Skill Station B

BREATHING

LEARNING OBJECTIVES

1. Assess and recognize adequate ventilation and 7. Perform a finger thoracostomy using a simulator,
oxygenation in a simulated trauma patient. task trainer, live anesthetized animal, or cadaver.

2. Identify trauma patients in respiratory distress. 8. Insert a thoracostomy tube using a simulator, task
trainer, live anesthetized animal, or cadaver.
3. Practice systematically reading chest x-rays of
trauma patients. 9. Discuss the basic differences between pediatric
chest injury and adult chest injury.
4. Recognize the radiographic signs of potentially life-
threatening traumatic injuries. 10. Explain the importance of adequate pain control
following chest trauma.
5. Identify appropriate landmarks for needle
decompression and thoracostomy tube placement. 11. List the steps required to safely transfer a trauma
patient with a breathing problem.
6. Demonstrate how to perform a needle
decompression of the pleural space on a simulator,
task trainer, live anesthetized animal, or cadaver.

Sk ill s Inc luded in this STEP 2. Look for evidence of respiratory distress.
Sk ill S tation •• Tachypnea
•• Use of accessory muscles of respiration
•• Breathing Assessment •• Abnormal/asymmetrical chest wall
•• Interpretation of Chest X-ray movement
•• Finger and Tube Thoracostomy •• Cyanosis (late finding)
•• Needle Decompression
STEP 3. Feel for air or fluid.
•• Use of Pediatric Resuscitation Tape
•• Hyperresonance to percussion
•• Dullness to percussion
Br e athing A s se s sment •• Crepitance

STEP 1. Listen for signs of partial airway obstruction Inter pr e tation of c he s t

or compromise. x- ray
•• Asymmetrical or absent breath sounds
•• Additional sounds (e.g., sounds indicative The DRSABCDE mnemonic is helpful for interpreting
of hemothorax) chest x-rays in the trauma care environment:

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­346 APPENDIX G n Skills
STEP 1. D—Details (name, demographics, type of
film, date, and time)
STEP 2. R—RIPE (assess image quality)
•• Rotation
•• Inspiration—5–6 ribs anterior in midcla-
vicular line or 8–10 ribs above diaphragm,
poor inspiration, or hyperexpanded
•• Picture (are entire lung fields seen?)
•• Exposure penetration
STEP 3. S—Soft tissues and bones. Look for
subcutaneous air and assess for fractures
of the clavicles, scapulae, ribs (1st and 2nd
rib fractures may signal aortic injury),
and sternum.
STEP 4. A—Airway and mediastinum . Look for signs
of aortic rupture: widened mediastinum,
obliteration of the aortic knob, deviation of
the trachea to the right, pleural cap, elevation
and right shift of the right mainstem
bronchus, loss of the aortopulmonary
window, depression of the left mainstem
bronchus, and deviation of the esophagus to
the right. Look for air in the mediastinum.
STEP 5. B—Breathing, lung fields, pneumothoraces,
consolidation (pulmonary contusion),
cavitary lesions
STEP 6. C—Circulation, heart size, position borders
shape, aortic stripe
STEP 7. D—Diaphragm shape, angles, gastric bubble,
subdiaphragmatic air
STEP 8. E—Extras: endotracheal tube, central
venous pressure monitor, nasogastric tube,
ECG electrodes, chest tube, pacemakers
Needle Decompr e s sion
STEP 1. Assess the patient’s chest and respiratory status.
STEP 2. Administer high-flow oxygen and ventilate
as necessary.
STEP 3. Surgically prepare the site chosen for
insertion. (For pediatric patients, the 2nd
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intercostal space midclavicular line is
appropriate.) For adults (especially with
thicker subcutaneous tissue), use the fourth
or fifth intercostal space anterior to the
midaxillary line.
STEP 4. Anesthetize the area if time and physio-
logy permit.
STEP 5. Insert an over-the-needle catheter 3 in. (5 cm
for smaller adults; 8 cm for large adult) with
a Luer-Lok 10 cc syringe attached into the
skin. Direct the needle just over the rib into
the intercostal space , aspirating the syringe
while advancing. (Adding 3 cc of saline may
aid the identification of aspirated air.)
STEP 6. Puncture the pleura.
STEP 7. Remove the syringe and listen for the
escape of air when the needle enters the
pleural space to indicate relief of the tension
pneumothorax. Advance the catheter into
the pleural space.
STEP 8. Stabilize the catheter and prepare for chest
tube insertion.
Fing er and Tube
Thoracos tom y
STEP 1. Gather supplies, sterile drapes, and antiseptic,
tube thoracostomy kit (tray) and appro-
priately sized chest tube ( 28-32 F). Prepare
the underwater seal and collection device.
STEP 2. Position the patient with the ipsilateral arm
extended overhead and flexed at the elbow
(unless precluded by other injuries). Use an
assistant to maintain the arm in this position.
STEP 3. Widely prep and drape the lateral chest wall,
include the nipple, in the operative field.
STEP 4. Identify the site for insertion of the chest
tube in the 4th or 5th intercostal space.
This site corresponds to the level of the
nipple or inframammary fold. The insertion
site should be between the anterior and
midaxillary lines.
STEP 5. Inject the site liberally with local anesthesia
to include the skin, subcutaneous tissue,
­347 APPENDIX G n Skills

rib periosteum, and pleura. While the STEP 13. Obtain a chest x-ray.
local anesthetic takes effect, use the
thoracostomy tube to measure the depth STEP 14. Reassess the patient.
of insertion. Premeasure the estimated
depth of chest tube by placing the tip near
the clavicle with a gentle curve of chest tube Use of Pedi atr ic
toward incision. Evaluate the marking on
the chest tube that correlates to incision,
R e sus c itation Ta pe
ensuring the sentinel hole is in the pleural
space. Often the chest tube markings STEP 1. Unfold the pediatric resuscitation tape.
will be at 10–14 at the skin, depending on
the amount of subcutaneous tissue (e.g., STEP 2. Place the tape along the side of the chest tube
obese patients). task trainer to estimate the weight and note
color zone.
STEP 6. Make a 2- to 3-cm incision parallel to the
ribs at the predetermined site, and bluntly STEP 3. Read the size of equipment to be used with
dissect through the subcutaneous tissues patient, noting chest tube size.
just above the rib.

STEP 7. Puncture the parietal pleura with the tip
of the clamp while holding the instrument
near the tip to prevent sudden deep
insertion of the instrument and injury to
underlying structures. Advance the clamp
over the rib and spread to widen the pleural
opening. Take care not to bury the clamp
in the thoracic cavity, as spreading will be
ineffective. Air or fluid will be evacuated.
With a sterile gloved finger, perform a finger
sweep to clear any adhesions and clots (i.e.,
perform a finger thoracostomy).
STEP 8. Place a clamp on the distal end of the tube.
Using either another clamp at the proximal
end of the thoracostomy tube or a finger as
a guide, advance the tube into the pleural
space to the desired depth.
Links to Futur e Le arning
Reassess breathing frequently during the primary
survey and resuscitation. Review the MyATLS mobile
app for video demonstrations of procedures. In
addition, www.trauma.org provides descriptions of
the management of a variety of thoracic injuries in
trauma patients.
Post ATLS—Practice using a structured approach to
reading chest x-rays before looking at the radiologist’s
interpretation to improve your proficiency. Review
the MyATLS video demonstration of chest tube
insertion prior to performing the procedure to reinforce
procedural steps.

STEP 9. Look and listen for air movement and bloody

drainage; “fogging” of the chest tube with
expiration may also indicate tube is in the
pleural space.

STEP 10. Remove the distal clamp and connect the

tube thoracostomy to an underwater seal
apparatus with a collection chamber. Zip
ties can be used to secure the connection
between the thoracostomy tube and the
underwater seal apparatus.

STEP 11. Secure the tube to the skin with heavy,

nonabsorbable suture.

STEP 12. Apply a sterile dressing and secure it with

wide tape.

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