Airway
- Chin lift, jaw thrust, head tilt –> 14 gauge needle through cricothyroid membrane or surgical cricothyroidotomy with #5 or #6 tube)
- Breathing (rate, rhythm, air entry, O2 sat)
- Circulation
History: ?accident, ?mechanism of injury
Physical:
- Inspection – lack of chest movement, broken ribs, flail chest
- Percussion – hyperresonant in pneumothorax, full in hemothorax, may have a pneumohemothorax
- Palpation
- Auscultation – decreased air sounds
- If tension pneumothorax: hypotension, distended neck veins, no breath sounds, hyperinflation, tracheal deviation, CP, increased work of breathing
- Place a 14 gauge needle in 2nd IC space midclavicular line (above 3rd rib)
- If tension pneumothorax: hypotension, distended neck veins, no breath sounds, hyperinflation, tracheal deviation, CP, increased work of breathing
Placing a chest tube
- Clean area
- Lidocaine freezing
- Incision above 6th rib in 5th IC (or 4th IC) space along anterior axillary line
- Bluntly dissect down with Kelly’s
- May use more freezing once intercostals are visible (block intercostals nerves)
- Pop through pleura and spread with Kelly’s and feel with finger
- Place a 32 french CT using Kelly’s directed superiorly and posteriorly
- Attach to under water seal suction at 20 mmH2O
- Check patient’s tetanus status –> treat if appropriate