CHEST INJURIES - Medicine for Mountaineering and Other Wilderness Activities - page 116

A person with a severe chest injury should be placed in the position that is most com-
fortable,butlyingonthesideorsittingmayallowforbetterrespirationthandoeslyingflat.
If blood loss has been significant, the individual may have to lie flat to maintain adequate
blood pressure (“Shock” in Chapter 3: Life-Threatening Problems ) .
CLOSED CHEST INJURIES
Fractured Rib
A forceful blow to the chest may break one or more ribs, but the ribs are so tethered by
surrounding muscles they do not need to be splinted or realigned like other broken bones.
Other than producing discomfort, most rib fractures are not serious injuries. However, the
discomfort can be disabling, and movement of almost any part of the body causes pain at
the fractured site that is accentuated by muscle spasm. Pain also interferes with motion of
the chest wall and limits breathing. Furthermore, a broken rib may be displaced inward,
puncturing the lung and producing a pneumothorax (air in the pleural space). As men-
tioned, the pleural space surrounding the lung normally does not contain air, but when the
lungispuncturedairescapesfromthelungandentersthepleuralcavityduetothenegative
pressure generated during breathing. With increasing size, a pneumothorax compromises
air exchange through the lungs.
A fractured rib should be suspected when pain and tenderness at the point of impact
follow a blow to the chest, particularly when deep breathing or movement aggravates the
pain. Rarely can a defect be palpated at the point of fracture because the ends of the rib are
held in position by surrounding muscles.
The pain of a fractured rib and associated muscle spasm may be severe enough to re-
quireanalgesicsforafewdays.Almostanymovementandsleepmaybeextremelyuncom-
fortable for several weeks, particularly when lying on the injured side, but the pain gradu-
ally disappears as the bones heal. Sudden sharp pain at the site of injury for weeks after
the injury should not arouse concern. Relief of pain so it does not interfere with breathing
is the most important aspect of managing broken ribs, particularly at high altitude, in the
elderly, and in individuals with reduced pulmonary function such as smokers.
Adhesive strapping over the rib is not advisable, particularly at altitudes above 10,000
feet (3000 m). Such immobilization further reduces movement of the chest on that side,
diminishes the capacity for exertion, and allows secretions to collect in the immobile lung.
Pneumonia is a potential complication of rib fractures. At lower elevations, if the pain can-
not be controlled with moderate analgesics, several two-inch-wide strips of adhesive tape
can be applied along the fractured rib from the midline in front to the vertebral column in
back. Taping provides some relief from pain but should be removed as soon as the indi-
vidual has been evacuated. Wrapping the chest circumferentially with an elastic bandage
should not be used since both sides of the chest are restrained, substantially reducing res-
piratory function.