Ski Patrol Magazine Archives

Summer 1999 - "Stay Abreast of Chest Injuries" - by Alan Fraser Houston, M.D.

This article is reprinted from Ski Patrol Magazine. All copyrights apply. Please see our copyright and disclaimer notice page.

About 10 years ago, I was skiing with a friend when he was suddenly cut off by a converging skier and fell on a patch of ice. Sliding downhill at close to 15 miles per hour, he became airborne off the crest of the run and landed like a rag doll, coming to rest with his chest wedged between a tree and a boulder.

I hurried to his side and no sooner had I finished my assessment than several patrollers arrived to help with what was obviously a "load and go" transport. While spineboarding my badly injured buddy, I felt strangely helpless. I knew my medical training was no match for the need get him off the hill and to a higher level of care. Fully immobilized and gray with chest and back pain, he was quickly taken down the mountain and loaded into a waiting ambulance for a 30-mile drive to the nearest hospital.

Because he had suffered rib and spine fractures and a renal contusion, morphine became a better friend to him than me for the next several days. Fortunately, he went on to make a full recovery.

As this example illustrates, chest injuries can sometimes prove quite challenging. Ranging in severity from simple to life-threatening and classified either as nonpenetrating or penetrating injuries, they can occur when skiers and snowboarders collide with solid objects such as trees, poles, lift towers, and rocks. Speeds need not be excessive: 15 to 20 mph may be sufficient to produce serious injury. Chest trauma may also result from falls, especially those from a significant height or those in which the force is exerted on a small area, e.g., a fall onto a camera in a chest pocket or onto an arm.

The type of terrain a person lands on is another significant factor that can affect the severity of injury. Powder snow is much more forgiving than a patch of ice.

Externally, the chest consists of the rib cage, with the intercostal muscles between the ribs, and the diaphragm, which separates the chest from the abdominal contents below. Within the chest, or thorax, lie the lungs, which take in oxygen from the air and expel carbon dioxide. Lung tissue is very lightweight, soft, and easily injured.

Inside the chest cavity, the right and left pleural cavities are separated by the mediastinum, the structure containing the great vessels (the aorta, the venae cavae, and their larger branches), the heart, and the trachea. The upper airway and trachea lie within and above the chest and are as vital to life as the lungs and the heart. The pleural cavities are lined by a thin membrane known as the pleura, which covers the outer surface of each lung and forms a dosed sac that contains a small amount of pleural fluid. In the snowsports environment, the lungs and the bony thorax (the ribs in particular) are relatively more prone to injury than the deeper-lying heart and great vessels.

Non-Penetrating Injuries

Generally caused by forces of deceleration and compression trauma when a skier or a snowboarder collides with a stationary object, non-penetrating injuries, i.e., closed or blunt injuries, are those in which the chest wall remains intact. Such injuries are typically accompanied by a normal exchange of air between the chest wall and the external environment. A simple non-penetrating chest injury may fracture a rib or ribs, or cause a pneumothorax (air in the pleural space, resulting in a collapsed lung) or hemothorax (blood in the pleural space, resulting in a collapsed lung). Pneumothorax and hemothorax can occur simultaneously, creating a dangerous condition called a hemopneumothorax.

Patients with non-penetrating injury and pneumothorax or hemothorax (or both) often have localized chest pain, made worse by breathing, and shortness of breath. If cyanosis is present-the bluish discoloration of the skin, fingernails, and lips-it's usually mild. In addition, the patient will experience chest wall pain and tenderness, which worsens if the chest is squeezed in the lateral or anterior-posterior dimension. Thus, the patient's level of discomfort has direct bearing on how you palpate the chest wall. The more severe the pain, the more gentle your exam should be. Do not exert pressure over likely rib fractures, for patients will find this quite painful.

Upon palpating the chest wall, you may feel a crackling sensation known as crepitation, which indicates that air has leaked into the subcutaneous tissues. You should also be aware of any clicking or grinding noise, called crepitus, which results when broken bone ends rub together.

The more severe the injury to the chest wall, the greater the likelihood of deeper injury. However, the absence of obvious chest wall injury does not exclude lung, heart, or great vessel injury.

To assess a chest injury, start with the ABCs: airway, breathing, and circulation. If the patient is responsive and speaking (i.e., is verbally responsive), the upper airway is usually functioning. If the patient complains of pain upon breathing or shortness of breath, proceed to the chest exam. A strong carotid pulse and the absence of bleeding indicates that circulation is intact, at least for the time being. Complications can occur with patients who are unresponsive or who have severe generalized pain but cannot localize their pain or injuries. Assume that unresponsive patients have multisystern injuries, and immediately arrange for transport to the nearest facility equipped for a higher level of care.

Among non-penetrating chest injuries, the conditions known as flail chest and tension pneumothorax are more life-threatening than rib fractures, simple pneurnothorax, and hemothorax. Both conditions may cause the patient to experience severe difficulty breathing, develop cyanosis, and go into shock.

Flail chest results when adjacent ribs that are broken in more than one place allow a section of the chest wall to move independently from the rest of the thorax. As the chest expands during inspiration, the fractured portion moves inward, defeating the diaphragm's effort to expand the lungs. Depending on the size of the flail portion of chest wall, the condition can be fatal. Equally or even more dangerous is the underlying lung injury: flail chest is often accompanied by a pulmonary contusion (bruised lung), which further inhibits the respiratory process. If the patient is cyanotic, in shock or unresponsive, endotracheal intubation or even bag-valve-mask ventilation may be life-saving.

In tension pneurnothorax, the lung is collapsed and the lungs, heart, and great vessels are under pressure from trapped air, which results when a defect at the injury site acts as a one-way valve, letting air into the pleural space but preventing it from escaping. This pressure builds until the patient's collapsed lung is eventually reduced to a the size of a small ball. Easily recognizable signs of tension pneumothorax are severe respiratory distress, cyanosis, distended neck veins, and shock. Less obvious signs of a tension pneurnothorax are reduced movement on the affected side of the chest when the patient breathes, and deviation of the trachea on the side opposite the pneumothorax. These signs, however, are not always obvious in cold weather.

Patients with tension pneurnothorax urgently need a chest tube, and thus should be transported to a primary care facility immediately. Emergency care providers trained at the paramedic level and above can insert a needle to relieve the tension, a potentially lifesaving measure that converts the condition to a simple pneumothorax. On the down side, if a patient is hyperventilating with pain and has blue lips from the cold, a needle in the chest may produce a pneurnothorax.

Other blunt injuries such as myocardial contusion and pericardial tamponade, which occur less frequently than the injuries previously discussed, are addressed in chapter 15 of Outdoor Emergency Care (third edition). Identifying these injuries is difficult, even in a hospital setting, and managing them in the cold is very problematic. If you suspect injuries to the heart or great vessels, immediately transport the patient to a hospital. Also assume that any significant injury to the chest might also have damaged the liver and/or spleen--the abdominal organs that underlie the lower ribs. Such injuries also require expedient transport.

Penetrating Injuries

In comparison with non-penetrating injuries, those of the penetrating, or open, variety--such as knife, projectile, or impalement wounds--are more likely to directly damage the heart, great vessels, or lungs, depending on their route into or through the chest. Penetrating chest injuries are infrequent in snowsports, although certainly not impossible. Occasionally, skiers and snowboarders impale themselves on tree branches or ski poles. Like blunt injuries to the chest, penetrating injuries may also result in pneurnothorax (both the simple and tension varieties) and hemothorax.

Recognizing penetrating injuries is relatively easy because the signs of penetration are often obvious: torn or "holed" clothing; bleeding; or possibly the presence of a branch, pole, or other object protruding from the patient's body. Check the patient's back as well as the front.

If possible, identify any bleeding and control it with pressure and a dressing. Stabilize any foreign objects protruding from the chest and leave them in place. If the patient has a sucking chest wound, which occurs when an entrance wound links the pleural space with the outside air, identify and treat it with a dressing left open on one side; completely sealing a chest wound may create a tension pneurnothorax.

It's vital to keep in mind that chest injuries can be fatal. Measures you can take to reduce the patient's risks include suctioning the airway, administering oxygen, and radioing for help early on. Next, perform a rapid evaluation and stabilize the patient for transport. Be sure to alert the base station and request that expedient ground or air transportation be arranged.

When time is of the essence and a delay could prove fatal, reality dictates using the "load and go" method of evacuation. Patients with chest injuries are better off en route to a primary care facility than waiting on the hill or in the aid room for extended assessment.