Management of chest injuries represents a challenge in out-of-hospital care. Common chest trauma injuries seen by paramedics and EMRs/FRs include rib fractures, flail chest, simple pneumothorax, hemothorax, open pneumothorax and tension pneumothorax. Paramedics and EMRs/FRs must maintain a high index of suspicion for underlying life-threatening injuries as many patients may present with initially stable vital signs.
Essentials
Closely monitor all patients with chest trauma for signs of deterioration, with particular attention to respiratory status. Be prepared to support oxygenation and ventilation as necessary.
Be suspicious of the potential for underlying torso injuries in cases of high mechanisms. Injuries to the great vessels, diaphragm, abdominal organs, and the myocardium can occur.
Differentiate between blunt and penetrating mechanisms of injury.
For open chest wounds, utilize a commercial vented chest seal (preferred) or leave open. If bleeding control necessary, gauze may be used.
Additional Treatment Information
Sealing of open chest wounds may place patients at risk for a tension pneumothorax.
Monitor these patients closely and relieve pressure by lifting the chest seal or occlusive dressing if a tension pneumothorax may be developing.
Entonox is contraindicated in patients with a suspected pneumothorax or inhalation injury.
Decompression of a suspected tension pneumothorax should be rapidly performed in patients with deteriorating respiratory and hemodynamic status (ACP/CCP).
Positive pressure ventilation may worsen clinical status in patients with an untreated tension pneumothorax.
All patients with chest trauma should be conveyed to the closest appropriate trauma receiving hospital as per local trauma destination guidelines or clinical pathway.
General Information
Palpation of the chest wall, axilla and neck can be helpful in feeling for the presence of subcutaneous emphysema.
CPAP is contraindicated in patients with a suspected pneumothorax.
Interventions
First Responder (FR) Interventions
Position patient sitting if other injuries permit
Perform basic airway interventions and be prepared to provide ventilatory support as needed
Consider targeted ultrasound assessment if appropriate
Ultrasound confirmation of pneumothorax is not expected in VSA patients, given the time-critical presentation.
In patients with vital signs present, ultrasound confirmation should be obtained where feasible, as part of the clinical assessment supporting EPOS or alternate consultation.
The clinical parameters below summarize the approved indications, contraindications, age-based approach, and decision-making framework for finger thoracostomy (FT).
Indications (Consultation NOT REQUIRED prior to FT):
Traumatic vital signs absent (VSA) patients with suspected or evidence of tension physiology
Peri-arrest traumatic adult patients with systolic blood pressure (less than 60 mmHg) and evidence of tension physiology
Indications (☎️Consultation REQUIRED prior to FT):
Adult traumatic chest injury with evidence of tension physiology and systolic blood pressure (greater than 60 mmHg)
Paediatric traumatic chest injury patient (less than 12 years).
Contraindications
There are no contraindications to finger thoracostomy when indications exist
Caution is advised in morbidly obese patients, pregnant patients and in anticoagulated patients.
Age-based Approach
Less than 12 years
Standard closed needle decompression (CND).
If unsuccessful – consult BCCH Trauma Team Leader (TTL) to discuss further therapeutic intervention.
If unable to reach TTL – consult EPOS
12 to 16 years
CND first
If unsuccessful, proceed to finger thoracostomy where clinically indicated and/or authorized
16 years and older
CND and/or finger thoracostomy based on clinical presentation
Clinical Decision-making
Finger thoracostomy should be performed only when the anticipated clinical benefit outweighs procedural risk and the patient's presentation is consistent with approved indications.
Clinical assessment, patient condition, mechanism of injury, response to prior interventions, and available diagnostic information should inform procedural decision-making.
If pleural access is not successfully achieved during finger thoracostomy, revert to standard CND and continue care in accordance with the applicable CPG and clinical consultation requirements.
Where consultation is required by the applicable CPG, consultation requirements remain unchanged by operational authorization for finger thoracostomy.