Scenario — Open chest wound with developing tension pneumothorax — AFL grand final event

advanced Trauma · Adult · 35yr · female

Patient Information

Dispatch	You are called to a 35YO female (Sarah Hennessy) in the outer concourse of Optus Stadium who was struck by a metal barrier that collapsed during a crowd surge. She is conscious and in significant respiratory distress.
Patient	Sarah Hennessy — 35yr (65kg)
Incident History	Pt was standing near a temporary crowd barrier that gave way under surge pressure during the AFL grand final. She was struck across the left lateral chest and fell onto the barrier corner. She has a visible penetrating wound to the left chest wall and is complaining of severe difficulty breathing.
Emergency Contact	Tom Hennessy (Husband) — 0412 558 903

Initial Rapid Assessment

Response	Alert
Airway	Patent. No airway obstruction. Nil stridor. Pt speaking in short fragmented sentences only.
Breathing	Laboured. RR 26/min. Reduced air entry left chest on auscultation. Visible sucking chest wound left lateral thorax approximately 3cm diameter. Paradoxical movement of left chest wall segment — approx ribs 5–7 midaxillary line flail. SpO2 88% on room air. Intercostal and accessory muscle use noted.
Circulation	Radial pulse rapid and weak. Skin pale and diaphoretic. Visible bruising left lateral chest. No major external haemorrhage. CRT 3 seconds.
Disability	GCS 14 (E4V4M6). Alert but distressed and anxious. Orientated to time, place and person. Pupils equal and reactive to light.
Exposure	Open penetrating wound left lateral chest wall — visible air movement with respirations (sucking chest wound). Paradoxical movement left ribs 5–7. Bruising and deformity left lateral chest wall. No abdominal wounds identified. Trachea midline at initial assessment.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Severe	26	118	100/70	3s	14	4 4 ++	–	–	9
10 mins	82% (O2 NRB 15L)	Severe	32	135	88/60	4s	11	4 4 +	–	–	10

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a penetrating open chest wound (sucking chest wound) with concurrent left-sided rib fractures causing a flail segment and a developing left-sided tension pneumothorax.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does NOT apply a three-sided occlusive dressing to the sucking chest wound within 3 minutes — the wound continues to suck air on every breath. At 5 minutes, facilitate visible worsening of respiratory distress: SpO2 drops to 82%, RR increases to 32, patient becomes more agitated and GCS drops to 12. Prompt with bystander: 'I can hear it sucking air with every breath — should we cover it?')
! (If the trainee applies the occlusive dressing on ALL FOUR sides rather than three — at 5 minutes the patient deteriorates rapidly: SpO2 drops to 80%, BP drops to 85/55, RR 34, trachea begins deviating to the right. Facilitator states: 'The patient is getting worse since you applied the dressing.' This requires trainee to recognise possible tension pneumothorax developing under the sealed dressing and to REMOVE or RESEAL the dressing on three sides only.)
! (If the trainee does NOT administer high-flow oxygen via NRB within 2 minutes — SpO2 remains at 88% or drops further. Facilitator: patient becomes increasingly agitated and says 'I can't breathe, I feel like I'm dying.' Prompt awareness of hypoxia.)
! (If the trainee does NOT identify tracheal deviation at the 8-minute reassessment — facilitator physically indicates by pointing: 'On reassessment you notice the trachea appears to be deviating slightly away from the midline to the right.' This signals developing tension pneumothorax.)
! (If the trainee does NOT remove the dressing when tension pneumothorax signs develop (SpO2 declining on O2, tracheal deviation right, BP falling, distended neck veins, decreasing GCS) — patient's GCS drops to 9, BP drops to 80/50, pulse 140, SpO2 78% on NRB. This represents imminent cardiovascular collapse. Facilitator: 'The patient is barely conscious and her blood pressure is crashing.' EHS scope: remove occlusive dressing from wound and treat as absolute emergency — Priority 1 immediate transport with pre-notification.)
! (If the trainee attempts needle thoracocentesis or any surgical airway intervention — stop and advise: 'Needle thoracocentesis and finger thoracostomy are Advanced Care and Critical Care procedures only. These are outside EHS scope. Your action must be to remove the occlusive dressing if tension pneumothorax is suspected, and transport Priority 1 immediately with pre-notification.')
! (If the paradoxical chest wall movement of the flail segment is NOT identified or managed — facilitator notes patient worsening ventilation. Prompt: 'You notice a section of the left chest wall appears to move in the opposite direction to the rest of the chest with each breath.' Expected response: support the flail segment with a gentle supporting hand or padding, position patient towards the injured side in a position of comfort.)

Treatment Objectives

1. Ensure scene safety — assess for ongoing crowd crush hazard and move patient to safe location at the FAP.
2. Don appropriate PPE — high risk of blood and body fluid exposure.
3. Perform Primary Survey with c-spine consideration given mechanism of injury (struck by barrier, fell).
4. Open, clear and maintain airway — patient able to maintain own airway at this stage; reassess frequently.
5. Administer oxygen via non-rebreather mask at 10–15 litres per minute — target SpO2 94–98%.
6. Identify sucking chest wound — left lateral thorax with audible air movement on respiration.
7. Apply occlusive dressing taped on THREE SIDES ONLY to the sucking chest wound — allows air to escape but prevents air entry. Use chest seal or foil from trauma dressing packaging with sterile side facing wound. Ensure dressing lies flat with no creases or folds.
8. Identify paradoxical movement of left chest wall (flail segment ribs 5–7) — stabilise with gentle supporting hand or appropriate padding in position of comfort.
9. Position patient towards injured side (left lateral) in a position of comfort — assists splinting of flail segment.
10. Perform Secondary Survey and CNS Survey — check for additional injuries, assess trachea position, assess for neck vein distension.
11. Perform Vital Sign Survey — establish baseline GCS, SpO2, RR, HR, BP, CRT, pain score.
12. Monitor persistently for signs of developing tension pneumothorax: worsening SpO2 despite O2, increasing respiratory distress, tracheal deviation away from injured side (right), falling BP, distended neck veins, decreasing GCS.
13. If tension pneumothorax suspected (respiratory distress worsens after occlusive dressing applied or above signs develop) — REMOVE the occlusive dressing from the chest wound immediately. This is the ONLY EHS-authorised intervention for suspected tension pneumothorax.
14. Reassess patient following dressing removal — if improvement, consider reapplying three-sided dressing; if no improvement, transport as absolute Priority 1 emergency with pre-notification.
15. Administer Methoxyflurane (Penthrox) 3 mL inhaled via Penthrox inhaler for pain management — if patient remains conscious, cooperative, and able to self-administer. Onset of pain relief after 6–10 inhalations.
16. Record full observations every 5 minutes given time-critical presentation.
17. Arrange Priority 1 transport immediately — pre-notify receiving facility with nature of injury, mechanism, vital signs, and interventions performed.
18. Reassure patient continuously throughout care.
19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Thoracic Trauma · Pneumothorax · Haemorrhage · Primary Survey · Secondary & CNS Survey · Oxygen Delivery · Direct Pressure and Trauma Bandages · Penthrox Inhaler Administration · Bag Valve Mask Ventilation

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Signs/Symptoms	Severe difficulty breathing, sharp left-sided chest pain, sensation of air hunger, dizziness, feeling of impending doom.
Allergies	Nil known drug allergies.
Medications	Oral contraceptive pill. No other regular medications.
Pertinent History	No prior respiratory or cardiac conditions. Non-smoker. No prior chest injuries or surgeries.
Last Oral Intake	Meal approximately 3 hours ago. Water approximately 30 minutes ago.
Events Leading	Pt was standing in the outer concourse watching the AFL grand final when a temporary crowd control barrier failed. She was caught in the surge and struck by the collapsing barrier across the left side of her chest, then fell onto the corner of the metal frame.
Treatment Prior	Bystander applied direct hand pressure to chest wound prior to EHS arrival. No other treatment.

Onset	Sudden — immediately following impact with metal barrier approximately 15 minutes ago.
Pain	Sharp, severe left lateral chest pain, worse on inspiration.
Quality	Sharp and stabbing, constant, worse with any chest movement or breathing.
Radiates	Left shoulder tip.
Severity	9/10 at rest, 10/10 on inspiration.