Trauma Advanced

Thoracic trauma with developing tension pneumothorax following crowd crush

Adult · 35yr · male

Patient Information

Dispatch: You are called to a 35YO male at the Subiaco AFL stadium who has been crushed against a barrier during crowd movement at half-time. Security staff report he is conscious but in significant respiratory distress. (Marcus Henley)
Patient: Marcus Henley — 35yr (80kg)
Incident History: Pt was pressed against a steel crowd control barrier by a surge of fans exiting the stands. Bystanders report he was trapped for approximately 2 minutes before crowd dispersed. Pt is now sitting on the ground, leaning forward, holding his right chest, in visible respiratory distress.
Emergency Contact: Renee Henley (Wife) — 0412 774 093

Initial Rapid Assessment

Response: Alert
Airway: Patent. No foreign body or obstruction. Pt speaking in short phrases only. No stridor at this time.
Breathing: Laboured. RR 24. Reduced chest wall expansion right side on visual assessment. Paradoxical movement of right lateral chest wall consistent with flail segment. Accessory muscle use present. Nil audible wheeze.
Circulation: Radial pulse rapid and weak. Skin pale and diaphoretic. No external haemorrhage identified. Trachea midline on initial assessment.
Disability: GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious and distressed.
Exposure: Significant bruising and swelling over right lateral chest wall (ribs 4–8 region). No open wounds. No abdominal bruising or tenderness on palpation. No other injuries identified.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Moderate	24	112	108/74	3s	15	4 4 ++	–	–	9
10 mins	84% (O2 NRB 15L/min)	Severe	32	130	88/60	4s	12	4 4 +	–	–	10

History Taking

Treatment Response

Diagnosis

This patient is suffering from thoracic trauma with multiple right-sided rib fractures causing a flail chest segment, with a developing right-sided tension pneumothorax.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 2 minutes of first contact, SpO2 drops to 87% on room air and patient becomes more agitated and distressed — prompt: 'Marcus is becoming increasingly anxious and says he cannot breathe properly.')
! (If the developing tension pneumothorax signs — tracheal deviation LEFT, worsening hypotension, and falling SpO2 despite high-flow oxygen — are not identified and escalated to CSP by the 8-minute mark, GCS drops to 12, BP drops to 88 systolic, and facilitator announces: 'You notice Marcus's trachea appears to be shifted slightly to the LEFT when you reassess his neck.')
! (If the occlusive dressing — three sides taped — is applied to a wound that does not exist and trainee has not correctly identified this is a CLOSED chest injury, facilitator corrects: 'On reassessment, there is no open chest wound — this is a closed injury. How does your management change?')
! (If paradoxical chest movement is not identified and documented, facilitator prompts: 'As Marcus exhales, you notice the right lateral chest wall moves inward — what does this suggest?')
! (If trainee attempts to remove or reposition the patient to standing to assist with breathing and SpO2 immediately drops further: 'Marcus states he feels faint when you try to stand him up — his blood pressure is now 88 systolic.')

Treatment Objectives

1 Ensure scene safety — assess environment at Subiaco AFL stadium for ongoing crowd movement risk prior to approaching patient.
2 Don appropriate PPE — gloves minimum; consider eye protection given mechanism.
3 Perform Primary Survey with C-spine consideration — mechanism (crush/barrier impact) raises suspicion for spinal injury; use jaw thrust if airway manoeuvre required.
4 Assess airway — confirm patent, patient speaking in short phrases; note increasing distress.
5 Assess breathing — identify raised respiratory rate (24), reduced chest wall expansion right side on visual assessment, paradoxical movement right lateral chest wall (flail segment), accessory muscle use; document findings.
6 Apply high-flow oxygen immediately via Non-Rebreather Mask (NRB) at 10–15 L/min — titrate SpO2 to target 94–98%.
7 Reassess breathing after oxygen application — note SpO2 response; if SpO2 does not improve or deteriorates despite NRB oxygen, escalate urgency.
8 Stabilise flail chest segment — apply gentle supporting hand pressure over right lateral chest wall to reduce paradoxical movement and improve ventilatory mechanics; position patient towards injured (right) side in a position of comfort.
9 Perform Secondary/CNS Survey — systematic head-to-toe assessment; palpate chest wall for crepitus, tenderness, deformity; note bruising right ribs 4–8; reassess tracheal position (initially midline — monitor for deviation).
10 Perform pain assessment — document pain score 9/10; note EHS analgesic options are limited to Methoxyflurane (Penthrox); however Methoxyflurane is CONTRAINDICATED in patients unable to cooperate or with significant respiratory distress and altered consciousness — reassess patient's ability to self-administer safely.
11 Reassess vitals at 5-minute intervals given time-critical presentation — note any deterioration in SpO2, BP, HR, GCS, RR.
12 Identify signs of developing tension pneumothorax — reassess for: tracheal deviation (LEFT shift), worsening hypotension (BP <90 systolic), increasing tachycardia, falling SpO2 despite oxygen, falling GCS — these are red flags requiring immediate escalation.
13 Recognise tension pneumothorax is developing — remove occlusive dressing, maintain airway, and escalate to CSP immediately.
14 Escalate immediately — call for CSP support.
15 If occlusive dressing is considered — clarify this is a CLOSED chest injury with no open wound; occlusive dressing applies to open/sucking chest wounds only; do NOT apply to this patient.
16 Position patient — position of comfort leaning towards injured right side; do NOT lay flat if SpO2 deteriorating; maintain spinal precautions if mechanism warrants.
17 Assist ventilations via BVM if patient's spontaneous respiratory effort becomes inadequate — ventilate at an appropriate adult rate; do not over-ventilate.
18 Monitor continuously — GCS, SpO2, RR, BP, HR, respiratory pattern, tracheal position; record full observations every 5 minutes given time-critical status.
19 Reassure patient continuously — calm, clear communication; explain each intervention.
20 Minimise on-scene time — package patient for urgent transport; perform ongoing management en route.
21 Scenario ends on arrival of ambulance and IMISTAMBO handover.
22 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Thoracic Trauma · Pneumothorax · Haemorrhage · Primary Survey · Secondary & CNS Survey · Oxygen Delivery · Bag Valve Mask Ventilation

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