5 Chest Trauma

Immediate priorities

Chest trauma can rapidly compromise breathing, circulation, or both. Recognize tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and cardiac tamponade as time-critical threats.

Follow local trauma protocols, activate the trauma team, and assist with invasive procedures as directed by qualified clinicians. Prioritize the trauma survey, rapid escalation, and repeated assessment of respiratory and circulatory status.

Do not postpone indicated emergency intervention for imaging when the patient is unstable.

Pneumothorax and open wounds

Severe shortness of breath, hypotension, and markedly reduced breath sounds on one side raise concern for tension pneumothorax. Tracheal deviation and hypotension can be late findings, so do not wait for late signs when the patient is deteriorating.

Alert the trauma team and prepare for immediate pleural decompression. Do not delay decompression to obtain a chest radiograph when the condition is suspected and the patient is unstable.

An open wound in the chest wall can cause an open pneumothorax and impair ventilation. While urgent help is arranged, apply an appropriate occlusive dressing configured to allow air to escape, according to protocol. Do not pack the wound deeply or probe it.

Hemothorax and blood loss

After chest injury, pallor, tachycardia, hypotension, decreased breath sounds, and dullness to percussion on one side are concerning for hemothorax, potentially massive. Chest trauma can cause hidden, life-threatening blood loss.

Escalate immediately, support oxygenation and circulation, and prepare for clinician-directed tube thoracostomy and blood-product resuscitation. If the patient is unstable, treatment should not be postponed for imaging.

Chest-wall and lung injuries

A chest segment that moves inward during inspiration and outward during expiration after multiple rib fractures suggests flail chest. Priorities are close respiratory assessment, oxygenation, effective pain management, and pulmonary hygiene. Escalate for ventilatory support if respiratory failure develops; a flail segment alone does not require mechanical ventilation when respiratory failure is absent.

Pulmonary contusion may become more apparent over time. If breathing difficulty or oxygenation worsens over the hours after blunt chest trauma, report deterioration promptly, repeat assessment of respiratory effort and oxygenation, and support the ordered respiratory plan. An initially reassuring assessment or image does not rule out evolving injury.

Blunt cardiac injury screening

For suspected blunt cardiac injury after significant blunt trauma to the front of the chest, obtain an admission ECG and measure troponin I as directed by the trauma team. EAST guidance states that a normal ECG together with a normal troponin I can rule out blunt cardiac injury.

New ECG abnormalities or elevated troponin warrant monitored evaluation. A sternal fracture alone does not establish cardiac injury.

Recognizing deterioration

Worsening oxygen saturation or work of breathing signals possible deterioration and takes priority for immediate reassessment, even when other patients have stable rib pain or minor chest-wall injuries.

Reassessment should include chest movement, breath sounds, vital signs, and oxygenation. Continue repeated respiratory and circulatory assessment because chest trauma can threaten either system and clinical status may worsen over time.