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The speaker discusses various medical conditions related to the lungs and chest trauma. They explain the use of a flutter valve to treat collapsed lungs and the importance of monitoring for attention pneumothorax. They also mention hemothorax, pericardial tamponade, and rib fractures as potential complications. The speaker emphasizes the need for rapid transport and medical intervention in these cases. who's digressing over that with the flutter valve. Every time I exhale, air comes out, and it kind of inflates that a little bit, and it gets better and better. We should hope so anyway. Or we can come in an ALS, and I can stick a needle between the second and third intercostal space. Right there. Needle goes in, pull out the needle, leave in the catheter, and you hear, whoosh. If the patient's conscious, they'll go, ah, I can breathe, I can breathe. If the patient's unconscious and you're bagging them, all of a sudden your partner will be like, oh, I can squeeze the bag again, this is great. You get good compliance with the bag. Open chest wounds, often called an open pneumoburts or a sucking chest wound, it will lead to a new attention pneumo if you don't treat it. There must be rapidly sealed inclusive dressing. I'm gonna slap my gloved hand on it, and then I'm gonna put an inclusive dressing right away. If it's bleeding a lot, I'll pack it, then put the inclusive dressing on it. That flutter valve is a one-way valve that goes over the wound itself. You'll see it when you open up one of those. Definitely monitor the patient for attention. What is the best way I can identify attention pneumo? By doing what? Listening. Listening to lung sound, very good. They should be equal, right to left. And if they're not, you make note of it. When you check them five minutes later, do they sound the same or is it even more muscle? That means it's getting worse. So that's basically what it is. Penetrating wound, air travels in and out of that, and as it gets trapped in that, it causes the collapsed lung. So what we wanna do is we want the air to come out without going in. That's what that flutter valve does. A simple pneumo does not cause changes in the patient's cardiac physiology. It doesn't change, right? It doesn't get worse. Patients can develop a condition called a spontaneous pneumo. Some patients can get it if you have smokers. Patients with Marfan's syndrome. Marfan's disease is a condition of, it's a connective tissue disorder. And so they have very long, thin extremities, and they have weakened joints, and sometimes weakened organs. And what happens is you get weakened lung tissue, the lung parenchyma, as they call it, you develop a bleb, like a little bubble, and it pops, and then you develop a pneumothorax. I had a friend who had, years ago, he had, when I was in the check-catching business, he had Marfan's disease, and he used to come in, because he used to do construction, and he wouldn't come in for a couple weeks, and he'd walk in, I'm like, I had another pneumo. He said, yeah, last I coughed, or I jumped off a truck or something, something caused the little bleb to pop, and he developed a simple pneumo. It didn't get worse, it was just there, he couldn't feel it, he had to go to the hospital, they put it in a chest tube, he got antibiotics for a few days, then he had to go home, and he was better. But it can get worse. Simple pneumo, the most common cause of it is blunt trauma that results in rib fractures, and those ribs pop the lung tissue. It can develop into a tension pneumo, and again, if a patient doesn't have a tension when you get them, and they develop one, you're doing something wrong. So tension pneumothorax results from ongoing air accumulation in the pleural space. Increased pressure in the chest causes a complete collapse of the unaffected lung to the unaffected lung, and it also collapses the heart, leading to that Vax triad in the cardiac tamponade. And that's basically what it is. And so we put the occlusive dressing in, feel it, boom. Now this won't get any worse, but it's not gonna get better. But if I were to put the occlusive dressing with the flutter valve, then every time I exhale, the air would come out, but no air would come in, and this would slowly begin to reinflate. Very slowly, but it would. So if you do that, you put that occlusive dressing on, then you call ALS. We'll completely reinflate it by doing a pneumothoracentesis. A hemothorax, blood collects in the pleural space from bleeding around the ribcage or from the lungs or great blood vessels. This we can't fix in ALS. I can't stick a needle in and aspirate out the blood. It doesn't work that way. So that one has to go to the hospital. They need a chest tube for that. And that's what it would look like. This is a full hemothorax like Reagan had. This is a pneumohemo with some blood and some air. The air will fill up much faster when you have a pneumohemo. More commonly, you're gonna have a pneumohemo or a hemodermal. So signs and symptoms would be shock without obvious external bleeding or apparent reason for shock. So you're gonna have a patient with some form of lung trauma or some form of thoracic trauma, whether it be penetrating or blunt. Signs of shock, but you don't see any external bleeding. No reason why they're in shock, but they're in shock having shortness of breath. And you're like, okay, hemothorax. Decreased breath sounds on one side, so there's something going on in that lung. Rapid transport. A cardiac tamponade, so we talked about this. The cardiac tamponade is caused by the tension pneumo. It's the collapsing of the lung. This is a pericardial tamponade. This is blood fills up in the pericardium, and the pericardium is very fibrous and tough. It doesn't expand, so what happens is it compresses the heart in this direction. As you can see right here, this is what happens. Now, this could be blood, this could be fluid from a pericarditis, a myocarditis, it could be cancer, whatever the case may be. And so what happens is we have to aspirate that blood out. I had a friend years ago, we owned an MS school together, and he had atrial fibrillation with atrial quivers. So the treatment for that is they put you on an EKG, and they put you in atrial fibrillation if you're not already in it. And then they burn parts of the atria until they find that pathway that produces the ectopy, the improper heart rate, and the dysrhythmia. Once they burn it, all of a sudden the heart rate goes back to normal. It's called ablation. And they can use heat ablation, thermal ablation, or cryoablation. So he had thermal ablation. So they go in and they burn it, and they stop the atrial fibrillation. But they nicked his myocardium, didn't notice it. So for about a day, day and a half, he started developing a pericardial tamponade. That was blood. So they realized it brought him in the OR, and they aspirated out the blood. They did what they call pericardial synthesis. They stuck a needle in his chest and aspirated out the blood and left it. Thought that was fine. It wasn't fine because he started bleeding again because they didn't fix the problem. So he had to go back in, have open-heart surgery, and they had to suture the nick that they did, the laceration, and then he was fine after that. That is actually a skill. It's taught in ATLS, Advanced Thrombolytic Supports, and Doctors and EDs, but it's actually taught to EMS services. We don't do it around here because we have short transport times, but if you go up to Colorado where they have three, three and a half hour transport times, they actually teach this. You pull the ambulance over, because you never do this in a moving ambulance, but you pull the ambulance over, you hook this long cardiac needle to the EKG and you insert it in the chest, and once you touch the myocardium, you see a jump on the monitor display. You're like, I'm in the pericardium, and you aspirate out that blood, and it works, saves lives. We don't do that around here. I don't know if I'd ever want to. I suppose if I had to, I could, but I wouldn't want to. So cardiac camponade or pericardial camponade, either one will produce that sex triad of symptoms, which is the muscles, heart tones, narrowing, pulse pressure, signs of shock, JVD, with altered mental status. What is the treatment? Support ventilations, rapid transport. You can call ALS, we'll come, but there's not a lot we can do for it either. Who's not around here? Rib fractures, common, particularly in older people. Older people fall more, so that's why it's more common. You know, it's more common and they have weaker bones, so they get motor vehicle crash, they break a rib. They fall against the bureau, or they fall against the bed or the banister, or against the door, and they get rib fractures. Very common. It's important to understand, as we go down the rib cage, these ribs get bigger, don't they? If I took a stick that was this big and snap it, right? Very easy, because I got a lot of, I got a good fulcrum, I got a lot of force. What about a stick this small? You ever try and break a stick that small? You can't do it, it's physics. These ribs are much harder to break than these. So especially in the elderly, a fracture of the first, second, or third ribs has a 60% mortality rate in the elderly, because it's a significant more force to break those than it is these. Fractures of the rib behind the scapula has a 60% mortality rate in the elderly, because the scapula protects the ribs. If you fracture a rib behind the scapula, a significant force was applied to the body in order to do that, okay? A fractured rib could cause a pneumothorax, a hemothorax, a pneumo... Pneumothorax. Signs and symptoms, would that... How do you transport it if it's broken in the back? You'd have to, you transport if the patient can tolerate it and it's not contraindicated, you can sit them up. I put a collar on them and have them sit up like in a modified trained elephant bird. I wouldn't have them lie flat, unless I had to. Signs of most likely, if they suffer that kind of a fracture, they'd probably be unresponsive anyway, and then you can put them on a backboard. So signs and symptoms of a rib fracture. Localized tenderness and pain when breathing. It hurts right here. Ah, they're gonna be able to tell you that. You're gonna be able to palpate, feel that crevice. You're gonna see the damage, the injury, right? The discoloration. Rapid shallow respirations, they'll be holding that affected portion. Oh, it hurts. Treatment in oxygen, call ALS. Now, broken bone is a BLS skill all day. We call it ALS for pain management. If I have a broken rib, Tylenol and ibuprofen's not gonna cut it. They need fentanyl to be able to take a breath. If I breathe like this long enough, I can develop the condition called anelectasis. That's a collapsing of the alveoli, which can lead to pneumonia. And that's it, that's classic right there. It's a flannel segment. There's three ribs broken in two or more places. So two or more ribs broken in two or more places. Does wrapping it help at all? No, well, wrapping it does help, but what happens is wrapping can cause constriction of respiration, and I'll be honest with you. We used to do that. We used to wrap, and then they used to take bulky dressings and tape them on to keep it, but what happens is they found that didn't make much of a difference and it actually restricted breathing. So now we don't do that at all. If you want to take a blanket or a towel and have them hold it like that, that doesn't really restrict their breathing, but it kind of keeps it stable a little bit, but the only way really to correct it is to ventilate. Can you tell me what anelectasis is again? Anelectasis is a collapsing of the alveoli. And you actually fight that once a minute. You don't even notice that. It's a modified form of respiration. A sigh, you ever notice that? Now you guys will watch for it. Everybody, watch. Watch people once a minute about, everybody goes, it's a sigh. Sigh is a modified form of respiration. It fights anelectasis. So pre-hospital treatment, maintain the airway, provide respirations if necessary, especially for the flail segment. Give supplemental oxygen and perform ongoing assessments. You want to watch those complications, the development of the pneumothorax, or the tension pneumo, you don't want that. Flail chest, treatment includes positive pressure ventilations with the BVM. We do not restrict the chest wall anymore. Although, again, a blanket or a pillow, hold it with your arm, that does help. Flail chest may indicate a serious internal damage because, again, if it takes that kind of force to cause that break, those ribs are rubbing against one another, they can cause damage to blood vessels. A pulmonary contusion. A flail segment will cause a pulmonary contusion. It will also cause a pneumothorax. Should always be suspected in a flail segment because, again, those ribs go in. Pulmonary alveoli become filled with blood, leaving the hypoxia, causing an exponential loss in oxygenated area. Pre-hospital treatment, have the patient sit up, bag them if necessary, high flow O2, and transport. These patients with a pulmonary contusion may have hemoptysis, coughing up blood. It's one of the more common causes of hemoptysis. Sternum fractures. The sternum, this is pretty stable. You fracture the sternum, you're taking a lot of force against the chest, so a cardiac contusion is not uncommon. You got a 40-year-old man, you take his pulse, it's irregular. Sir, do you have a cardiac history? No. Have you ever been told you have an irregular heartbeat? No. You took a shot to the chest, classic presentation for a cardiac contusion, causes an irregular heartbeat. If it's bad enough, you can end up with cardiogenic shock. Clavicular fractures. Underneath each rib is an artery vein and a nerve, we call it a neurovascular bundle, that feeds that intercostal muscle. Underneath the clavicle, you have a neurovascular bundle too but they're not small blood vessels like here. That's your subclavian artery, your subclavian vein, and the subclavian nerve that runs down becomes your brachial nerve. So those are large blood vessels. You can have a clavicular fracture that fractures the clavicle, ruptures one of those blood vessels, and you can exsanguinate into your thoracic cavity. You can bleed to death from a clavicular fracture. That's one of the guys, remember we talked about slinging a swath of clavicle injury? That's why we immobilize it so those bone ends don't rub together and cut blood vessels. This is traumatic asphyxia. This is a rapid compression of the chest. As you can see right here, it looks like he either got run over or something hit him right here. I'm thinking a tire or something landed on him like that and it rapidly compressed the chest. As you can see, he has bilateral chest tubes. He's obviously dead, you can tell that. You see all this blotching right here, all these red blotches? This is called faticia. This is red blood, these are bloods, capillary blood, but capillary beds have all popped. And it's like, we call it faticial hemorrhage. But you see the bluing, it's probably a better picture in your book, but you see the bluing, that's cyanosis. So the patient will have the cyanosis with the faticial hemorrhage, right? You can even look at his chest, because look it, one nipple's up here, one's way over here. Look at the shape of the chest, right? Looks like his chest was crushed, okay? Patient will have distended neck veins, that JVD, probably bloodshot eyes, a bloody nose, the faticial hemorrhage in the face, along with signs of cyanosis. Traumatic insistence suggests an underlying injury to the heart and a pulmonary confusion. Oh, I guarantee, especially if the sternum is involved, there is a cardiac and pulmonary injury. Penitentiary support, call ALS, you may have to, we may have to intubate this patient, which is not a fun thing to do. Blood pile, cardio injury, bruising of the heart muscle, the heart may be unable to adequately pump blood, cardiogenic shock. You're gonna have an irregular heart pulse rate, chest pain, it hurts right here, and it may hurt on inspiration, because the sternum will be affected as well. Suspect in all cases of severe blood injury to the chest, carefully monitor the pulse, the blood pressure, oxygenation, and transport. Comotional cortis, also known as traumatic arrest. It's a trauma to the heart that stops the heart. So, we talked about the blood, we talked about a rhythm, right? So, if we look at it, that's one complex, that's one heartbeat. This is the P wave, that's the atria contracting, this is the QR and the S, that's the ventricle contracting, and that's the T wave, that's the ventricle refilling. The atria refills, but it's buried in here, in the QRS. So, in this heartbeat, there are two stages. One right down the center of the QRS. This is the relative refractory period, this is the absolute refractory period. So, during the relative refractory period, if I hit the heart, electrically shocked it, or I hit it, it will probably throw an extra beat, an ectopic beat, it'll contract again. But at this point, if it hits here, it usually goes to about mid of the refilling of the ventricle, repolarization of the ventricle. In this area, if you hit the heart, what'll happen is it'll throw the heart into what we call tombstones, which is also known as, which is a form of ventricular fibrillation, okay? This is one of the reasons why you, if you go to football games, basketball games, baseball games, any EMS, you're supposed to have an AED with you, because this is what happens. When I was first in the Army, obviously we didn't have AEDs back then in the field, and we used to teach the pre-cordial pump. Hold your hand about 12 inches above the chest and just let it drop. That delivers about five to 10 millivolts, the equivalent of a five to 10 millivolt charge across the heart, which is enough to possibly get it started again. You don't do this. It's not like wrestling or anything. I remember reading about, maybe seven years ago, it was a story I read about a girl, her fiance, she came home one day, she was taking karate, and she thought she was all cool. You know, the one heart punch, the death punch? She said, I can stop your heart by punching you in the chest. So he said, yes, go ahead, show me a bit. So she punched him in the chest. She hit him at the exact relative refractory period, chopped his heart open. Didn't survive. She didn't get charged because she didn't mean to do it. It was literally a joke. She didn't think she could do it. So that happened. Last year, year before, the football player got hit in the chest. Remember that? He's playing now, he's back to play. No better. It didn't do any better for him. But he got hit in the chest and stopped his heart. They got out on the field, started CPR, they shocked him like three times or four times, but they got his heartbeat back and he survived. Same with you. You go to a baseball game or some form of a sport and you arrive and you're there and this happens. Start CPR and put the AED on right away. You will get that patient back. The AED will shock their heart back again. So just remember that. It's called traumatic arrest. Commercial accordance. Lacerations of the great blood vessels. Again, rapidly fatal. You lacerate the aorta, 70 milliliters of blood come out each heartbeat. So every minute, you've got 70 beats at 70 per beat. That's you could lose all of your blood volume in a minute. Doesn't take long. These can be rapidly fatal, sometimes even within a matter of seconds. So what are we gonna do? CPR, bag them, transport. Your chances of getting, depends on how big the laceration is. There's a potential if you get them to the hospital fast enough that they can stop the bleeding, transfuse them and fix it. Highly doubt it. These patients will literally die in front of you. They'll be in the front seat. They took a traumatic trauma to the chest. You'll be talking to them and as they're cutting the car around the patient to get them out, the patient starts trailing off. They start to turn cool and pale, shortness of breath. They start getting more and more obtunded and they literally die right in front of you. So what do we do? When the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration, the resulting injury that kills almost one third of patients, sometimes within seconds. Oh, I just thought I saw that word on her hand. What's that? She just don't need this stuff. T. I just talked about it. The aorta's tearing, right, T. Right, the tearing of the aorta. Happens in T-bones and lateral injuries, lateral spins and sometimes in rollovers too. Size and symptoms of chest wall injury include all the following except we are not gonna speak in chest wall injuries. Asymmetric chest movement. Wait, that means chest injury, yeah. Asymmetric means uneven. Oh, I thought that's what that meant, sorry. Symmetrical means they're working evenly. So asymmetrical means one's moving one's chest. So which one? Which one? Pain, but hematemesis. What is this? What's A? Coughing up blood. Coughing up blood. What's B? Vomiting up. Vomiting up. Vomiting is from the GI tract, right? Not pulmonary. Hematemesis. And that's partially, you see coughing around looking and it looks like partially digestive blood. During the assessment of a patient who was stabbed, you see an open wound to the left anterior chest. Your most appropriate action should be cover the wound with an occlusive dressing. Your bare hand, or not your, no. Take that back. Gloved hand. Your gloved hand, please. And then an occlusive dressing. Don't put your bare hand on anything. When caring for a patient with signs of pneumothorax, your most immediate concern should be what's gonna kill a patient faster than anything else? Which one? Yes, ventilatory inadequacy. See, very good. Airway. It's always about airway first. That's why it comes first on the list. What purpose does the one-way flutter valve that's built into the commercial occlusive dressings we use now, use in a patient with a pneumothorax? It keeps the oxygen out, like it keeps air out. Well, it does keep air out, but it doesn't let it come in. Well, no. It allows air to come out without going back in. It's meant to keep air. It's meant to allow air to come out. Right. So it allows the release of trapped air in the portal space without allowing more air in, to reverse the pneumothorax. Signs of cardiac tamponade include all the following, except, remember what the next triad is. Which one are you not going to see? Is it CJV, or JVD? It's JVD. What does JVD stand for? Jugular vein distension. So you're not gonna see collapsed jugular veins, right? You're gonna see distended, blood's backing up because the heart's not beating properly. So the answer is C. A patient experiences a severe compression to the chest with a trap between a vehicle and a heart. You have a trap between a vehicle and a brick wall. You suspect traumatic asphyxia because of the hemorrhages to the sclera of the eyes. His eyes are all bloodshot. And which other sign? You're gonna see cyanosis of the face and neck with petechial hemorrhage, this pinpoint red rupture in the blood vessels. A 14-year-old baseball player was hit in the chest with a line drive using cardiac arrest. What happened? C. Comotio. Comotio cortis, yeah. Latin for cortis is for muscle. And then comotio means motion. So it's like something, motion, stop motion. Paralogical chest movement is typically seen in patients with a flail chest. Two or more ribs broken and two or more flails. Very good. A 40-year-old man who was on the street for a driver of a car that hit a tree at high speed struck the steering wheel with his chest. He has a large bruise over his sternum and an irregular pulse of 120. He's 40 with an irregularly tachycardia. Is that what I'd expect to see? It may be tachycardia because he just had an accident and he's scared, but should it be irregular? So what do you think happened? Which one? B or A? Why did you say A? What is a myocardium? Your heart muscle. So if he has an injured heart muscle, what's he gonna do with his pulse rate? It's gonna make it irregular. An irregular pulse in a patient that normally doesn't have one after a trauma, classic. And this is difficult. Bruised myocardial contusion is a difficult thing to identify, even in the ER. But that's what they look for, that irregular pulse rate. Any questions on that stuff? All right, why don't you take a quick five and then we'll get into the next chapter, which really is the first chapter of this tonight. You got a warning? Yeah. I'm telling you to get back in line. Oh my. I don't know what you mean. I don't know what you're talking about. We're hands on. Air doesn't get in, but air will come out. Now, there are two. The old-fashioned ones just sealed it. The new one has to flutter down. But then why would they, like ALS, do the one that releases the air? Well, we want to release the air to reinflate the lung. We can rapidly reinflate. Your acoustic resting is gonna do it slowly. We can rapidly reinflate with the needle decompression. I don't remember it at all, where it kind of releases. No, because the air gets in. Oh. I want to keep the air from going in and allow it to come out. Oh, that's what I'm worrying about. Right. I'm sorry. It's fine. It's fine. It's fine. It's fine. It's fine. It's fine. It's fine. It's fine. 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How you doing? Good, awesome. How you doing? You're doing pretty well. Oh, is that the, that's the one I showed you the other day. Mm-hmm. You see this? That's the kind with the new inflatable circle collar. Oh, one size fits all? Pretty much. But then you have to keep it inflated though. That's, that's just a regular, that's a BP cuff inflation. Pretty much, yeah. They deflate. Yeah, not really. It's impressive. It occurs with people a lot. Yeah. And that's interesting. Yeah. Check this out. Great. Check it out. Ooh. Ooh, that is good. You can use it to scrape. Ah, things. These things. Oh, I saw that. Yeah. And then pull the tips, don't. H's and T's. Oh, it's pretty cool, I thought. It's pretty cool. Should we give that to you for free? Yeah, it's a little bit camera-like, but. It's pretty cool. You can use it to, you know, keep it in your wallet or something. Yeah, no, it's cool. And you can have it, so. Keep it in your pocket. And hey, you know. You'll always have it in your pocket, so you just keep it in there. Exactly. It doesn't take up any space or anything like that. And then what'll happen is, you'll refer that a few times, and then you'll memorize it, you'll never look at it again. Exactly. And you have it if you need it. It's not, so. Yeah. So, it's a fun time, though, isn't it? It's pretty cool. There's a lot of interesting stuff there. Yeah, those expo's are great. Yeah. How much was it to get in? So, it's $2.50 per day, if you go for like a lecture and everything, but they just see Exhibit Hall itself is free. Oh. That box was so good. Yeah, so they just want you to go. They, yeah, you have to pay, because they gotta pay those presenters. Exactly. Otherwise, the expo, they just want people to show up, so they can sell stuff. Yeah, it's pretty cool. A guy out of Maine, who, he bought a, utility bought from LA Fire, had it shipped back to Maine, and he found, oh no, yeah, he found it in storage. Then, from LA Fire, they bought, he bought like a Dodge, or something like that. They didn't exact replica. Oh, nice! I love how they do that. And. But it's not the original. It's not. Even like all the gear, and everything like that. That's hard to find that gear. Sorry, he found all the, all the hard to find. That's hard to find that stuff. Hold on, hold on. It was impressive. Like, you know, it's not the real thing, but to see it up close like that, it was cool. That's awesome. Yeah. I'm sure I'll do it again. I'm 24. You'll hear that, I'm probably doing it again. Oh, okay. It was a good time. You had some fun. I know, I did. I'm doing it again, probably. Yeah, it's funny. Yeah, it is. Thank you. Good morning. Good morning. Tomorrow we're coming. Tomorrow's class. No, not tomorrow. Tomorrow. Yes, tomorrow. Tomorrow at the garden. Yes, it is. What's our room number? What does it matter? It's the same one. I know it's the same one. I know it's the same one, but I don't know the room number. What's the room number? I wanted to ask you if you know any, know any, I only really saw around here, because most of them are... Yeah, when I first came here, what do they have? Do they have a TV program? TV. TV. TV. Not that much. Yeah. We have a presentation here, and then when we move here from there... So, basically, it's a Princeton... You'd have to work it out. Three times. Right, right. Oh, God. You may end up in New Hampshire, and then Princeton, but we've already printed them out. And you still have to meet. But I'm here in Delphi, and Princeton doesn't matter. We're kind of the back side. Yeah, yeah. Because you must get... So, I'm 15 minutes. I mean, it's fine. If you want to do that, you can get 20 minutes from me. For those who don't write, I'm a New Hampshire partner. All right, let's get back to it.