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painiac's Essential Guide to Physical Assessment Skills: Part 2, Cardiothoracic Issues, Respiratory Complaints, and Chest Pain


People frequently present to the Emergency Room for evaluation with a complaint of chest pain, shortness of breath, or both. There are numerous possible causes, ranging from minor to life-threatening. Diagnosis is often made simple with laboratory testing and Xray/CT imaging, but this may not always be available.

There are a lot of lung diseases that this primer cannot cover, since a diagnosis is only possible with the resources of a hospital.

The only essential equipment for assessment is a stethoscope. A blood pressure cuff is useful, too, but isn't strictly necessary. A pulse oximeter may also be helpful, but is expensive and not necessary in most circumstances.

The following equipment may be necessary for interventions:
Supplemental oxygen and tubing with nasal cannula
Non-rebreather mask
Emergency blind airway
Bag-valve mask with ambu bag
14g needle for chest decompression
Chest tube and drainage canister setup
Occlusive dressing such as a HALO chest seal
IV fluids (usually just 0.9% Normal Saline) and IV supplies

If you are implementing any of the above interventions (with the possible exception of supplemental oxygen and IV fluids), urgent evacuation to a hospital is mandatory. Many of these conditions will require at least a few days in an Intensive Care Unit.



Underlying Anatomy
The thoracic cavity contains the heart, lungs, and blood vessels. The diaphragm is a muscle that borders the bottom of the thoracic cavity, through which the esophagus passes.

When the diaphragm contracts, the area inside the thoracic cavity increases which creates negative pressure, and consequently the atmospheric pressure causes the lungs to fill with air. It's the same principle as drinking with a straw: you're not forcefully sucking air in. Oxygenated air (room air is about 21% oxygen) enters past the epiglottis in the throat through the trachea, down the main bronchus, splits off into the left and right bronchus, which then branches throughout the lungs into increasingly smaller air passages which finally end in tiny sacs called alveoli. In the alveoli, which together comprise a huge amount of surface area, blood passes close to the surface, and oxygen molecules are exchanged for carbon dioxide molecules. When the diaphragm relaxes, the area inside thoracic cavity decreases and the air is pushed back out of the lungs, taking the carbon dioxide waste with it. Problems in the lungs are either an issue with air flow, or with gas exchange.

The heart consists of four chambers: the two smaller upper chambers are the atria, and the two larger lower chambers are the ventricles, which all alternately contract to pump blood throughout the body. Blood first enters the atrium on the right side of the heart from the major veins of the body, then passes through a valve into the right ventricle. The right ventricle pumps the blood to the vessels in the lungs, where gas exchange takes place in the alveoli. The now-oxygenated blood then enters the left atrium, then is passed through a valve into the left ventricle. The left ventricle then contracts and pumps the oxygenated blood out through the major arteries out to the rest of the body.



Primary Assessment
The initial (primary) assessment looks at the good old "ABC's": Airway, Breathing, Circulation. If one or more of these is a problem, you must implement some intervention before proceeding with your secondary assessment. You'll be evaluating the quality of the pulse and breathing, but leave the actual measurement of vital signs for your secondary assessment.


Airway:
Is the airway open, or is it obstructed? If the patient is speaking to you, their airway is open. You may be able to hear wheezing or stridor without the aid of a stethoscope, which indicates airway constriction or partial obstruction. If they are unconscious, feel for air movement from the mouth and nostrils, while observing the chest for expansion. Both sides of the chest should rise and fall symmetrically.

An airway obstruction can be a foreign object (food, broken teeth, etc), vomit, blood, swelling (from trauma, burn, or allergic reaction), or it can be positional. A conscious patient will automatically protect their own airway, but an unconscious or barely conscious patient cannot.

Positional airway obstruction is resolved by the head tilt chin lift to place the head in a sniffing position. Take care not to hyper-extend the neck, which can counter-productively obstruct the airway. Infants and young children require only a slight tilt to the head, closer to a neutral position, to open the airway. If any possible mechanism of injury would lead you to suspect a cervical spine injury, do NOT tilt the head: instead stabilize the cervical spine and perform a jaw thrust maneuver.

An oral or nasopharangeal airway may be indicated, as may intubation. The standard disclaimer applies: do not attempt any artificial airway if you're not trained and qualified to perform these procedures. Note that if you intubate a patient, you've committed to deliver respirations for them (hopefully with an ambu bag!) for the duration.

If swelling is the cause of airway obstruction, you need to get the patient intubated IMMEDIATELY. Particularly if there is any obvious burns or soot around the mouth and nostrils, or any history of facial trauma, high heat exposure, or chemical inhalation, you need to intubate promptly because airway swelling will progress suddenly and will likely be fatal if you don't intervene.


Breathing:
Are their respirations easy, labored, or absent?
If the patient has ineffective oxygenation or perfusion, they will begin to take on a bluish or cyanotic color, particularly in the fingertips and lips. Any problem with airway or breathing is an indication for supplemental oxygen, UNLESS the patient is hyperventilating from an anxiety attack. If breathing is absent or inadequate, provide artificial breaths. A bag-valve mask with ambu bag is ideal, mouth-to-mouth is not so ideal. We will listen to their lung sounds during the secondary assessment to get a better idea of what might be going on.


Circulation:
If the patient is breathing, feel for the patient's pulse at the radial artery (on the inner wrist below the base of the thumb). Use the pads of both your index and middle fingers at the same time to feel for a pulse: do not use the pad of your thumb, because you have a small artery there that could cause you to mistake your own pulse for that of your patient's. If the patient is not breathing, instead feel for the pulse at the carotid artery (along the side of the anterior neck at the base of the jaw).

At this point, we mainly want to feel for the quality of the pulse: is it strong, weak, or absent? A very weak pulse is described as "thready", which is an ominous finding and indicates that the organs are not being perfused. If absent, or if it's weak and the patient is unconscious, start chest compressions. Current ACLS guidelines for out-of-hospital CPR is to provide continuous chest compressions, and to dispense with rescue breaths altogether.

You can (kind of) very roughly estimate blood pressure based on the strength of the pulse: If you can feel a radial pulse, the systolic blood pressure is probably at least 90. If you cannot feel a radial pulse, feel at the femoral artery in the inner thigh just below the inguinal fold: if you can only feel a femoral pulse, the systolic blood pressure is probably between 70-80. If you cannot feel a femoral pulse, feel at the carotid artery along the side of the anterior neck at the base of the jaw: if you can only feel a carotid pulse, the systolic blood pressure is probably around 60. Note that this is a very rough estimate, and I believe it was removed from ACLS protocols because it is not to be relied upon for accuracy: the point is, if you can't find a good pulse, or you're questioning whether you can feel the pulse or not, you need to start chest compressions because the pulse isn't strong enough to perfuse the organs.

Is there any bleeding? Superficial bleeding is not a concern at this point, but will give clues to deeper injuries which you will investigate during your secondary assessment. Bright red blood that is spurting out of a wound is an arterial bleed that needs to be addressed right now. Apply direct pressure. For severe arterial bleeding on an extremity, don't spend a whole lot of time before escalating to a tourniquet. (I'll probably cover lacerations in another guide.)


AVPU:
Simultaneously, assess the patient's level of consciousness. Are they alert? Or do they respond to verbal stimuli? Or will they only respond to a painful stimuli? Or are they unresponsive to any stimuli? (AVPU is shorthand for Alert, Verbal, Painful, or Unresponsive)


As time and circumstances permit, proceed to the secondary assessment which goes into more detail.


Mass Casualty Triage
Under normal circumstances ("normal" emergencies, if you will), those patients who are most critical receive the highest priority because those are the patients who might be saved. We bring to bear all of the tools and resources of modern medicine that are likely to provide benefit to them. However, in an incident with an overwhelming number of casualties, we simply cannot dedicate limited staff and resources to highly critical patients who are unlikely to receive higher-level care in time to save them. It sucks, but reality sucks sometimes. If you tie up all of your resources performing CPR on a dead patient, not only will that patient not survive, but several other people who might have been saved could also die because they didn't receive help or you didn't have any resources to help them with. For this reason, there's a quick and dirty algorithm that gets activated in a mass-casualty incident.

If they have relatively minor injuries ("walking wounded") are green tagged as low priority.

If they have a respiratory rate less than 30, a radial pulse, good capillary refill, and good mental status they are yellow tagged as delayed priority.

If they are unconscious and not breathing effectively, position them to open the airway. If they then begin breathing spontaneously and effectively, they are an immediate priority.

If they have a respiratory rate great than 30, do not have a good radial pulse, have delayed capillary refill, and/or do not obey command, they are red tagged as immediate priority.

If they do not begin breathing spontaneously or are not breathing effectively, then are black tagged as deceased/expectant and moved to the morgue area as soon as practical.


Secondary Assessment

Collect a set of vital signs.

Temperature:
Should be between 97.0 and 98.9 degrees Fahrenheit orally. A temp below 97 may indicate hypothermia, but may also indicate that they were mouth-breathing or just drank something cold. You need a core (rectal) temperature to confirm hypothermia. A fever usually indicates an infection, often viral. Hypothermia results from environmental exposure or from some metabolic problems (such as low blood sugar). Essential chemical reactions inside the body can only take place within a narrow range of temperatures: anything greatly outside this range is, in technical terms, "incompatible with life".

Severe hypothermia results in increasing confusion, then death. Hypothermia slows necessary chemical reactions. The flip side to this is that controlled hypothermia can increase the chance of resuscitation.

A fever is not an illness, but the body's reaction to some illness. A low-grade fever between 99 and 101 does not require any treatment. In a child, a fever is not usually a concern up to 102 degrees, unless the child is acting lethargic. A fever of 104 or greater puts the patient (and particularly a child) at risk of a febrile seizure. Fevers above 102 should be treated with alternating doses of acetaminophen and ibuprofen every 3 hours (so that each dose of acetaminophen comes 6 hours after the previous dose of acetaminophen, and each dose of ibuprofen comes 6 hours after the previous dose of ibuprofen). You might also try cold packs under the arms and neck, but do not immerse the patient in cold water. Especially do not under any circumstances immerse the patient in alcohol, because the alcohol fumes themselves can precipitate a seizure.


Blood pressure:
Textbook normal is 120/80. The first number the systolic pressure, which is the pressure in the circulatory system when the heart contracts. The second number is the diastolic pressure, which is the pressure in the circulatory system when the heart is relaxed. A systolic pressure above 140 is considered hypertension. A systolic above 190 and/or a diastolic pressure above 100 is too high, and puts you at higher risk of a stroke. Children have a slightly lower normal systolic blood pressure: to calculate it, multiply their age in years by two and then add 70. (For example, a 7 year old would be: 7 x 2 + 70 = 84 systolic).

Blood pressure will be elevated above normal when the patient is experiencing pain or anxiety. A systolic pressure below 80 is not sufficient to perfuse the organs, so IV fluids are often necessary. A blood pressure below 60 is usually time to start chest compressions.


Heart rate:
Don't waste a lot of time counting the pulse unless it is very irregular: count for 15 seconds and multiply the result by 4 to get the rate per minute. The exception is infants, who have a very fast irregular heartbeat: to get an accurate rate, you have to use a stethescope and listen to count their heart rate for a full minute. For adults and adolescents, feel a radial pulse. For children, feel for the pulse at the brachial artery on the inside of the upper arm.

The pulse rate should be between 60-100 for adults and adolescents. Athletes will have a lower resting pulse rate, sometimes as low as 40-60. Babies have a normal pulse rate between 100-200, decreasing to 100-140 for toddlers, 75-120 for school-aged children.

Respiratory rate:
Don't waste a lot of time: count for 15 seconds and multiply by 4 to get the rate per minute. Note that if you tell the patient you're counting their respirations, they will be conscious of their breathing and the count may be altered. I prefer to count respirations while the patient has a thermometer in their mouth so they aren't talking and aren't thinking about their breathing. A normal rate is 12-18 for an adult, up to 40 for infants, up to 25 or 30 for toddlers, and 12-28 for the elderly. A high respiratory rate is an indication of distress or anxiety, and a low rate is indicative of some type of respiratory failure.


Oxygen Saturation:
A pulse oximeter shines red light through a fingertip (typically) to a sensor which then calculates the degree to which the hemoglobin molecules in the blood are saturated with oxygen molecules (known as the "SpO2"). A good range is 90-99%. Normally a sat below 90% is a finding that oxygenation is inadequate, and supplemental oxygen is indicated.

If you're giving supplemental oxygen and the sat is 100%, you should consider decreasing or stopping the oxygen because studies are showing a correlation between high oxygenation and poorer survival rates, because high concentrations of oxygen are harmful to tissue.


Pain:
If present, is rated on a scale of 1 (almost no pain) to 10 (worst pain imaginable). This scale is subjective, but gives you a baseline against which you evaluate the success of treatments.


Next, collect a SAMPLE history (Signs/Symptoms, Allergies, Medications, Past Illnesses, Last Meal, Events). Get this from the patient if possible, or family may be able to provide it.

Signs/Symptoms:
Symptoms are things the patient reports or complains of such as pain, shortness of breath, itching, etc.
Signs are objective things that can be seen or measured such as bleeding, swelling, elevated blood pressure, etc.

Allergies:
Particularly to medications, but also to food, bee stings, etc. This is not only important to what medications can be used, but may shed some light on the cause of the current situation. I always ask initially, then ask again before administering any medications. Believe it or not, people sometimes don't bother to mention deadly allergies the first time you ask.

Medications:
What medications does the patient take, and why? Note that a large percentage of people have no idea what they take or why ("well, it's a little white pill..."), but may be able to provide a list. If time permits, you might be able to contact their pharmacy to obtain their current list of medications.

Past Illnesses:
What medical problems does the patient have? It's very useful to know if the patient has any cardiac or lung history, and whether they are a current or former smoker. Getting a good history can be like pulling teeth. People frequently say they don't have any history of high blood pressure or heart disease, while taking five medications for high blood pressure and heart disease. Or they omit important history because they don't see how it's relevant. Or they genuinely forget.

Last Oral intake:
May be relevant in this case to food allergies.

Events:
Leading up to present problem. Also, how long they've had their complaint.


Mental status:
Is the patient alert, lethargic, or unconscious? If alert, do they answer your questions appropriately? Are they oriented to their name, location, time/date, and situation? If so, they are said to be "Alert & Oriented x4", or "A&O x4"". If disoriented to one or more, you have to specify to which. In the 10 years I've been working, I've only ever encountered one person who said they didn't know their own name or birthday, and they had very advanced dementia. Most elderly patients don't know the year. Confusion (from lack of perfusion to the brain, severe dehydration or electrolyte imbalance, head injury, advanced infection, etc) may cause people to not know where they are, what the date is, or even why they are talking to you. Mental status will be the first thing to change when things start to go wrong in the body, and the elderly are even more susceptible to this.


Lung sounds:
You've already determined the airway to be open in your primary assessment. If the patient is responsive have them breathe deeply and exhale while you listen to their lung sounds with your stethoscope. The textbooks will show you couple dozen areas to listen throughout all the lung fields, but you really only need to listen to 8 key areas. Start with one side of the chest and then listen to the same point on the opposite side so you can compare. Listen at the spot below each of the clavicles, then on each side near the bottom of the ribcage, then on each side of the upper back above the shoulder blades, then on each side of the mid back near the bottom of the ribcage. These main areas will give you a pretty good overview, and you can listen to more areas if you hear anything suspicious.

Lung sounds should be clear throughout.

If the patient is not moving a lot of air, or simply not taking deep breaths, the lung sounds will be dim but clear throughout, and more dim in the lower posterior lung fields.

A wheeze is a high-pitched sound that occurs at the end of inspiration (inhaling) and at the beginning of expiration (exhaling), and is an indication of a narrowing of the smaller airways. This narrowing can be the result of swelling, smooth muscle constriction, congestion, secretions, scarring, foreign bodies, or a mass (such as a tumor).

Wheezes that occur only on expiration are not as problematic as wheezes with inspiration. You can usually determine if a wheeze originates from the upper or lower airways.

If they're a smoker, you'll typically hear dim lung sounds with wheezes scattered throughout, which are indicative of chronic inflammation and poor air movement.

Stridor is a high-pitched sound, usually described as a "musical" tone that occurs with an upper airway obstruction such as asthma. These are often audible (meaning you can hear it without the aid of a stethescope).

Crackles are heard when the terminal airways are not open like they should be. You can't actually hear air moving through the alveoli, but you can hear the tiny airways that lead to them popping open from the pressure if inhalation. To get an idea what crackles sound like, pinch some of your hair between two fingers and then slide your fingertips together right in front of your ear. Crackles can be fine or coarse.
Crackles are an indication of inflammation, swelling, and/or the accumulation of secretions. Crackles primarily indicate either pneumonia or fluid overload.

Heart Sounds:
Listen on the left side of the anterior chest. The sound of the heartbeat should be strong and clear.

You can listen over many points of the heart to hear various things, but if you aren't a cardiologist most of what you hear will be of no consequence to you. For instance, you may hear a heart murmur, which is a "whooshing" sound that indicates blood is regurgitating due to a faulty heart valve. Murmurs are typically chronic and typically cause no symptoms. Many children have a murmur which resolves as they get older. Make a note of it and move on.

Feel for the radial pulse at the same time you are listening to the heart: you should feel the pulse a fraction of a second after you hear each heartbeat.

Is the heartbeat regular, or irregular? A young person will almost always have a regular pulse, and many elderly patients will have an irregular pulse due to a heart arrhythmia. They may be able to tell you if they have a history of this, but a new-onset irregular heartbeat (particularly if the rate is rapid) will likely be the root cause of shortness of breath.

If the heart sounds are muffled or "distant", this is a sign that you might be dealing with fluid or air in the pericardial sac that surrounds the heart. If enough accumulates in that sac, the pressure prevents the heart from pumping blood efficiently. This is an emergency that needs to be drained with a needle. Obviously, only a trained physician should be poking at the heart with anything.

Also check for brisk capillary refill by lightly pressing on the fingernail (or the side of the fingertip, if they're wearing nail polish) to create blanching. When you release the pressure, the skin should turn pink within within a second or so and this indicates good peripheral circulation. If perfusion is poor, the capillary refill will be delayed by several seconds.



Complaints and Problems

Chest Pain:
When we think of chest pain, the first thing that comes to mind (with good reason) is a heart attack. The technical term is "myocardial infarction", or "MI", which is when a blockage occurs in the arteries that supply the heart, and the heart tissue begins to die. This results in pain, pressure, and/or tightness in the chest (left, right, midsternal) or back, and may also travel to the jaw or down the (usually left) arm. Diabetics will sometimes not experience any pain because they often develop neuropathy. Shortness of breath and/or dizziness are also common. This will proceed to shock and death.

It is not possible to definitively rule out an MI without a 12-lead electrocardiogram (ECG or EKG) and a serum troponin level. An ECG shows electrical conductivity across the heart tissue, which becomes disrupted in measurable ways that show where the damage is occurring. Troponin is a chemical that is reasonably specific to cardiac muscle, which leaks into the blood when the heart tissue is damaged. We check this upon presentation to the ER, and then check it every 4 hours for the following 12 hours to watch for elevation. Obviously, this is not possible without a laboratory.

Incidentally, you can pay a hefty chunk of change to buy ECG leads that plug into your smartphone, though you still have to know how to read their output. But... under normal circumstances outside of a hospital, this critical testing is not possible.

It should go without saying that you should NOT use this primer to attempt diagnosis of chest pain in yourself or anyone else instead of seeking emergency medical assistance. Do not practice medicine without a license. With that disclaimer out of the way, there are many signs and symptoms that come along with chest pain of different causes that might point you in another direction.


Muscle strain:
Frequent coughing, such as from a severe cold or from pneumonia, will often strain muscles attached to the ribs. This will typically present as soreness that increases with coughing or deep inspiration, and will be mildly to moderately tender to touch.


Pneumonia:
Infection and resulting inflammation in one or more lobes of the lung. This usually causes cough and fever, and can progress to the point where it causes shortness of breath.

Listening to the lungs with your stethoscope, you will hear coarse crackles in the affected lung fields.

You will describe the patient's cough as dry, hacky, or moist. Also ask whether or not they are coughing up any sputum (productive or non-productive). If productive, ask about the color of the sputum: white, tan, brown, yellow, green, blood-tinged. Smokers typically cough up tan or brown crap. Contrary to popular belief, yellow versus green does not distinguish between a bacterial or viral cause. Coughing up blood is a classic sign of tuberculosis, but a blood tinge in the sputum much more likely originates from very minor bleeding in the nose or throat.


Costochondritis:
Inflammation where the ribs attach to the sternum. This will present as midsternal chest pain that is tender to touch and usually worsens with deep inspiration. This can occur without any obvious precipitating history.


Pleuritis:
inflammation of the membranes that separate the lungs from the chest wall, which causes the membranes to rub together rather than sliding smoothly across each other. This is very painful with every breath taken. With your stethescope, you can hear a pleural rub (the membranes rubbing together), which kind of sounds like rubbing your palm on a balloon.


Anxiety:
Can directly cause chest pain, which resolves when the anxiety goes away. Anxiety can be a primary problem, but can also result from chest pain or particularly from shortness of breath. People can get into a feedback loop: they have difficulty breathing so they feel anxious, which causes difficulty breathing, and this causes more anxiety which makes it even more difficult to breathe. An anti-anxiety medication is very helpful.


Hyperventilation:
Sometimes an anxious person will breathe very rapidly. This over-breathing makes them blow off more carbon dioxide than normal. In trying to compensate for this, the blood becomes alkalotic, which causes tingling in their extremities and lips. This tingling sensation usually makes these people alarmed, because in their already anxious state they believe something is seriously wrong. The old trick of breathing into a paper bag helps, because it forces them to inhale more carbon dioxide. The good news is that even if you can't get them to concentrate on slower breathing, hyperventilation is a self-correcting problem: eventually they will pass out, and their breathing will return to normal. If you were to bother checking pulse oximetry in a hyperventilating patient, it will be 100%. Do not treat their shortness of breath with supplemental oxygen!


Anaphylaxis:
An allergic rash does not usually progress to respiratory involvement, but any swelling involving the face or neck (angioedema) is an emergency, because occlusion of the airway is often not far behind. An epi-pen is a great idea, and you should have a low threshold for intubation. Benadryl and a steroid are also commonly used.


Dizziness/Syncope:
A common complaint is feeling dizzy or passing out (syncope). A heart dysrhythmia is a prime suspect, but a more common cause is dehydration. If they've been feeling ill and have vomiting and diarrhea, you can probably lean towards dehydration. These patients will usually feel better lying down.

Orthostatic vital signs can be instructive: check a blood pressure and pulse while the patient is lying supine, then while the patient is sitting, and again while the patient is standing. If you get a significant drop in blood pressure with standing (more than 20 or 30 systolic), this tells you that a blood pressure drop is the cause of their syncope. This is known as "orthostatic hypotension". If the blood pressure stays pretty level but you get a jump in pulse rate, this means the body is compensating for this problem. A bolus of IV fluid will usually correct this.

If instead they feel like the room is spinning, or the dizziness is not relieved by lying flat, you're likely dealing with an inner ear issue. Labyrinthitis is an inflammation in the inner ear, which throws off the sense of balance.


Inhalation or Burn injury:
The history will be your guide here if it can be obtained. As discussed in the Airway portion of the Primary Assessment, any signs of burns, soot, or visible chemical residue around the nostrils and/or mouth are great clues. If somebody is able to tell you what chemical is involved, consult the Material Safety Data Sheet for any special considerations regarding decontamination and treatment.


Carbon monoxide poisoning:
This type of inhalation injury bears special mention. Carbon monoxide is given off by the burning of carbon-based combustible materials, and it will accumulate to a dangerous concentration In an area that is not well-ventilated. When inhaled, carbon monoxide molecules bind to hemoglobin in the blood more strongly than do oxygen molecules. Symptoms start with headache, and then a steady decline in mental status from confusion to unconsciousness to death.

The body has trouble stripping the carbon monoxide from hemoglobin, and the carbon monoxide greatly reduces the amount of oxygen the blood can carry. However, since a pulse oximeter only reads how saturated your hemoglobin is, you will actually get a reading of 99% or 100%. That's why history is so important. There is a detector for carbon monoxide that is essentially a more sophisticated pulse oximeter that can distinguish between oxygen and carbon monoxide molecules in the blood.

The only treatment is high-flow oxygen or even keeping the patient in a hyperbaric oxygen chamber (though the effectiveness of this is controversial): in other words, supportive care until the blood can return to its normal oxygen-carrying capacity.


Trauma:
Any history of chest trauma can obviously point away from a heart attack as the cause of the pain. However, circumstances may indicate that trauma (car accident or fall) might have actually resulted from a loss of consciousness caused by a sudden heart attack or other cardiac issue.

In assessing chest trauma, look for any bruising or swelling, seatbelt abrasions, lacerations or other wounds. Also look for "paradoxical movement" of an area of the chest, which we'll cover in a moment. Palpate the chest to feel for ribcage stability, protrusions, point tenderness, and localized swelling. Also look at the trachea in the neck to see if it is midline or deviated to one side or another. Listen with your stethoscope to the areas discussed previously. Any wound to the chest wall also raises suspicion for damage to underlying organs, such as a cardiac contusion or lung injury.


Contusion:
Any trauma to the chest can cause, at a minimum, contusion (bruising). These cause pain that often increases with movement or deep inspiration. There may or may not be noticeable swelling or visible external bruising, and the area is usually somewhat tender to touch.


Rib Fracture:
A fractured rib causes much more pain, increasing with inspiration and expiration, and is tender to touch. Breathing is painful because many muscles attach to the rib cage that aid in the movements of respiration, and they pull on the fractured rib. Point tenderness (pain to a specific spot when touched) is usually present.

If more than one adjacent rib is each broken in more than one place, that portion of the chest wall will demonstrate what is called paradoxical movement. The rest of the chest will expand with inspiration, but that portion will suck in slightly; the rest of the chest will contract with expiration, but that portion will bulge outwards slightly. This is called a "flail chest".


Pneumothorax:
"Pneumo" in this context means "air", so pneumothorax means air in the thoracic cavity where it should not be. A punctured or ruptured lung allows air to leak into the pleural space (between the lung and chest wall), which as it progresses causes the lung on that side to collapse. Lung sounds on that side will be regionally or totally absent. These patients will become progressively short of breath with a consequent drop of SpO2. A chest tube is necessary to allow the lung to re-expand over the following days.

A small pneumothorax is not a large concern if it isn't getting worse. You may be able to hear dim lung sounds near the shoulder where the small amount of air accumulates.

A pneumothorax can occur with trauma: a lung that is full of air upon impact can rupture, and people reflexively suck in air when they see an impact coming. It is also possible for an existing rib fracture to later puncture a lung. A spontaneous pneumothorax is also possible, which often occurs when a bleb in the lung bursts. COPD patients can develop this, but the classic walking risk factor for spontaneous pneumothorax is being a tall and skinny male.


Sucking chest wound:
It's been said that ALL chest wounds suck, but we are referring specifically to a wound that penetrates the chest wall and allows air to be sucked in. This causes a pneumothorax as discussed above. You will be able to hear air hissing in and out of the hole, and may see blood frothing or bubbling slightly. It is imperative to get an occlusive dressing on the wound promptly, one that forms a one-way valve to allow air to escape the chest cavity but does not allow air back in with each breath.


Tension Pneumothorax:
A pneumothorax can progress to a "tension pneumothorax", where so much air accumulates in one side of the chest cavity that it begins to push the heart and other structures towards the opposite side of the chest. This pushing interferes with the expansion of the lung on the opposite side, and impairs the functioning of the heart as well. Because all of these structures are attached to the trachea, you will actually be able to see the trachea in the neck deviating off towards the opposite side instead of being centered with the midline like normal.

In this case, an emergency needle decompression is necessary. To do this, one would insert a 3.25 inch long, 14g or 16g needle into the second intercostal space in the midclavicular line (just above the rib to avoid the artery that runs along the bottom of the rib). An alternative site that's gaining popularity is the fourth or fifth intercostal space at the anterior axillary line (where the chest wall is thinner and has less vital structure behind it). When successful, you will hear a hiss as the excess air is allowed to escape. This may occlude with clotting blood, but can be repeated with a new needle if necessary. This only buys you time to get a proper chest tube in place.


Hemothorax:
"Hemo" means blood, so hemothorax means blood in the thoracic cavity where it should not be. A large amount of bleeding that is pooling in the thoracic cavity will prevent expansion of the lung. A chest tube allows it to drain out.

A trauma might result in a "hemo-pneumothorax", which just means you're dealing simultaneously with blood and air in the thoracic cavity.


Pleural effusion:
Other body fluids, such as serous fluid, can accumulate in the pleural cavity and interfere with lung expansion. This usually needs to be drained, but does not usually require a chest tube.


Asthma:
A recurring condition in which the airways become inflamed/swollen and tend to spasm closed, which makes breathing difficult. You will usually, but not always, hear wheezing or stridor.


Bronchitis:
This usually presents as a sore throat and a non-productive cough, and sometimes with chest pain from excessive coughing. This is usually viral. Smokers frequently present with chronic or recurring bronchitis.


COPD:

Long-time smokers typically develop Chronic Obstructive Pulmonary Disease, which is a combination of chronic bronchitis and emphysema (chronic over-inflation and destruction of the alveoli in the lungs. These people have little oxygen reserve, so become short of breath with even mild exertion. As their disease progresses, they are short of breath even at rest. They will typically exhale with pursed lips, and when most short of breath they will lean forward with their arms or elbows on a table in a tripod position to maximize the effectiveness of their respiratory efforts.

Those who are still able to compensate fairly well are called "pink puffers": they have to work for it, but their oxygenation is still adequate and their skin color remains pink.

Those in end-stage COPD who are no longer able to compensate well are called "blue bloaters". Long-term overinflation of the lungs causes them to develop a characteristic barrel-shaped chest, and they always appear cyanotic.

People with COPD are accustomed to an SpO2 in the 80-89% range, and if you bring their saturation up into the mid to high 90s it can temporarily knock out their respiratory drive and cause them to stop breathing (because it's carbon dioxide accumulation that triggers a breath, and people with COPD are accustomed to a higher-than-normal amount in their lungs).


Congestive Heart Failure:

A condition where the heart is unable to pump blood effectively due to some damage (for example, from surviving a heart attack), so as a result blood backs up in the circulatory system. This causes shortness of breath.

If the left side of the heart is affected, blood backs up in the pulmonary circulation. This manifests in shortness of breath with activity (and, in advanced cases, at rest) that is worse when lying flat. You will typically hear crackles in one or more lung fields, indicating pulmonary edema. You can also see distention in the jugular veins.

We don't see it nearly as often anymore because management with medications has greatly improved, but these patients can go into "flash pulmonary edema" (a life-threatening condition where the fluid backup in the lungs is so severe that the lungs start to fill up with fluid, and the patient begins coughing up a lot of frothy sputum.)

If the right side of the heart is affected, blood backs up in the peripheral circulation. This manifests in edema to the lower legs, then can progress to edema in the upper extremities and in the abdomen (ascites).

CHF is treated with diuretics to remove excess fluids, as well as carefully-selected cardiac medications to reduce strain on the heart.


Pulmonary embolism:
An embolism is a piece of material (usually a blood clot, but can also be fat, air, or a foreign object) that occludes a blood vessel. An embolism to the brain is a stroke; an embolism in the heart is a heart attack; an embolism to the lungs is a pulmonary embolism (or "PE"). The clot blocks blood flow to the lungs, not only preventing normal gas exchange but also causing lung tissue to die.

A fractured long bone (particularly the femur) presents a particular risk of a fat embolism.

A strong risk factor is known or suspected deep vein thrombosis in a lower extremity. Note that a thrombosis in a superficial vein is not itself considered at risk for becoming an embolus.

When an embolism occurs in the lungs, the patient will experience shortness of breath at a minimum. A small occlusion is typically survivable, and treatment consists of supplemental oxygen, and anticoagulation to minimize the chance of further clots forming or attaching to the existing ones.

A larger embolism requires immediate "clot-buster" medication. With a very large embolism, patients die quickly. These patients have a feeling of impending doom, and will often tell you that they are going to die. They are usually right. They will be cyanotic and their skin will be mottled, often characteristically being mottled only up to a noticeable point of the chest. Unfortunately, even intubation by itself cannot help these people.


Shock:
I'm only going to cover this briefly, because shock is a complex subject that could double the length of this already long guide. Shock is a life-threatening condition where body tissues receive increasingly poor perfusion, which results in organ failure and progresses to death. Shock is the end of the line for most critical illnesses.

Shock is categorized as hypovolemic, cardiogenic, distributive, and obstructive.

It follows a predictable course, starting with the initial stage where the patient begins to become hypoxic.

The body then enters the Compensatory stage, where the respiratory and heart rate will increase in an attempt to compensate for a decrease in blood pressure and the blood becoming more acidotic. Urine output will be low because the kidneys are not being well-perfused.

When the compensatory mechanisms can no longer keep up, the body enters the Progressive stage. Among other problems, organ function begins to be compromised. Children tend to compensate better for shock than do adults, but then drop off precipitously.

Finally, the body enters the Refractory stage. At this point, the damage is irreversible and death is imminent.

Treatment typically consists of intubation to protect oxygenation, aggressive IV fluid administration, and the adjusted continuous infusion of vasopressor medications to keep the vasculature constricted in order to keep blood pressure adequate. If the cause is reversible, we try to reverse it. If the cause is not reversible, we try to support the body in hopes the problem will resolve, or we do everything possible to keep the patient comfortable while they die.


Cardiac arrest:
Something has caused the heart to stop beating, or to stop beating in an effective rhythm. All you will be able to do outside of a hospital with ACLS resources is to provide good-quality chest compressions and try to defibrillate if indicated, and evacuate to a hospital. The chances of successful resuscitation drop off precipitously every moment that passes without spontaneous circulation.

In searching for a possible correctable cause for a cardiac arrest, we look at the "H's and T's":
Hypovolemia, Hypoxia, Hydrogen ions (acidosis), Hyperkalemia, hypokalemia, Hypothermia, Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary)
Note that Hypoglycemia and Trauma used to be "H and T" considerations in ACLS, but the former doesn't cause cardiac arrest by itself, and the latter will not be correctable. ("Trauma dead stays dead").

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Thanks for posting! I'm still reading and absorbing the material!

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Do you find the rescue airway particularly useful in the EM setting? The vast majority of use I've seen is for airway management under sedation, either peri-procedure or secondary to RSI with a failed tube insertion. Other than that, BLS airway works for me.


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Good write-up. It must have taken you some time. I appreciate the time you took to do it, but did you mention it was from your perspective ? Seeing patients for first contact initially in the ER? Is that where most of your assessment is based ? .......You did make a few jumps though. Assessment for you as an ER Tech ? Or working in the ER is actually different for us in the field, on the ground. For one, it's a lot quicker, has several levels, and all your stethoscope based conclusions or findings? Are difficult when a tank is driving by or other people are screaming. I also don't immediately assume that someone with a chief complaint of "chest pain" is having an MI......and if someone is in traumatic arrest and doesn't have injuries incompatible with life, I do not write them off. I'm six hours ahead of the East Coast and have to go to work, but I'd like to hear more....


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VXMerlinXV wrote:
Do you find the rescue airway particularly useful in the EM setting? The vast majority of use I've seen is for airway management under sedation, either peri-procedure or secondary to RSI with a failed tube insertion. Other than that, BLS airway works for me.


I find rescue airways extremely useful, as RSI is a skill that is only available to intensive care paramedics over here.

Excellent write up, I'm copying the post to add to my cardiac notes as I write. any one who has had a heart attack will be on the 'cardiac cocktail' (aspirin, Beta Blocker, antiplatelet, etc)Bear in mind IF you are qualified to carry and administer medications then you have further options for diagnosing chest pain, such as seeing if the condition improves after administering GTN (vasodilator) and aspirin (anti-platelet),

My closing comment and one my fellow paramedics drive into use newbies is 'if vitals are good and stable, but the person LOOKS sick then something is wrong', knowing numbers is great, but that doesn't explain the pain

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taipan821 wrote:
I find rescue airways extremely useful, as RSI is a skill that is only available to intensive care paramedics over here.

Have you had a patient that would take a King, Combi, LMA, etc. that wouldn't tolerate an ET tube? I'm just not familiar with a case like that. If a person can take a rescue airway unassisted, they can generally take an ET tube unassisted. Other than that, BLS airway can properly manage most emergent patients. Supergallotic airways in the field setting give, in my experience, a false sense of security.


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VXMerlinXV wrote:
Do you find the rescue airway particularly useful in the EM setting? The vast majority of use I've seen is for airway management under sedation, either peri-procedure or secondary to RSI with a failed tube insertion. Other than that, BLS airway works for me.


In the ER where I work, we've only used one of the rescue airways once or twice just prior to flying a patient to a better-equipped hospital. Now that I think about it, I'm pretty sure those were put in by the flight crews. Our ER docs always prefer to go for full intubation. We have a great assist tool called a GlideScope, which is a fiber-optic camera integrated into a laryngoscope blade that allows you to actually see what's going on down there. Normally, the rescue airways are an excellent pre-hospital tool to get the airway secured quickly, but are not suitable for use if the patient needs to be on a ventilator overnight.



IANMCDEVITT wrote:
Good write-up. It must have taken you some time. I appreciate the time you took to do it, but did you mention it was from your perspective ? Seeing patients for first contact initially in the ER? Is that where most of your assessment is based ? .......You did make a few jumps though. Assessment for you as an ER Tech ? Or working in the ER is actually different for us in the field, on the ground. For one, it's a lot quicker, has several levels, and all your stethoscope based conclusions or findings? Are difficult when a tank is driving by or other people are screaming. I also don't immediately assume that someone with a chief complaint of "chest pain" is having an MI......and if someone is in traumatic arrest and doesn't have injuries incompatible with life, I do not write them off. I'm six hours ahead of the East Coast and have to go to work, but I'd like to hear more....


You're right, I should have specified my perspective. I am an RN who works in ER and ICU.
I am not a combat medic, so my experiences are vastly different from yours. My patients encompass the entire age range, though the majority are middle-aged to elderly with lots of chronic health problems. I think I would be right in assuming that vast majority of your patients are young, fit, healthy men with traumatic injuries. If you ever had the time, I'm sure you could add much valuable info from your perspective on assessment of these types of patients.

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Good answer. I like your attitude already.....you didn't assume I was attacking you. I respect that cool informational head....yes, it is different for me now but for many many years it wasn't. I actually prefer dogs over humans now as patients. When I'm on rotation here in East Africa, I usually use my eyes ears and nose as input to gather as much information immediately before actual physical patient contact. I very rarely worry about any medical possible diagnosis any more ( unless I'm working on dogs ). Things happen very very fast and I haven't carried a BP cuff or Stethescope by choice in awhile, except Ukraine for a short time. Everything is differnet and must rely on your gut feeling as even IF THERE IS a hospital in the country, my injured may not survive to make it there.....but, good for you. Good write up.


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Here you go, this is why I left that tiny world of EMS and will never be back (and that type of assessment )....NYU University Tisch School of Film made this and it went to a buncha film festivals. Let's see if I can post the link properly. https://vimeo.com/87810522.


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IANMCDEVITT wrote:
Good answer. I like your attitude already.....you didn't assume I was attacking you. I respect that cool informational head....yes, it is different for me now but for many many years it wasn't. I actually prefer dogs over humans now as patients. When I'm on rotation here in East Africa, I usually use my eyes ears and nose as input to gather as much information immediately before actual physical patient contact. I very rarely worry about any medical possible diagnosis any more ( unless I'm working on dogs ). Things happen very very fast and I haven't carried a BP cuff or Stethescope by choice in awhile, except Ukraine for a short time. Everything is differnet and must rely on your gut feeling as even IF THERE IS a hospital in the country, my injured may not survive to make it there.....but, good for you. Good write up.


Good stuff.
I like animals more than people, too, but I have no experience with veterinary stuff.

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VXMerlinXV wrote:
Do you find the rescue airway particularly useful in the EM setting? The vast majority of use I've seen is for airway management under sedation, either peri-procedure or secondary to RSI with a failed tube insertion. Other than that, BLS airway works for me.


Emergency medicine physician here. For me, they are only useful as a temporizing measure. It sounds like you are coming from an OR/anesthesia perspective. The difference with my patients in the emergency department is that I usually do not have the option of waking them up if we are unable to get a definitive airway--they are either in respiratory failure or not protecting their airway and that is why they need to be incubated, rather than for a procedure.

The rescue devices--LMA, King, CombiTube--are not definitive airways. I would put one in as a brigpdge to intubation--e.g., put one in a patient I can't bag effectively to preoxygente them in preparation for intubation. But they need a tube in their trachea. If I (or anesthesia, if I'm somewhere I have them as backup) can't get them intubated orally or nasally, they're getting a surgical airway (i.e. cricothyroidotomy) by me or a surgeon.

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GP11 wrote:
VXMerlinXV wrote:
Do you find the rescue airway particularly useful in the EM setting? The vast majority of use I've seen is for airway management under sedation, either peri-procedure or secondary to RSI with a failed tube insertion. Other than that, BLS airway works for me.


Emergency medicine physician here. For me, they are only useful as a temporizing measure. It sounds like you are coming from an OR/anesthesia perspective. The difference with my patients in the emergency department is that I usually do not have the option of waking them up if we are unable to get a definitive airway--they are either in respiratory failure or not protecting their airway and that is why they need to be incubated, rather than for a procedure.

The rescue devices--LMA, King, CombiTube--are not definitive airways. I would put one in as a brigpdge to intubation--e.g., put one in a patient I can't bag effectively to preoxygente them in preparation for intubation. But they need a tube in their trachea. If I (or anesthesia, if I'm somewhere I have them as backup) can't get them intubated orally or nasally, they're getting a surgical airway (i.e. cricothyroidotomy) by me or a surgeon.


Thanks for the reply, I actually come from a strictly EM/EMS background myself. My LMA exposure comes mostly from OR rotations, or in talking airway with anesthesia friends. To be honest, never used or seen used a rescue airway in the ED, but we've been glide-scoping for years now, and in the few instances that, anesthesia, and ENT didn't work, we went with a surgical cric. But typically it's BVM to ET tube, or back to BVM if we nedd a :cough: second or so attempt.

The reason I brought it up in this thread was as a challenge the idea that a rescue airway was needed for proper cardiac care, as stated in paniac's initial posting (which was, for the most part, awesome, and spot on) Without RSI, a patient can either be BVMed, or will be without a gag and either tubed (which wasn't listed as an option) or managed with BLS airway. I could not come up with a reason a provider would need a rescue airway, but not intubation equipment.


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VXMerlinXV wrote:
The reason I brought it up in this thread was as a challenge the idea that a rescue airway was needed for proper cardiac care, as stated in paniac's initial posting (which was, for the most part, awesome, and spot on) Without RSI, a patient can either be BVMed, or will be without a gag and either tubed (which wasn't listed as an option) or managed with BLS airway. I could not come up with a reason a provider would need a rescue airway, but not intubation equipment.


The lack of clarity on this point was my error.
The intended focus of these guides is survival medicine, but muddied with the requisite disclaimers to get the patient to a hospital ASAP. The focus is not necessarily to educate people who are already qualified to perform endotracheal intubation, but I do hope that everyone is able to learn a few useful things from it.

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painiac wrote:
VXMerlinXV wrote:
The reason I brought it up in this thread was as a challenge the idea that a rescue airway was needed for proper cardiac care, as stated in paniac's initial posting (which was, for the most part, awesome, and spot on) Without RSI, a patient can either be BVMed, or will be without a gag and either tubed (which wasn't listed as an option) or managed with BLS airway. I could not come up with a reason a provider would need a rescue airway, but not intubation equipment.


The lack of clarity on this point was my error.
The intended focus of these guides is survival medicine, but muddied with the requisite disclaimers to get the patient to a hospital ASAP. The focus is not necessarily to educate people who are already qualified to perform endotracheal intubation, but I do hope that everyone is able to learn a few useful things from it.


Don't sweat it in the slightest, I was nit-picking what is one of the best posts on here in a while.


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VXMerlinXV wrote:
Don't sweat it in the slightest, I was nit-picking what is one of the best posts on here in a while.


Thank you. I'm glad that you did, because the additional discussion is valuable expansion to anyone who reads through the thread.

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VXMerlinXV wrote:
Do you find the rescue airway particularly useful in the EM setting? The vast majority of use I've seen is for airway management under sedation, either peri-procedure or secondary to RSI with a failed tube insertion. Other than that, BLS airway works for me.



Standard practice in the ER is to keep a "Plan B" airway handy. I'm fond of the King Air, the LMA and the fairly new iGel.

The biggest issue here is that after we've established an airway in the back country we've got to BREATH for the patient. Rarely do I see BVM's in most medical kits.

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VXMerlinXV wrote:
taipan821 wrote:
I find rescue airways extremely useful, as RSI is a skill that is only available to intensive care paramedics over here.

Have you had a patient that would take a King, Combi, LMA, etc. that wouldn't tolerate an ET tube? I'm just not familiar with a case like that. If a person can take a rescue airway unassisted, they can generally take an ET tube unassisted. Other than that, BLS airway can properly manage most emergent patients. Supergallotic airways in the field setting give, in my experience, a false sense of security.



In a failed intubation, without RSI, pre-hospital, then I'd go for the King airway. A bougie can be fitted down the slot for a retrograde intubation with much higher success rates. I agree that most "crash airways" in the field (absent trauma to the neck or inhalation pattern burns) can be solved with good BLS.

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