🫁 Thoracic Trauma High-Yield (NCLEX/ED)

I) 🌪️ Tension Pneumothorax (TPTX)

Key idea: Clinical dx—treat now, don’t wait for imaging. Patho: One-way valve → air traps in pleura → lung collapse + mediastinal shift → ↓venous return → obstructive shock; often from PPV with visceral injury. Meds: O₂ (often high-flow). Analgesia after stabilization. Team: MD does immediate needle/finger decompress → chest tube. RN preps gear, monitors vitals, reassesses; eFAST must not delay care. Cues (prio): 🟥 Hypotension/shock; 🟥 unilateral absent breath sounds; 🟧 severe tachypnea/air hunger; 🟧 tracheal deviation (late); 🟨 JVD; 🟨 cyanosis (late). RN actions: High-flow O₂; set up needle decompress (5th ICS, anterior to MAL) → mandatory tube. Reassess for recurrence. Quick: TPTX = air trapping + shock. Priority = decompression → tube. Avoid too-medial field placement.

II) 🩸 Massive Hemothorax (MHX)

Def: >1500 mL (or ≥⅓ blood volume) rapidly in chest. Patho: Blood in pleura → hypovolemic shock + lung compression → hypoxia. Tx fluids/blood: Large-bore IV/IO; crystalloids judiciously; start uncrossmatched/type-specific blood; consider autotransfusion. Team: MD inserts 28–32 Fr chest tube; considers thoracotomy. RN runs rapid infuser, assists tube, logs initial/ongoing output. Cues: 🟥 Shock; 🟥 initial tube output >1500 mL; 🟧 ↓/absent breath sounds; 🟧 dullness to percussion; 🟨 flat neck veins (often). RN actions: Two large IVs, rapid blood; assist tube (5th ICS, anterior to MAL); track loss—>200 mL/hr ×2–4 h = call for OR. Quick: Simultaneous volume + decompression; thresholds drive thoracotomy.

III) ❤️ Cardiac Tamponade (CT)

Patho: Blood in pericardium → restricted filling → ↓CO (obstructive shock). Definitive: Surgery (thoracotomy/sternotomy). Pericardiocentesis = bridge. FAST for dx. Cues: 🟥 Hypotension/poor response to fluids; 🟥 PEA arrest; 🟧 muffled heart sounds; 🟧 JVD (may be absent if hypovolemic); 🟨 Kussmaul’s sign. RN actions: Rapid IV fluids (temporize), continuous ECG, facilitate FAST, prep for OR. Quick: Think CT with PEA + shock in chest trauma.

IV) 🕳️ Open Pneumothorax (OPX) / “Sucking Chest Wound”

Patho: Large chest wall defect (~≥⅔ tracheal diameter) shunts air via wound → failed ventilation → hypoxia/hypercarbia. Team/Tx: Three-sided occlusive dressing (flutter valve) → chest tube remote from wound → surgical closure. Cues: 🟥 Hypoxia/hypercarbia; 🟧 audible sucking; 🟧 tachypnea/dyspnea; 🟨 ↓breath sounds. RN actions: Seal with sterile occlusive taped on 3 sides; watch for tension; place tube ASAP; secure airway if needed. Quick: Four-sided seal can create TPTX—avoid.

V) 🔑 Associated Injuries & Nursing Pearls

Airway obstruction: Look/listen/feel for stridor, voice change, neck crepitus. Suction blood/vomit; prep definitive airway; reduce posterior clavicle dislocation if obstructing. Flail chest + Pulmonary contusion: Contusion = common lethal chest injury. Give humidified O₂, ventilatory support PRN; judicious fluids; aggressive analgesia (IV/regional). Rib fractures: Pain → splinting → atelectasis/PNA. Treat pain (systemic or regional). Never tape/belt. Ribs 1–2 = high-force (check great vessels). Ribs 10–12 → suspect hepato-splenic injury. Older adults = higher mortality.

🚑 Trauma Shock & Thorax Emergencies

I) 🩸 Hemorrhagic (Hypovolemic) Shock

Patho: Acute blood loss ↓preload → ↓SV/CO; early tachycardia + vasoconstriction; prolonged hypoperfusion → lactic acidosis; lethal triad = 🧊 hypothermia + 🩸 coagulopathy + acidosis. Fluids/Blood:

• Warm crystalloids (1 L adult, 20 mL/kg peds) → avoid excess; consider permissive hypotension.
• MTP: pRBCs/Plasma/Plts (warm). O neg for childbearing-age females; AB plasma if unknown type.
• TXA: within 3 hrs (bolus then 8-hr infuse).
• Calcium: guide by ionized Ca²⁺. No vasopressors first-line. Team: MD leads definitive bleed control (OR/angio); RN gets 2 large-bore IVs/IO, gives warmed fluids/blood, binder/pressure, tracks response; Lab preps products. Priority cues: Marked tachy + hypotension + narrow PP + ↓LOC (Class IV); cool, pale skin; ↓UO. Elderly may lack tachy on β-blockers—SBP 100 can be shock. RN priorities: Categorize response (rapid/transient/non-), direct pressure/binder, target UO ≥0.5 mL/kg/hr, warm patient & fluids to 39 °C, trend lactate/base deficit. High-yield: Don’t rely on SBP alone—watch pulse pressure; stop bleeding + balanced resus; vasopressors 🚫 initial.

II) 🌪️ Tension Pneumothorax (Obstructive Shock)

Patho: One-way valve air → ↑pleural pressure → lung collapse + mediastinal shift → ↓venous return. Management: Immediate decompression (needle/finger) → chest tube. Don’t wait for X-ray. Cues: Hypotension/CO drop, severe dyspnea/air hunger, absent unilateral breath sounds, hyperresonance, tracheal shift (late), JVD. RN: Set up decompression ASAP, then assist sterile tube; monitor hemodynamic rebound. Pearl: Think triad—hypotension + unilateral absent sounds + hyperresonance.

III) ❤️ Cardiac Tamponade (Obstructive Shock)

Patho: Blood in pericardium → impaired filling → ↓CO. Often penetrating trauma. Management: Definitive surgery; pericardiocentesis = temporizing. FAST to detect fluid. Cues: Beck’s triad = hypotension, muffled heart sounds, JVD; tachy; poor response to fluids. RN: Prep for OR, support FAST, note non-response to resus; educate that surgery removes pericardial blood.

IV) 🧠 Neurogenic Shock (Distributive)

Patho: Cervical/upper thoracic SCI → loss of sympathetic tone → vasodilation & hypotension; may coexist with bleeding. Isolated head injury doesn’t cause shock unless brainstem involved. Distinct cues: Hypotension without tachycardia, warm/dry skin (no vasoconstriction), normal/wide PP. Management: Treat as hypovolemic first; if unresponsive to fluids, pursue neurogenic cause with advanced monitoring. Maintain full C-spine precautions. High-yield: Key differential = low BP + no tachy + warm skin.

🛑 Acute Airway & Ventilation Review

1) 🫁 Acute Airway Obstruction & Compromise

Patho: Fastest killer in trauma. Obstruction may be complete/partial/progressive. Common: tongue occluding hypopharynx with ↓LOC; also vomit, blood/secretions, teeth/FBs. ↓LOC → high aspiration risk → often needs definitive airway. RSI Meds:

• Etomidate 0.3 mg/kg → sedation w/ minimal BP/ICP effect; watch adrenal suppression & hypovolemia.
• Succinylcholine 1–2 mg/kg → rapid, brief paralysis; avoid in crush/burns/electrical/CKD/neuromuscular dz (↑K⁺). If fail intubation → BVM until recovery. Team Roles: 👨‍⚕️ Leader/Airway → assess & choose route/timing; plan for difficult airway. 👩‍⚕️ RN → suction ready, draw RSI meds, SpO₂/ETCO₂ monitoring, manual C-spine restriction. 🫁 RT → ventilator setup, capnography confirmation. 🧠 Consultants (neurosurg) for head-injured timing. Key Signs (🚨): No response/abnormal speech, stridor/gurgle/snore, absent breath sounds, agitation (hypoxia), tachypnea, cyanosis (late). RN Actions: Stimulate for verbal response; jaw-thrust/chin-lift; suction + log-roll lateral if vomit (maintain C-spine); pre-oxygenate 100% before/after attempts; OPA/NPA as bridge; high-flow O₂ ≥10 L/min; continuous SpO₂ + ETCO₂. Quick Hits:
• Priority #1 = airway & ventilation.
• Intubate if GCS ≤8, seizures, cannot maintain patency/oxygenation.
• Maintain C-spine throughout.
• Drug-assisted intubation needs rescue plan (surgical airway).
• Confirm ETT: bilateral breath sounds + exhaled CO₂ ✅.

2) 🗣️ Traumatic Airway Injuries (Laryngeal/Neck/Maxillofacial)

Patho: Neck hematoma displaces airway; larynx/trachea disruption → bleeding into tree; facial fx + swelling/teeth/secretions obstruct; bilateral mandibular fx = loss of support (esp. supine). Med pearls: Avoid nasal tubes if cribriform/basilar skull fx suspected. Team: 🔪 Surgeon → hemorrhage control & emergent airway (cric > trach in ED). 🖼️ Imaging (CT) after airway secure. 👩‍⚕️ RN/Airway → anticipate rapid loss; gentle ETT under direct vision if laryngeal injury. Red Flags (🚨): Laryngeal triad = hoarseness + subQ emphysema + palpable fracture; expanding neck hematoma/stridor; basilar skull signs (raccoon eyes, Battle’s, CSF leak) → no nasotracheal; refusing supine (mandible issues). RN Actions: Watch for swelling/SC air; be ready for surgical airway; avoid nasal routes with facial/skull fx. Quick Hits: Cric preferred; LEMON for difficulty; OTI is first-line when feasible.

3) 🌬️ Ventilatory Compromise

Patho: Ventilation failure from chest mechanics (rib fx/flail), CNS depression, or SCI.

• SCI: Above/below C3 → diaphragmatic-only breathing; rapid shallow ≠ effective → atelectasis → failure.
• Chest trauma: Pain → splinting → shallow breaths → hypoxemia. Sedation/Analgesia: Helps tolerance of assisted ventilation, but excess can abolish tone → airway loss ⚠️. Team: 👩‍⚕️ RN/Airway → assess symmetry, listen for ↓/absent sounds; beware PPV converting simple → tension pneumo or causing barotrauma. 🫁 RT → PPV, ETCO₂ monitoring. 👨‍⚕️ MD → ABGs; treat pain/CNS causes. Key Signs (🚨): Seesaw/abdominal breathing (SCI), asymmetrical rise (pneumo/flail), ↓/absent sounds, accessory muscle use. RN Actions: Check symmetric rise & bilateral air entry; 2-person BVM if needed; if poor sounds → alert for pneumo; continuous ETCO₂ for ventilation; protect head-injured from hypercarbia.

🫁 Airway Compromise & Obstruction (A)

Pathophysiology: Life-threatening blockage → prevents gas exchange. Causes: foreign bodies, fractures, blood/secretions, trauma, ↓LOC (GCS ≤8). Failure to speak/respond = urgent airway issue. 💊 TXA: ↓bleeding, ↑survival if given ≤3 hrs post-injury. Continue infusion 8 hrs after bolus. Team Roles: 👨‍⚕️ Leader → directs & coordinates 👩‍⚕️ Airway manager → secures airway 👩‍🔬 Nurses → prep/test equip, stabilize c-spine 🩺 Surgeon → perform surgical airway if needed Key Signs: Can’t speak, GCS ≤8, visible obstruction, facial/laryngeal trauma. Nursing Focus:

• Assess speech → suction blood/secretions 💨
• Maintain c-spine alignment 🔒
• Monitor GCS & prep for intubation if ↓LOC
• Reassess airway frequently 🔁 ⚡ Quick Tips:
• Airway first, spine protected
• GCS ≤ 8 = intubate
• Test gear; frequent reevaluation
• Surgical airway if intubation fails

🌬️ Breathing & Ventilation Failure (B)

Patho: Airway patency ≠ ventilation. Check gas exchange. Threats: tension pneumo, hemothorax. 💊 O₂: All trauma pts need it; use mask-reservoir if not intubated. Team: Clinician = chest exam 🔍 | RT/Nurse = monitor O₂ & CO₂ | Surgeon = chest decompression. Signs: Dyspnea, pain, ↓SpO₂, distended neck veins, tracheal shift. Nursing:

• Monitor SpO₂, ABG, ETCO₂ 📊
• Give O₂ immediately
• Avoid PPV until decompressed if pneumo suspected 🚫 ⚡ Summary:
• Tension pneumo = clinical dx—treat fast!
• Pulse ox + capnography = vital
• Watch for simple pneumo → tension after PPV

💉 Hemorrhagic/Hypovolemic Shock (C)

Patho: Blood loss = main preventable death. Hypotension → assume hemorrhage until ruled out. 💊 Fluids/Blood/TXA:

• Warm crystalloids (≤1.5 L) 🌡️
• MTP for transfusion; never microwave blood 🩸
• TXA within 3 hrs ↓mortality Team: Leader = find/control bleed | Nurse = IV access, warm fluids | Surgeon = definitive control. Signs: Rapid, thready pulse 💓, ashen skin, altered LOC, pelvic pain/ecchymosis. Nursing:
• 2 large-bore IVs/IO for fluids
• Monitor pulses, urine (≥0.5 mL/kg/hr) 💧
• Apply pelvic binder for suspected fracture ⚡ Summary:
• Warm all fluids
• Avoid over-resuscitation
• TXA + balanced transfusion = best outcome

🧠 Disability (D) & 🌡️ Exposure (E)

Patho: LOC changes = possible brain injury; prevent hypoxia/hypoperfusion. Hypothermia = lethal. 💊 Small IV opiates/anxiolytics (avoid IM). Team: Neuro consult early 🧠 | Nurse = monitor temp & record events | All = PPE 🧤 Signs: ↓GCS, unequal pupils, cold skin. Nursing:

• Reassess ABCDEs if neuro decline
• Warm pt + fluids (39°C) 🔥
• Pain relief = careful titration ⚡ Summary:
• Complete primary survey before secondary
• Maintain spine restriction
• Urinary output = perfusion check
• Avoid nasal tubes if facial fx

✅ Overall Priorities: 1️⃣ Airway w/ spine protection 2️⃣ Breathing (O₂ & chest) 3️⃣ Circulation (bleeding control + warm fluids) 4️⃣ Disability (neuro status) 5️⃣ Exposure (prevent hypothermia)

This episode lets you guys know I found an ATLS manual to upload. I am super excited

Hey guys

I cuss a few times in this episode. To ER is to be the BEST! :)

this episode is about me discussing the possible certification material I will upload later.

the certifications I currently hold as an LVN are as follows and these are the certification materials I will be uploading:

-ACLS

-BLS (not really a cert right? LOL)

-PALS

-ABLS

-ASLS

-Letter of completion TNCC

If you guys want me to upload different courses and materials send them to me at

Statstitch@gmail.com

or leave a comment or review on apple podcast or whatever platform you're listening from.

1️⃣ Bradyarrhythmias (Slow Rhythms)

Definition: HR <60 bpm with poor perfusion = treat immediately.

🌡️ Causes

Hypoxia (MOST COMMON), heart block, vagal stimulation, hypothermia, drugs.

🫀 Sinus Bradycardia

• Recognition: P waves present, regular rhythm, slow rate.
• Peds Tip: Normal in athletes/sleeping; NOT normal with poor perfusion.

🟪 AV Blocks

1° AV Block:

• PR prolonged (>0.20s adult-equivalent), but every P → QRS.
• Usually benign; watch for progression.

2° Type I (Wenckebach):

• PR progressively lengthens → dropped QRS.
• “Longer, longer, longer, drop ▶️ Wenckebach.”
• Usually transient, often vagal.

2° Type II:

• Normal PR intervals with random dropped QRS.
• Bad. Can progress to complete block.

3° Complete Heart Block:

• Atria + ventricles beat independently.
• Regular P waves, regular QRS—but no relationship.
• Often bradycardic, poor perfusion.

2️⃣ Tachyarrhythmias (Fast Rhythms)

Definition: Above age-appropriate range (often >180 infants, >160 children).

⚡ Supraventricular Tachycardia (SVT)

• Rate: 180–300 bpm
• P waves: Absent or hidden
• QRS: Narrow
• Onset: Abrupt
• Key Tip: Infant may just appear irritable, poor feeding, or pale.

⚡ Atrial Flutter

• Sawtooth F-waves
• Rate often 250–350
• Rare in kids (post-op congenital heart disease)

⚡ Ventricular Tachycardia (VT)

With Pulse:

• Wide QRS, regular rhythm
• Rate usually 120–250
• May have poor perfusion

Pulseless VT:

• Treat like VF (defibrillate)

💥 Ventricular Fibrillation (VF)

• Chaotic, no identifiable waves
• No pulse → CPR + defibrillate immediately

😵 Asystole (Flatline)

• No electrical activity
• Confirm in 2 leads
• CPR + epinephrine only (NO shock)

🌪️ PEA (Pulseless Electrical Activity)

• Organized electrical rhythm without a pulse
• Causes = H’s & T’s (hypoxia, hypovolemia, hypothermia, H+ acidosis, hypo/hyperK, tension pneumo, tamponade, toxins, thrombosis)

3️⃣ How to Rapidly Recognize Rhythms (PALS Algorithm)

Step 1: Pulse Check

• Present? → Rhythm with pulse
• Absent? → Treat as cardiac arrest rhythm

Step 2: Narrow vs. Wide QRS

• Narrow (<0.08s): SVT, sinus tach, atrial flutter/fib
• Wide (>0.08–0.12s): VT, aberrancy

Step 3: Regular vs. Irregular

• Regular: SVT, VT, sinus tach
• Irregular: Atrial fibrillation/flutter with variable block, polymorphic VT

Step 4: P Waves Present?

• Yes → sinus or atrial rhythm
• No → SVT or VT

1️⃣ MANAGEMENT OF RESPIRATORY DISTRESS (Compensation Phase)

Goal → Support oxygenation & ventilation BEFORE fatigue sets in.

A. Airway Opening Maneuvers

• Positioning is everything
  • Infants: sniffing position
  • Older kids: tripod or chin lift / jaw thrust
• Avoid hyperextension in infants (soft trachea collapses)

B. Oxygen Administration 🫧

Start low → escalate:

1. Blow-by (infants, mild)
2. Nasal cannula
3. Simple mask / NRB
4. Humidified O₂ for croup

Target SpO₂ ≥ 94% unless chronic lung disease.

C. Treat the Underlying Problem

• Upper airway (stridor):
  • Racemic epi neb
  • Dexamethasone
  • Avoid upsetting the child ❗
• Lower airway (wheezing):
  • Albuterol ± ipratropium
  • Magnesium sulfate (severe)
  • Steroids
• Parenchymal (pneumonia):
  • Antibiotics
  • High-flow nasal cannula if hypoxemic
• Fluid overload: diuretics
• Foreign body: encourage cough; prepare for removal

D. Monitoring

• Continuous pulse ox
• Reassess work of breathing q5–10 min
• Cap refill, mental status, perfusion
• Prepare airway equipment early

E. Red Flags That Require Escalation

• Increased fatigue
• Declining retractions (NOT improvement)
• Rising CO₂ signs: headache, confusion, lethargy
• SpO₂ not improving with O₂

2️⃣ MANAGEMENT OF RESPIRATORY FAILURE (Decompensation Phase)

Goal → Ventilate & oxygenate NOW. Fatigue → arrest in minutes.

A. Call for Help / Activate PALS Team 🚨

Failure means the child cannot compensate. You need backup.

B. Immediate Bag-Mask Ventilation (The #1 lifesaving step)

• Correct size mask → seal with “EC clamp”
• Rate: 12–20/min (1 breath q3–5 sec)
• Use PEEP valve if available
• Watch chest rise and SpO₂
• Avoid over-ventilation (↓ venous return → ↓ BP)

C. Consider Airway Adjuncts

• OPA if no gag
• NPA if gag intact
• Suction PRN

D. Prepare for Intubation

Indications:

• Fatigue
• Worsening hypoxemia
• Hypercarbia
• Apnea / bradypnea
• Diminished or silent chest

Setup:

• Appropriate ETT size
• Stylet
• Suction
• BVM with PEEP
• Confirm with waveform capnography

E. Ventilation Strategy Post-Intubation

• Use lowest pressures needed
• Avoid breath stacking
• Adjust rate for CO₂ goals
• Reassess every few minutes

F. Treat the Cause (Critical)

• Anaphylaxis → IM epi, fluids
• Asthma → continuous albuterol, steroids, mag, possible ketamine
• Croup → racemic epi, steroids
• Bronchiolitis → suction, high-flow