First Aid for Chest Injury

A chest injury is an injury that occurs in the chest wall or the bones,
skin, fats, and muscles surrounding your lungs, including the ribs and
sternum. It can also occur in any of the organs found inside the chest.

Introduction

Chest trauma can result in fractures, lung or heart contusions, and rib
bruising due to wall injury. It can compromise breathing, resulting in hypoxia.
Hypoxia is a disease in which the body as a whole (generalized hypoxia) or
a specific part of the body (tissue hypoxia) is deprived of sufficient oxygen.
A chest injury that goes untreated can cause one or both lungs to collapse,
putting pressure on the heart and resulting in cardiac arrest.

Types

Closed: The skin is intact and air does not enter the chest cavity
through the chest wall. For example: a rib injury.
Open: The chest wall has been penetrated by a foreign object. For
example: pneumothorax, penetrating chest wound.

Causes

• Blunt trauma
• Crush injuries
• Penetrating objects

Step-by-step guide on how to respond:

1. Ensure Scene Safety and Call for Help

• Safety First: Before approaching, make sure the scene is safe for both you and the injured person.
• Call Emergency Services: Dial 911 (or your local emergency number) immediately. Clearly describe the nature of the injury and any visible signs of distress.

2. Assess the Injured Person

• Check Responsiveness: Determine if the person is conscious and alert. Gently tap and speak to them to assess their level of responsiveness.
• Airway, Breathing, and Circulation (ABCs):
  • Airway: Ensure the person’s airway is open.
  • Breathing: Look for regular, unlabored breathing. Abnormal or labored breathing can indicate internal complications such as a collapsed lung (pneumothorax).
  • Circulation: Check for a pulse and signs of adequate blood flow.

3. Identify the Type of Chest Injury

• Blunt Trauma:
  • This might include rib fractures or chest wall bruising. The person may experience severe pain, shallow breathing, or difficulty taking deep breaths.
• Penetrating Trauma:
  • An open or “sucking” chest wound (air can be heard entering the chest with each breath) indicates that air might be entering the chest cavity.
  • Do Not Remove Impaled Objects: If there’s an object embedded in the chest, leave it in place to prevent further damage or bleeding.

4. Provide Appropriate First Aid Based on Injury Type

• For Open or Sucking Chest Wounds:
  • Cover the Wound: Quickly cover the wound with an occlusive dressing (a material that doesn’t let air in).
  • Tape on Three Sides: Secure the dressing on three sides only. This creates a one-way valve, allowing trapped air to escape from the chest cavity while preventing more air from entering.
• For Bleeding:
  • Apply Direct Pressure: If there’s significant bleeding, cover the area with a sterile dressing and apply gentle, continuous pressure.
• For Blunt Trauma (e.g., Rib Fractures):
  • Comfortable Positioning: Help the person sit up or lie in a position that eases their breathing (unless a spinal injury is suspected).
  • Minimize Movement: Encourage them to remain still to avoid worsening the injury.

5. Support and Monitor Until Help Arrives

• Monitor Vital Signs: Keep a close watch on their breathing, level of consciousness, and skin color.
• Watch for Shock: Signs of shock include pale or ashen skin, rapid breathing, a weak pulse, and confusion. If these signs develop:
  • Help the person lie down (if no head, neck, or back injury is suspected).
  • Keep them warm with a blanket, and if possible, elevate their legs.
• Offer Reassurance: Stay calm and continuously reassure the injured person that help is on the way.

First Aid for Various Types of Chest Injuries

Rib Injuries

• A direct impact to the chest from a hit or a fall, or a crush injury, might fracture one or more ribs.
• The casualty’s respiration may be substantially hampered if there is a wound over the fracture or if a broken rib pierces a lung.
• An injury to the chest can result in a “flail chest” injury, in which a section of cracked ribs separates from the rest of the chest wall
• When the casualty inhales, the separated portion moves within, and when he exhales, it moves outward. This is known as “paradoxical” breathing.
• Lower rib fractures can induce internal bleeding and injury to internal organs including the liver and spleen.

Signs and Symptoms

• Trouble breathing
• Shallow breathing
• Tenderness at site of injury
• Deformity and bruising of chest
• Pain upon movement/deep breathing/coughing
• Dusky or blue lips or nail beds
• Crackling feeling upon touching victim’s skin
• Assess for the signs of internal bleeding such as coughing up of bright red frothy blood.

Steps to do

1. 1 Assist the casualty to a seat and ask him to support the damaged side’s arm; assist him if necessary. Put the arm on the affected side in a sling for added support.
2. Place large amounts of padding over the flail area.
3. Monitor and observe the victim for any breathing problems.
4. Arrange for the casualty to be taken or sent to the hospital.

Penetrating Chest Wound

• If a sharp item penetrates the chest wall, the organs in the chest and upper abdomen may be severely damaged, leading to shock.
• Lungs are especially vulnerable to injury, either from internal damage or wounds that perforate the two-layered membrane (pleura) that surrounds and protects each lung.
• Pneumothorax occurs when air enters between the membranes and exerts pressure on the lung, causing the lung to collapse (Fig. 30.2).
• The pressure around the wounded lung may build up to the point where it affects the unaffected lung, leaving the victim breathless.
• This pressure buildup in a tension pneumothorax may prevent the heart from adequately filling with blood, limiting circulation and causing shock.
• Sometimes, blood collects in the pleural cavity (a hemothorax) and puts pressure on the lungs.

Signs and Symptoms

• Difficult and painful breathing
• Cyanosis of skin and lips (gray or bluish coloration)
• Clammy, pale skin
• Breathing is fast and shallow.
• Asymmetrical movement of chest as the injured side may not rise.

If there is a sucking chest wound:

• Sound of air being drawn into the wound along with bubbling blood.
• Crackling feeling to the skin around the wound due to air entry.
• Neck veins are becoming more visible.
• Blood is gushing from the wound.

Steps to do

1. Assist the victim in taking a seat. Encourage him to lean toward the wounded side of his body and cover the wound with his palm.
2. Wrap a plastic bag or foil around the wound and the surrounding region.
3. Only tape the plastic covering on three sides to prevent air from getting in but not out.
4. If the victim loses consciousness, check their breathing and open the airway.
5. If required, perform cardiopulmonary resuscitation (CPR). If they are breathing, put them in the recovery position, with the wounded lung on the bottom. This will assist protect the healthy lung.
6. Call for emergency help. While waiting for help, continue to support the casualty in the same position as long as he remains conscious.
7. Until emergency help arrives, monitor and record the casualty’s vital signs—level of reaction, respiration and pulse.

Flail Chest

How to recognise a ‘flail chest’:

• One or more broken ribs that are broken in more than one place;
• Instead of rigidly holding the normal shape of the chest, flail chest results in a segment of the chest wall flailing back and forth in the opposite direction of the rest of the chest wall – this is called paradoxical breathing;
• When you are doing your casualty checks and you (Circulation or Damage checks), you will notice a difference in the springiness or flexibility of the rib cage;
• If not treated promptly, flail chest can lead to serious complications.

How to treat a flail chest injury:

• Stabilize the flail chest….
• Use a hard pad to put pressure on the flail segment. Holding the flail segment in place keeps it from moving in an opposite direction as the surrounding muscle and bone. Carefully tape the pad down over the flail area – a folded up triangular bandage or similar is useful for this;
• Sit the conscious casualty down leaning towards the injured side.
• Unconscious casualties should be put into the recovery position and rolled onto the injury.
• This injury requires emergency medical treatment.

Ongoing monitoring of chest injuries:

Recognising the specifics of internal chest injuries is difficult and the most important step is getting professional emergency medical help. Careful observation is important.

Signs to monitor and watch out for include:

1. Severe shortness of breath
2. Unequal chest (one side looks bigger than the other)
3. Tracheal movement to the uninjured lung
4. Veins on the neck bulging
5. Blue lips and neck (lack of oxygen)
6. No lung sounds on one side

Special Considerations

• Check for breathing difficulties, chest pain, or visible wounds.
• Look for signs of shock, such as pale skin, rapid pulse, or confusion.
• If the person is unresponsive, begin CPR if necessary.
• Cover the wound with a sterile dressing, leaving one side open to prevent air buildup.
• Avoid removing embedded objects—stabilize them instead.
• Monitor for signs of pneumothorax (collapsed lung), such as difficulty breathing.
• If possible, place the person in a semi-upright position to ease breathing.
• If a rib fracture is suspected, encourage shallow breathing to reduce pain.
• Apply gentle pressure over a dressing to control bleeding.
• If blood soaks through, add another layer instead of removing the original dressing.
• Continuously check breathing and responsiveness.
• Call emergency services immediately for severe injuries.
• Be prepared for rapid deterioration, as chest injuries can worsen quickly.

REFERENCES

1. Sanju Saira, First Aid Manual for Nurses, 3rd Edition, CBS Publishers & Distributors Pvt Ltd, ISBN 978 9394525252.
2. Singletary, E. M., Zideman, D. A., De Buck, E. D., Chang, W. T., Jensen, J. L., Swain, J. M., … & Hood, N. A. (2015). Part 9: first aid: 2015 international consensus on first aid science with treatment recommendations. Circulation, 132(16_suppl_1), S269-S311. DOI 10.1161/CIR.0000000000000278
3. Zideman, D.A, Singletary, E.M., De Buck, E., Chang, W.T., Jensen, J.L., Swain, J.M., … & Yang, H.J. (2015). Part 9: First aid: 2015 International consensus on first aid science with treatment recommendations. Resuscitation.95. e225-e261. DOI: 10.1016/j.resuscitation.2015.07.047
4. Centre for Evidence-Based Practice. (2019). Evidence summary. Open chest wound – non-occlusive dressing. Belgian Red Cross-Flanders. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

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