Chest Wall Trauma (HB)

Whenever a patient has a trauma mechanism that involves the chest, you should make sure to do a good physical exam. We are looking for a couple of conditions that would contribute to respiratory problems.

Pneumothorax

Air should be inside the lungs or out in the atmosphere. If for some reason, it gets inside the chest cavity, it causes problems. A pneumothorax is simply a collapsed lung.

Trauma to the chest is the most common cause. A penetrating injury to the chest that punctures the lung creates two points for air to enter the chest cavity (potentially three if the object went all the way through). Blunt trauma to the chest can fracture ribs, and the impact can “pop” a lung. A fractured rib can lacerate the lungs.

Either one of the conditions is bad if the air is not allowed to escape and can lead to enough of a buildup of pressure in the chest cavity that the lungs are not able to inflate—the pressure inside the lungs cannot overcome the pressure trapped in the chest cavity and is called a “tension pneumothorax.” If allowed to progress, this will eventually lead to death. The solution is to vent the air inside the chest cavity using a large-bore needle or a chest tube, neither of which are in this course’s scope of practice.

You can confirm a pneumothorax by auscultating (listening) to the chest even with your ear pressed against the chest—you will hear diminished sounds on the side with the collapse (or you will not hear any sound at all). However, the symptoms you will have noted by this point should already have indicated a serious problem. This diagnostic is interesting, but you should not wait until you have it to act.

Note: If the injury was from a penetrating mechanism, you should have already managed it during the primary assessment with a vented chest seal. If the seal that you used is not able to vent, a tension pneumothorax can develop.

Flail chest

A flail chest is defined as three or more broken ribs adjacent to each other.

As the patient breathes in, the chest wall should expand outward equally. However, when the patient has a flail chest, the damaged section of the ribs gets pulled in on inhalation and pushed out during exhalation. The flail chest causes the chest wall to “see-saw,” One side going out while the other side goes in.

You can see an extreme example of a flail chest here:

We can reduce the pain and problems from a flail chest by securing a semi-rigid object (like a water bladder) directly to the affected side. You can also apply direct pressure with your hand to the flail segment or position the patient, so they are laying on the flail segment. Make sure you frequently monitor the patient for signs of increasing respiratory problems.