Sucking Chest Wounds and Exsanguinations, by Walker in the Woods

Wednesday, Dec 14, 2011

With all of the injuries that we learn to treat in the Army’s combat medic training program, there are two killers that must be addressed immediately after any contact with the enemy. The first is the sucking chest wound... and I have to say, these quite frankly, suck. Forgive the humor but they do just that. The medical field describes these wounds as this: Sucking Chest wound- a wound received by way of penetration or laceration to the thoracic cavity which causes air and or blood to be trapped in the pleural space. Air is sucked through the wound during exhalation and then is trapped, causing pressure. This pressure slowly builds and will eventually cause the pressure to be applied to the heart. This pressure will eventually cause hypoxia and cardiac arrest as the lungs cannot draw in enough oxygen to keep the body going or the heart will be pressed to the point that it cannot function. This of course will lead to death. When treating these types of wounds, the medic must assess whether or not there is an exit wound, and whether or not bleeding can be successfully stopped without causing further bleeding inside the chest cavity. If there is an exit wound, that wound must be covered with thick gauze padding and then an occlusive dressing (occlusive means that air cannot pass through.) this means using a piece of plastic to cover the gauze then tapping the whole thing down making sure to seal all four sides. Once this is accomplished the next step is to cover the entrance wound with an occlusive dressing, again sealing it on all four sides. This being done there are several things one must monitor.

Breathing: This will be the most telling of vital signs, respiration rates will tell you whether or not there is a problem inside your patient’s chest cavity. Look for increased and/or increasingly strained respirations from your patient. If the respiration rate goes up and they are straining harder and harder to breath then you will need to find out what is going on inside the chest. Do this by listening to the chest on both sides with a stethoscope. If there are decreased lung sounds on the injured side you must let the pressure out somehow. The easiest and safest way to do this is to perform a needle chest decompression. This is a procedure that will alleviate pressure in the chest cavity and allow your patient to breathe easier. To do this you will want to find the second and third rib on the side with reduced lung sounds. This is usually just in line with the armpit. Once you have this location, find the pint on this rib that is also in line with the nipple. To do this you will need a 14 gauge angiocath that is 3.25 inches long. Place the tip of the angiocath at the place where the two lines meet and just above the third rib. Insert the angiocath until you hear a hissing sound. This is the air escaping through the lumen of the needle. Then advance the catheter portion of the needle and remove the actual needle itself. This will leave the catheter in the chest cavity. Now tape this down without covering the hole at the top and place the patient on the injured side if he is unconscious. If the patient is conscious then place him or her in a position of comfort. This will usually be sitting up with the hands on the knees or a variation of. We call this the tripod position. Get the patient to advanced medical care as soon as possible and monitor the patient’s breathing and blood pressure every five minutes. At no time should the patient be left alone, even for a second as the patient is very likely to become worse if left unmonitored.

Exsanguination is another term for massive hemorrhage. This will lead to hypovolemic shock and death if ignored and is the number one cause of preventable battlefield deaths in the combat world. The usual suspect of a wound that will cause this would be arterial damage that is not checked or stopped by the body’s natural defenses. This can be caused by amputation, laceration from flying debris, penetrating trauma that damages the vascular system sufficiently that the body cannot stop the flow and also by blunt trauma. In an austere environment there is not much you can do to actually permanently treat many of the injuries that cause this. Surgery is not a thing to take on lightly and never without proper training.

To stop any bleeding the first step is to apply direct pressure to the wound itself. After two to five minutes most bleeding will have stopped as the body will have had a chance to clot the area that is open. However, you will want to bandage the area with clean bandage material if it is available and apply a pressure dressing to it to keep pressure on it. If the injury is more severe than what pressure may fix then you will want to apply pressure to the artery that feeds the limb with blood. Once bleeding has stopped bandage as necessary.

With arterial bleeds that jet out bright red you will need to tourniquet the limb as close to the trunk of the body as possible. Do this as soon as possible as well as this will lessen the amount of blood lost and will keep the patient from going into hypovolemic shock. Once you have the tourniquet on, write the time and date it was placed on the patient in a visible area and also chart it on a record of the injury. The tourniquet is safe up to twelve hours but may cause some nerve and vascular damage if on for too long. Make sure that the patient is moved to medical help as soon as possible. This will ensure that the limb is not lost due to necrosis (dead flesh) and will also ensure the patient will get the wound closed as soon as possible. To avoid further infection of the wound place a bandage with plenty of gauze to cushion the wound and protect it from further injury.

My last bit of information in this article is to add a note from my personal experience. As a medic I see many things that will probably be with me the rest of my life. At the time it happens I have to remain calm and not let the patient know that the injury is as bad as it is. And at the same time I cannot be an uncaring automaton that simply follows a set of steps and forgets the part of the equation that matters most at that time, the patient. When dealing with a serious injury you will get freaked out, feel nauseous; want to yell at everyone around you and everything else in the world that will distract you from treating the patient. Remember, the worst thing you can do when coming up on a patient who is conscious and screaming because his leg just got crushed or blown off is say: "Oh Sh**". Remain calm, and do what you need to do, and remember to talk to him or her and try to keep them calm. If you have medical training and have been in the field long enough, you know how it all clicks off and your training comes to the fore. Use this to keep yourself from making a mistake, as it could cost someone their life.

Remember that this article in no way shape or form takes the place of proper medical training; I always suggest that people take at least a first aid course. First responder’s course is better as it covers some cardiac related issues and also some more advanced airway techniques but can be pricey and time consuming. I also want to point out that these things I have discussed in this article are considered advanced medical techniques and as such, I recommend that you use them only if there is no way to get help in time. To perform most of these you will need medical equipment that can be bought online and through medical supply stores. If you own an IFAK medical kit then you will have a good but limited selection of medical supply that will help in some of the extreme cases that I have outlined here so it would be a great idea to get one if you do not own one already.

And as always, please do not let prepping be all consuming, if you are missing house payments because you just bought that new rifle or that truckload of MREs, then you are missing the point. Disaster preparedness is not about praying for something to go wrong, it is a hedge against hard times. We should all live our lives to the fullest, and if you can find a way to do that and be prepared at the same time then you will be a much happier person. Take care and keep your eyes open, and failing that, listen closely to the signs that are given. Live long and love deeply.

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