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Treatment of Life-threatening Injuries on Initial Survey (airway obstruction, tension PTX, hemothorax, cardiac tamponade)

April 29, 2022 - read ≈ 14 min



Kerri McKie, MD

Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA


Reza Askari

Division of Trauma, Critical Care, and Acute Care Surgery, Brigham and women’s Hospital, Boston MA



The primary or initial survey is intended to identify and treat , life threatening injuries  including airway obstruction, tension PTX, hemothorax, and cardiac tamponade. These injuries should be at the forefront of any examiner’s mind as they make their way through the ABC’s of the primary survey. At each interval, should a life-threatening injury be identified, this necessitates a pause for management of this injury prior to proceeding with the remainder of the survey. This chapter aims to further describe the signs and symptoms of each of these injuries and the subsequent steps of management. 

Airway Obstruction:

I: Introduction: In evaluating the airway during the primary survey, concern for airway obstruction necessitates a pause in proceeding to the next area of evaluation until this can be improved. This section will review the possible causes of airway obstruction, maneuvers to alleviate airway obstructions, and indications to proceed with obtaining a definitive airway with intubation from above or a surgical airway.

II: Clinical Presentation: The simplest way to evaluate for a patent airway is to have the patient phonate by answering a question. A patient who is unable to phonate or whose phonation is altered should raise concern for a compromised airway. 

III: Evaluation: Inspection of the airway for obstruction should be undertaken to see if there is a clear or obvious reason for airway obstruction, which may include a foreign body in the airway or injury to the airway which may be obvious due to injuries to face and neck. Some patients own normal anatomy can cause airway obstruction including large tongues,  may requiring repositioning of the anatomy with jaw thrusts or insertion of an oropharyngeal or nasopharyngeal airway. Additionally, this is the opportunity to mentally prepare for what this specific airway will require in order to secure the airway. This includes 3-3-2 rule (incisor distance < 3 fingers, hyoid mental distance < 3 fingers, thyroid to mouth < 2 fingers), the Mallampati score (Image I), and neck mobility (is it restricted for any reason including C-collar position, other neck injuries). These components help to predict the ease of intubation and prepare for what may be required in order to secure their airway with either endotracheal intubation or surgical cricothyroidotomy.

IV: Management:

  1. Identifying an obstruction that is removable or reversible: If there is an obvious foreign body or presence of vomitus or saliva in the mouth, removal with suction catheter or careful removal with specific care to not push the object further into the airway can be performed. If the obstruction is relieved with a jaw thrust, one can continue to have a member of the team hold a jaw thrust or carefully insert and OPA or NPA to help maintain a patent airway.
  2. If you are unable to secure an airway or relieve an obstruction, the next step is to secure an airway with endotracheal intubation.
    • Endotracheal intubation: placement of endotracheal tube from above either by direct laryngoscopy or video assisted.
    • Indications include Airway obstruction, Hypoventilation, Persistent hypoxemia (SaO2 ≤ 90%) despite supplemental oxygen, Severe cognitive impairment (Glasgow Coma Scale [GCS] score ≤ 8), Severe hemorrhagic shock, and Cardiac arrest. Relative indications include patients with smoke inhalation with major cutaneous burn, oropharyngeal burn, airway injury seen on endoscopy or neck/facial injury with potential for airway obstruction.
    • Equipment: endotracheal tube (ETT), laryngoscope, bag-valve mask, ventilator, medications for rapid sequence intubation (induction with etomidate/ketamine and paralysis with succinylcholine/rocuronium). Other adjuncts for intubation include gum elastic bougie, video laryngoscope.
    • Steps of endotracheal intubation:
      • Maintain spinal neutrality either in C-collar or with second assist holding C spine
      • Administer induction agent and paralysis agent via intravenous (IV) or intraosseous (IO) access
      • With laryngoscope, obtain view of cords. Have suction available and possibly a second assist to apply cricoid pressure to help with visualization.
      • Insertion of endotracheal tube just beyond cords, with inflation of balloon after placement. Attach bag valve mask to ETT.
      • Confirm correct placement of ETT with auscultation of breath sounds bilaterally or end tidal CO2. If available can perform chest xray to confirm tip of ETT is ~2cm above the carina.
      • Should the obstruction prohibit intubation from above, prepare  to perform an emergent cricothyroidotomy.
  3. If you are unable to secure airway with endotracheal intubation, the final step is a surgical cricothyroidotomy.
    • Cricothyroidotomy: placement of airway tube via incision in the cricothyroid membrane
    • Indications include inability to secure airway with less invasive procedure, or inability to ventilate after intubation from above which may indicate and obstruction beyond the level of the vocal cords.
    • Equipment: scalpel, endotracheal tube or tracheostomy tube, gum elastic bougie, tracheal hook, Trousseau dilator, medications for RSI as above.
    • Steps of cricothyroidotomy
      • Identify cricothyroid membrane via palpation with non-dominant hand (Image 2).
      • Prep area with sterile solution of Betadine or alcohol-based prep.
      • Perform vertical incision in the midline with scalpel ~3-4cm.
      • Blunt dissection through subcutaneous tissues and muscles to level of cricothyroid membrane.
      • Perform transverse incision with scalpel in cricothyroid membrane
      • Either use tracheal hook to stabilize opening and insert Trousseau dilator through opening in cricothyroid membrane, OR dilate opening with forceps and insert Bougie, aiming posteriorly and inferiorly.
      • Slide tracheostomy tube or ET tube through Trousseau dilator or over bougie aiming caudally. Remove Trousseau dilator and tracheal hook or bougie.
      • Inflate balloon cuff and attach to bag valve mask or ventilator.
      • Confirm placement with auscultation of bilateral breath sounds or end tidal CO2.

Tension Pneumothorax/Hemothorax:

I. Introduction: In evaluation of breathing in the primary survey, there can be several life-threatening injuries that should be evaluated for and corrected prior to continuing the remainder of the primary survey. Possible injuries that should be managed at this stage include tension pneumothorax and hemothorax, which are life threatening injuries should they go unidentified during the primary survey.

II. Presentation: Difficulty with taking breaths or ability to phonate should immediately require re-evaluation of the airway as described above. Difficulty ventilating or low oxygenation despite a secure airway, should raise concern for a life-threatening injury in the chest. Immediate auscultation of breath sounds should be undertaken, including careful auscultation for absent breath sounds or significantly dampened breath sounds in one side (or both sides) of the chest.

III. Evaluation: Both inspection of the chest and auscultation of bilateral breath sounds are critical components to the evaluation of breathing. Absence of breath sounds on both sides, should necessitate a re-evaluation of the airway, as obstruction in the more proximal airway should be corrected with airway adjuncts described above. Absence of breath sounds on a single side (or absence of breath sounds bilaterally despite a secure airway) should necessitate a pause in the survey and further evaluation of that side. Absence of breath sounds should raise concern for a pneumothorax, or air in the accumulating between the parietal and visceral pleura. If there is concomitant hypotension, tachycardia, jugular venous distention, tracheal deviation, or cyanosis, this raises concern for a tension pneumothorax, which occurs when pneumothorax causes mediastinal shift and collapse of cardiovascular structures in the chest. Similar presenting signs can also be suggestive of a hemothorax, or accumulation of blood in the parietal and visceral pleura.

IV: Management: Management of a tension pneumothorax in the pre-hospital setting often includes needle decompression, which we will review in this section. However, definitive management of both a tension pneumothorax and hemothorax is a tube thoracostomy.

  1. Identifying a concern for either a tension pneumothorax or hemothorax described above should immediately initiate a set up for a needle decompression or tube thoracostomy. Adjuncts to physical exam can includes a chest x-ray (CXR) or beside ultrasound (US), however, should the patient be unstable with the above physical exam findings, confirmation with CXR or US is not required prior to definitive management.
  2. In the pre-hospital setting or concern for a prolonged time for set up for a tube thoracostomy, a needle decompression can be performed on the side of the chest with suspicion for pneumothorax. Needle decompression will likely not be helpful in changing the physiology driven by hemothorax.
    • Needle decompression involves insertion of a needle at least 14-16 gauge or larger with a length of at least 5-cm in the second intercostal space in the midclavicular line. Newer texts have suggested placement in the 4th or 5th intercostal space at the mid to anterior axillary line where a chest tube will ultimately be placed.
    • Needle decompression should be followed by tube thoracostomy placement.
  3. Management in the trauma bay of both tension pneumothorax and hemothorax includes tube thoracostomy.
    • Tube thoracostomy: insertion of a chest tube into the pleural space to evacuate air or blood. The chest tube is then placed to a pleura-evac or one way chamber to allow air or fluid to be removed from the chest but not allowing air or fluid to reflux back into the chest as the patient breathes.
    • Indications include concern for air, fluid, or blood collecting in the pleural space causing poor ventilation or hemodynamic instability.
    • Equipment required includes: chest tube (range from 6Fr-40Fr, ideally for an adult aim for 28-34Fr for trauma) which are fenestrated on one end, scalpel, hemostat or Kelly clamp, large silk suture, Pleur-evac system, suction tubing, local anesthetic.
    • Steps of tube thoracostomy:
      • Position patient laterally (or supine with head elevated at 30 degrees), with chest tube insertion site up, and arm extended above head. A second provider may be required to hold patient in this position.
      • Prep area with sterile solution of Betadine or alcohol-based prep.
      • Identify landmarks: insertion should be in the 4th or 5th intercostal space at the mid to anterior axillary line. This can be identified by identifying inframammary fold and tracing laterally to the mid-anterior axillary line.
      • If the patient is awake, use of local anesthetic can be used on skin and subsequently through each layer down to the chest wall.
      • Incision should be made ~1-2cm along top of the rib with a scalpel.
      • Blunt dissection with finger, Hemostats or Kelly clamp should be performed to level of chest wall.
      • Entrance into pleural space should be done with forceful insertion of a closed Hemostat or Kelly clamp. Successful entry will be met with rush of air or fluid/blood. Tract should be dilated with spreads of Kelly or Hemostat.
      • While holding tract dilated with spread Kelly or hemostat, chest tube should be inserted with fenestrated end inserted into chest through opening aiming posteriorly and anteriorly. The chest tube can be guided with a Kelly clamp on the fenestrated end or with your finger.
      • Chest tube should be connected to Pleur-evac set up, which is then connected to wall suction via tubing if available.
      • Tube should be secured to the skin with a silk suture. A second suture may be required to close the skin incision tightly around the tube to prevent drainage or air or fluid around the tube.
      • Occlusive dressing includes Vaseline gauze (such as Xeroform) and transparent watertight film dressing (such as Tegaderm).
      • Post-insertion CXR should be performed to confirm position (should be aimed towards apex of lung lying posterior to lung parenchyma and relief of pneumothorax or hemothorax.
  4. Post-procedure complications:
    • With regards to a hemothorax, should there be output of > 1500cc in 24 hours, 300-500 in 2-4hours post placement or concern for other intra-thoracic injuries including great vessel or cardiac injury, proceeding to surgical intervention including thoracotomy should be undertaken.
    • Improper positioning of chest tube on CXR, or dislodgement of chest tube requires replacement of the chest tube.
    • With regards to pneumothorax, inability for lung to stay inflated with clamping or water-sealing of the chest tube may require surgical intervention such as video assisted thoracoscopy for pleurodesis. This is outside of the setting of the trauma bay and would be encountered in subsequent days after initial stabilization of the trauma patient.

Cardiac Tamponade:

I: Introduction: In evaluating the circulation component of the primary survey, identifying cardiac tamponade as the cause of hemodynamic instability is critical. Cardiac tamponade is the result of blood accumulation in the pericardial sac causing reduced ventricular filling and cardiac output leading to hypotension and circulatory compromise. Traumatic injuries that may lead to cardiac tamponade include direct cardiac injury such as penetrating trauma to the ventricles/atria of the heart, or shearing forces from blunt trauma including aortic root dissection or abruption. Concern for cardiac tamponade should result in a pause in the primary survey for management of this life-threatening condition.

II: Clinical presentation: Signs of possible cardiac tamponade include evidence of penetrating trauma to the anterior portion of the chest or mechanism suggestive of blunt chest wall trauma. Other signs include hemodynamic instability (tachycardia, hypotension), jugular venous distention, muffled or distant heart sounds.

III: Evaluation: In addition to inspection of the chest for traumatic injury, auscultation of heart sounds and hemodynamic monitoring, adjuncts that can help identify tamponade, but are not required, include ultrasonography of the heart to identify fluid in the pericardium, or CXR which may demonstrated enlarged cardiac silhouette, widened mediastinum.

IV: Management of cardiac tamponade in the trauma bay:

  1. Any of the above signs or symptoms of cardiac tamponade should necessitate the set up for a pericardial window or needle decompression by pericardiocentesis as a bridge to sternotomy/anterior thoracotomy.
  2. Indications for pericardial window or pericardiocentesis include the above concern for cardiac tamponage, which include hypotension, muffled heart sounds on auscultation, jugular venous distention, enlarged cardiac silhouette on imaging, or positive fluid on US of pericardium
  3. Equipment required:
    • Pericardial window equipment: scalpel, scissors, forceps or hemostats.
    • Pericardiocentesis equipment: Optimal 16-18 gauge needle, 6-8Fr dilator and introducer sheaths, J-tip guide wire, drainage catheter
  4. Steps of pericardial window
    • Identify xiphoid and widely prep with betadine or alcohol-based prep (Image 3).
    • Using scalpel, perform 4-8cm incision over Xiphoid extending down onto abdomen through linea alba
    • Blunt dissection posterior to xiphoid/sternum is performed with finger dissection or blunt spreads with hemostats, often requiring second assistant for retraction of the sternum
    • When pericardium is encountered, should be grasped with two hemostats or clamps and traction applied inferiorly.
    • Pericardium should be sharply incised
  5. Steps of pericardiocentesis:
    • Identify preferred approach either subxiphoid (between xiphoid and left costal margin) or parasternal (5th left intercostal space) and widely prep with betadine or alcohol-based prep.
    • Local anesthetic can be placed at insertion site.
    • Needle within sheath should be advanced under US guidance with negative pressure placed on an attached saline-filled syringe advanced in the direction of the fluid-filled space.
    • When bloody fluid is aspirated, the sheath is advanced over the needle and needle withdrawn, with sheath remained in the pericardial space. The J-tip guidewire should be advanced through the sheath, which can then be removed.
    • A small incision should be made at the entry site followed by the introduction of a sheathed dilator (6 Fr to 8 Fr) over the guide. The dilator should be removed and a drainage catheter can be inserted.
  6. After temporizing with pericardial window or pericardiocentesis with confirmation of ongoing bleeding in the pericardial sac, exploration of the mediastinum via thoracotomy or median sternotomy for definitive management is required.
    • Left anterior thoracotomy can be performed in the trauma bay for access to the pericardium in order to relieve tamponade and for operative repair of myocardial injury.


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