Chest Injuries | Chest Disorders

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What is the chest?

The chest is the part of your body between your neck and your abdomen (belly). The medical term for your chest is thorax.

Your chest holds many important structures for breathing, digestion, blood circulation, and other important body functions. These structures include your:

• Ribs and breastbone
• Esophagus, the tube between your mouth and stomach
• Trachea, your windpipe
• Bronchi, the tubes that carry air from your windpipe to your lungs
• Lungs
• Pleura, a thin layer of tissue that covers the lungs and lines the inside wall of the chest space
• Heart and large blood vessels
• Thymus, a gland that’s part of your immune system
• Nerves

What are chest injuries and disorders?

Chest injuries and disorders are problems that affect any of the organs or structures located in your chest.

There are many types of chest injuries and disorders, for example:

• Broken ribs
• Esophagus disorders
• Swallowing disorders, also called dysphagia
• Tracheal disorders
• Bronchial disorders
• Lung diseases and collapsed lung
• Pleural disorders
• Heart diseases
• Mediastinal diseases, which are tumors, inflammation, and other problems with the structures in the mediastinum, which is the space between your lungs, breastbone, and spine
• Thoracic aortic aneurysm
• Thoracic outlet syndrome

Chest injuries may happen from the force of car accidents, falls, or sports injuries. Or the chest may be pierced by a bullet or sharp object. Because your chest holds so many important structures, certain chest injuries may be life-threatening.

How are chest injuries and disorders diagnosed?

Diagnosis of chest injuries or disorders depends on the type of symptoms you’re having and whether you’ve had a chest injury. Injuries are usually obvious, but in most cases, you’ll need tests to know how serious an injury is.

There are many types of tests for diagnosing different types of chest injuries and disorders, for example:

• Diagnostic imaging tests
• Heart tests
• Lung function tests
• Bronchoscopy
• Pleural fluid analysis
• Dysphagia tests
• Biopsy

Treatments will depend on the type of chest injury or disorder you have.

• Bronchoscopy and Bronchoalveolar Lavage (BAL)

  (National Library of Medicine)

  Also in Spanish

• Chest X-Ray (Chest Radiography)

  (American College of Radiology; Radiological Society of North America)

  Also in Spanish

• Tests for Lung Disease

  (National Heart, Lung, and Blood Institute)

  Also in Spanish

• What Is a Cardiothoracic Surgeon?

  (Society of Thoracic Surgeons)

  Also in Spanish

• Costochondritis

  (Mayo Foundation for Medical Education and Research)

• Mediastinitis

  (Merck & Co. , Inc.)

• Rib Fractures

  (Merck & Co., Inc.)

  Also in Spanish

• ClinicalTrials. gov: Mediastinal Diseases

  (National Institutes of Health)

• ClinicalTrials.gov: Rib Fractures

  (National Institutes of Health)

• ClinicalTrials. gov: Thoracic Diseases

  (National Institutes of Health)

• ClinicalTrials.gov: Thoracic Injuries

  (National Institutes of Health)

• Article: Novel nomogram for predicting pulmonary complications in patients with blunt chest. ..

• Article: Pros and cons of rib unfolding software: a reliability and reproducibility…

• Article: Ground level falls: computed tomography findings and clinical outcomes by age. ..

• Chest Injuries and Disorders — see more articles

• National Heart, Lung, and Blood Institute

Chest Trauma – StatPearls – NCBI Bookshelf

Continuing Education Activity

Chest trauma has quickly risen to the second most common traumatic injury in non-intentional trauma. Trauma to the chest comes with the highest mortality; in some studies, up to 60%. Quick thinking and early interventions are key factors for evaluations, management, and survival. This activity reviews the cause and presentation of chest trauma and highlights the role of the interprofessional team in its management.

Objectives:

• Review the etiology of chest trauma.

• Describe the presentation of chest trauma.

• Summarize the management of chest trauma.

• Outline improving care coordination among interprofessional team members to improve outcomes for patients affected by chest trauma.

Access free multiple choice questions on this topic.

Introduction

Chest trauma has quickly risen to the second most common traumatic injury in non-intentional trauma. Trauma to the chest comes with the highest mortality; in some studies, up to 60%. [1] Quick thinking and early interventions are key factors for evaluations, management, and survival.

Etiology

Chest trauma can be a result of penetrating or blunt trauma. Blunt trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-threatening. It is essential to know the mechanism as management may be different.[2][3] Most blunt trauma is managed non-operatively, whereas penetrating chest trauma requires operative intervention.

Epidemiology

All age ranges are at risk for chest trauma. After head and extremity trauma, chest trauma is the third most common blunt injury and quickly rises to second. Motor vehicle injuries are the most common of these. However, this is declining with the advent of improved vehicle safety.[3][4][5][6][7]

Evaluation

Early recognition of trauma to the chest is a priority. The first 3 steps of trauma evaluation involve evaluation, recognition, and intervention of potential injuries to “the box.” Following a routine method of evaluation reduces missed injuries. Injuries to the heart and lungs are primary and vital since they have the highest mortality if missed. Injuries to other thoracic structures also need to be considered; ribs, clavicle, trachea, bronchi, esophagus, and arteries including the aorta and veins need to be evaluated in the secondary and tertiary survey.

The primary survey serves as a time to identify immediately life-threatening injuries. These injuries should be addressed at the time of identification.

Potential injuries that should be ruled out are:

Once the initial exam is complete and adjunct imaging is complete, a secondary survey may reveal:

There are physical exam findings that increase suspicion of chest trauma. Contusions of the chest wall in the pattern of seatbelts, point tenderness over the ribs, decreased breath sounds over the hemothorax, tachypnea, hypoxia, alone or in conjunction with other findings suggest thoracic trauma. The mechanism should also be considered. If the mechanism warrants a high level of suspicion, an ECG should be done to evaluate cardiac contusion.[5][7]

Diagnostics

While chest radiography prevails, it does have limitations. Since chest radiography is achieved in the supine position, small and medium-sized pneumothoraces and hemothorax may be missed.[8][9][10]

The extended-Focused Assessment with Sonography in Trauma (eFAST) may be done with the primary survey, especially in the unstable patient. This can help quickly identify places with air and or blood and direct, definitive management. Compared to supine chest radiography, bedside eFAST is more sensitive to evaluate for pneumothorax. [11][12][13][14]

The 4 views of the traditional Focused Assessment with Sonography in Trauma (FAST) exam include the cardiac (subxiphoid) window, right upper quadrant (RUQ, or Morrison’s pouch), left upper quadrant (LUQ), and suprapubic (bladder) window. The presence of a black collection outside of an organ, viscera, or pericardia suggests a +FAST exam.

The eFAST includes pulmonary views to evaluate for pneumothorax and hemothorax, in addition to the traditional four views. eFAST should be started in the area where there is the highest suspicion for injury. If the thorax is of concern, then this is where the eFAST should begin. This includes anterior chest wall evaluation between ribs for pneumothorax and looking for the continuation of the spinal stripe caudal to the diaphragm in the RUQ and LUQ windows to evaluate for hemothorax. The spinal stripe can be present in cases of pleural effusion. Similar to a positive FAST exam, any presence of fluid in the trauma patient is assumed to be blood.

Computed tomography (CT) is more sensitive and specific. However, this requires the patient to be stable enough for transport.

Other adjuncts include endoscopy, bronchoscopy, and electrocardiography to complete evaluation when warranted. [15][16]

Treatment / Management

Once the ABCs (airway, breathing, circulation) have been addressed, injury-specific interventions should be undertaken.

Immediate life-threatening injuries require prompt intervention, such as emergent tube thoracostomy for large pneumothoraces and initial management of hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted thoracoscopic surgery.[15][17]

The majority of thoracic trauma can be managed non-operatively. However, operative management should not be delayed when appropriate. Operative exploration of thoracic injuries should be considered if tube thoracostomy drainage exceeds 1000-1500mL immediately, about 200 mL per hour for 2 to 4 hours, or ongoing resuscitation (blood transfusion, persistent hypotension) with no other discernable cause.

Admission

Minor injuries may require close monitoring and pain control. Care should be taken in the young and the elderly. Patients with 3 or more rib fractures, a flail segment, and any number of rib fractures with pulmonary contusions, hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at an advanced level of care.

Pain Control

Pain control significantly affects mortality and morbidity in patients with chest trauma. [18]  Pain leads to splints which worsen or prevent healing. In many cases, it can lead to pneumonia. Early analgesia should be considered to decrease splinting.  In the acute setting, push doses of short-acting narcotics should be used.

Other pain control options include intrapleural nerve blocks, transdermal patches, intravenous patient control analgesia (PCA), and epidural analgesia.

Nonnarcotic transdermal patches are safe pain management options for many patients. It should be considered for patients with persistent chest wall pain despite lack of confirmed rib fractures, the patient’s being discharged, or as an adjunct while admitted.

Antibiotics

Prophylactic antibiotics administration for tube thoracostomy for blunt thoracic trauma did not reduce the incidence of empyema or pneumonia when placed with sterile technique.[19]

It should be considered in cases of grossly contaminated wounds or where the sterile technique was broken.

Following steps should be considered in managing pulmonary contusion due to chest trauma.

Operative Management of Rib Fractures

Open reduction and internal fixation (ORIF) has been shown to decrease mortality in patients with flail chest, shorten the duration of mechanical ventilation, reduce hospital length of stay, and reduce intensive care length of stay.[20]

Most pulmonary contusions require supportive therapy until the contusion heals. Because contusions can gradually evolve over the first 24-48 hours after trauma, close monitoring is required. The goal of therapy is to prevent respiratory insufficiency, failure, and complications.[21] There should be appropriate pain control to prevent splinting of chest muscles secondary to injury and allow lung expansion. 

Supportive care like postural drainage, suctioning, chest physiotherapy, incentive spirometry, encouraging coughing, and deep breathing can be tried to prevent atelectasis. Positive pressure ventilation using CPAP and BiPAP may be used.[22]It is of utmost importance to provide minimum positive end-expiratory pressure (PEEP) to maintain the lungs open, recruit maximum alveoli, and prevent barotrauma. [23]Prone positioning of the patient with contusion reduces stress on the diaphragm, and positioning of the contused lung in a non-dependent position helps in recruiting alveoli. Noninvasive ventilation can cause gastric distention and aspiration significantly if the level of consciousness is impaired. If positive pressure ventilation fails, invasive ventilation is required. Large tidal volume can have adverse effects; hence the use of low tidal volume is suggested. Patients with severe hypoxia and poor response to other therapies can benefit from nitric oxide. Diuretics can be used in a contusion to reduce pulmonary venous resistance and pulmonary capillary hydrostatic pressure.[5] If fluid therapy is required to maintain euvolemia, measuring pulmonary artery pressure is recommended to avoid pulmonary edema.

Surgical stabilization may be required in the case of multiple rib fractures/ flail chest to correct pulmonary mechanics. Patients refractory to all conventional therapies have been successfully managed by extracorporeal gas exchange (ECMO). [24]

Differential Diagnosis

A complete primary, secondary, and tertiary survey should be completed to avoid missed or confounding injuries.

Pearls and Other Issues

Special Populations

Geriatric patients have higher mortality compared to younger patients with the same injuries.

Elderly patients with a single rib fracture have twice the mortality as their younger counterparts with the same injury. Mortality increases by 19% for each additional rib and the risk of pneumonia by 27%.[25][26]

Enhancing Healthcare Team Outcomes

Chest trauma is a common problem encountered by emergency department physicians. Because there are usually many other organs involved in chest trauma, the condition is best managed by an interprofessional team that consists of a trauma surgeon, nurse practitioner, anesthesiologist, thoracic surgeon, ICU nurses, and cardiac surgeon. In many cases, it takes enormous force to cause injury to the organs inside the chest cavity and associated organ injury is common.  

Depending on the extent of injury, the outcomes of chest trauma vary. For isolated rib fractures, the prognosis is good, but if the aortic has been disrupted or there is lung or cardiac contusion, the recovery is often prolonged. The highest morbidity following chest trauma is seen in very young and very old patients.[27][28] [Level 5]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

References

1.

Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma. 1988 Mar;28(3):298-304. [PubMed: 3351988]

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Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994 Dec;37(6):975-9. [PubMed: 7996614]

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Veysi VT, Nikolaou VS, Paliobeis C, Efstathopoulos N, Giannoudis PV. Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience. Int Orthop. 2009 Oct;33(5):1425-33. [PMC free article: PMC2899104] [PubMed: 19266199]

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LoCicero J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. 1989 Feb;69(1):15-9. [PubMed: 2911786]

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Ekpe EE, Eyo C. Determinants of mortality in chest trauma patients. Niger J Surg. 2014 Jan;20(1):30-4. [PMC free article: PMC3953631] [PubMed: 24665200]

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Davis JS, Satahoo SS, Butler FK, Dermer H, Naranjo D, Julien K, Van Haren RM, Namias N, Blackbourne LH, Schulman CI. An analysis of prehospital deaths: Who can we save? J Trauma Acute Care Surg. 2014 Aug;77(2):213-8. [PubMed: 25058244]

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Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C, Gruzinski G, Chan L. Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005 Sep;201(3):343-8. [PubMed: 16125066]

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Ebrahimi A, Yousefifard M, Mohammad Kazemi H, Rasouli HR, Asady H, Moghadas Jafari A, Hosseini M. Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos. 2014;13(4):29-40. [PMC free article: PMC4386013] [PubMed: 25852759]

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Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011 Apr;77(4):480-4. [PubMed: 21679560]

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Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care. 2013 Sep 23;17(5):R208. [PMC free article: PMC4057340] [PubMed: 24060427]

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Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest. 1995 Nov;108(5):1345-8. [PubMed: 7587439]

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Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 2011 Oct;140(4):859-866. [PubMed: 21546439]

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Hyacinthe AC, Broux C, Francony G, Genty C, Bouzat P, Jacquot C, Albaladejo P, Ferretti GR, Bosson JL, Payen JF. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012 May;141(5):1177-1183. [PubMed: 22016490]

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Mumtaz U, Zahur Z, Raza MA, Mumtaz M. Ultrasound And Supine Chest Radiograph In Road Traffic Accident Patients: A Reliable And Convenient Way To Diagnose Pleural Effusion. J Ayub Med Coll Abbottabad. 2017 Oct-Dec;29(4):587-590. [PubMed: 29330983]

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Mowery NT, Gunter OL, Collier BR, Diaz JJ, Haut E, Hildreth A, Holevar M, Mayberry J, Streib E. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011 Feb;70(2):510-8. [PubMed: 21307755]

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Casós SR, Richardson JD. Role of thoracoscopy in acute management of chest injury. Curr Opin Crit Care. 2006 Dec;12(6):584-9. [PubMed: 17077691]

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Chou YP, Lin HL, Wu TC. Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin Pulm Med. 2015 Jul;21(4):393-8. [PMC free article: PMC5633323] [PubMed: 25978625]

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Galvagno SM, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, To KB, Fox AD, Alley DE, Ditillo M, Joseph BA, Robinson BR, Haut ER. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016 Nov;81(5):936-951. [PubMed: 27533913]

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Heydari MB, Hessami MA, Setayeshi K, Sajadifar F. Use of prophylactic antibiotics following tube thoracostomy for blunt chest trauma in the prevention of empyema and pneumonia. J Inj Violence Res. 2014 Jul;6(2):91-2. [PMC free article: PMC4009174] [PubMed: 24045157]

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Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, Bosarge PL, Love J, Haut ER, Como JJ. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017 Mar;82(3):618-626. [PubMed: 28030502]

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Rendeki S, Molnár TF. Pulmonary contusion. J Thorac Dis. 2019 Feb;11(Suppl 2):S141-S151. [PMC free article: PMC6389561] [PubMed: 30906578]

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Ganie FA, Lone H, Lone GN, Wani ML, Singh S, Dar AM, Wani NU, Wani SN, Nazeer NU. Lung Contusion: A Clinico-Pathological Entity with Unpredictable Clinical Course. Bull Emerg Trauma. 2013 Jan;1(1):7-16. [PMC free article: PMC4771236] [PubMed: 27162815]

23.

Požgain Z, Kristek D, Lovrić I, Kondža G, Jelavić M, Kocur J, Danilović M. Pulmonary contusions after blunt chest trauma: clinical significance and evaluation of patient management. Eur J Trauma Emerg Surg. 2018 Oct;44(5):773-777. [PubMed: 29167928]

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Paolone S. Extracorporeal Membrane Oxygenation (ECMO) for Lung Injury in Severe Acute Respiratory Distress Syndrome (ARDS): Review of the Literature. Clin Nurs Res. 2017 Dec;26(6):747-762. [PubMed: 27836935]

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Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000 Jun;48(6):1040-6; discussion 1046-7. [PubMed: 10866248]

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Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012 Jan;43(1):8-17. [PubMed: 21256488]

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Boutillier J, Deck C, De Mezzo S, Magnan P, Prat N, Willinger R, Naz P. Lung injury risk assessment during blast exposure. J Biomech. 2019 Mar 27;86:210-217. [PubMed: 30808500]

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Pehlivanlar Küçük M, Küçük AO, Aksoy İ, Aydın D, Ülger F. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit: 10-year clinical outcomes. Ulus Travma Acil Cerrahi Derg. 2019 Jan;25(1):46-54. [PubMed: 30742286]

Disclosure: Ashika Jain declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Waseem declares no relevant financial relationships with ineligible companies.

First Aid for Chest Injuries: Steps and Tips

Contents

• 1 First Aid for Chest Injuries: Doctors’ Tips
  • 1.1 First Aid for Chest Trauma
    • 1.1.1 Steps for Chest Trauma
    • 1.1.2 Recommendations for chest trauma
  • 1.2 Chest trauma: what is it?
  • 1.3 What causes a chest injury?
  • 1.4 Symptoms of chest trauma
    • 1.4.1 Pain and discomfort
    • 1.4.2 Difficulty breathing
    • 1.4.3 Swelling and bruising
    • 1.4.4 Shock
  • 1.5 First aid for chest injuries: actions and recommendations
    • 1.5.1 What should I do if I have a chest injury before the ambulance arrives?
  • 1.6 What should I do if I have a chest injury?
  • 1.7 How to properly lay down a victim with a chest injury?
    • 1. 7.1 Important to know!
    • 1.7.2 How to lay the victim down correctly?
    • 1.7.3 What to do next?
  • 1.8 First aid preparations for chest trauma
    • 1.8.1 Antibiotics
    • 1.8.2 Analgesics
    • 1.8.3 Adrenaline
    • 1.8. 4 Midazolam
  • chest injury?
    • 1.9.1 Severe injuries
    • 1.9.2 Pain and difficulty breathing
    • 1.9.3 Further severe deterioration
  • 1.10 How to prevent chest injury?
  • 1.11 What are the guidelines for caring for a victim after a chest injury?
  • 1.12 Complications of a chest injury
  • 1.13 Q&A:
    • • 1.13.0.1 How to provide first aid for a broken rib?
      • 1.13.0.2 What to do about pneumothorax?
      • 1.13.0.3 Is it possible to warm the chest if the chest is bruised?
      • 1.13.0.4 How to recognize a chest fracture?
      • 1.13.0.5 What to do in case of lung injury?
      • 1.13.0.6 Can you pierce the breathing tube yourself with a closed pneumothorax?

Learn the basic rules of first aid for chest injuries – how to relieve pain, stop bleeding, support the victim’s breathing. Careful and correct action can save a person’s life in a critical situation.

Injuries to the chest can result from motor vehicle accidents, falls from heights, or sports injuries. Regardless of the cause, chest injuries can be dangerous and require prompt and proper first aid.

Injuries to the chest may present either openly, where the bony area prolapses, or closed, where internal injuries can only be determined with the help of additional examinations. In both cases, the first thing to do is to assess the condition of the victim and immediately call an ambulance.

However, first aid given before the ambulance arrives can save the victim’s life. In this article, we will look at how to provide first aid for chest injuries, actions and recommendations that can help minimize the damage from the injury and save lives.

First Aid for Chest Trauma

Chest Trauma Treatment

Chest trauma can be caused by a blow, a fall, or a car accident. In the event of a chest injury, the first thing to do is call an ambulance or send the victim to the hospital yourself. Prior to the arrival of medical workers, the following actions should be taken:

• Assess the condition of the victim . Check for breathing, pulse and consciousness. If the victim is unconscious, resuscitation should be started immediately.
• Breathe . If the victim has difficulty breathing, it is necessary to free the upper respiratory tract from foreign objects and relieve him of tight clothing. If this does not help, artificial respiration should be started.
• Treat bleeding . If the victim has wounds, it is necessary to stop the bleeding with direct pressure on the wound.
• Keep victim from drinking liquids or food . If the victim has wounds in the chest, then when eating or drinking, there is a risk of them entering the lungs, which can lead to a sharp deterioration in the condition.

Chest Trauma Advice

After first aid and until medical help arrives, stay close to the victim and monitor their condition. It is important to provide the victim with maximum comfort and peace. If he has pain, analgesics can be given, but only after consulting a doctor. Cardiac massage and artificial respiration can be performed to prevent cardiac arrest.

After providing first aid, it is necessary to take the victim to the hospital as soon as possible, where he will be provided with the necessary medical assistance.

Chest injury: what is it?

Chest injury is an injury that can result from a blow, fall, accident or other injury. This can lead to various injuries to the chest, including fractured ribs, damage to the lungs, heart, or other organs in the chest cavity.

A chest injury is usually accompanied by chest pain, shortness of breath, hemoptysis, heart rhythm disturbances, and other symptoms.

Be aware that a chest injury can be very serious and requires immediate medical attention. It is also important to know how to provide first aid for such an injury in order to minimize its consequences.

What causes a chest injury?

Chest injury can be caused by a variety of factors. One of the most common is traffic accidents, which can result in a strong blow to the chest area.

A chest injury can also occur as a result of a fall from a height, such as a ladder, on ice, or on an unstable surface.

There is also a risk of chest injury in sports such as football, hockey, boxing.

Causes of a chest injury can be varied, but regardless of this, it is important to know how to provide first aid in such an event.

Symptoms of a chest injury

Pain and discomfort

The most common symptom of a chest injury is pain, which can be moderate to severe. The pain often gets worse with movement, coughing, or breathing. There may also be discomfort, tightness, and a feeling of constriction in the chest area.

Difficulty breathing

Injury to the chest may cause difficulty in breathing, which may be caused by damage to the lungs, a hole in the chest, or a reduction in the volume of the chest cavity. In such cases, urgent medical attention is needed.

Swelling and bruising

Swelling and bruising may occur at the site of a chest injury. Swelling can occur due to inflammation and accumulation of fluid in the tissues. Bruising can be caused by damage to the blood vessels and bleeding into the tissue. If symptoms do not disappear within a few hours, see a doctor.

Shock

In some cases, chest injuries can lead to shock, which occurs due to a lack of blood and oxygen in the body. The shock can cause severe weakness, nausea, loss of consciousness, and unconsciousness. If these symptoms appear, call an ambulance immediately.

How to give first aid for chest injuries: actions and recommendations

What to do with a chest injury before the ambulance arrives?

In the event of a chest injury, an ambulance must be called immediately. However, before her arrival, you can perform a number of actions that will help alleviate the condition of the victim.

1. Reassure the victim. Injury to the chest may cause severe pain and difficulty in breathing, which may cause panic and fear in the victim. Ask him to calm down and stay close to observe his condition.
2. Help the casualty into a comfortable position. This may be in a sitting or reclining position. The main thing is that the victim feels as comfortable as possible.
3. Cover the victim with a warm blanket. A drop in body temperature can aggravate the condition of the victim, so it is necessary to create conditions to maintain normal body temperature.
4. Do not give the victim food, drink or smoke. In case of chest injury, there may be a risk of rupture of an ulcer or pulmonary spasm, therefore food and liquid intake should be avoided.

These simple steps can help relieve the victim until the ambulance arrives. However, do not forget that a chest injury can be very serious and dangerous, so you should always call an ambulance.

What should I do if I have a chest injury?

A chest injury is a serious tissue injury requiring first aid. First of all, you need to call an ambulance.

However, it is possible to help the victim before the arrival of the medical team:

• Assess breathing. If the casualty has stopped breathing, give artificial respiration immediately.
• Apply a firm bandage. Applying a rigid bandage to the chest area will help prevent further injury.
• Give me an analgesic. At the first moment, the victim needs to relieve pain in order to prevent loss of consciousness.

If you are not confident in your abilities, you should stay close to the victim until the arrival of the medical team, speak to him with all your strength and reassure him.

How to properly lay down a victim with a chest injury?

Important to know!

Before laying the casualty down, make sure there is no bleeding or other injury to ensure safe handling.

In the event of a chest injury, lay the casualty on their back with a pillow or blanket under their head. Folded clothing can be placed under the knees to relieve tension in the chest area.

How to lay the victim down correctly?

• Approach the casualty and lower their arms to their chest.
• Using your palms, grasp his torso and turn him towards you.
• Have another person keep their hands on the victim’s chest.
• Perform the lifting maneuver and place the casualty on their side with their head turned to the side.

What to do next?

After you have laid the casualty down, call an ambulance and stay with the casualty until they arrive.

If necessary, support the casualty and monitor his breathing and pulse.

Chest trauma first aid

Antibiotics

Used for open chest wounds to prevent infection. The doctor must select an antibiotic and determine the dosage.

Analgesics

Used to relieve pain in chest injuries. It is recommended to use paracetamol, aspirin and other non-steroidal anti-inflammatory drugs. The dosage must be determined by the doctor.

Adrenaline

Used for anaphylactic shock, which can be caused by trauma. Adrenaline enhances the contractile function of the heart and constricts blood vessels, which improves blood circulation and reduces tissue swelling.

Midazolam

Used for rib fractures to relieve pain and reduce muscle tension. It is prescribed by a doctor and only if necessary. The dosage must be strictly controlled.

• Important: Before using any drugs, you should consult your doctor and follow his recommendations.
• Important: self-administration of medicines without consulting a specialist is not recommended.

When should I seek medical attention for a chest injury?

Serious Injuries

If your chest has been injured as a result of an accident, fall from a height, or other serious incident, seek immediate medical attention. Such injuries can cause damage to internal organs or bleeding, which may require urgent medical attention.

Pain and difficulty breathing

If severe pain or difficulty in breathing develops due to a chest injury, medical attention also becomes necessary. These symptoms may be associated with a variety of injuries, including broken ribs or lung damage.

Further sharp deterioration in condition

If after first aid (puffing up the gills, removing foreign objects, placing the victim in a safe position), the victim’s condition deteriorated sharply, severe bleeding occurred, breathing became more difficult or absent, you should immediately call an ambulance.

How to prevent chest injury?

Chest injury prevention includes a number of activities that help reduce the risk of injury:

• Proper use of seat belts in cars and helmets on motorcycles;
• Avoidance of extreme sports without adequate protection;
• Incorporate exercises that improve chest muscles into a training regimen;
• Use of protective equipment when working with dangerous tools;
• Avoiding the use of drugs and alcohol, which may lead to inappropriate behavior or incoordination.

Taking these preventive measures will help reduce your risk of chest injury and keep you healthy.

What are the guidelines for caring for a victim following a chest injury?

After providing first aid to a victim with a chest injury, it is necessary to provide him with maximum comfort and help him recover faster. The following suggestions will help ease the recovery process:

• Analyze the condition of the victim . In the first few hours after a chest injury, it is necessary to monitor the condition of the victim, listen to his breathing, control his pulse and the level of oxygen in the blood.
• Keep calm . In the first days after the injury, it is necessary to provide the patient with peace and avoid physical exertion. The pillow and mattress should be soft and comfortable enough.
• Watch your diet . The body of the victim needs a lot of vitamins, proteins and carbohydrates in order to recover as quickly as possible. Watch your diet and drink plenty of fluids.
• Continue treatment as directed by your physician . For a quick recovery, it is necessary to continue treatment according to the doctor’s recommendations and visit him on a regular basis.

By following these guidelines, you can help the victim recover more quickly from a chest injury and return to a normal life.

Complications of chest trauma

Chest trauma can lead to serious complications. First of all, it can be a violation of breathing, since with a chest injury, the organs of the respiratory system can be damaged or a pneumothorax can form. This is a condition where air enters the pleural cavity, resulting in a decrease in total lung volume and impaired respiratory function.

Trauma to the chest can also cause bleeding and hematoma formation, which can lead to circulatory failure and eventually tissue degeneration.

It is important to know that if you have a chest injury, seek medical attention immediately, as any of the complications described can lead to serious consequences and even death.

Q&A:

How to provide first aid for broken ribs?

If a rib is broken, an ambulance must be called immediately. Before the arrival of doctors, you need to lay the victim on his back, put a soft pillow or folded clothes under his chest to reduce pain and ease breathing. It is forbidden to give the patient food, liquid and medicine until the arrival of doctors.

What to do with pneumothorax?

For pneumothorax, place the victim in a semi-sitting position. This will relieve pressure on the lungs and make breathing easier. Then you need to provide first aid, if possible, covering the real wound with an airtight material, such as a band-aid. It is forbidden to remove foreign objects from the wound, inject injections and pour in liquids. An ambulance should be called immediately.

Is it possible to warm the chest if the chest is bruised?

No, when the chest is bruised, it is necessary to apply cold to the injury site. This will help reduce swelling and relieve pain. Cold can be applied in the form of special ice bags wrapped in a soft cloth. The duration of application of cold should not exceed 20 minutes. If the victim’s condition worsens, you should immediately consult a doctor.

How to recognize a chest fracture?

A chest fracture may present with chest pain, swelling and bruising at the site of the injury, difficulty breathing, heart rhythm disturbances, and circulatory disturbances. For an accurate diagnosis, you need to see a doctor who will conduct an x-ray of the chest. If you suspect a chest fracture, you should not straighten the damaged area yourself or massage the chest.

What to do if you have a lung injury?

In the event of a lung contusion, it is necessary to lay the victim on his side on the side of the injury and keep him calm. It is necessary to call an ambulance and entrust the provision of medical care to professionals. Before paramedics arrive, you can help the casualty by extending their arms and legs and helping them take deep breaths to help them breathe easier. If the victim also suffered a bruise of the chest, you need to put him in a half-sitting position.

Is it possible to pierce the breathing tube with a closed pneumothorax?

No, piercing the breathing tube with a closed pneumothorax can be very harmful and even fatal. You should not make any manipulations with the tube yourself, including replacing it. Such an action can lead to lung prolapse, as well as the formation of pneumomediastin.

strategy for expanding the possibilities of stabilization of multiple and floating rib fractures

Multiple and floating rib fractures are among the most severe forms of mechanical damage, the frequency of which reaches 20-35% of all closed chest injuries, and the mortality rate is 10-46% [1, 2]. Chest injury with violation of the integrity of the rib cage in 80-90% of cases are accompanied by intrapleural complications: hemothorax and pneumothorax, contusion of the lungs and heart, diaphragm injuries [3—5].

The problem of treatment of multiple and floating rib fractures is still far from being solved [6—9]. Despite the presence of several significant clinical studies of different levels of evidence confirming the greater effectiveness of surgical chest stabilization techniques compared to any other, this approach has not yet become widespread [10–14]. The reasons are the lack of clear indications for fixation of rib fractures, the resource intensity of technologies, and the long-term traditions of certain scientific schools. Along with this, it requires continuous improvement in the technique of osteosynthesis of the ribs, as well as the development of its combined implementation with intrapleural minimally invasive manipulations [15–17]. It is necessary to clarify the indications for the use of other methods of chest stabilization: artificial lung ventilation (ALV), external fixation device (AVF) [18, 19]. Not a single modern study considers the stages and continuity in the use of different medical methods, there is no scientific justification for their combined use, and treatment and diagnostic protocols for providing care to these patients at all stages of medical evacuation require clarification [20–22].

The aim of the study was to improve the tactics of surgical treatment of patients with multiple and floating rib fractures.

Material and methods

The work is based on the analysis of the results of surgical treatment of 315 patients with multiple and floating rib fractures treated in the Department of Thoracic Surgery of the Samara Regional Clinical Hospital named after I.I. V.D. Seredavina” (SOKB), as well as in the general surgical departments of the State Budgetary Institution of Healthcare “Samara City Clinical Hospital No. N.I. Pirogov” and GBUZ “Samara City Clinical Hospital No. 2 named after A.I. ON THE. Semashko” in the period from 2006 to 2015

In accordance with the time periods of admission of patients and differences in the basic principles of medical care, all patients were divided into two groups. The comparison group included 148 patients with multiple and floating rib fractures hospitalized in the period from 2006 to 2010. In this group, mainly methods of conservative treatment, mechanical ventilation, skeletal traction were used. The main group included 167 patients treated in 2011-2015. In the treatment of these patients, we applied the surgical tactics developed by us, based on differentiated, staged and combined use of various methods of chest stabilization and high-tech methods of medical care (rib osteosynthesis, thoracoscopy).

There were no statistically significant differences between the groups in terms of age, gender, circumstances of injury. The distribution of patients depending on the number of rib fractures and the presence of concomitant injuries is shown in Table. 1.

Table 1. Distribution of patients depending on the number of rib fractures and concomitant injuries Note. Differences between the groups are statistically insignificant: χ2=2.045 (p>0.05).

In 82 (55.4%) patients of the control group and in 100 (59.9%) of patients of the main group, the multiple nature of rib fractures led to the formation of various pathological conditions that aggravated the course of chest trauma (Table 2).

Table 2. Clinical and anatomical characteristics of rib fractures

In general, there were no statistically significant differences between the groups in terms of the number and structure of intrapleural and associated injuries.

The diagnostic algorithm included physical and general clinical examination, computed tomography of the chest and other areas, blood gas analysis.

In the treatment of patients in both groups, different methods were used to stabilize the chest and repair damage to the intrapleural organs. At the same time, both medical approaches that are absolutely identical in terms of technical implementation, as well as fundamentally different types of high-tech assistance that were first used in the treatment of this category of patients, were noted.

The tactics of providing assistance at the first stage of treatment of patients with multiple and floating rib fractures in the comparison group did not differ from that in the main group and included anti-shock measures and relief of the main manifestations of the injury and the pathological syndromes caused by it. All operations performed in the future were aimed at stabilizing the bone frame of the chest and eliminating damage to the intrapleural organs.

In the comparison group, surgical chest stabilization consisted of skeletal traction and AVF. Mechanical ventilation was carried out in the mode of mechanical forced ventilation through an endotracheal or tracheostomy tube in normoventilation parameters. A retrospective analysis showed that these ventilation parameters did not provide the effect of “internal pneumatic stabilization”, since the main indicators of positive pressure at the end of inspiration were not achieved, and the PSV (pressure support ventilation) mode was not used.

The tactics of treating patients in the main group was based primarily on determining the degree of damage to the sternocostal frame and internal organs. In addition, such important factors as the conditions for providing medical care, the presence and severity of concomitant injuries and background diseases were taken into account. Based on this, even in patients initially admitted to level II and III trauma centers, the tactics were initially coordinated with the specialists of the trauma center of level I of the SOCH and finally implemented after the transfer. One way or another, in addition to mandatory anti-shock measures and urgent elimination of injuries, the need for chest stabilization was immediately assessed and its types, stages and combination of methods were determined. Intrahospital movement of patients was carried out in accordance with the standard principles of care for chest trauma and polytrauma.

All chest stabilization methods we used were divided into temporary stabilization methods and definitive stabilization methods. The first provided stabilization of the chest without achieving fixation of fractures – this is skeletal traction, stabilization due to the creation of negative pressure in the treatment of chest wounds – negative pressure wound therapy (NPWT) and mechanical ventilation in the internal pneumatic stabilization mode. The latter contributed equally to the achievement of stabilization of the chest and fixation of rib fractures – external fixation using devices of various designs and internal fixation by osteosynthesis of the ribs. However, due to the lack of a direct reparative effect on the damaged bone, external fixation is rather intermediate between the methods of temporary and final stabilization of the chest. It should be noted that the methods of temporary stabilization in a number of cases became final due to various circumstances – the effectiveness of the method, the severity of the patient’s condition, which does not allow surgical intervention, the anatomical characteristics of rib fractures.

After determining the method of stabilization at the initial stage of treatment, the stages of these operations were evaluated, as well as the need to combine different methods depending on the severity of the chest injury, associated injuries and the conditions for providing medical care.

Speaking about internal pneumatic stabilization, it should be emphasized that if in a number of patients it was chosen as the main and only method of stabilizing the chest, then in all other patients it was combined with one or another surgical method of stabilization.

Results and discussion

Intrahospital routing of patients did not undergo significant statistically significant changes in the main group compared to the comparison group.

Emergency surgical interventions within the first 2 hours from the moment of hospitalization were performed in 139 (83.2%) patients of the main group and in 130 (87.8%) patients of the comparison group (Table 3). The purpose of these operations was to eliminate emergency conditions resulting from trauma: stop bleeding, eliminate organ damage, external drainage of pathological accumulations of blood and air, temporary stabilization of the chest.

Table 3. The volume of interventions on the chest organs during emergency operations Note. χ2=6.975; p>0.05.

There were no statistically significant differences between groups depending on the nature of emergency surgical interventions. However, in the main group, if indications for intrapleural interventions were indicated, thoracoscopy was performed, while in the comparison group, thoracotomy was performed.

In patients of both groups, during the emergency phase of care after the elimination of life-threatening injuries, chest stabilization was performed – skeletal traction by the ribs or sternum in 8 patients of the comparison group and in 8 patients of the main group. If in the patients of the comparison group it was considered as the main intervention that provides stabilization of the chest, then in the patients of the main group it was a temporary method used at the first stage of treatment due to low trauma and speed of execution.

Urgent surgical interventions within 2 hours to 7 days were performed in 113 (67.7%) patients of the main group and in 87 (58. 8%) patients of the comparison group (Table 4).

Table 4. Volume of urgent interventions on the chest organs χ2=153.304; p<0.01.

Statistically significant differences were obtained between groups depending on the nature and frequency of urgent interventions. Thoracoscopy (χ ² =68.301; p <0.01). As measures to stabilize the chest and fix rib fractures, skeletal traction was more often used in the comparison group (45.3%), and rib osteosynthesis (58.1%) was used in the main group.

In the comparison group with multiple and floating rib fractures, surgical treatment of patients with chest instability was carried out by skeletal traction behind the sternum or ribs or by applying AVF (Table 5). These methods of stabilization, as a rule, became final, and mechanical ventilation was performed as a method of treating acute respiratory and multiple organ failure, but not to create internal pneumatic stabilization.

Table 5. Methods of chest stabilization Note. χ2=131.118; p<0.01. In the main group, due to a combination of stabilization methods, the total number of operations exceeds the number of patients.

In patients of the main group, only surgical fixation by rib osteosynthesis was considered as the main and final method of chest stabilization, so most other methods either served as temporary stabilization measures or were used in the absence of conditions for rib osteosynthesis. In this regard, we obtained statistically significant differences in the frequency of application, primarily of rib osteosynthesis (χ ² =124.214; p <0.01).

In the main group, in the treatment of one patient, several methods were often used, therefore, the effectiveness of the final stabilization method was evaluated. Thus, rib osteosynthesis was finally performed in 10 out of 25 patients who underwent skeletal traction at the first stage, in 2 out of 10 who underwent AVF, in 2 out of 4 patients who underwent NPWT. The possibility of stabilizing the bone frame and eliminating intrapleural injuries in patients of the main group was associated with the introduction of a fundamentally new strategy for the treatment of patients with concomitant trauma, which provides for a staged assistance.

Due to the fact that internal pneumatic stabilization was considered by us as an obligate method accompanying all surgical methods of stabilization, its results were evaluated only in those patients in whom surgical techniques were not used. In table. Table 6 shows the distribution of patients depending on the type of injury (isolated or combined) and the final method of chest stabilization.

Table 6. Distribution of patients depending on the type of injury and the final method of chest stabilization

Operations to repair damage to internal organs in patients of both groups were performed in accordance with the classical indications for drainage of the pleural cavity, thoracoscopy, thoracotomy. The frequency of combinations of various methods of chest stabilization and various operations to eliminate damage to internal organs is given in Table. 7.

Table 7. Combination of various methods of chest stabilization and repair of internal injuries

It should be noted that in both groups we adhered to the principle of succession in the application of various surgical interventions. Thus, at the first stage in most patients (90.5% in the comparison group and 92.8% in the main group; χ ² = 0.536; p >0.05), pleural cavity drainage was performed as an emergency measure. At the same time, there is a significant difference in the frequency of thoracoscopy. If in the comparison group it was used in 22.3% of observations, then in the main group – in 71.3% of observations (χ ² \u003d 75.326; p <0.01). This made it possible to reduce the incidence of late intrapleural complications and, consequently, reduce the need for repeated interventions and thoracotomy.

Evaluation of the effectiveness of each method of stabilization was carried out on the basis of an analysis of clinical, laboratory and instrumental signs. The clinical criteria were the relief of paradoxical breathing – the absence of chest flotation, the restoration of the shape and volume of the chest, auscultatory signs of lung expansion, the cessation of air leakage and exudation through the drains, and the restoration of spontaneous breathing. As instrumental indicators, radiographic signs of lung expansion, reduction of contusion and infiltration, absence of pathological accumulations of air and fluid were used; patency and sanitation of the respiratory tract with fibrobronchoscopy. Laboratory criteria included improvement in blood gas parameters.

An integral assessment of the results of using various methods of chest stabilization was carried out (Table 8).

Table 8. Results of various methods of chest stabilization Note. * — number of patients who underwent mechanical ventilation.

The largest number of days of respiratory support was observed in the subgroup of patients who received only mechanical ventilation – internal pneumatic stabilization without the use of surgical methods of stabilization. This explains the high rates of complications and mortality. When comparing surgical techniques, the best results were obtained in patients who underwent rib osteosynthesis.

The obtained data made it possible to draw a conclusion about the effectiveness of the developed tactics in patients of the main group as a whole (Table 9).

Table 9. Comparative analysis of treatment outcomes

Significant statistically significant differences in the incidence of complications and mortality in both groups were obtained. In addition, in patients of the main group, the duration of mechanical ventilation and stay in the ICU decreased, which indicated the effectiveness of the developed surgical tactics.

Thus, surgical tactics in the treatment of patients with multiple and floating rib fractures should be based on an analysis of the type of fracture, the nature of internal injuries, the severity of the associated injury, and the conditions for providing medical care.