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The rib cage is 12 ribs and a sternum attached to the clavicle and scapula as well as intercostal and abdominal muscles. (1)

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Beneath each rib runs a nerve artery and vein. (1)

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Encased in the rib cage is the lungs of which the apex extends slightly above the clavicles. The diaphragm is a large muscle that sits directly below the lungs and assists with respiration. (1)

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Chest injury can occur predominantly from blunt or penetrating trauma. Most presentations appear as respiratory distress and pain on inspiration. Morbidity and mortality is a consequence of disruption of respiration and circulation which ultimately leads to hypoxia.

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Chest Trauma is the primary cause of mortality in 25% of trauma cases and contributes to a further 25%. (2)

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Supplementary Oxygen - 15L NRB

Pain Relief - conservative due to respiratory depression with excess opiates

Position: upright if adequate perfusion, no altered conscious state, barotrauma or spinal precautions.

Open Chest Wound

Do not occlude dressing, control heamorrhage

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Most common for rib 3-8.

Rib 1-2 is associated with high force injury due to force needed to fracture.

Rib 9-12 is associated with other organ damage due to proximity in thorax.

Extreme pain causes hypoventilation and thus reduced gas exchange.

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Case Study - Clinical photos used with consent from patient.

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Each side of the chest can hold 2.5-3L of blood.

Can be in combination with air for heamopneumothorax.

Hypovolaemic shock and hypotension can occur.

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Two or more adjacent rib fractures in two or more places producing a free-moving segment.

Produces paradoxical movement - movement in opposite direction.

Likely to cause lung injury including contusion and pneumothorax.

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Bleeding within lung causing a bruise.

Fluid collects between pulmonary capillary and alveoli decreasing oxygenation.

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While usually of medical origin, can be caused by blunt or penetrating chest trauma.

Up to 200ml of blood collects between heart and pericardium from coronary arteries or myocardium.

Becks Triad: Low arterial blood pressure, distended JVP & muffled heart sounds.

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Tracheal Rupture

Oesophageal Rupture

Aortic Rupture

Diaphragmatic Injury

If you would like to do some further reading please research these other chest traumas.

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82 year old made fell from a segue in Cows, traveling at 10km/hr. You arrive 1 hour after the incident.

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GCS 15, HR 113, BP 125/90, O2 sats 90%
Respiratory rate 22 with increased WOB and diminished sounds to the right side.
Small heamatoma to right arm and leg as well as pain in the mid chest (rib 5).
There is mild swelling to extremities which progressed to neck and face during your assessment.

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What is your initial diagnosis?
Do you require MICA or other back-up?
Does he meet trauma time critical guidelines?
Where should you transport to?

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Describe your management plan referring to appropriate CPGs

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Over half of major trauma patients in NSW in 2019-20 experienced chest injuries. The most common injury in traumas with greater than moderate severity was 3+ rib fractures without a flail segment.(3)

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Blunt chest trauma mainly occurs from high energy multi vehicle collisions, accounting for 70-80% of blunt chest trauma cases.(2) Although it is more common for elderly people to experience chest trauma when falling from standing height. (1)

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From this video you can see that the paramedics initially treated this patient with adrenaline for anaphylaxis due to the visual similarities. However it is important to remember that subcutaneous emphysema has 'lip sparing' where the lips and tongue do not swell as in anaphylaxis.

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1. Legome E. Initial evaluation and management of blunt thoracic trauma in adults. 2022; Available from: https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-thoracic-trauma-in-adults
2. Fitzgerald, M., Gocentas, R., & Stevens, J. Chest Trauma. Textbook of Adult Emergency Medicine. 4th Edition (pp. 104-109).  2015. Sydney.
3. Sisson G, Singh H, Curtin E. Major Trauma in NSW, 2019-2020. A Report from the NSW Trauma Registry.
4. Kuo K, Kim AM. Rib Fracture. Treasure Island; 2022. Available from: http://www.ncbi.nlm.nih.gov/books/NBK541020/
5. Ambulance Victoria. AV CPG: Chest Injuries A0802. 2018. p. 247–9.