Assess airway patency, chest injury and delivered breaths before choosing the next intervention.
| Finding | Next checks |
|---|---|
Blood or vomit in the airway | Use the available suction action and reassess airflow |
Poor chest movement or falling oxygenation | Check airway position, delivered breaths and both sides of the chest |
One sided abnormal chest findings | Assess for pneumothorax, hemothorax and a tube that has advanced too far |
Deterioration after a procedure | Recheck device placement, remaining leak, drainage and ventilation |
Deterioration after a blast | Assess both chest injury and the separate blast lung model |
Open Use ACCUVAC or Use Suction Bag from the airway actions. Your carried equipment selects the device, with ACCUVAC taking priority when you carry both. Keep the suction tip inside the mouth and watch the fluid clear.
Manual suction bagLeft mouse gives one squeeze. Keep the tip in the mouth and click again after each squeeze completes. Holding the button does not repeat squeezes. Watch the collection bag fill; a full bag stops drawing.
Original mod audio. Select Play to hear each clip.
Steady powered suction.
One squeeze of the bulb.
The suction power down sound.
Suction controls, device selection and sounds checked against ACM Extended 21f8694. Mouse controls · SALAD parking · Oxygenation effect
Confirm the tube position
Confirm the tube’s position and reassess after moving it. A tube that advances into one main bronchus reduces the lung available for ventilation; the model reduces effective compliance and oxygenation. A partially placed obstructing tube can produce a flat capnograph.
CautionWithdrawal and sedation checks
Deflate the cuff before withdrawing the tube. Pulling repeatedly against an inflated cuff can cause airway injury. Sedation and paralysis have separate effects: rocuronium does not provide sedation or analgesia. Use the medication cards and ketamine pupil finding together.
A capnograph shows CO2 leaving the airway throughout each breath. Read the shape, rate and trend together with the patient’s pulse, chest movement and delivered breaths.
Normal plateau, example CO2 level 40 mmHg and breathing rate 12/min.
A quick rise, a gently rising plateau, then a sharp return toward zero.
The default shape when neither obstruction nor unresolved ventilator effort is selecting another pattern. A normal shape can still have a low or high CO2 value.
Compare the CO2 trend with breathing rate, delivered volume and perfusion. The shape alone does not establish adequate circulation or oxygenation.
A slower, slanted rise and a less distinct plateau. Increase obstruction severity to see the fin become more pronounced.
Blood or vomit obstructing the airway, or a partially placed tube, can select this pattern. A separate bronchospasm diagnosis is not required by the current waveform selector.
Reassess airway contents and tube position, use suction where indicated, and check the delivered breaths. Recheck the waveform after correcting the obstruction.
A notch interrupts the plateau as the patient makes an effort that is not coordinated with the ventilator. Increasing the example effort makes the notch deeper and wider.
Unresolved respiratory effort or coughing while the ventilator is driving breaths can create a cleft. An awake patient who is completely paralyzed cannot create a notch through awareness alone.
Reassess patient effort, ventilator coordination and the ongoing sedation and paralysis plan. A cleft is not a direct measurement of sedation; rocuronium provides paralysis without sedation or analgesia.
No exhaled CO2 waveform. This example stays at zero regardless of the selected rate or peak.
An inserted but incompletely seated, obstructing ETT forces the flat shape. No breathing or no effective exhaled CO2 also removes the waveform.
Check the airway and device position, chest movement, actual delivered breaths and circulation immediately. A flat trace has more than one possible cause.
Waveform shape, waveform height and the breath averaged number answer different questions. Allow the number to settle after a change and reassess the patient when the shape changes.
Game patterns: waveform selection · EMMA shape functions. Waveform interpretation: Masimo capnography reference.
CautionBefore needle placement
Examine the patient before placing a needle. An unnecessary decompression can create a simple pneumothorax. Continued progression depends on the air leak, available drainage, positive pressure and altitude changes.
Reassess after decompression
A decompression outlet can relieve pressure while the underlying leak remains. Reassess after placement and if the patient worsens. Repeated needles should prompt a check of the diagnosis, catheter function and need for more durable drainage.
In gameNeedle decompression option
Addon Options > ACM Extended: Trauma > Procedures > Allow Needle Decompression controls new needle placements. The procedure minigame and available equipment can add their own requirements.
Cover the actual chest wound with the seal and inspect the other surface for additional wounds. Seal placement and peeling change the patient’s chest seal state. A seal does not remove pleural blood or clear blast lung.
Chest sealPurpose: cover the actual open chest wound.
Recheck: seal position, other wounds and the patient’s response.
ThoracostomyPurpose: create a pleural opening for drainage.
Recheck: opening, remaining air leak and any change after closure.
Chest tubePurpose: maintain a drainage route, including passive pleural blood drainage.
Recheck: tube position, drainage and breathing.
Finger thoracostomy and a chest tube create different drainage conditions. The thoracostomy minigame requires site preparation, incision and completion of the opening. Inadequate preparation can seed infection. A placed tube can passively drain pleural blood, with a configured base rate of 0.12 L/min.
CautionReassess after tract closure
Closing or sealing a thoracostomy tract changes its drainage status. Reassess after closure, tube adjustment or a change in positive pressure. The chest seal tray action on a completed thoracostomy routes through the same clinical closure function as closing the tract.
Burping lifts a corner of an applied seal to release trapped pleural air. In ACM Extended, bleeding from penetrating chest wounds can clog the seal’s outlet. If air enters faster than it escapes, the pneumothorax can grow and develop tension. Burping restores venting and gives immediate pressure relief when a seal outlet is present.
Lift the corner completely, let the seal vent, then lay it flat and reassess.
Restoring an outlet lets trapped gas leave. The game reduces its pleural air burden, resets the pressure burden and clears the tension state after a completed burp with a seal outlet.
Bleeding can obstruct the outlet again. An internal leak, an uncovered entry or exit wound, positive pressure or a pressure change during flight can upset the balance again.
Recheck after new or worsening chest findings, oxygenation or circulation, and after treatment or transport changes. A dry treated wound has no mandatory clog timer, so the mod does not require burping every seal on a fixed schedule.
Game controls: wheel and full lift · cursor release. Game effects: outlet obstruction · burping relief. Background on venting and reassessment: CoTCCC chest seal rationale.
The game tracks the internal air leak, accumulated pleural air, pressure and residual collapse separately. Improvement requires air entry to fall and an effective outlet to remove the trapped air. The leak can settle over time while the remaining collapse still needs drainage.
Cover every communicating chest wound, including the exit. Treat ongoing bleeding. A missed opening keeps admitting air and sharply reduces the benefit of the other seals. Support breathing while avoiding unnecessary pressure on an injured lung.
A completed burp, needle decompression or an open pleural tract can relieve pressure. Keep checking the result. A chest tube provides a stronger outlet and clears the model’s residual collapse floor.
The internal leak gradually shrinks. Continued bleeding slows this process. Protect the patient from another chest injury, recheck after changing support, and allow drainage to keep pace while the leak settles.
| Intervention | What can improve | What still matters |
|---|---|---|
Seal every open wound | Reduces entry through chest wall openings and provides the seal’s venting benefit. | Ordinary seal placement does not instantly reset established tension. Check for an obstructed outlet and retained air. |
Burp the seal fully | Restores the seal outlet and immediately relieves the modeled pressure burden when a seal outlet is present. | The internal leak remains. Some residual collapse can remain, and the outlet can obstruct again if bleeding continues. |
Needle decompression | Provides a drainage outlet and relieves pressure after successful placement. | It does not close the internal leak or remove the residual collapse floor. Reassess the patient and the actual outlet. |
Complete finger thoracostomy | An open, completed tract creates a strong pleural outlet and relieves pressure. | A partial incision or dissection is not yet a patent outlet. Closing or sealing the completed tract removes its open drainage route. |
Insert a chest tube | Maintains a strong outlet, clears the residual collapse floor and allows remaining pleural air to drain toward zero. | New air entry can still outpace the treatment. Pleural blood, edema and blast lung are separate problems that may keep breathing abnormal. |
Oxygen and ventilation | Support oxygenation and delivered breaths while the chest problem is managed. | Oxygen does not directly drain the pleural space or accelerate the PTX leak settling term. Actual positive pressure increases flow through an existing internal leak. |
Falling PTX severity reduces its penalties to lung compliance, delivered ventilation and oxygenation. Reassess chest movement, breath sounds, ventilator pressures and delivered volume together.
Relieving tension removes the tension state. Continue reassessing pulse and blood pressure as well as oxygenation; hemorrhage or another injury may still be driving deterioration. SpO2 alone is unreliable in a poorly perfused patient.
The source keeps diminished lung sounds while any PTX remains. Hemothorax, edema, blast lung or a misplaced ETT can also explain abnormal findings after the air problem improves.
Pneumothorax leak settling time, under ACM Extended: Trauma > Pneumothorax, defaults to 600 seconds. This is a scale for reducing a normalized leak of 1 to zero, not a fixed ten minute recovery for every patient. A leak of 0.25 takes about 150 seconds with no ongoing bleeding; the same leak takes about 225 seconds at the model’s maximum bleeding modifier. New injury can increase the leak again.
The leak decreases even if the patient is unconscious or sedated. Sedation, a particular blood pressure and a particular ventilator mode are not prerequisites for this PTX healing term. Open chest wounds still admit air until covered, and actual positive pressure increases entry through an existing leak.
The default 60 second Pneumothorax stability interval only records a period of controlled air accumulation internally. It does not clear residual collapse, treat tension or produce a provider notification. Established tension still needs venting; a stopped leak and a quiet timer do not remove it.
Recovery mechanics checked against ACM Extended dd50edf: open wounds, outlets and pressure · treatment and residual collapse · clinical state updates · delivered ventilation · oxygenation · lung sounds.
CautionReassess circulation after support
Positive pressure can reduce estimated stroke volume when circulating volume is low. Both active BVM ventilation and the ventilator participate. Higher PEEP can increase the penalty. Treat hemorrhage and inadequate ventilation together, then reassess pressure and pulse after starting support.
See the positive pressure and preload calculation and Ventilator Settings & Tips.
The remaining airway mechanics were reviewed against ACM Extended source 4848f63. The burping and pneumothorax recovery sections use dd50edf; capnography and suction use the revisions linked in their sections. Game defaults can change with mission settings. Waveform conditions · EMMA readout · Tube mechanics · Seal effects · Thoracostomy defaults