7-2
Breathing: In the conscious patient, who is alert and breathing normally, no interventions are required. If the
patient has signs of respiratory distress such as tachypnea, dyspnea, or cyanosis, which may be associated
with agitation or decreasing mental status, an aggressive search for an etiology is required. Injuries that may
result in significant respiratory compromise include tension pneumothorax, open pneumothorax (sucking chest
wound), flail chest, and massive hemothorax. The patient’s chest and back should be quickly exposed and
inspected for obvious signs of trauma, asymmetrical or paradoxical movement of the chest wall, accessory
muscle use and jugular venous distention. If possible, auscultation should be performed listening for abnormal
or decreased breath sounds. The chest wall should be palpated to identify areas of tenderness, crepitus,
subcutaneous emphysema or deformity.
Open pneumothorax should be treated with a three-sided occlusive dressing and a tension pneumothorax with
needle decompression (see Procedure: Thoracostomy, Needle).
The field management of a flail chest centers on controlling the patient’s pain and augmentation of the patient’s
respiratory efforts with bag valve mask ventilation. Chest wall splinting with tape, sandbags and the like has
been advocated in the past but should no longer be performed as it decreases the movement of the chest
wall and will further compromise the patient’s ability to ventilate. These casualties may have significant injury
to the underlying lung and may deteriorate rapidly requiring endotracheal intubation and positive pressure
ventilation.
Management of a massive hemothorax in the field should be directed at maintaining adequate ventilation with
a BVM. If evacuation is delayed and the patient continues to deteriorate, consideration may be given for the
placement of a chest tube. If more than 1000cc of blood is immediately drained by the chest tube or if the
output is more than 200cc per hour for 4 hours, the patient likely has injury to the great vessels, hilum, heart or
vessels in the chest wall that will require surgical repair.
Flail chest and massive hemothorax are difficult injuries to treat in the field and should be evacuated are
rapidly as possible.
Circulation: Uncontrolled hemorrhage is the leading cause of preventable battlefield deaths. Rapid
identification and effective management of bleeding is perhaps the single most important aspect of the
primary survey while caring for the combat casualty.
Obvious external sources of bleeding should be controlled with direct pressure initially followed by a field
dressing or pressure dressing. If bleeding is not controlled by the previous measures or if gross arterial
bleeding is present, an effective tourniquet should immediately be applied. Clamping of injured vessels is
not indicated unless the bleeding vessel can be directly visualized. Blind clamping of vessels may result in
additional injury to neurovascular structures and should not be done.
NOTE: The current ATLS manual discourages the use of tourniquets in the pre-hospital setting because
of distal tissue ischemia, tissue crush injury at the tourniquet site, which may necessitate subsequent
amputation. This admonition is based on the civilian model of trauma care where most penetrating injuries
are low velocity in nature and rapid evacuation to a trauma center is available. Withholding the use of
tourniquets on the battlefield for patients with severe extremity hemorrhage may result in additional death or
injury that might have otherwise been prevented.
Sources of internal hemorrhage should be identified. A significant amount of blood can be lost into the chest
and abdominal cavities, the retroperitoneal space and the soft tissues surrounding fractures of the pelvis
and lower extremities. Significant bleeding into the thoracic and abdominal cavities following trauma will
require surgical exploration. In the absence of a head injury, hypotensive resuscitation will help prevent more
bleeding. Bleeding from injuries to the pelvis and groin or from fractures of the lower extremities not otherwise
amenable to treatment with a tourniquet and not associated with thoracic injuries may be controlled with the
application of Pneumatic Anti-Shock Garment (PASG), AKA Military Anti-Shock Trousers (MAST).