hypoventilation that stems from opioid abuse, medullary disease or hemorrhage, respiratory muscle paralysis, or cardiopulmonary arrest
intrapulmonary obstruction associated with airway obstruction, pulmonary edema, pneumonia, and near drowning
extrapulmonary obstruction, as in tracheal compression from a tumor, pneumothorax, strangulation, trauma, or suffocation
inhalation of toxic agents, resulting from carbon monoxide poisoning, smoke inhalation, and excessive oxygen inhalation.
Neurologic damage
Death
On general observation, the patient typically appears anxious, agitated or confused, and dyspneic, with prominent neck muscles.
Other common signs and symptoms include wheezing, stridor, altered respiratory rate (apnea, bradypnea, occasional tachypnea, and decreasing pulse oximetry), and a fast, slow, or absent pulse.
Inspection may reveal little or no air moving in or out of the nose and mouth. You may note intercostal rib retractions as the intercostal muscles pull against resistance.
You may note pale skin and, depending on the severity of the asphyxia, cyanosis in mucous membranes, lips, and nail beds.
Trauma-induced asphyxia may cause erythema and petechiae on the upper chest, up to the neck and face.
In late-stage carbon monoxide poisoning, mucous membranes appear cherry red.
Auscultation reveals decreased or absent breath sounds.
Arterial blood gas (ABG) analysis, the most important test, indicates decreased partial pressure of arterial oxygen (less than 60 mm Hg) and increased partial pressure of arterial carbon dioxide (more than 50 mm Hg).
Chest X-rays may detect a foreign body, pulmonary edema, atelectasis, or pneumothorax.
Pulmonary function tests may indicate respiratory muscle weakness.
Toxicology tests may show drugs, chemicals, or abnormal hemoglobin levels.
ASPHYXIA TEACHING TOPICS
To prevent drug-induced asphyxia, warn the patient about the danger of taking alcohol with other central nervous system depressants.
If the patient works with toxic chemicals, stress the importance of adequate ventilation in the workplace and the use of protective gear supplied by the employer.
If a foreign body is blocking the patient’s airway, perform abdominal thrust.
In an unconscious patient, the tongue may obstruct the airway. You may be able to open the airway by simply repositioning the patient.
If the patient has no spontaneous respirations and no pulse, begin CPR.
If needed, assist with ET intubation to provide an airway, and give supplemental oxygen or provide mechanical ventilation as ordered. Monitor ABG levels, the best indicator of oxygenation and acid-base status.
Ensure I.V. access, monitor I.V. fluids, and obtain laboratory specimens as ordered.
If the patient ingested poison, insert a nasogastric tube or an Ewald tube for lavage.
Give medications for opioid overdose such as naloxone as ordered.
Monitor the patient’s cardiac status, vital signs, and neurologic status throughout treatment.
Continually reassure the patient throughout treatment because respiratory distress is terrifying.
If asphyxia was intentionally induced, such as carbon monoxide poisoning, refer the patient to a psychiatrist. (See Asphyxia teaching topics.)
hypovolemia resulting from massive blood loss
hypoxemia resulting from airway alteration; damage to the chest muscles, lung parenchyma or ribs; severe hemorrhage; collapse of the lungs; or pneumothorax
cardiac failure resulting from an increase in intrathoracic pressure or subsequent cardiac injury, such as cardiac tamponade or contusion.
INJURY | PATHOPHYSIOLOGIC MECHANISM OF INJURY | ASSESSMENT FINDINGS | TREATMENT CONSIDERATIONS |
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Pneumothorax | Blunt or penetrating injury allowing air to accumulate in the pleural space |
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Tension pneumothorax | Blunt or penetrating injury allowing air to accumulate in the pleural space without a way to escape, leading to complete lung collapse |
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Hemothorax | Blunt or penetrating trauma allowing blood to accumulate in the pleural space |
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Chylothorax | Blunt or penetrating trauma usually to the thoracic duct or lymphatics allowing lymphatic fluid to drain and accumulate in the pleural space |
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Pneumomediastinum | Blunt or penetrating trauma allowing air to accumulate in the mediastinum |
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Flail chest | Blunt trauma resulting in rib or sternal fractures leading to instability of the chest |
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Pulmonary contusion | Blunt trauma injuring lung tissue with the potential to cause respiratory failure |
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Tracheobronchial tear | Blunt trauma causing injury to the tracheobronchial tree, possibly leading to airway obstruction and tension pneumothorax |
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Diaphragmatic rupture | Blunt trauma causing a tear in the diaphragm, possibly allowing abdominal contents to herniate into the thorax |
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Cardiac contusion | Blunt trauma resulting in bruising of the cardiac muscle |
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Cardiac tamponade | Blunt or penetrating trauma allowing blood to accumulate in the pericardial sac, ultimately impairing venous return and cardiac output |
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Great vessel rupture | Blunt trauma resulting in injury to major blood vessels such as the aorta |
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burn tissue, fracture bone, disrupt vascular structures, or cause a bullet embolism.
AGE AWARE
A patient with a sternal fracture—usually a transverse fracture located in the middle or upper sternum—may complain of persistent chest pain, even at rest.
A patient with a rib fracture may complain of tenderness over the fracture site and pain that worsens with deep breathing and movement.
Inspection reveals shallow, splinted respirations (a result of the painful breathing).
Palpation reveals slight edema and crepitus over the fracture site.
You may note hypoventilation on auscultation.
If the patient develops hemothorax, he’ll report chest pain after the injury, along with some form of respiratory distress.
Depending on the seriousness of hemothorax, inspection may show no obvious respiratory distress, mild respiratory distress, or severe dyspnea with restlessness and pallor or cyanosis.
The patient may have asymmetrical chest movements and flat jugular veins.
In massive hemothorax, you may observe bloody sputum or hemoptysis.
Palpation of hemothorax may reveal unilateral decreased fremitus and decreased chest expansion on inspiration.
If hemothorax is small, percussion won’t detect changes.
If hemothorax is moderate or massive, percussion reveals dullness over the area of fluid collection.
Auscultation may reveal unilateral diminished breath sounds or, in more severe hemothorax, unilateral absent breath sounds.
The patient with moderate or massive hemothorax also has hypotension and tachycardia.
If the patient develops pneumothorax, he’ll usually complain of acute, sharp chest pain and shortness of breath.
Inspection of the patient may show an obviously increased respiratory rate, cyanosis, agitation and, possibly, asymmetrical chest expansion.
Percussion reveals unilateral hyperresonance. On auscultation, breath sounds are diminished or absent on the affected side.
You’ll also note a crunching sound that occurs with each heartbeat—Hamman’s sign, which indicates mediastinal air accumulation.
If tension pneumothorax develops, the patient may complain of acute chest pain.
On inspection, you may observe cyanosis, increasing dyspnea, tracheal deviation, distended jugular veins, and asymmetrical or paradoxical neck movement.
Palpation confirms the tracheal deviation and may disclose subcutaneous crepitus in the neck and upper chest area.
Percussion usually reveals unilateral hyperresonance.
On auscultation, you’ll note unilateral absent breath sounds, muffled heart sounds, and hypotension.
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