"Dispatch to Quint and Ambulance 14. This patient is reported to have been stabbed several times in the chest. Police have been dispatched and should arrive about the same time as your units. Use caution approaching the scene."
Injuries to the chest are relatively common as our society continues to attempt to address interpersonal conflict through the use of guns and knives. The rapid assessment and treatment of chest injuries can be one of those skills whereby a first responder can make a difference in the survival of these patients.
The chest cavity contains the lungs, the heart and several major blood vessels. The cavity is surrounded and protected by the chest wall, which is made up of the ribs, cartilage and associated chest muscles. The most common chest injuries are fractures of the ribs, flail chest and penetrating wounds.
Fractures Of The Ribs
Injury may produce fracture of one or more ribs. Even a simple fracture of one rib produces pain at the site of the fracture and difficulty with breathing. Multiple rib fractures will result in significant breathing difficulty. The pain may be so intense that the patient cannot breathe deeply enough to take in adequate amounts of oxygen. Rib fractures may be associated with injury to the underlying organs.
To tell if a rib is bruised or broken, apply some pressure to another part of the rib. If the pressure produces pain in the injured area, you can presume that the rib is cracked or fractured. If the injury is to the side of the chest, place one hand on the front of the chest and the other on the rear of the chest and gently squeeze your hands together. To check an injury to the front or back of the rib cage, put your hands on either side of the chest and gently squeeze. If there is no pain, the rib is probably not broken. In every case of rib fractures, be alert for signs and symptoms of internal injury, particularly shock.
A patient with rib fractures can be made more comfortable and reassured by placing a pillow against the injured ribs to splint them. Prevent excessive movement of the patient as you prepare for transportation to an appropriate medical facility. Admin-ister oxygen if it is available and you are trained to use it.
If three or more ribs are broken in at least two places, the injured portion of the chest wall does not move at the same time as the rest of the chest. The injured part bulges outward when the patient exhales and moves inward when the patient inhales. This reversed movement is called a flail chest. A flail chest results in a decreased amount of oxygen and carbon dioxide exchange in the lungs. It causes breathing problems that become progressively worse.
You can identify a flail chest by examination of the chest wall and by observation of chest movements during breathing. If the injured portion of the chest moves inward as the rest of the chest moves outward (and vice versa), the patient has a flail chest.
If the patient is having difficulty breathing, firmly place a pillow (or even your hand) on the flail section of the chest to stabilize it. In severe cases of flail chest, it may be necessary to support the patient's breathing. This can be done by first responders, emergency medical technicians (EMTs) or paramedics with mouth-to-mask or bag-valve-mask resuscitation devices and by using supplemental oxygen. Monitor and support the patient's ABCs and arrange for prompt transport to an appropriate medical facility.
Penetrating Chest Wounds
Penetration of the chest wall by an object (usually a knife or bullet) often results in the introduction of air between the lung and chest wall, as well as bleeding into this space. The air and blood cause the lung to collapse. Lung collapse greatly reduces the amount of oxygen and carbon dioxide that is exchanged and can result in shock and death. Blood loss into the chest cavity can produce hemorrhagic shock. Quickly seal an open chest wound with something that will prevent more air from entering the chest cavity. You can use Vaseline gauze, aluminum foil, plastic wrap or even cellophane.
In rare cases, sealing the wound may cause the patient to have increased difficulty breathing. If a patient has more difficulty breathing after you seal the wound, uncover one corner of the occlusive dressing to see if breathing will improve. Administer oxygen if it is available and you are trained to use it. If a knife or other object is impaled in the chest, do not remove it. Seal the wound around the object with a dressing to prevent air from entering the chest. Stabilize the impaled object with bulky dressings.
A chest injury that results in air leakage and bleeding requires prompt attention. For these reasons, patients with severe chest injuries should be transported rapidly to an appropriate medical facility. A conscious patient with chest trauma may demand to be placed in a sitting position to ease breathing. Unless you must immobilize the spine or treat the patient for shock, help the patient assume whatever position eases breathing.
If oxygen is available, administer it. If the patient's respirations are excessively slow or absent, perform mouth-to-mouth breathing. A mouth-to-mask device or a bag-valve mask may also be used by trained personnel. If the heart stops, begin chest compressions, regardless of whether there are chest injuries.
Garry Briese is the executive director of the International Association of Fire Chiefs (IAFC) and, along with David Schottke, co-author of the new edition of First Responder: Your First Response In Emergency Care, available in summer 1996 from Jones & Bartlett Publishers. The book is produced by the American Academy of Orthopaedic Surgeons and the National Safety Council.
