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crazydoctorbob

Penetrating Chest Trauma -Positioning for Transport

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I've seen a number of different opinions on how to transport a patient with penetrating thoracic trauma and a controversy has arisen in a refresher course I'm currently teaching (and learning from).

Some of the EMT's and Paramedics I've spoken to advocate simply placing the conscious patient with penetrating chest trauma in a semi fowlers position or in the most comfortable position, and an unconscious victim of penetrating chest trauma, in the supine position.

I've talked to others who advocate always placing the patient on the injured side to allow the "good lung" unimpeded expansion.

The latter is also advocated in at least one popular EMT textbook (although I've found most texts to be mute on this point).

It's impractical to place a conscious patient in a semifowler's position leaning on the injured side.

Placing an unconscious patient on the injured side is logical except that if the penetrating trauma is on the right side, the patioent is now facing the wall in most ambulances. This can make for difficult airway control .

Does it make sense to anyone to place the conscious patient lying down on the injured side ?

I'd like to hear other opinions inclduing the logic behind them.

Thanks

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Position of comfort in the awake breathing patient. The patient will generally find a position that allows for the least work of breathing, not unlike the COPD/asthma pt assuming a "tripod" position. If the patient is unconscious secondary to the penetrating chest injury, they are intubated and transported supine. If the patient is unconscious they are likely severely hypovolemic, have tension ptx or tamponade. Placing them supine may improve cerebral perfusion, and allows for repeat assessment of the airway, trachea, anterior neck and chest.

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Good question. As an instructor I've been asked the same question myself. The answer I give (may not be perfectly correct) is positioning is dependent on whether the PT presents with a Hemothorax or a pneumothorax. The literature I have states that for a Hemo it's good side up and for a pnemo it's bad side up. My understanding of this is in the event of a Hemo we want the blood to drain or pool away from the "good" lung and the heart, with a pneumo we're attempting to get the air up and out rather than building up in the thoracic cavity. The problem I see is that the only way to "differentiate" in the field is by percussion and this tends to be a late stage sign and an acquired skill. Now while I have yet to "see" any in my practice I would think that by placing the concious patient in a fowlers postion we would be benefiting the patient the most by allowing the fluids to drain down and the air to shift up and hopefully away from the good side. Also providing a pillow so the patient can lean to one side is also very helpfull. As for facing the ambulance wall if they are lying on their right side, not a major problem in full size mods with the CPR seat. Having said all this it is only my humble oppinion and I am open to "correction" :)

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If there is a risk of a tension pneumo, then I would think you would need to get unimpeeded access to 3 sites, 1st is the wound itself (if you plan on burping it, rather than needeling the chest) and the others are the insertion points for needle decompresion of the chest. If the patient is alert and able to FIND a comfortable position, that would be most prudent.

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I think the reason there is controversy on this topic is because there hasn't really been any actual research done. I recall a similar debate several years ago in school about which side to put a CVA pt on when transporting. It was the same arguments as noted above i.e. a hemorrhagic stroke should be placed semi-prone with neurologically impaired side up and normal side down (this is all assuming the pt is exhibiting hemi-plegia/paresis) in order for the blood in the cranial cavity to pool on the already injured side.

Some of the arguments against this were that: 1) This positioning may cause the pt distress since they will have no or impaired function of the free extremities (those that they are not lying on). 2) There is no evidence that this is even effective practice and therefore, the possibility of harm caused outweighing benefit is present.

Other issues that arose: In the field it is often difficult to differentiate between a hemorrhagic CVA vs. an occlusive CVA - although there are certain tell tale indicators, e.g. sz, uncosciousness, etc.

One of my instructors ended the whole debate when she said that all pt's either ride supine (with varying degrees of head inclination based on pt condition) or on their left side. This is for the reason stated by the OP, namely that you need access to the pt and therefore they should not be facing the wall. Bottom line is that the same reasoning applies to the question at hand.

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