Chest Wall Trauma

Tom RaderStaff - June 1, 2021

Whenever a patient has a trauma mechanism that involves the chest, you should make sure to do a good physical exam. We are looking for a couple of con
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In this lesson, you’ve written:

You can confirm a pneumothorax by listening to the chest, even just with your ear pressed against the chest — you will hear diminished sounds on the side with the collapse (or you will not hear any sound at all)

However, in this article it says:

You need training (and additional equipment instead of Dr. Clooney’s magical ears) to know when to recognize this specific problem and how to do it without causing more damage.

Can you recognize a tension pneumothorax with your ears?

I figure it doesn’t really matter though: Hole in chest? Slap a vented chest seal on it!

 

Relatedly, how do you know whether a lung has been punctured? If there’s a wound on the torso, how do you decide between a chest seal vs pressure dressing?

If there seems to be severe bleeding from a chest wound, will a chest seal be enough to stop the bleeding? Would you first try to stop the bleeding with direct pressure and then when it seems you’ve done that clean the area enough that a chest seal will stick? Might taking away whatever you used to stop the bleeding cause bleeding to restart?

 

@Lowell: What should bleeding in this area so strong that a pressure dressing should be required and feasible to avoid severe blood loss?

The only things I can imagine are the lungs, the Breast artery and the heart itself but there you will not be able to stop the bleeding with a pressure dressing anyway (with field methods). But I’m not a medicine, so lets wait for the experts. 

 

This is essentially the answer. If there’s enough blood coming out of a chest wall penetration that you think “wow this seems like a massive hemorrhage that I need to control immediately,” then some core structures in the heart / lungs / surrounding area have been compromised and the patient will die without quick professional care.

According to Tom: “There is nothing in the areas where you’d use a chest seal that you would use a pressure dressing on. No overlap.”

 

>If there seems to be severe bleeding from a chest wound, will a chest seal be enough to stop the bleeding?

And what if someone has a lot of body hair or other gunk in the way. Just seal or tape as best you can, and it’s still better than nothing?

 

Solid question! Similar for using an AED, I wonder if I should carry a razor in my FAK to de-hair someone’s chest if need be. 

 

You could even use your Bic lighter in the most extreme scenario

 

I updated the text to clarify. Store-bought products, such as chest seals and AEDs, have special adhesives that will handle normal body hair, blood, sweat, etc. So it’s more about a cursory wipe to get the real barriers out of the way, such as leaves that stuck to the skin as the patient rolled out of the car upon crash, or whatever.

Instead of thinking “I should prep for this by having a razor,” instead you should just have a proper chest seal product. And then, if need be, you probably have a field knife / multitool / shears with you in a pinch.

 

I updated the text to clarify. You can confirm with a stethoscope if you want to after seal placement. But this is not a necessary step because, as you said, if you see a hole in the chest… slap on a chest seal.

You might hear stories of people that confirmed pneumo / tension pneumo with their ears, but it’s unlikely and inconsistent in these kinds of field settings.

 

I would also be interested in learning what to do in case of deep wounds in the stomach area (and what not to do)

 

There’s basically nothing you can do for/inside the abdomen in an austere context. Treat the bleeding and other symptoms that you’re aware of. But if there’s a deep penetration into the abdo, they need professional medical help / surgical intervention, or perhaps luck + time.

 

Thx, John (sorry, I missed the answer somehow until now)

 

Thanks Brian, fixed!

 

Great explanation on the use of a chest seal for penetrating trauma. I think it might benefit the student to also mention that non-penetrating hemo and  pneumothorax may also be of concern. While there isnt anything we can do (thoracostomy is outside our expertise unfortunately ha), those conditions would have an impact on the urgency of getting the patient to more definitive care. I’d hate for someone to think “no hole, no problem” regarding the lungs.

Also, I was taught that there are two additional symptoms to look out for when identifying a collapsed lung, paradoxical chest movements (albeit not as dramatic as the flail chest chest video), and in the severe later stages, the displacement of the trachea. You think those are actually noticeable in real life?

 

Trachea deviation can be a late sign for thoracic injuries.  Being able to visually identify paradoxical movement can be difficult and not always super easy to spot right away.  

Any thoracic injury, penetrating or not certainly can be life-threatening.  Even spontaneous pneumothorax are severe, although rare.  

A good, thorough patient assessment is key.  

 

Very helpful discussion.  Chest seals look much simpler and safer than chest darts.  Plus, they have the added bonus of no flinch factor, unlike when inserting a needle into the patient’s chest cavity 🙂