Within the United Kingdom (UK), severe thoracic injuries are one of the most common causes of death from trauma, accounting for approximately 25% of trauma deaths. Within pre-hospital care, the most common problem associated with severe chest injury is hypoxia. This can be either through primary injury which impairs the patients’ ventilation, or secondary to hypovolemia from significant bleeding into the chest or major vessel disruption.

Types of injury:

Depending on the Mechanism of Injury (MOI), several injuries can present in chest trauma:

Rib fractures:

Rib fractures can be very painful and cause the patient great discomfort. They will often present with localised bruising and pain that worsens on inspiration, movement, and palpation. On its’ own, a stable rib fracture will not likely cause any damage to the underlying tissues. It can take between 1 to 2 months for a rib fracture to heal on its’ own. The patient may have some difficulty in breathing due to the pain, but this can be managed with analgesia, ongoing support, and rest.

Where an unstable rib fracture(s) is present, this may cause damage to the underlying tissues and organs. If the patient is short of breath, hypoxic, has diminished breath sounds on the affected side, or has signs of hypovolemic shock, suspect that the fractured rib(s) may have cause significant internal damage such as puncturing a lung, tearing or puncturing the aorta and other organs. MOI, surround factors, and signs/symptoms of the patient will help in determining how severe their injury may be.

Flail chest/segment:

A flail chest/segment can be defined as a fracture of two or more ribs in two or more places, usually in a row or next to each other. This usually requires significant blunt trauma to the thorax. The injury can present with abnormal chest movement where the injured section moves independently of the rest of the thorax. Further symptoms can include shortness of breath, hypoxia, and pain. Where rib fractures occur either side of the sternum, a sternal flail can present.

A flail injury can cause significant harm to a patient due to its’ effects on the patients’ ability to adequately ventilate their lungs and allow for gaseous exchange to occur. There are several pathophysiology’s that can occur:

• The patients’ ability to ventilate air into their lungs is compromised due to the flail section disrupting the negative pressure respiratory process. This is as a result of the flail sections’ independent movement.
• The area of lung underneath the flail section will likely be damaged, resulting in some haemorrhage and oedema. This will affect the alveoli and could diminish gaseous exchange within the area.
• The pain of multiple rib fractures over a large area will make the patient reluctant to try and breath normally, resulting in some hypoventilation.

A patient with a flail chest/segment will likely require oxygenation, analgesia, and supportive measures to their ventilations. If possible, try and allow the patient to sit at a 30–45-degree angle and continue with corrective and supportive measures on the primary survey.