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EMT Exam: Injuries That Affect the Airway and Breathing

By Arthur Hsieh

You will need to be familiar with all types of injuries for the EMT exam. The injuries you will find here require rapid identification and, in some cases, immediate action on your part. These are conditions that either block (obstruct) the airway or somehow impair the patient’s ability to breathe adequately. Without the ability to move air well, the patient’s ability to survive any injury is severely compromised.

Injuries that block the airway

No airway, no life; that’s pretty much the message you hear all along in your EMT training. Here’s a list of key trauma reasons why an airway becomes blocked and what action you should perform to relieve the blockage.

Problem Signs and Symptoms Action Steps
Obstructions in the mouth Blood, other secretions; broken/missing teeth; bleeding from
nose
Suction mouth; if possible, position patient lateral
recumbent
Tongue obstruction as a result of altered mental status or
unconsciousness
Snoring respirations; no breathing sounds; head and neck
flexed
Manual spine precautions; modified jaw thrust; oropharyngeal or
nasopharyngeal airway; head-tilt, chin-lift if modified jaw thrust
is unsuccessful
Soft tissue swelling as a result of heat or chemical burns Hoarse, muffled, or whisper voice; stridor during breathing;
reddened tissues in mouth; excessive saliva/secretions
Maintain an optimal head/neck position that minimizes stridor;
sit patient up if no cervical-spine precautions; suction carefully,
if at all, to avoid irritating tissue (allow patient to drool)
Impaled object in cheek Um, something stuck in cheek Suction as necessary; if airway is blocked, cut object as short
as possible and pull it forward through the opening; apply pressure
to opening to control bleeding

A 35-year-old female strikes a tree while skiing downhill. She is unconscious, with slow, irregular respirations. You can hear snoring. She has a large laceration along the left parietal skull that is oozing blood. You should first

  • (A)suction her airway for no more than 10 seconds.

  • (B)apply a head-tilt, chin-lift maneuver.

  • (C)establish manual spine precautions.

  • (D)control the bleeding with mild, direct pressure.

The best answer is Choice (C). There is evidence of a significant mechanism of injury, and the patient is unconscious and unable to provide you any information. Therefore, minimizing movement to the spine is important in this scenario.

There is no evidence of blood in the airway, making Choice (A) irrelevant. Choice (B) may be required, but only if you are unable to open the airway with a jaw thrust. The bleeding from the laceration is not significant enough to override airway control as the priority, as Choice (D) suggests.

Injuries that make breathing difficult

In order to survive, you have to maintain levels of oxygen and carbon dioxide no matter what. When a patient begins to fail at maintaining ventilation, you need to step in to supplement oxygen or take over ventilation; Check out the action steps.

Problem Signs and Symptoms Action Steps
Open chest wound, causing air to leak into the chest
cavity
Incision or opening on chest wall (don’t forget the
back!); sounds of air at site (though not always); uneven chest
rise and fall; decreased lung sounds on affected side; dyspnea;
tachycardia
Seal wound immediately with gloved hand; replace with occlusive
chest seal; closely monitor for developing tension under seal and
relieve it as patient exhales; if patient is unable to breathe
adequately, provide oxygen and ventilate carefully to avoid
worsening the problem
Pneumothorax, open or simple, causing a portion of the lung to
collapse
Possible diminished lung sounds over affected side; decreased
oxygen saturation; dyspnea; tachycardia; possible chest pain
Provide oxygen to maintain saturation; ventilate carefully if
patient is unable to maintain
Tension pneumothorax, causing excess air pressure inside chest
wall and squeezing the lungs, heart, and great vessels
Diminished lung sounds over affected side; jugular venous
distension; unequal chest rise and fall; rapidly falling blood
pressure; severe dyspnea and tachycardia
If tension develops after occlusive seal is applied to an open
chest wound, lift one side of seal to “burp” the wound
and relieve tension. Call advanced life support (ALS) if possible;
a paramedic can insert a long needle into the chest to relieve the
tension
Hemothorax, causing blood to pool into the chest cavity and
squeezing the lung
Diminished lung sounds over affected side; flat neck veins;
hypotension (from blood loss); dyspnea and tachycardia
Provide oxygen to maintain saturation; ventilate carefully if
patient is unable to maintain
Rib fractures, causing pain Pain and point tenderness over affected region; pain on
inspiration; dyspnea
If possible, place patient in best position of comfort; provide
oxygen to maintain saturation
Flail chest, causing loss of chest wall integrity Pain over affected region; in later stages, paradoxical chest
movement, dyspnea
Provide oxygen to maintain saturation; ventilate carefully if
patient is unable to maintain adequate tidal volume; some regions
suggest splinting with a pillow or bulky dressing to reduce
pain

Notice that many of the following trauma conditions have similar signs and symptoms; that’s why diagnosis may be difficult. However, also notice that the treatment is very similar for many conditions.

A pedestrian was struck by a motor vehicle that was moving at a high rate of speed. He is anxious and confused, with cool, pale, and diaphoretic skin. You note crepitus on palpation across the right lateral chest wall, from the region of T4 through T10.

Breath sounds are diminished over the right side of the chest. His neck veins are flat. His pulse rate is 130, and his blood pressure is 80/60 mm Hg. Which of the following injuries is most likely?

  • (A)Tension pneumothorax

  • (B)Hemothorax

  • (C)Simple pneumothorax

  • (D)Fractured ribs

The best answer is Choice (B). Bleeding inside the chest cavity can be significant and cause shock. The mechanism of injury, physical findings, and his poor skin and vital signs support this answer. You would expect to see jugular venous distension in Choice (A). Neither Choice (C) nor (D), by itself, would cause such poor vital signs.