Chest (thoracic) trauma is a major cause of trauma deaths. It is classified as blunt (motor vehicle and motorcycle crashes, falls, assaults — most common) or penetrating (stab and gunshot wounds). Injuries threaten life by three main routes: hypoxia (airway or lung injury), hypovolemia (bleeding into the chest), and impaired cardiac function (tamponade, tension pneumothorax, cardiac injury). Most chest injuries are managed with oxygen, analgesia, and a chest tube; a minority need surgery.
| Injury | Mechanism and key facts |
|---|
| Rib fractures | Most common chest injury; pain limits breathing → atelectasis and pneumonia. Older adults are at especially high risk of complications. Fractures of ribs 1–2 suggest high force (great vessel injury); lower ribs → liver or spleen injury |
| Flail chest | Two or more adjacent ribs each fractured in two or more places (some trauma guidelines use three or more) → a free segment moves paradoxically (in on inspiration, out on expiration). The underlying pulmonary contusion is the main cause of hypoxemia |
| Pulmonary contusion | Bruising and bleeding into lung tissue; worsens over 24–72 hours; can progress to pneumonia and ARDS |
| Pneumothorax (simple, open, tension) | Air in the pleural space; see Pneumothorax topic |
| Hemothorax | Blood in the pleural space from lung, intercostal, or great vessel injury; massive hemothorax causes hypovolemic shock |
| Cardiac tamponade | Blood in the pericardial sac compresses the heart → obstructive shock |
| Blunt cardiac injury | Dysrhythmias, wall-motion abnormalities, rarely rupture |
| Blunt thoracic aortic injury | Rapid deceleration tears the aorta, usually just beyond the left subclavian artery; most victims die at the scene |
| Tracheobronchial injury | Large continuous air leak, persistent pneumothorax despite a chest tube, extensive subcutaneous emphysema |
| Diaphragmatic rupture | Abdominal organs herniate into the chest (bowel sounds heard in the chest), more often on the left |
Primary survey — find and treat immediate life threats in order (many trauma systems control massive external bleeding first): Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure.
| Injury | Key findings |
|---|
| Rib fractures | Localized pain and tenderness worse with breathing, shallow splinted breathing, crepitus |
| Flail chest | Paradoxical chest wall movement, severe pain, dyspnea, hypoxemia |
| Pulmonary contusion | Increasing dyspnea, hypoxemia, crackles, hemoptysis over hours to days |
| Simple pneumothorax | ↓/absent breath sounds, hyperresonance, subcutaneous emphysema |
| Tension pneumothorax | Hypotension, tachycardia, JVD, tracheal shift to the opposite side, absent breath sounds |
| Open pneumothorax | Sucking sound at the wound, bubbling blood |
| Hemothorax | ↓breath sounds, dullness to percussion, signs of hypovolemic shock; X-ray may show fluid or an air-fluid level (hemopneumothorax) |
| Cardiac tamponade | Beck's triad: hypotension, distended neck veins, muffled heart sounds; pulsus paradoxus (> 10 mmHg fall in systolic BP on inspiration); PEA |
| Aortic injury | Chest or back pain, unequal arm pulses or BP, hypotension; widened mediastinum on X-ray |
Also assess: pain score, SpO₂, ABG, level of consciousness, skin color, seat-belt or steering-wheel bruising, associated abdominal and head injuries.
| Test | Use |
|---|
| eFAST (extended focused assessment with sonography in trauma) | Rapid bedside detection of pericardial fluid, hemothorax, pneumothorax, abdominal bleeding |
| Chest X-ray | Fractures, pneumothorax, hemothorax, widened mediastinum |
| CT chest; CT angiography (CTA) | CTA is the primary diagnostic test for blunt aortic injury — it has replaced catheter aortography in most trauma centers |
| ECG, troponin | Screen for blunt cardiac injury |
| ABG | Respiratory acidosis (↓pH, ↑PaCO₂) with hypoxemia = impending respiratory failure (e.g., flail chest with contusion) |
| CBC, type and crossmatch, lactate, coagulation tests | Blood loss, shock, coagulopathy |
- Oxygen; airway management and positive-pressure ventilation (noninvasive or intubation) for respiratory failure
- Tension pneumothorax: immediate needle or finger decompression, then chest tube
- Open pneumothorax: vented chest seal or three-sided dressing, then chest tube
- Hemothorax: chest tube — traditionally large-bore; small-bore catheters are acceptable in stable clients (the drained blood may be autotransfused). Indications for surgical exploration (thoracotomy): initial drainage ≥ 1,500 mL, or ≥ 200 mL/hour for 2–4 hours, or ongoing need for transfusion
- Hemorrhagic shock: two large-bore IVs or intraosseous access; balanced blood product resuscitation rather than large volumes of crystalloid; tranexamic acid within 3 hours of injury where protocols apply (risks: thrombosis, seizures)
- Cardiac tamponade: pericardiocentesis as a bridge; definitive surgical repair (thoracotomy/sternotomy)
- Flail chest and rib fractures: multimodal analgesia is the cornerstone — scheduled acetaminophen, opioids, regional techniques (epidural, paravertebral, or serratus plane blocks), sometimes ketamine; ventilatory support as needed; surgical rib fixation for selected clients. External binding or taping of ribs is no longer used — it restricts breathing
- Pulmonary contusion: oxygen, pulmonary hygiene, avoid fluid overload while maintaining perfusion
- Blunt aortic injury: control heart rate (target about < 100/min) and systolic BP (about < 100–120 mmHg, as ordered) with short-acting IV beta-blockers (e.g., esmolol) to reduce wall stress; endovascular repair (TEVAR) is preferred for most
- Impaled objects: stabilize in place; remove only in the operating room
- Tetanus prophylaxis for penetrating wounds
Drug safety
- Opioids: respiratory depression, sedation, hypotension, constipation — monitor RR and sedation scale; naloxone available
- NSAIDs: bleeding, kidney injury, GI ulceration — avoid in active bleeding, hypovolemia, kidney injury
- Local anesthetics for blocks/epidurals: watch for local anesthetic systemic toxicity — perioral numbness, metallic taste, tinnitus, seizures, dysrhythmias; lipid emulsion is the antidote. Epidural: hypotension, motor block; check anticoagulant timing
- Ketamine: hypertension, tachycardia, emergence reactions
- Esmolol: bradycardia, hypotension, bronchospasm
Listed in priority order.
- Airway with cervical spine protection
- Breathing
- High-concentration oxygen (e.g., non-rebreather mask at 10–15 L/min) for the injured, hypoxemic client; titrate once stable
- Continuous SpO₂, RR, breath sounds, chest wall movement
- Recognize tension pneumothorax and prepare for immediate decompression
- After placing a three-sided dressing on an open wound, monitor closely for tension pneumothorax; if signs develop, lift one edge of the dressing to release air and notify immediately
- Circulation
- Two large-bore IVs, draw type and crossmatch, warm blood products and fluids, prevent hypothermia
- Monitor BP, heart rate, urine output, lactate
- Chest tube output: report promptly any sudden increase or bright red drainage (commonly > 100 mL/h, or per provider threshold); initial drainage ≥ 1,500 mL or ≥ 200 mL/h for 2–4 hours indicates the need for surgery — notify immediately
- Watch for Beck's triad and prepare for pericardiocentesis
- Pain control — scheduled, multimodal; reassess pain and sedation; good analgesia is what makes effective breathing possible
- Pulmonary hygiene
- Semi- to high-Fowler's position when spine is cleared
- Incentive spirometry, deep breathing, and coughing with splinting (pillow held against the chest)
- Early mobilization
- Chest tube care — see Pneumothorax topic; continuous large bubbling in the water seal after trauma may indicate major airway injury — report immediately
- Psychosocial support; assess for other injuries and for abuse or violence where relevant
- Rib fractures: take pain medication on schedule so you can breathe deeply; use the incentive spirometer for 10–15 breaths every 1–2 hours while awake, or as ordered; hold a pillow against the chest to cough
- Do not wrap or bind the chest
- Report fever, productive cough, worsening shortness of breath, or increasing chest pain (pneumonia, delayed pneumothorax or hemothorax)
- Avoid heavy lifting, contact sports until cleared
- Opioid safety: no driving, no alcohol or sedatives, prevent constipation
- Injury prevention: seat belts, motorcycle helmets and protective gear, fall prevention for older adults
| Complication | What to watch for |
|---|
| Tension pneumothorax | Hypotension, JVD, tracheal shift, absent breath sounds |
| Massive hemothorax / hemorrhagic shock | Hypotension, tachycardia, high chest tube output, dullness to percussion |
| Cardiac tamponade | Beck's triad, pulsus paradoxus |
| ARDS (after contusion, flail chest, transfusion) | Worsening hypoxemia over 24–72 hours, bilateral infiltrates |
| Acute respiratory failure | Respiratory acidosis, hypoxemia, fatigue |
| Pneumonia, atelectasis | Fever, new crackles — especially with poorly controlled pain |
| Dysrhythmias | After blunt cardiac injury |
| Empyema, retained hemothorax | Fever, persistent opacity |
| Fat embolism (with long-bone fractures) | Hypoxemia, confusion, petechiae 24–72 hours after injury |
- Primary survey: airway with C-spine, breathing, circulation — treat life threats as found
- Flail chest = ≥ 2 adjacent ribs broken in ≥ 2 places → paradoxical movement; the underlying contusion causes hypoxemia
- Pulmonary contusion worsens over 24–72 h and can lead to ARDS
- Air-fluid level + shock after trauma → hemothorax, the most urgent problem
- Massive hemothorax: ≥ 1,500 mL initially or ≥ 200 mL/h for 2–4 h → surgery
- Beck's triad = hypotension, JVD, muffled heart sounds → tamponade
- Tension pneumothorax → decompress immediately; after a three-sided dressing, watch for tension
- Blunt aortic injury: CT angiography is the diagnostic standard; control HR and BP
- Respiratory acidosis + hypoxemia on ABG = respiratory failure
- Priority nursing diagnosis for open chest wound with dyspnea: impaired gas exchange
- Rib fractures: multimodal analgesia, incentive spirometry, no rib binding
- Continuous heavy bubbling in the water seal after trauma → large air leak — report immediately
Country Notes
United States
- Trauma care is organized by verified trauma center levels (Level I–IV); severely injured clients are transferred to the highest-level center available.
- Many trauma nurses complete the Trauma Nursing Core Course (TNCC), which follows the same primary survey approach.
Philippines
- Motorcycle crashes are a leading cause of blunt chest trauma; the Motorcycle Helmet Act (RA 10054) requires helmets for riders.
- Blood product availability varies by facility; early coordination with the blood bank or Philippine Red Cross blood service may be required for transfusion.