12.1 Chest Wall and Pulmonary Trauma
Key Takeaways
- Any pneumothorax can tension on climb under Boyle's law—decompress before altitude if you suspect pleural air.
- A vented commercial chest seal beats an unvented patch; burp the seal if tension physiology appears.
- Do not clamp a bubbling chest tube; a clamped leak becomes a closed space that can obstruct venous return.
- Pulmonary contusion is a fluid-and-ventilator problem: do not drown the lung, and use lung-protective volumes.
- First-rib and scapular fractures are high-energy markers; a massive ongoing air leak after a good tube is tracheobronchial until proven otherwise.
Chest trauma is a Boyle's-law problem wearing a trauma label. Domain 3.D of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests thoracic trauma—chest wall and pulmonary injuries here, cardiac and great-vessel injuries in section 12.2—because a small pneumothorax at the landing zone can tension on climb, a bubbling tube you clamp becomes obstructive shock, and a first-rib fracture is a high-energy marker, not a bruise. Burns belong in Chapter 13.
Ribs, flail, and high-energy stamps
A rib fracture is pain plus a puncture risk. Several broken ribs drop tidal volume. The patient splints, pulse oximetry (SpO2) drifts, and you inherit a tube you might have avoided with analgesia, oxygen, and a careful search for pleural air. Flail chest, in Advanced Trauma Life Support (ATLS)-style teaching, is two or more adjacent ribs fractured in two or more places so a segment moves paradoxically—in on inspiration, out on expiration. The moving plate is dramatic. The pulmonary contusion underneath is what wrecks gas exchange.
First-rib and scapular fractures are high-energy stamps. The first rib sits behind the clavicle and the subclavian vessels. The scapula is wrapped in muscle. Breaking either usually means a crash or a fall that also injured lung, brachial plexus, or great vessels. Do not treat the scapula as the disease. Treat the mechanism: look for pneumothorax, hemothorax, blunt aortic injury (section 12.2), and a chest that will not tolerate altitude.
| Injury | What you see | Flight trap |
|---|---|---|
| Simple rib fractures | Focal pain, splinting | Hypoventilation and a missed pneumothorax on climb |
| Flail chest | Paradoxical segment | Contusion and hypoventilation, not the plate itself |
| First-rib or scapular fracture | High-energy mechanism | Occult pleural, vascular, or plexus injury |
| Open (sucking) chest wound | Bubbling hole, air hunger | Tension if you seal it without a vent |
Open pneumothorax: three-sided, commercial, burp
An open pneumothorax is a chest-wall hole large enough that inspired air prefers the wound to the trachea. Classic teaching is a three-sided occlusive dressing: tape three sides and leave one side as a flutter valve. When you have a commercial vented chest seal, use it. The vent is the one-way path. A fully unvented occlusive seal can convert an open wound into a tension pneumothorax.
If the patient deteriorates after a seal—jugular venous distention (JVD), falling end-tidal carbon dioxide (ETCO2), rising peak inspiratory pressure (PIP), hypotension—burp the seal. Lift a corner, let trapped air out, reseat the seal, and reassess. Persistent tension is a finger or tube problem, not a tape problem.
Simple versus tension versus hemothorax
A simple pneumothorax is air in the pleural space without obstructive shock. A tension pneumothorax is a one-way leak that collapses the lung, shifts the mediastinum, and kinks venous return. That is obstructive shock (Chapter 9), not a little air. A hemothorax is blood in the same space. Massive hemothorax teaching thresholds from ATLS-style practice are often about 1,500 mL immediately or roughly 200 mL/hour—clinical numbers, not a BCEN formula. The flight issue is volume loss plus a lung that cannot expand. Autotransfusion from the chest drain is program-dependent.
Boyle's law (pressure times volume is constant at a given temperature) says any residual pleural air expands as cabin altitude rises. A simple pneumothorax can tension on climb. If you suspect pneumothorax in a patient who will fly, decompress before altitude rather than diagnosing shock at 6,000 feet. Request a lower cabin when the aircraft can give you one. Recheck after every climb.
Needle, finger, and tube
Decompression tools:
- Needle decompression: current ATLS-style teaching prefers the fifth intercostal space, mid-axillary line; many protocols still list the second intercostal space, mid-clavicular line. Use the site your program authorizes. A rush of air is encouraging, not definitive, especially under positive-pressure ventilation (PPV).
- Finger (simple) thoracostomy: an incision and a finger into the pleural space. You feel lung, you vent air and blood, and you leave a path. Many flight and prehospital systems prefer this over a lone needle when the patient is already intubated.
- Tube thoracostomy: the drain you want for a longer flight if time, skill, and sterility allow.
Do not clamp a bubbling chest tube. Continuous bubbling means air is still entering the system. Clamping converts a controlled leak into a closed space that can tension under Boyle's law. Leave the tube open to the drain or a one-way valve. A tube that suddenly stops draining in a hypotensive patient may be kinked, clotted, or malpositioned—unkink it; do not congratulate yourself for a dry chamber.
Pulmonary contusion and tracheobronchial injury
Pulmonary contusion is bruised lung that floods over hours. Avoid drowning it in crystalloid (Chapter 8). Use lung-protective ventilation: typical adult teaching is about 6 mL/kg ideal body weight tidal volume and a plateau pressure under 30 cm H2O, with positive end-expiratory pressure (PEEP) for recruitment—not a BCEN-owned table. Expect worsening on climb as Dalton's law drops inspired oxygen tension; raise fraction of inspired oxygen (FiO2) and consider a lower cabin.
Tracheobronchial injury presents as massive subcutaneous emphysema, a lung that will not re-expand, and a massive air leak after a correctly placed tube. You cannot out-suction a mainstem tear. Support oxygenation, avoid high airway pressure when you can, notify a receiving thoracic surgeon, and do not clamp the bubbling tube. Selective intubation of the opposite mainstem is a protocol and anatomy decision, not a ramp experiment.
A rotor-wing crew is about to climb with a blunt-chest patient who had a rush of air on needle decompression but remains on positive-pressure ventilation. Saturation is drifting and peak inspiratory pressure is rising. What is the Boyle's-law flight plan?
A sucking chest wound is covered with a commercial vented chest seal. Mid-flight the patient develops jugular venous distention, hypotension, and falling end-tidal carbon dioxide. What is the immediate chest-seal action?
A chest tube placed for suspected tracheobronchial injury bubbles continuously and the lung will not re-expand as you prepare to climb. Which action is correct?