due to increase in CO2
during inspiration
● Electrical Alterans
○ P, QRS, & T amplitude
changes in every other
cardiac cycle
● PEA
Pathophysiology of Thoracic Trauma
Cardiovascular Injuries
Myocardial Aneurysm or Rupture
● Occurs almost exclusively with
extreme blunt thoracic trauma
● Secondary due to necrosis resulting
from MI
● Signs & Symptoms:
- Severe rib or sternal fracture
- Possible signs and
symptoms of cardiac
tamponade
- If affects valves only (Signs &
symptoms of right or left
heart failure)
- Absence of vital signs
Traumatic Aneurysm or Aortic Rupture
● Aorta most commonly injured in
severe blunt or penetrating trauma
- 85-95% mortality
● Typically patients will survive the
initial injury insult
- 30% mortality in 6 hrs
- 50% mortality in 24 hrs
- 70% mortality in 1 week
● Injury may be confined to areas of
aorta attachment
● Signs & Symptoms
- Rapid and deterioration of
vitals
- Pulse deficit between right
and left upper or lower
extremities
-
Other Vascular Injuries
● Rupture or laceration
○ Superior Vena Cava
○ Inferior Vena Cava
○ General Thoracic
Vasculature
● Blood Localizing in Mediastinum
○ Compression of:
 - Great vessels
- Myocardium
- Esophagus
● General Signs & Symptoms
○ Penetrating Trauma
○ Hypovolemia & Shock
○ Hemothorax or
hemomediastinum
Pathophysiology of Thoracic Trauma
Other Thoracic Injuries
Traumatic Esophageal Rupture
● Rare complication of blunt thoracic
trauma
● 30% mortality
● Contents in esophagus/stomach
may move into mediastinum
- Serious Infection occurs
- Chemical irritation
- Damage to mediastinal
structures
- Air enters mediastinum
● Subcutaneous emphysema and
penetrating trauma present
Tracheobronchial Injury
● MOI
○ Blunt trauma
○ Penetrating trauma
● 50% of patients with injury die within
1 hr of injury
● Disruption can occur anywhere in
tracheobronchial tree
● Signs & Symptoms:
○ Dyspnea
○ Cyanosis
○ Hemoptysis
○ Massive subcutaneous
emphysema
○ Suspect/Evaluate for other
closed chest trauma
Traumatic Asphyxia
● Results from severe compressive
forces applied to the thorax
● Causes backwards flow of blood
from right side of heart into superior
vena cava and the upper extremities
● Signs & Symptoms:
○ Head & Neck become
engorged with blood
- Skin becomes deep
red, purple, or blue
- NOT RESPIRATORY
RELATED
○ JVD
○ Hypotension, Hypoxemia,
Shock
○ Face and tongue swollen
○ Bulging eyes with
conjunctival hemorrhage
Assessment of the Thoracic Trauma
Patient
● Scene Size-up
● Initial Assessment
● Rapid Trauma Assessment
○ Observe
- JVD, SQ Emphysema,
Expansion of chest
○ Question
○ Palpate
○ Auscultate
○ Percuss
○ Blunt Trauma Assessment
○ Penetrating Trauma
Assessment
● Ongoing Assessment
Management of the Chest Injury Patient
General Management
● Ensure ABC’s
○ High flow O2 via NRB
○ Intubate if indicated
 ○ Consider RSI
○ Consider overdrive
ventilation
■ If tidal volume less
than 6,000 mL
■ BVM at a rate of
12-16
- May be beneficial
for chest contusion
and rib fractures
- Promotes oxygen
perfusion of alveoli
and prevents
atelectasis
● Anticipate Myocardial Compromise
● Shock Management
○ Consider PASG
- Only in blunt chest
trauma with SP <60
mm Hg
○ Fluid Bolus: 20 mL/kg
○ AUSCULTATE!
AUSCULATE!
AUSCULATE!
Management of the Chest Injury Patient
Rib Fractures
- Consider analgesics for pain and to
improve chest excursion
- Versed
- Morphine Sulfate
CONTRAINDICATION:
Nitrous Oxide (May migrate into pleural or
mediastinal space and worsen condition)
Sternoclavicular Dislocation
- Supportive O2 therapy
- Evaluate for concomitant injury
Flail Chest
- Place patient on side of injury
(ONLY if spinal injury is NOT
suspected)
- Expose injury site
- Dress with bulky bandage against
flail segment (Stabilizes fracture site)
- High flow O2 (Consider PPV or ET if
decreasing respiratory status)
- DO NOT USE SANDBAGS TO
STABILIZE FX
Open Pneumothorax
- High flow O2
- Cover site with sterile occlusive
dressing taped on three sides
- Progressive airway management if
indicated
Tension Pneumothorax
● Confirmation
○ Auscultation & Percussion
● Pleural Decompression
○ 2nd intercostal space in
mid-clavicular line
- TOP OF RIB
○ Consider multiple
decompression sites if
patient remains symptomatic
○ Large over the needle
catheter: 14ga
○ Create a one-way-valve:
Glove tip or Heimlich valve
Hemothorax
● High flow O2
● 2 large bore IV’s
○ Maintain SBP of 90-100
○ EVALUATE BREATH
SOUNDS for fluid overload
Myocardial Contusion
● Monitor ECG
○ Alert for dysrhythmias
● IV if antidysrhythmics are needed
Pericardial Tamponade
● High flow O2
● IV therapy
● Consider pericardiocentesis; rapidly
deteriorating patient
Aortic Aneurysm
● 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