Assessment and Treatment of Chest Injuries: Part 2
By Steve Shotz
Chest injuries often result in serious complications. This paper (part two of two) gives an overview of some of the most common complications that patrollers should watch for when aiding patients. This information is only intended to provide a broader perspective on chest wounds and should not be construed as a "How to" resource. Do not perform any medical aid that is beyond your level of training.
This occurs when air is trapped within the chest but outside of the lung. If a lung is damaged, (e.g. punctured by a fractured rib) air can escape from the lung into the space surrounding it. As the amount of air outside of the lung increases, it compresses the lung, impairing oxygen exchange. (pneumothorax diagram) . The PARIETAL PLEURA is a membrane attached to the inside of the chest wall. Attached to the outside of the lungs is a membrane called the VISCERAL PLEURA. These slippery membranes are normally in contact with each other. Simply put, it is like a balloon inside of a baggie. There should be no space in the area between these two membranes, paradoxically called the PLEURAL SPACE. (normal lung diagrams: Fig. one, Fig. two)
After an injury, the amount of air that accumulates outside the lung will vary and the lung may take minutes or hours to collapse.
Look for pain when the patient inhales, difficulty breathing, and decreased breath sounds over the injured area. Expect anxiety or even panic. As oxygen levels decrease, watch for signs of inadequate perfusion (shock). Patients need emergency evacuation and treatment at a hospital, where a chest tube will be inserted to relieve the pressure. Administer oxygen in the field if you have it. Treat as discussed in Part I, with awareness of other injuries also present.
B. Open Pneumothorax
This is also called a SUCKING CHEST WOUND. A pneumothorax can be caused by air that that enters the chest from a hole in the lung or from a hole in the chest wall that lets in environmental air. In the latter case, air will be drawn into the chest but outside of the lung. When the patient breathes, you will hear air moving in and out of the wound, making a sucking noise. If you seal the external wound tightly, you can cause a TENSION PNEUMO-THORAX to develop. Therefore, many authorities recommend making a flutter valve bandage to cover the hole in the chest wall. Use an OCCLUSIVE DRESSING (such as tin foil, a piece of plastic, a baggie, or anything non-permeable) or a specialized dressing, like the Asherman Chest Seal. Cut the dressing large enough so that it cannot be sucked into the wound (at least an inch beyond the hole in all directions). Tape three sides of the dressing to the chest, leaving the bottom side open. This will allow exhaled air to escape through the open side, but will seal against the wound upon inspiration. Leaving the bottom edge open also allows fluids to drain from the wound. This dressing should relieve some of the internal pressure.
C. Tension Pneumothorax
This occurs when the pressure from air accumulating outside the lung becomes significant. Because there is no way to vent the accumulating pressure within the chest cavity, the lung collapses. As the air pressure surrounding the lung on the damaged side continues to increase, it pushes the MEDIASTINUM, the part of the chest containing the heart and large vessels, away from the injury toward the other side of the chest, compressing it in the process. Blood cannot return to fill the heart, eventually causing shock and heart failure. Look for pain, difficulty breathing, jugular vein distention, a trachea that is displaced to the side away from the wound, decreased breath sounds on the injured side, rapid heart rate, cyanosis of the skin, and low blood pressure. The definitive treatment involves relieving pressure with a needle, which is beyond the scope of most first responders. If Tension Pneumothorax is due to an open wound, treat it with a flutter valve bandage. If not, provide oxygen and immediate transportation.
D. Hemothorax and Hemopneumothorax
When blood, instead of air, fills the pleural space, it is called a hemothorax. A hemopneumothorax occurs if both blood and air accumulate in the pleural space, as is usually the case with a traumatic injury. Because bleeding can result from damage to the heart or great vessels, look for and anticipate the onset of shock. The symptoms, complications, and field treatment of hemo-and hemopneumothoraces are essentially the same as for pneumothoraces for first responders.
Chest injuries of the type described here represent true emergencies. Stay calm and be thorough in your assessment. Since definitive treatment must be provided at a hospital, your primary job is to facilitate rapid evacuation without causing the patient any further trauma. Don't forget to monitor vital signs frequently, obtain SAMPLE history, and provide oxygen when available.
sjsconsulting [at] comcast [dot] net (Steve Shotz) is an Emergency Medical Technician and an Outdoor Emergency Care instructor for the National Ski Patrol. He welcomes your questions on first aid practices.