Broken Cage – Part 1: Prehospital Management of Trauma Patients with Rib Fractures

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Picture of Mohamed Hagahmed, MD, EMT-P
Mohamed Hagahmed, MD, EMT-P
Mohamed is an Emergency Medicine Physician and EMS director. His main areas of interest are Critical Care, Ultrasound, Prehospital Resuscitation, and Medical Education. Find him on Twitter @HagahmedMD

The Pre-brief

Rib fractures are associated with a direct, blunt force trauma to the thorax. It is estimated that 10% of all patients who were admitted to the hospital after blunt chest trauma have at least one rib fracture. In the prehospital setting, trauma victims with rib fractures can have various presentations, from unconscious to awake and in obvious distress. Depending on the mechanism of injury, many of these patients will harbor serious life-threatening injuries that are not obvious initially to the prehospital clinician. An organized and systematic approach to the trauma patient with rib fractures as well as timely lifesaving interventions will ensure their better prognosis.

Ensure scene safety

Scene safety is paramount in any prehospital emergency. Consider using the SAFE approach:

  • Shout or call for help or backup with additional resources
  • Assess the scene for hazards or toxins
  • Free from danger?
  • Evaluate the casualty and consider the need for immediate evacuation

Prehospital assessment

Look

After ensuring C-spine immobilization and controlling any external bleeding, look for any obvious chest wall bruising or wound (especially a sucking chest wound). Assess the movement of the chest wall and look carefully for any asymmetrical chest wall features. Is there a flail segment with a paradoxical or abnormal movement of a section of the chest wall? Do you see the trachea deviating to one side with a reduced movement of the chest wall and hyper expansion on the opposite side suggesting a tension pneumothorax? You can also see reduced chest wall movement with a simple pneumothorax, hemothorax, or secondary to pain.

Feel

Crepitus is grinding or crunching of bone ends rubbing together or crackling in the soft tissues beneath the skin indicating surgical emphysema from a bronchopleural fistula or pneumomediastinum. Sometimes you can feel the deviated trachea if it’s not obviously visible in the obese patient. In the awake and conscious patient with rib fractures, feel for tenderness or obvious deformity in the affected area. It is also important to examine the armpits and back area in order to avoid missing posterior and lateral fractures.

Listen

Auscultation in the prehospital setting is often compromised by surrounding noise as well as the training level of the prehospital clinician. Absent or adventitious lung sounds can be missed because of transmitted sounds from the contralateral chest wall. Auscultate the lateral chest and anterior armpit for findings such as diminished or absent breath sounds, crackles, wheezing, or other evidence of underlying chest injury. 

Prehospital Interventions

ABC

As with any trauma patient, the vital role of the prehospital clinician is to ensure airway patency by maintaining an open airway with simple maneuvers like the jaw thrust, or by inserting airway adjuncts (i.e., oropharyngeal and nasopharyngeal airways). Patients with rib fractures need supplemental oxygen and close monitoring with an EKG and pulse oximetry. 

A flail chest is a paradoxical movement of the chest wall and rare complication of rib fractures. Respiratory compromise and hypoxia, secondary to pain and shallow breathing, are the feared consequences of a flail chest. Manual splinting of the flail segment is not supported by current evidence, and the focus of prehospital care should be on maintaining adequate oxygenation and aggressive pain control. In the absence of respiratory failure, intubation and ventilatory support are usually not required. 

Cover open chest wounds with commercial non-occlusive dressings if possible (such as the Asherman chest seal) as three-sided chest dressings are often ineffective. However, use a three-sided dressing if no other option is available. The skin may need to be shaved or wiped dry of sweat or blood in order to ensure adequate adhesion. The purpose of the three-sided dressing is to allow for “burping” of the dressing should evidence of pneumothorax occur due to the accumulation of air in the pleural space.

Tension pneumothorax is relatively a rare occurrence in the prehospital setting, particularly in blunt trauma. Some studies show its prevalence to be <6%. However, there is a risk of this condition due to lung puncture as a result of rib fractures.

The Debrief

  • The prehospital evaluation of patients with rib fractures, like any trauma patient, emphasizes scene safety, airway, breathing, and circulation
  • Paramedics should have a high index of suspicion for underlying devastating injuries
  • Manual stabilization of a flail segment, as well as IV analgesia, are important prehospital interventions
  • Rapid stabilization and transfer to a trauma center contribute to better outcomes in patients with rib fractures

Next in Part 2: We will discuss the challenges of identifying and managing tension pneumothorax in the prehospital setting as well as EMS pain management.

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