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Traumatic Dyspnea Barry Jensen, NREMT-P, NCEE EMT Program Director UCLA Center for Prehospital Care [email protected]

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Page 1: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Traumatic Dyspnea Barry Jensen, NREMT-P, NCEE

EMT Program Director

UCLA Center for Prehospital Care

[email protected]

Page 2: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

www.itaccs.com – International Trauma Care

http://www.itaccs.com/
Page 3: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Combat Death

• 31% Penetrating head trauma • 25% Surgically uncorrectable torso trauma • 10% Potentially surgically correctable trauma • 9% Hemorrhage from extremity wounds • 7% Mutilating blast trauma • 5% Tension pneumothorax • 1% Airway problems • 12% Mostly from infections and complications

of shock

Page 4: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Preventable Causes of Combat Death

60% Hemorrhage from extremity wounds

33% Tension pneumothorax

6% Airway obstruction e.g., maxillofacial trauma

* Data is extrapolated from Vietnam to present day Iraq and Afghanistan

Page 5: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

The Fick Principle

These four elements must exist for perfusion to take place

• Adequate oxygen in the alveoli

• Adequate oxygen exchange to the pulmonary capillaries

• Adequate circulation

• Adequate RBC’s, adequate perfusion pressure

• Adequate oxygen exchange into the tissues

Page 6: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Airway

Page 7: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Thorax and Respiratory System

Page 8: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Respiratory Tree and Perfusion

Page 9: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Thorax and Respiratory System

Page 10: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Hypoxia and the Brain

Page 11: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma
Page 12: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Oxygenation

Page 13: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Ventilation

Page 14: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Respiration

Page 15: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Biphasic (Bilevel) Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure (CPAP)

• Two Levels (10/5) vs. One Level (10)

• Indications

• Contraindications

Page 16: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Primary Assessment

Scene

Responsiveness

Airway

Breathing

Circulation

Disability / Deformity

Environment / Expose

Page 17: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Assessment and Interventions

• Intervene During Primary

• Secondary on-scene vs. enroute

• Most ALS on the way to hospital

Page 18: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Pulse Oximetry

• Measures oxygenation

Page 19: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Capnography

• Measure ventilatory status

• ETCO2 35-45 mm Hg is the normal value for capnography

Page 20: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Hyperventilation

http://medicscribe.com/capnography/ 11/10/2013

http://medicscribe.com/capnography/
http://medicscribe.com/capnography/
Page 21: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Hypoventilation

Page 22: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Intubated?

Page 23: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Arterial Blood Gas

• Partial Pressure of CO2 (PaCO2) and Oxygen (PaO2) in blood and pH

Page 24: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

MECHANISM OF INJURY

Page 25: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Front Impact

Page 26: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Lateral Impact

Page 27: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Pedestrian

Page 28: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Typical Pediatric Pattern and Considerations

Page 29: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Ultra slow motion footage of several thousand pounds of black powder exploding, showing very clearly the otherwise invisible shock wave. Music: Paul Haslinger, www.youtube.com 11/6/2012

http://www.youtube.com/
Page 30: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Mechanisms of Blast Injury

• Primary

• Over-pressurization wave

• Gas filled structures

• Lungs

• GI Tract

• Middle Ear

Page 31: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Blast Lung

Page 32: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Hanging or Near-Hanging?

Page 33: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma
Page 34: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Case

32 y.o. in traffic accident, 70 mph frontal impact, unrestrained

Chest exam reveals diminished breath sounds on the left, dullness on percussion

You hear …

Page 35: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Acute diaphragmatic rupture occurs in 1% to 7% of patients after major blunt trauma and the diagnosis is missed on initial presentation in up to 66% of these patients. Only about 10% diagnosed in acute phase of treatment.

Page 36: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

How Would You Manage This Patient?

Page 37: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Upper Airway

Page 38: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma
Page 39: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Severe facial injuries after intubation on scene.

P P B et al. Emerg Med J 2012;29:767-768

Copyright © BMJ Publishing Group Ltd and the College of Emergency Medicine. All rights reserved.

Page 40: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Figure 1: A 19-year-old Afghan man sustained extensive facial injuries and lost parts of his

left forearm and left lower leg after a blast from an improvised explosive device, causing

extensive soft tissue, neurovascular and bone injury.

Macdonald J C , Tien H C CMAJ 2008;178:1133-1135

©2008 by Canadian Medical Association

Page 41: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Needle Cricothyrotomy Procedure

Page 42: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma
Page 43: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Why Would This be Needed?

Page 44: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Combat Device

Page 45: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Pneumothorax on X-Ray

Page 46: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma
Page 47: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

How would you intervene?

Page 48: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

What Potential Injuries?

Page 49: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

How would you intervene?

Page 50: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

CASE STUDY: “ROLLOVER”

Page 51: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Mechanism

Page 52: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Scene Size-Up

• Saturday, 0754

• Dispatch directs you to a car collision on the outskirts of town

• Highway patrol have diverted traffic

• There is one patient

• The fire department is already on scene, scene is safe

Page 53: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Initial Assessment

• Awake, supine, lying on ground

• A: Open, patient is moaning

• B: Rapid rate; labored, decreased tidal volume

• C: Skin pale, cool, dry; pulse rapid, weak, regular

• D: Severe due to pain, GCS: 3-3-5=11

• E: Obvious facial bruising and swelling with some right neck swelling

Page 54: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

• What is your general impression of this patient?

Page 55: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

General Impression

• Patient’s airway may be compromised

• She may have impending respiratory failure

• She is in probable shock (hemorrhagic)

Page 56: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

• What are your initial management priorities?

Page 57: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

BLS Management Priorities

• Place patient in spinal immobilization

• Give 15L O2 by non-rebreather mask

• Place patient in supine for shock

• Initiate rapid transport

Page 58: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

ALS Management Priorities BLS management plus . . . • Re-evaluate airway/breathing

• Establish 2 large bore IVs en route to trauma center

• Apply cardiac monitor en route

Page 59: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Rhythm?

Page 60: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Case Progression

• Sinus tachycardia @ 136

• Accessory airways not tolerated

• The patient is loaded on a backboard into the ambulance without difficulty

• Transport initiated to the nearest ED with lights and sirens

• En route the patient’s breathing becomes more labored

Page 61: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Additional Assessment

• Vital signs: RR 32, HR 136, BP 82/53, Wt 50kg

• S: Facial pain, shortness of breath, abdominal pain

• A: Unknown

• M: Unknown

• P: Unknown

• L: Unknown

• E: Patient was unrestrained driver whose face hit the windshield (“spidered”); there is steering wheel damage

Page 62: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Detailed Physical Exam

• Head: pupils midrange, reactive; facial edema and crepitus over cheeks with deformity

• Neck: swelling on right side; no JVD or tracheal deviation

• Lungs: clear and equal bilaterally

• Chest: no signs of trauma

• Abdomen: soft, non-tender, no distention

• Pelvis: stable, nontender, no instability

• Extremities: stable, nontender; no obvious trauma

Page 63: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Case Progression

• En route, the patient becomes unresponsive, and her O2 saturation drops to 80%

• Repeat VS: RR 6, HR 42, BP 60/p

• Teeth are clenched

• Cannot visualize the vocal cords

Page 64: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

• What do the vital signs indicate?

• What are your options for airway management?

Page 65: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Case Progression

• Patient is in respiratory failure

• Options:

• Assist ventilation with bag-mask

• Attempt intubation again - use paralytic

• Perform needle cricothyrotomy

• Bag-mask ventilation is difficult because of facial deformities

Page 66: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Case Progression

• Needle cricothyrotomy is successful; you are able to oxygenate the patient

• You arrive at the emergency department 5 minutes later without further incident

• The patient was taken to the operating room within 3 minutes of arrival

• A tracheostomy was performed

• She has facial surgery and exploratory abdominal surgery

Page 67: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

Case Outcome

• She was found to have multiple facial fractures and a ruptured spleen

• She was hospitalized in the ICU for 1 week and was discharged after 3 weeks

• After 2 more facial surgeries, she was doing well

Page 68: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma
Page 69: Traumatic Dyspnea - UCLA CPC Causes of Combat Death 60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

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