There are a number of ways that a person could receive a traumatic chest wound. In almost all cases this is the result of an accident of some type. The same type of accident that is likely to happen if there is a disaster, especially a long-term disaster. Whether it is a gunshot wound, stab wound, falling onto a piece of rebar, or falling off a ladder; there are many scenarios that might include chest trauma. Because these types of injuries can be very life threatening, it is important to know the initial steps that should be taken if you find yourself needing to provide aid to a person with chest trauma.
Summarizing everything traumatic as a traumatic injury is oversimplifying things, traumatic chest injuries fall into one of two categories: penetrating trauma or blunt trauma.
Penetrating Trauma – Injury caused by an object that pierces the skin and causes a wound in the body that is exposed to the outside.
Blunt Trauma – Injury caused when the body is injured by impact that causes injury to the body without a wound that is exposed to the outside.
The typical signs and symptoms associated with chest trauma include:
Abnormal Rise and Fall of the Chest
Rapid, Shallow Breathing
Pale, Cool, and Clammy Skin
Rapid Heart Rate
Low Blood Pressure
Coughing Up Blood
Common Chest Wounds
Pneumothorax – There are two types of pneumothorax, sometimes called a pneumo (pronounced like new-mo) for short; a tension pneumothorax and an open pneumothorax.
Tension Pneumothorax: The accumulation of air within the pleural space (the space between the inside of the ribs and the lung) that can lead to the collapse of the lung.
Open Pneumothorax (Sucking Chest Wound): A wound that is through the chest wall and into the chest cavity in a way that impairs normal breathing function. This is classically called a sucking chest wound and is characterized by the sucking of air into the wound and may possibly be visibly bubbling.
Hemothorax – The accumulation of blood in the pleural space. There can be up to four liters of blood that can accumulate in this space, a danger because you can bleed to death this way without any blood even leaving the body.
Hemopneumothorax - There is also the possibility that a casualty could have both a hemothorax and a pneumothorax simultaneously. If this is the case, there is both blood and air in the chest cavity.
Flail Chest (Flail Segment) – A free-floating segment of the rib cage that is caused by having two or more ribs that are each broken in at least two places. A flail chest is a significant indicator of underlying blunt trauma. Always consider that whatever organs are beneath the traumatized area are also likely injured. The key method to determine if a patient has a flail chest is to look for paradoxical motion when they breathe. Paradoxical motion can be detected by watching the breathing of the patient for unequal rise and fall of the chest. This is indicated by sinking on the injured side of the chest while breathing in, while the uninjured side will rise. While breathing out, you will see the injured side rise while the uninjured side of the chest falls. It is also possible that while inspecting the chest for injury that you will feel the free segment in the ribs.
Treating Chest Trauma
Primary treatment for any casualty should start with completely exposing the injured area by removing all clothing. The best way to do this is by cutting them off with trauma shears or bandage scissors. After exposing the injured area, an assessment of the casualty’s airway, breathing, and circulation (A,B,C’s) should be completed. This is especially true with chest trauma. Unless you have x-ray vision, it is rather difficult to tell what is going on inside the body and vital signs can provide you some idea of how things are working, or not working.
A good method for assessing airway and breathing is to look, listen, and feel. Look at the chest for rise and fall. Place your ear over the patient’s mouth and nose, while looking at their chest, listening for air moving in and out. Feel for inhalation and exhalation by placing your hand on the chest of the patient.
*One of the best ways to learn to check vital signs is to search for nursing skills videos on YouTube.
If the casualty has a good airway (screaming, talking, moaning, etc. are all good indicators that there is an intact airway) then assess the quality of the breathing. Is there equal rise and fall of the chest? Are the breaths shallow or deep, rapid or slow? How many times is the person breathing a minute? Using a stethoscope, listen to both lungs and assess for an absence of breath sounds on either side. The absence of breath sounds can be an indicator of a collapsed lung. Once the quality of breaths has been assessed, check for a pulse and any obvious bleeding. If any life threatening injuries are found, treat them according to your level of training and skill.
Normal Breathing and Pulse Ranges
Heart Rate (Beats/Minute)
Following the A, B, C’s, check the entire body from head to toe for deformities, contusions, abrasions, punctures/penetrations, burns, tenderness, lacerations, and/or swelling.
Keep in mind that many cases of chest trauma may need surgical intervention to be fully treated. With this being the case, the most prudent course of action is to treat immediate life threats and get the injured person to a health care provider at the soonest opportunity. When transporting a casualty with chest trauma, it is almost always the best course of action to transport the casualty sitting up unless indicated otherwise.
Blunt Trauma –
Rib fractures are the most common type of injury as a result of blunt trauma to the chest along with bruising, abrasions, and possibly lacerations. Simple rib fractures (a single break in one rib) can most often be treated minimally with NSAID’s (Non-Steroidal Anti-Inflammatory Drugs), time, and observation. It can also be more comfortable for the person injured if their ribs are wrapped with an ACE wrap. Always ensure that the wrap is not so tight that it causes any difficulty with breathing.
If a compound rib fracture (a fractured rib that has broken through the skin) is present, care needs to be taken to ensure that the broken rib does not puncture a lung or other organ and the injured individual should be taken to see a health care provider.
Most rib fractures just need time to heal but if a fracture is severe enough, there may need to be surgical intervention and even mechanical ventilation in the most extreme cases. Other blunt trauma injuries; bruising, lacerations, abrasions, etc. will need to be treated accordingly with bandages and pain medication (if needed).
Penetrating Trauma –
If an object is impaled in the chest, NEVER remove the object! An impaled object should be stabilized and bandaged around the object. Impaled objects will be removed at the hospital. The danger in removing an impaled object is that the impaled object could be occluding the flow of blood from a wound or damaged circulatory system and removing this object could allow the blood to flow freely and cause additional complications. It is also possible that an impaled object could tear into arteries, vessels, and organs if someone other than a surgeon removes it.
Primary treatment for penetrating chest trauma should be application of a chest seal. An appropriate seal for a chest wound will preferably be a purpose made chest seal dressing like the Bolin or Hyfin Chest Seals but a piece of plastic that will completely cover the chest wound and is taped on all four sides can be substituted. The only way that any chest seal will work is if it is completely airtight.
When applying a chest seal, wait until the casualty exhales to place the seal on the chest. If the casualty is conscious, and can, have them exhale and hold their breath while you apply the chest seal. If the casualty is unconscious, simply wait for the chest to fall and then place the chest seal on the casualty.
If there is an entry wound and an exit wound, apply a chest seal to both wounds.
Tension Pneumothorax –
The definitive treatment of a tension pneumothorax is any procedure that will
evacuate the air from the pleural space. Most often, this is the insertion of a chest
tube on the effected side. A common treatment in the field that will buy some
time until a casualty gets to definitive care is a needle decompression of the chest.
With the absence of advanced medical training that facilitates placement of a
chest tube or performing needle chest decompression, the best thing that can be
done is to monitor the patient’s airway and breathing. Encourage the person to
stay calm. If you have a stethoscope, you can listen to both lungs. The absence of
breath sounds on one side is a typical indicator of a pneumothorax. Allow the
patient to sit or lay in a position of comfort. A very common position of comfort
is seated while leaning forward slightly.
If a pneumothorax is detected, the best chance of survival is provided by further
treatment at a hospital.
Open Pneumothorax –
Treatment for an open pneumothorax is essentially the same as the penetrating trauma treatment listed above. The key is to ensure that all open wounds are sealed and any impaled objects are stabilized.
Intervention for a hemothorax is typically limited to placement of a drain into the chest cavity. This requires the ability and equipment to safely place a chest tube. Without this skill, your best bet is to get the casualty to a hospital or medical clinic as soon as possible. Always monitor vital signs and treat any life threatening injuries that you are capable of treating.
Treatment of a hemopneumothorax in the field is nearly identical to the treatment of a pneumo or hemothorax. Having a hemopneumothorax is a condition that will require surgical intervention. If a hemopneumothorax is suspected; assess vitals, treat any life threatening injuries, and transport the injured person to a higher level of care as quickly as is possible.
Flail Chest (Flail Segment) –
The treatment associated with a flail chest is fairly similar to fractured ribs associated with blunt trauma. While successful treatment is often accomplished with pain medication, time, and observation; the risk of poor outcome is higher in elderly patients. There is also the potential need for additional treatment such as a chest tube or intubation and ventilation.
AFTER PROVIDING ANY SORT OF TREATMENT, ALWAYS GO BACK AND REASSESS THE PATIENT’S VITAL SIGNS TO ENSURE THAT THE TREATMENT WAS EFFECTIVE AND NOTHING HAS CHANGED FOR THE WORSE.
Complications Associated With Chest Trauma
It is sometimes hard to get a grasp on, but it is imperative that it is understood that if there is a wound to the chest, there could also be internal injury to the abdominal cavity. This is scary territory but the assumption has to be made that if there is a traumatic injury to the chest (at the nipple line or lower), there is also an injury in the abdominal cavity until proven (or reasonably confirmed) otherwise. As an example, a very large organ that is right below the diaphragm is the liver, holding about 15% of the body’s blood volume. So it is easy to understand that if the source of trauma passes through the diaphragm into the abdominal cavity, there could be catastrophic damage. In fact, it is estimated that a person could bleed enough from their liver to lead to almost certain death in as little as 10 minutes.
Often times, the complications that are seen with chest trauma are a result of penetrating trauma (specifically projectiles like bullets). Once a bullet enters the body, it does not travel in a straight line. A bullet will do things like strike a rib and follow it around the inside of the chest cavity or hit a rib on the other side of the chest cavity and travel downward into the abdominal cavity. Bullets and projectiles are not the only reason that chest trauma can get complicated. A knife wound can be a potential issue with organ involvement if it the blade tracked towards and into an organ(s).
It is worth noting that approximately one-third of preventable deaths on the battlefield are a result of a tension pneumothorax alone and that upwards of an estimated 75% of traumatic deaths every year are at least partially attributable to thoracic trauma.
Being Prepared To Deal With Chest Trauma
There are two simple steps that can be taken to ensure your preparation to deal with chest trauma; skills and supplies. Having the skills to do what needs to be done and having the supplies to do it are the keys to stabilizing a chest trauma patient and getting them to a higher level of care.
- Identify the signs and symptoms of chest trauma.
- Be familiar with the normal ranges of vital signs.
- Know how to take the vital signs of a patient.
- Assess ABC’s.
- Be able to listen to a patient’s lungs and correctly recognize lung sounds.
- Identify and treat life-threatening injuries.
- Stabilize and bandage an impaled object.
- Properly apply a purpose built and improvised chest seal.
- Assess the chest for trauma but always remember the potential for additional injury in the abdominal cavity.
- Chest Seals (Hyfin and Bolin are the chest seal of choice for the U.S. military.)
- Materials for improvised chest seals (durable plastic and water resistant tape).
- Blood Pressure Cuff
- Bandages and stabilizing materials.
It is pretty clear that by reading this article, chest trauma can be difficult to deal with and more often than not may require surgical intervention of some type. At the end of the day, if you do not get an injured person to additional care alive, it will not matter that you got them to higher care. Having a few basic skills and materials will allow you to stabilize a person that has sustained chest trauma and get them to definitive care. This can be a vital skill set when considering the potential for this type of trauma in the wake of disaster.