Sucking Chest Wound
A punctured lung is a dangerous condition that can lead to death if left untreated or treated improperly. One type of punctured lung injury particularly common for those in combat roles is a sucking chest wound. This injury is characterized by air entering the pleura from the outside of the body and applying positive pressure to the lungs, collapsing them and preventing inhalation.

Key terms and anatomy:
1. pleura - the fluid-filled space surrounding the lungs in which they inflate and deflate as air is exchanged, providing a barrier between the rest of the body and the closed system of the lungs
2. open pneumothorax - a condition in which air is exchanged between the lungs and the outside atmosphere through a puncture in the thoracic wall
3. trachea - the primary airway through with we inhale, located in the neck where it later splits into two primary bronchi
4. bronchi - paths that guide air from the trachea to the inside of the lungs
5. shunt - any pathway through which a fluid is evacuated to another part of the body or removed from the body
6. anterior axillary line - a vertical line (when patient is upright) extending from in front of the armpit down to the hip
7. intercostal space - region between ribs; this guide references the second and third space, which is between the second and forth ribs
8. pleural effusion - a condition in which excess fluid builds in the pleura and causes pressure on blood vessels and local organs such as the heart, lungs, and stomach

Treatment:
1. Establish ABCs: is the airway clear, is breathing normal, is circulation proper? Determine the severity of issues as they present themselves from this assessment and plan to treat the most life-threatening injuries first.
2. Allow ease of access to the wounded area by cutting away clothing to expose the torso entirely.
3. Place a respirator over the patient's nose and mouth and apply high-flow oxygen. Place a bag-valve mask over the patient's nose and mouth and have it pumped to supply air if oxygen is unavailable.
4. If the patient is secure and in the medbay, use an iodine-based anti-septic solution on a foam pad to clean the area around the wound.
5. Apply a sealed bandage to prevent air from exchanging through the wound.
6. Create a shunt by using a syringe to puncture the pleura through the anterior axillary line of the second or third intercostal space. Remove the plunger from the syringe and increase oxygen flow through the mask. Listen for hissing from the syringe. If no hissing is heard, confirm the correct placement of the syringe before seeing treatment for a pleural effusion.
7. Transfer the patient to an officer qualified as a thoracic surgeon for final treatment.

[font]Establishing An Airway[/font]
[font]One of the most important things anyone can do to help an injured patient is to establish an airway. Without an open airway, a patient is incapable of communicating with the responder, runs the risk of suffocating very quickly, and will likely panic and become uncooperative with treatments. The airway can become obstructed or damaged through a variety of injuries, and this will not cover all of them but will simply go over different ways to establish an effective and safe airway through which a patient can breathe. It will start from the simple use of a bag-valve mask, go up through intubation and the use of a nasopharyngeal airway, all the way to tracheotomy.[/font]

Key terms and anatomy:
[font]1. [/font]bag-valve mask - a device consisting of a sealed face mask with a bag and valve assembly attached: the bag is compressed to push air into the patient's lungs while the valve allows it to escape unimpeded, but keeps air from entering back through and ensures the patient is not inhaling exhaled carbon dioxide
[font]2. nasopharyngeal airway[/font][i] - also known as a "nasal trumpet" due to its shape, this rubber tube is inserted up through a patient's nose and extends down into the pharynx and opens a clear airway through the nasal passage to avoid obstructions from the tongue or relaxed muscles in the neck: it is not often needed due to methods that open the airway already, but may be useful in the event that an unconscious patient must be moved often and the airway cannot be manually held[/i]
[font]3. [/font][font]endotracheal airway - also known as intubation, this is a common practice that involves placing an artificial airway down a patient's trachea through the mouth in order to allow air to pass unimpeded, and is effective in anaphylactic shock or cases where a patient is unconscious and needs an airway to be established to ensure proper breathing[/font]
[font]4. [/font]tracheotomy - a surgical procedure through which an incision is made in the trachea and the stoma, or hole, dilated to allow the insertion of a breathing tube, bypassing any obstruction in the mouth or upper airway that cannot be removed or bypassed conventionally
[font]5. t[/font]rachea - the primary airway through with we inhale, located in the neck where it later splits into two primary bronchi
[font]6. [/font][font]laryngoscope - an instrument with a camera, light, and extended arm with a flat edge called a blade guided into a patient's mouth and down into the throat to guide the insertion of an airway or find the source of an obstruction[/font]
[font]7.[/font][font] palate - the hard bone in the roof of the mouth separating the nasal passage from the mouth[/font]

Treatment:
[font]1. Establish ABCs: is the airway clear, is breathing normal, is circulation proper? Determine the severity of issues as they present themselves from this assessment and plan to treat the most life-threatening injuries first.[/font]
[font]2. Determine how the patient's airway is being threatened. If there is damage to the palate, the only options for establishing an airway are a tracheotomy and using a bag-valve mask. A laryngoscope cannot be used if the palate is damaged. Attempting any of these procedures may result in displacing the damaged palate further and causing the patient unnecessary pain or further damaging the affected area.[/font]
[font]3. Remember to pick a method that is least obtrusive while being most appropriate for the situation. A patient that is unconscious with a fully intact facial structure and palate likely does not need a tracheotomy and will benefit perfectly fine from a bag-valve mask. Conversely, a patient in shock with severe facial deformities will need a tracheotomy as anything less would be ineffective.[/font]
[font]4a. Using a bag-valve mask is a very simple procedure, as the device is designed to allow natural breathing alongside presenting outside air to the lungs. First place the mask over the patient's nose and mouth, ensuring a good seal over the area before beginning.[/font]
[font]4b. Use one hand to hold the mask in place and another to slowly compress and release the bag, which is approximately one liter in volume. Allow one second to pass between deflating and inflating the bag.[/font]
[font]5a. Not many situations actually call for the use of a nasopharyngeal airway, or a nasal trumpet, but it is useful when an endotracheal tube is not necessary because the airway below the pharynx is clear. It creates an airway through the nasal passage and allows the tongue and jaw, which naturally become relaxed during an unconscious state, to remain in an obstructive position in the mouth. This would normally prevent easy breathing, but the airway holds the nasal passage open and keeps breathing easy during unconsciousness.[/font]
[font]5b. Ensure you are only using a clean nasal trumpet, do not attempt to reuse these devices, they are DISPOSABLE.[/font]
[font]5c. Use vaseline, KY, or the patient's saliva to lubricate the narrow end of the trumpet. Do NOT use your own saliva.[/font]
[font]5d. Have an assistant perform the jaw-thrust maneuver by tilting the head backwards just slightly and holding the jaw forward, this opens the airway as much as it can and will allow an easier insertion of the device.[/font]
[font]5e. Slowly insert the tube up through one of the patient's nostrils. Stop when the flared end of the tube reaches the tip of the nose, which marks the highest point of the gag-reflex and where you should no longer insert the tube.[/font]
[font]5f. To remove the airway, simply perform the jaw-thrust maneuver once more and pull it out slowly. Do not leave this type of airway in for long periods of time as it bypasses the nasal mucous barrier and allows infection to easily pass directly into the airway.[/font]
[font]6a. Inserting an endotracheal airway, or intubation, is a common and non-invasive procedure performed to establish an airway through the mouth via a tube. It should be performed when a patient's airway is at risk of closing, though not while it is closing, or if the patient's airway below the pharynx is otherwise partially obstructed.[/font]
[font]6b. Using a laryngoscope, place the blade of the device on the patient's tongue and rotate it upward to slide it down the throat. Use the light and camera to quickly determine the state of the upper airway. If it is closing or has closed, do not attempt intubation. Otherwise, proceed as normal.[/font]
[font]6c. Have an assistant keep the patient's jaw forward and neck tilted back to fully dilate the upper airway. [/font]
[font]6d. Using a clean endotracheal airway, insert the bulb-end of the tube down into the patient's mouth and trachea, continuing to feed it through until the pilot and end of the airway are the only parts remaining outside of the mouth.[/font]
[font]6e. Use an empty syringe to push air into the pilot tube of the airway, which will inflate the balloon at the end of the airway. This balloon prevents foreign materials from entering the lungs when the airway is opened and ensures gases are kept within the lungs during the procedure.[/font]
[font]6f. Use tape to hold the airway down to the side and keep it out of the way of looking into the mouth.[/font]
[font]7a. A tracheotomy is an extreme procedure in airway management to be performed only in the case that no other option is available and an airway is still not established.[/font]
[font]7b. Have an assistant perform the jaw-thrust maneuver by pulling the patient's jaw outward and tilting the neck back. This will open the airway as much as possible and exposes the most surface area for the insertion of an airway.[/font]
[font]7c. Quickly clean the surface of the neck with an iodine-based anti-septic.[/font]
[font]7d. Using a scalpel, cut a 15-20mm incision in the trachea just below the cricoid cartilage, which can be located by finding the bump of the patient's thyroid cartilage and traversing down below its lower portion.
7e. Using forceps, dilate the incision and insert the hard plastic guide of the tracheotomy kit.
7f. Insert the inner catheter of the kit through the guide and lock it into place, pulling the obturator back through the catheter to open the pathway for air to flow.
7g. Use an empty syringe to pump air into the pilot tube and inflate the balloon at the end of the catheter, securing the airway while blocking foreign material from entering the lungs.
8. Following a tracheotomy or intubation, a bag can be attached to the device which may or may not include a high-oxygen flow. A ventilator can also be attached to regular breathing automatically.
9. All methods but the nasal trumpet and airway established in the tracheotomy can be used sustainably with minimal management. The nasal trumpet cannot be used for long periods and the inner catheter must be replaced regularly for a tracheotomy.[/font]