Management of chest injuries represents a challenge in out-of-hospital care. Common chest trauma injuries seen by paramedics and EMRs/FRs include rib fractures, flail chest, simple pneumothorax, hemothorax, open pneumothorax and tension pneumothorax. Paramedics and EMRs/FRs must maintain a high index of suspicion for underlying life-threatening injuries as many patients may present with initially stable vital signs.
Essentials
Closely monitor all patients with chest trauma for signs of deterioration, with particular attention to respiratory status. Be prepared to support oxygenation and ventilation as necessary.
Be suspicious of the potential for underlying torso injuries in cases of high mechanisms. Injuries to the great vessels, diaphragm, abdominal organs, and the myocardium can occur.
Differentiate between blunt and penetrating mechanisms of injury.
For open chest wounds, utilize a commercial vented chest seal (preferred) or leave open. If bleeding control necessary, gauze may be used.
Additional Treatment Information
Sealing of open chest wounds may place patients at risk for a tension pneumothorax.
Monitor these patients closely and relieve pressure by lifting the chest seal or occlusive dressing if a tension pneumothorax may be developing.
Entonox is contraindicated in patients with a suspected pneumothorax or inhalation injury.
Decompression of a suspected tension pneumothorax should be rapidly performed in patients with deteriorating respiratory and hemodynamic status (ACP/CCP).
Positive pressure ventilation may worsen clinical status in patients with an untreated tension pneumothorax.
All patients with chest trauma should be conveyed to the closest appropriate trauma receiving hospital as per local trauma destination guidelines or clinical pathway.
General Information
Palpation of the chest wall, axilla and neck can be helpful in feeling for the presence of subcutaneous emphysema.
CPAP is contraindicated in patients with a suspected pneumothorax.
Interventions
First Responder (FR) Interventions
Position patient sitting if other injuries permit
Perform basic airway interventions and be prepared to provide ventilatory support as needed