Injuries — chest

If any danger signs — consider life-threatening but treatable problem

• Blocked upper airway
• Tension pneumothorax
• Massive haemothorax
• Penetrating chest injury
• Flail chest

Remember: A pneumothorax may develop slowly. Consider if breathing trouble develops

Pneumothorax

Tension pneumothorax

• Air trapped between outside of lung and inside of ribcage, under high pressure
• Be aware that many of the classical clinical signs listed can be difficult to elicit, especially in the early stages
• Be alert for increasing respiratory distress

Check

• Cardiac monitoring and ECG
• Head-to-toe exam — with attention to
• Increasing respiratory distress
• Colour — shock (pale) cyanosis (blue)
• Distended neck veins
• Less or no chest movement on injured side
• Less or no breath sounds on injured side
• Hyper-resonance to percussion on injured side
• Crepitus (crackly feeling under skin) around neck and top of chest, caused by subcutaneous emphysema (bubbles of air)
• Fractured ribs — bruising, pain, tenderness
• Shift of trachea (windpipe) away from injured side — late sign

Do

• Give 100% oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Urgent medical consult
• Needle decompression, leave cannula in place and opened to air
• Put in chest drain if person stable — not urgent. Can wait hours before putting in drain
• Give pain relief 
• Put in 2 IV cannula or intraosseous if unable to get IV access
• Assess/manage other injuries

Non-tension pneumothorax

Air trapped between outside of lungs and inside of ribcage and not under pressure. Person not usually very breathless or in shock

Check

• Cardiac monitoring and ECG

Do

• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD  88–92%
• Put in 2 IV cannula, or intraosseous if unable to get IV access 
• Give pain relief
• Urgent medical consult
  
• If person flying — may need to put in chest drain

Massive haemothorax

Large amount of blood in chest cavity between lungs and inside of ribcage

Check

• Cardiac monitoring and ECG
• Head-to-toe exam — with attention to
• Respiratory effort
• Less or no chest movement on injured side
• Less or no breath sounds on injured side
• Dull to percussion on injured side

Do

• Urgent medical consult
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Put in 2 IV cannula, largest possible or intraosseous if unable to get IV access
• If low BP — run blood if available, otherwise Hartmann's solution or normal saline in 250–500mL boluses. Target systolic BP 80–90mmHg

If serious respiratory distress

• Check for tension pneumothorax — do needle decompression
• If air rushes out — leave cannula in place and open to air
• If no improvement with needle decompression, discuss with medical officer. May need second attempt with larger needle or in a different location as directed
• If still serious trouble breathing — will need chest drain. Expect a lot of blood
• Assess/manage other injuries
• Give pain relief

Penetrating (open or ‘sucking’) chest injury

Do not

• Do not remove objects sticking into chest
• Do not probe wound (poke or feel around in)
• Do not use gauze or combine dressing

Check

• Cardiac monitoring and ECG

Do

• Urgent medical consult
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Cover wound, tape on 3 sides only to make a valve — Figure 2.20
  
• Use piece of thin, flexible, waterproof paper or material a bit bigger than wound (eg Op-site or defibrillator pad packet, thin strong paper). Do not use gauze or combine dressing

• Put in 2 IV cannula or intraosseous if unable to get IV access
• Give pain relief
• Give cefazolin IV — adult 2g, child 50mg/kg/dose up to 2g — doses — every 8 hours until sent to hospital
• If allergy — medical consult
• Assess/manage other injuries

Flail chest

• Usually happens when chest smashes against steering wheel or something hard
• Caused by 2 or more ribs being fractured in 2 places

Check

• Cardiac monitoring and ECG
• Head-to-toe exam — with attention to
• Chest movement — one part of ribcage sucks in and rest moves out as person breathes in
• Shortness of breath

Do

• Urgent medical consult — send to hospital
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Put in 2 IV cannula, or intraosseous if unable to get IV access
• Give pain relief

Fractured ribs

• Most fractured ribs are not complicated
• If a lot of pain or person unwell — consider Flail chest, or damage to organs underneath fracture — lungs, liver with right lower rib fractures, spleen with left lower rib fractures
• X-rays are of little use for fractured ribs — unless worried about pneumothorax or flail segment

Check

• If suspected sternal injuries ECG and cardiac monitoring
• Head-to-toe exam — with attention to
• Localised tenderness over rib/s
• Pain if you gently spring chest. Gently squeeze chest once from side to side or front to back. If no pain — unlikely to be fractured rib

Do

• Give pain relief pain relief
• Encourage person to do regular coughing and breathing exercises (10 deep breaths and 2 coughs every hour) to lessen risk of pneumonia
• If they can’t do this — medical consult, may need to go to hospital