Chest Trauma
Chest seals, tension pneumothorax, flail chest, tamponade and commotio cordis
The chest holds the heart, the lungs and the great vessels, so an injury here can kill by stopping breathing, by stopping blood flow, or both. You cannot open a chest in the field. What you can do is seal a hole, support breathing, spot the patient who is getting worse and move fast.
Open chest wounds
A hole in the chest wall lets air get pulled into the space around the lung with each breath. You may hear sucking or see bubbling blood. Cover it at once with your gloved hand, then replace the hand with a vented chest seal or the occlusive dressing your service carries. Then look for more holes. Check the back, the sides and both armpits, because a bullet or blade that went in may have come out, and an unsealed second wound undoes the first seal.
A sealed chest can still trap air. If the patient gets worse after the seal goes on, with harder breathing, a faster pulse or a falling pressure, lift one edge of the seal and let the air escape, then reseal it.
Pneumothorax and tension pneumothorax
A pneumothorax is air between the lung and the chest wall, so the lung collapses partly or fully. Expect sharp chest pain, shortness of breath and quieter breath sounds on the injured side. It can follow blunt or penetrating injury. A tension pneumothorax is the same problem with a one-way leak: air goes in and cannot get out. Pressure builds until it squeezes the heart and the big veins, and blood stops returning to the heart.
- Severe and worsening trouble breathing
- Breath sounds absent on one side
- A fast, weak pulse and a falling blood pressure
- Bulging neck veins
- A windpipe pushed away from the injured side, which is late and hard to see
Give high-flow oxygen, assist ventilations gently if breathing is failing, release a chest seal if one is on, and transport fast. Call for ALS early, because paramedics can decompress the chest with a needle and you cannot.
Flail chest
When three or more ribs next to each other each break in two or more places, a piece of chest wall floats free. It moves in when the patient breathes in and out when they breathe out, which is called paradoxical motion. The broken segment is not the main danger. The bruised lung under it is, because it stops moving oxygen into the blood. Give oxygen, and if breathing is shallow or oxygen levels stay low, assist ventilations with a bag-valve-mask. Do not strap sandbags or tight bindings over the segment. That limits breathing even more.
Tamponade and commotio cordis
Cardiac tamponade is blood filling the sac around the heart, usually after a stab or gunshot wound near the breastbone. The heart cannot fill, so the blood pressure drops, the top and bottom numbers move closer together, the neck veins bulge and heart sounds turn muffled. Nothing in your kit fixes it. Oxygen, rapid transport and an early warning to the hospital are the care.
Commotio cordis is a blow to the chest that lands at the wrong instant in the heartbeat and throws the heart into ventricular fibrillation. The classic patient is a young athlete hit by a ball or puck who collapses seconds later. Treat it as the cardiac arrest it is: CPR at once and the AED as soon as it is there.
Bulging neck veins and low blood pressure with muffled heart sounds point to tamponade. The same signs with breath sounds absent on one side point to tension pneumothorax.
This lesson teaches general principles. Your local protocols and your medical director decide what you carry, when you use it and where you transport. Follow them on real calls.