EMT Standing Order:

• Routine Patient Care.
• If the patient is in shock, see Shock Protocol - Adult or Shock Protocol - Pediatric.
• Impaled objects:
• Do not attempt to remove an impaled object; instead, stabilize it with a bulky dressing or other means. If the impaled object is very large or unwieldy, attempt to cut the object to no less than 6 inches from the patient.
• Open chest wound/penetrating injuries to the chest or upper back:
  • Cover with an occlusive dressing, or use a commercial device. If the patient’s condition deteriorates, remove the dressing momentarily, then reapply. Monitor for tension pneumothorax.
• Flail segment with paradoxical movement and in respiratory distress:
  • Consider positive-pressure ventilation for severe distress.
  • Apply no weight to the flail segment. Do not splint the chest.
• Abdominal penetrating injuries
  • Apply an occlusive dressing.
  • For evisceration, cover the organs with a saline-soaked sterile dressing and then cover it with an occlusive dressing.
  • Do not attempt to put the organs back into the abdomen.
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Paramedic in patient care.
• Minimize scene time.
• See Trauma Triage and Transport Decision Policy.

AEMT/PARAMEDIC Standing Order:

• Establish IV/IO access.
• Administer fluid bolus 500 mL (20 mL/kg for pediatric) 0.9% NaCl IV/IO.
• Consider pain management, see Pain Management Protocol - Adult & Pediatric.
• In the presence of tension pneumothorax, perform needle decompression on the affected side. (See Needle Decompression Thoracostomy (NDT) Procedure)
• For massive flail chest with severe respiratory compromise, consider endotracheal intubation and then assist ventilations.
• For traumatic asphyxia, support ventilations with BVM, establish two large bore IVs and infuse at least 1,000 mL 0.9% NaCl before or immediately after removal of compressive force.

NOTE:

SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX:

• Increasing respiratory distress or hypoxia, AND.
• Increasing signs of shock including tachycardia or hypotension AND one or more of the following:
  • Diminished or absent unilateral breath sounds.
  • JVD (neck vein distension)
  • Possible tracheal deviation above the sternal notch away from the side of the injury (late sign).
  • Tympany (hyper resonance) to percussion on the affected side.

PEARLS:

• Open chest wounds occur when the chest wall is penetrated by some object or the broken end of a fractured rib.
• Chest pain due to blunt trauma may be an indication of underlying injury.
• For blunt chest injuries, consider acquiring and transmitting a 12-lead ECG, if available.
• If occlusive dressing is not available, consider using a bulky dressing to seal open chest wounds.