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Chest injuries can be life-threatening because they can compromise breathing, circulation, or both. They are common in high-impact trauma (falls, road traffic collisions, mountain bike accidents, etc). and may involve damage to the lungs, ribs, or heart. Options for management can be limited, and the best course of action may be to stabilise the patient, offer pain management, and expedite exfiltration.
Open Chest Wound
An open chest wound is any break in the chest wall. It may be caused by penetrating trauma (e.g. stabbing, shrapnel, impalement).
The signs and symptoms will include a visible open wound on the chest wall, bleeding which may be severe, pain, reduced chest movement, shortness of breath, and cyanosis.
Open Chest Wounds are a category of wounds rather than a specific. For example, an open pneumothorax is a type of open chest wound. Management will include monitoring the casualty’s SpO2, supplying oxygen as required, and evacuating the casualty to hospital care.
Simple (Closed) Pneumothorax
A simple pneumothorax is where air leaks from the lung into the pleural space without an open external would. This can occur with blunt trauma (e.g. due to a rib fracture puncturing the lung) or barotrauma.
The signs and symptoms may include chest pain, shortness of breath, decreased chest expansion on the affected side, with reduced or absent breath sounds on the affected side.
Management will include monitoring the casualty’s SpO2, supplying oxygen as required, and evacuating the casualty to hospital care.
Open Pneumothorax (“Sucking chest wound”)
An open pneumothorax is caused by a penetrating chest trauma that creates a hole in the chest wall. This allows air to enter the pleural space through the wound during inspiration, preventing proper lung inflation.
The signs and symptoms may include chest pain, shortness of breath, decreased chest expansion on the affected side, with reduced or absent breath sounds on the affected side, as well as a visible open wound in the chest wall, an audible sucking sound at the wound site, bubbling blood/air at the wound site, and potentially paradoxical movement near the wound.
Management will include covering the wound with a vented chest seal, monitoring the casualty SpO2, supplying oxygen as required, and evacuating the casualty to hospital care. Constant monitoring is required in case this develops into a tension pneumothorax.
Tension Pneumothorax
A tension pneumothorax occurs where air enters the pleural cavity but cannot escape. This increase the intrapleural pressure, compressing the lung, and can obstruct venous return to the heart. This can be rapidly fatal without intervention.
The signs and symptoms may include severe chest pain, shortness of breath, decreased chest expansion on the affected side, with reduced or absent breath sounds on the affected side, as well as a visible open wound in the chest wall. However it may quickly develop to include severe respiratory distress, distended neck veins, tracheal deviation, hypotension, tachycardia, and cyanosis.
Early identification is critical as a tension pneumothorax will potentially require a needle decompression which may require a paramedic to perform and as they can be rapidly fatal the time between identification and a paramedic being able to reach the casualty will be short.
All pneumothoraxes require evacuation and you should be prepared for rapid deterioration, especially during transport. Monitor key vital signs and regularly reassess.
Advanced Skill: Needle Decompression
A needle decompression is typically performed with a large-bore (14 gauge) cannula inserted just above the border of the rib. This is generally placed in the 5th intercostal space, anterior axillary line, but alternatively may be placed in the 2nd intercostal space, midclavicular line.
Flail Chest
A “flail chest” refers to a wound where two or more ribs are fractured in two places leading to a “floating” section of ribs. This is generally caused by blunt trauma to the chest and are often associated with pulmonary contusion.
The signs and symptoms may include severe chest pain, shortness of breath, crepitus, instability or deformity of the ribs, paradoxical movement of the ribs when breathing.
Management will include monitoring the casualty’s SpO2, supplying oxygen as required, and evacuating the casualty to hospital care. You should not strap or tightly bandage the chest, or attempt to split the wound site.