Flail Chest Trauma Overview and Practice Questions

Chest Trauma: Overview and Practice Questions (Flail Chest)

by | Updated: Aug 22, 2023

Chest trauma is a type of injury that occurs to the thoracic region, usually as a result of a direct blow or impact. This can include injuries to the chest wall, ribs, lungs, or heart.

It can range from mild to severe and can be life-threatening in severe cases. In this article, we will provide an overview of chest trauma, its causes, symptoms, and treatment options. We provided helpful practice questions for your benefit as well.

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What is Chest Trauma?

Chest trauma refers to any type of trauma or injury to the chest wall. This can include anything from a minor bruise to a major wound.

This type of trauma can be caused by a number of things, including car accidents, falls, and sports injuries.


There are two primary types of chest trauma:

  1. Blunt
  2. Penetrating

Blunt chest trauma occurs when the chest wall is hit by a blunt object. This can cause a number of injuries, including broken ribs, internal bleeding, and damage to the lungs.

Penetrating chest trauma occurs when the chest wall is pierced by a sharp object. This can also cause a number of injuries, including internal bleeding and damage to the lungs.

Sign and Symptoms

The signs and symptoms of chest trauma can vary depending on the severity of the injury. Some common examples include:

  • Chest pain
  • Shortness of breath
  • Tachypnea
  • Shallow breathing
  • Hypoxemia
  • Bruising
  • Inflammation
  • Paradoxical chest movement
  • Pneumothorax

Each patient may experience different signs and symptoms, depending on the severity of the injury to their chest wall.


The treatment for chest trauma will vary depending on the severity of the injury. For minor injuries, rest and ice may be all that is needed. More severe injuries may require hospitalization and surgery.

Oxygen therapy may be indicated if hypoxemia is present. In severe cases, intubation and mechanical ventilation would be indicated for the treatment of apnea or ventilatory failure.

If the patient is experiencing extreme levels of pain, analgesic medications would be indicated.

Hyperinflation therapy, such as incentive spirometry, would also be helpful in treating and preventing atelectasis. If damage occurs to the lungs, causing a pneumothorax, the insertion of a chest tube would be indicated.

What is a Flail Chest?

A flail chest is a type of chest trauma that occurs when a portion of the rib cage is fractured and becomes detached from the chest wall. It occurs when there is a fracture of three or more adjacent ribs.

When this happens, it can result in a number of complications, including difficulty breathing and internal bleeding.

A flail chest often results in a pneumothorax due to the puncturing of the lungs by one of the broken ribs. A pneumothorax is a condition in which air accumulates in the pleural space and makes it difficult for the patient to breathe.

Chest Trauma Practice Questions:

1. What is chest trauma?
It is any form of physical injury to the chest (including the ribs, heart, and lungs). These chest injuries are typically caused by blunt mechanisms such as motor vehicle collisions or penetrating mechanisms such as gunshot wounds or stabbings.

2. What are the two types of chest trauma?
Blunt and penetrating.

3. Blunt trauma can be caused by which mechanisms?
Deceleration (motor vehicle accident), shearing, and compression.

4. Penetrating trauma can be caused by which mechanisms?
Gunshot and stabbing.

5. What tests are ordered initially for patients with chest trauma?
Chest x-ray, CT of chest/abdomen, CBC, type and cross-match, electrolytes, O2 saturation, ABG and EKG.

6. Where are chest tubes inserted?
Right or left pleural spaces or mediastinum.

7. Why are chest tubes inserted?
Restores negative pressure and helps lungs re-expand.

8. What are the two types of chest tubes?
Small bore and large bore (connected to chest drainage system).

9. What are the types of chest drainage systems?
Wet (water seal) and dry suction. Both systems can operate via gravity in emergency situations.

10. What will the wet drainage system look like when the chest tube is placed in the mediastinum?
It may pulsate with the patients’ heartbeat.

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11. What can be done to prevent excessive negative pressure in the chest tube drainage system?
Having the water level at the 2 cm mark.

12. What are the benefits of a dry suction chamber?
Can be set up quickly in emergency situations, still works even if it is knocked over and useful for patients being transported or ambulating.

13. What are the consequences of a dry suction chamber?
No way to tell if the pressure in the chest has changed.

14. What can be done if an air leak in a dry suction chamber?
Inject 30 mL water into air leak indicator. Note that bubbles will appear if air leak present.

15. What should be done if the patient has a chest tube and needs to be transported to another area of the building?
Place drainage system below chest level while transporting.

16. What should be done if while transporting the patient with a chest tube, the tubing disconnects?
Cut off contaminated tips, insert the sterile connector into cut ends, and reattach to the draining system.

17. What should not be done on the chest tube during transport?
Clamp the chest tube.

18. When is the only acceptable time to clamp a chest tube?
Right before removal.

19. What are the priorities when removing a patient’s chest tube?
Preventing air from entering the pleural cavity and preventing infection. The tube is removed quickly after being clamped.

20. What dressing is used on the chest tube site after the tubing is removed?
Petroleum gauze applied followed by 4×4 gauze and thoroughly covered and sealed with tape.

21. What treatment should be done on sternal/rib fractures?
Treat the pain as patients need to be able to breathe adequately. Avoid excessive activity. Apply ice over the fracture site. Use a chest binder. Rib fracture heals in about 3-6 weeks.

22. What is flail chest?
Flail chest is a condition where several ribs are fractured in different sites, which results in free-floating rib segments. The chest wall loses stability causing respiratory distress and it usually accompanied by underlying lung/heart contusion. It is multiple rib fractures that result in an unstable chest wall. It occurs when a segment of the thoracic cage is separated from the rest of the chest wall. It is at least two fractures per rib (producing a free segment), in at least two ribs. The segment of the chest wall that is flail is unable to contribute to lung expansion and may be large enough to require mechanical ventilation.

23. What can be observed on the ABG in patients with flail chest?
Respiratory acidosis (patient retaining CO2 d/t impaired gas exchange).

24. What treatment is done in patients with flail chest?
Ventilatory support (IS, deep breathing, bronchodilators, intubation), airway management, clearing secretions from the lungs, controlling pain and surgery if the injury is really bad. Stabilize area, intubate, and ventilate. Positive pressure ventilation stabilizes the area. Disrupting of chest wall integrity alters intrathoracic pressure. Penetrating chest wall injury.

25. What should be monitored in patients with flail chest?
Serial chest x-ray, ABG, pulse oximetry, and bedside pull functioning.

26. What is a pulmonary contusion?
Bruised lung, usually d/t blunt force trauma and may not show up on chest x-ray for a couple days.

27. What is cardiac tamponade?
Compression of heart from fluid/blood in the pericardial sac. Blood rapidly accumulating in the pericardial sac, compressing myocardium.

28. What is a pneumothorax?
Pneumothorax is a collection of air in the chest /pleural space that causes part or all of the lung(s) to collapse due to the loss of negative pressure in the chest cavity (ATI) and treated with a chest tube. It is a breach in parietal or visceral pleura resulting in exposure to positive atmospheric pressure.

29. What are the three types of pneumothorax?
Simple or spontaneous, traumatic, and tension.

30. What is a simple pneumothorax?
It is spontaneous and can sometimes occur in a relatively healthy person.

31. What is a traumatic pneumothorax?
Pleura are punctured or air enters pleural space. A wound in the chest wall allows air to escape and enters the pleural space.

32. What is tension pneumothorax?
Pneumothorax which causes so much pressure inside the pleural cavity that is outside the lung. It trapped air that causes pressure on the heart and great vessels thus negatively affecting circulation. Pressure pushes everything to the opposite side (mediastinal shift). Air enters pleural space and continues to build up with each inhalation and lung collapses. Trachea will be shifted towards the unaffected side (tracheal deviation). It is the worst type of pneumothorax. It can cause death if not treated rapidly. Treatment is with a chest tube and can be immediately relieved with an emergency procedure, then a chest tube is inserted.

33. What are the signs and symptoms of a pneumothorax?
Sudden pleuritic pain, dyspnea (severe or minimal, depending on type), anxiety and chest discomfort.

34. What is the treatment for a pneumothorax?
Decompress the pleural cavity with chest tube or needle. Chest tube for simple pneumothorax will be relatively small and high in the chest wall. Inserted on the affected side.

35. What is hemothorax?
It is an accumulation of blood in the pleural cavity. Much like a pneumothorax, but instead of only air in the pleural space, there is air and blood. Air goes up, blood goes down. Treatment is with a chest tube, but placement will be lower than for a pneumothorax (ATI).

36. What is the difference between the treatment for a hemothorax and pneumothorax?
Chest tubes for pneumothorax are high in the chest wall, around ICS 2-3, whereas blood is heavy and will be closer to the diaphragm while for a hemothorax; chest tube is placed lower in the chest wall, ~ICS 7.

37. What are some causes of hemothorax?
Blunt, blast or penetrating chest trauma. Rarely can be caused by COPD or advanced age (ATI).

38. What are some causes of a pneumothorax?
High inspiratory pressure on the ventilator, COPD (spontaneously popping a bleb) and smoking.

39. What are some causes of a tension pneumothorax?
Pneumothorax or hemothorax where air or fluid cannot escape out of chest wall, high inspiratory pressure, blast injuries and chest tube occlusion (ATI, I&W), trauma PEEP, clamping of chest tube, or taping an open pneumothorax on all four sides without an air valve.

40. What are some clinical manifestations of patients with a pneumothorax or hemothorax?
Shortness of breath, chest pain, dyspnea, subcutaneous emphysema, tracheal deviation (away from affected side), reduced or absent lung sounds over affected lung, asymmetrical chest wall movement (ATI, I&W), hyper-resonance on percussion due to trapped air, and dullness on percussion due to trapped blood.

41. What position is best for patients with a pneumothorax?
High Fowler’s position.

42. How does a chest tube ‘fix’ a hemothorax or pneumothorax?
It is inserted by the physician into pleural space, drains blood/fluid/air/pus and re-establishes negative pressure in the thoracic cavity facilitating lung expansion (ATI, I&W).

43. What is an air leak and what should be done for this?
An air leak is the continuous rapid bubbling in the water seal chamber. When this happens, start at the insertion site and assess along the tubing to locate the leak. Frequently, it is at the insertion site

44. What happens to the lung with pneumothorax or hemothorax?

45. What does subcutaneous emphysema air trapped in tissue feel like?
Feels like rice Krispy sound and usually in the neck, face, and chest.

46. What treatment is done for hemothorax or pneumothorax?
Thoracentesis, chest tubes, and daily chest x-ray.

47. What are some signs and symptoms of tension pneumothorax?
Subcutaneous emphysema, absence of breath sounds on one side, asymmetry of the thorax, and respiratory distress.

48. How can a tension pneumothorax be fatal?
It can be fatal as accumulating pressure compresses vessels, then decreases venous return, then decreasing cardiac output.

49. What is the treatment for a tension pneumothorax?
Large bore needle placed into the 2nd intercostal space by the provider to allow excess air to escape. When cause found, chest tubes will be inserted.

50. What is an open pneumothorax?
Sucking chest wound. It is an opening through chest that allows air into the pleural space.

51. What is the treatment for open pneumothorax?
Have the patient inhale and hold or Valsalva. Increase the intra-thoracic pressure so no more outside air can get into the body. Then place a piece of petroleum gauze over area and tape down three sides. Patients sit up to expand lungs but may stay flat if other injuries.

52. What are the most common injuries from chest trauma?
Fractures of ribs and sternum.

53. What are the signs and symptoms of fractures of ribs and sternum?
Pain and tenderness, crepitus or bones grating together, shallow respirations and respiratory acidosis.

54. What is the treatment for fractures of ribs and sternum?
Non-narcotic analgesic, nerve block to assist with productive coughing, support injured area with hands, not recommended to immobilize with chest binders and straps as this can lead to shallow breathing, atelectasis, and pneumonia.

55. What complications should you observe for with fracture of ribs and sternum?
Observe for complications such as pneumothorax, hemothorax, and flail chest.

56. When may flail chest occur?
Occurs with multiple rib fractures.

57. What are the signs and symptoms of flail chest?
Pain, paradoxical chest wall movement, dyspnea, cyanosis, increased pulse, moves in with inspiration/out with expiration, increased work of breathing, hypoxemia, and tachycardia.

58. What is paradoxical chest wall movement?
A see-saw chest. Chest sucks inwardly on inspiration and puffs out on expiration. To assess chest symmetry, always stand at foot of the bed to observe how the chest is rising and falling.

59. What can cause a penetrating chest wound?
Stabbing or gunshot wound.

60. What is a blunt chest wall injury?
It is the damaged structures in the chest cavity without disrupting chest wall integrity.

61. What is the leading cause of a blunt chest injury?
MVA (motor vehicle accident).

62. What are the symptoms of cardiac tamponade?
Muffled, distant heart sounds, hypotension, neck vein distinction and increased CVP.

63. What is the medical treatment for cardiac tamponade?

64. What are the symptoms of a rib fracture?
Pain at the site of injury, localized tenderness, crepitus, splinting of the chest, and shallow breathing.

65. Why can rib fractures cause atelectasis?
Rib fractures are painful and this makes the patient not want to breathe.

66. What is used in the diagnosis of rib fractures?
Chest x-ray.

67. What is the main goal of the treatment of rib fractures?
Pain management.

68. Why are opioids used cautiously in rib fractures?
They can suppress respiration.

69. What is the number one way to diagnose flail chest?
Visual inspection.

70. How is flail chest diagnosed?
Chest x-ray and visual inspection.

71. What is the best position for a patient with flail chest?
On the affected side.

72. What is a closed pneumothorax?
No external wound in this pneumothorax.

73. What is subcutaneous emphysema?
Presence of air in subcutaneous tissue.

74. What are the treatments for a pneumothorax and hemothorax?
Needle aspiration, Heimlich valve, and chest tube.

75. How much water is needed to be in the water seal container for a chest tube?
2 cm.

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76. When do we mark the collection chamber?
At the beginning and end of every shift.

77. What should be assessed in the water-seal chamber?

78. What does excessive bubbling mean?

79. What does no bubbling mean?
The lung is expanded or there is a kink.

80. What do we do if the drainage system breaks?
Place the end of the chest tube in 2 cm of sterile water.

81. When to report chest tube drainage?
More than 200 mL in an hour or 2.

82. What do you do for sucking chest wounds?
Cover it on three sides.

83. What is included in chest trauma?
Blunt, penetrating trauma and pneumothorax.

84. What type of chest trauma that is more commonly harder to determine the extent of damage?
Blunt trauma.

85. What are the causes of blunt trauma?
Cause is sudden compression or positive pressure to the chest wall, like from a MVA, steering wheel, seat belt, falls.

86. What is a blunt trauma?
Chest trauma that is more common, harder to determine the extent of the damage. It is caused by a sudden compression or positive pressure to the chest wall, like from a motor vehicle accident, steering wheel, seat belt, falls. Three types of blunt trauma includes fractured sternum and ribs, flail chest, and pulmonary contusion.

87. What is a penetrating chest trauma?
A foreign object enters the chest wall, like from a gunshot wound and stabbings

88. What is the most common type of chest trauma?
Rib fractures

89. What is the prognosis of sternal and rib fractures?
Most are benign but can be life-threatening. It happens commonly on the 5th – 9th site and usually heals in 3-6 weeks.

90. What conservative treatment is available for sternal and rib fractures?
Pain control, avoid excessive activity, deep breathing exercise, rib belt and surgical intervention if gross deformity only.

91. How are blunt injuries most commonly managed?
Non-operatively or with simple interventions like intubation and ventilation and chest tube insertion.

92. What important fact should be noted on patients with penetrating trauma compared to patients with a blunt injury?
Patients with penetrating trauma may deteriorate rapidly, and recover much faster than patients with blunt injury.

93. What is the medical management for patients with chest trauma?
Establish/secure airway (maybe via intubation/ventilation). Re-establish chest wall integrity (occluding open chest wounds, correct fluid volume, and negative intrapleural pressure or drain intrapleural fluid) and control bleeding.

94. What is a paradoxical movement?
Flail area moves in opposite direction to the intact portion of the chest wall. During inspiration, the affected portion is sucked in with mediastinal shift to the uninjured side or unaffected side. On expiration, the flail section bulges outward with mediastinal shift to the injured side (can see one side of chest wall rises higher than the other). This results in hypoxemia, respiratory acidosis, and hypotension.

95. What are the treatment goals for a patient with flail chest?
Depends on the degree of respiratory dysfunction and will include controlling of pain, clearing secretions and ventilatory support.

96. What interventions are used to clear the airway for patients with flail chest?
A cough and deep breath, positioning, and suction the secretions.

97. What are the causes of a simple or spontaneous pneumothorax?
Rupture of a bleb, rupture of a bronchopleural fistula, rupture of air-filled blister in a healthy person and may be associated with severe emphysema or interstitial lung disease.

98. What are the causes of traumatic pneumothorax?
Causes include blunt trauma, penetrating chest trauma, abdominal trauma, and invasive thoracic procedures.

99. What are the clinical manifestations of a pneumothorax?
Pleuritic pain, tachypnea, anxiety, dyspnea with air hunger, use of accessory muscles, decrease/absent breath sounds, decrease movement on the affected side and subcutaneous emphysema.

100. What are the results if there is a progressive buildup of pressure in the pleural space from a tension pneumothorax?
Mediastinum pushed to the unaffected side and venous return to the heart is obstructed.

101. What is the progression of a tension pneumothorax?
Air enters wound in the chest wall and becomes trapped. With each breath, tension increases in the pleural space. Lung collapses. Mediastinal structures shift to the opposite side.

102. What are the classic signs of a tension pneumothorax?
Deviation of the trachea away from the side with the tension, hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves little with respiration, and central venous pressure is usually raised but will be normal or low if the patient is hypovolemic.

103. What is a positive pressure?
Whenever fluid accumulates in the pleural space.

104. What happens to the lungs under positive pressure?
They collapse.

105. Why are chest tubes inserted?
To drain the pleural space and reestablish negative pressure, allowing for proper lung expansion.

106. What are the different chest tubes?
Large chest tubes (36-40F) used to drain blood. Medium chest tubes (24-36F) used to drain fluid. Small chest tubes (12-24F) used to drain air.

107. What does an anterior chest tube remove?

108. What does a posterior chest tube remove?

109. Is bubbling in the water seal chamber of a chest tube drainage system normal?
Intermittent bubbling is normal, not continuous bubbling.

110. What is the purpose of intermittent bubbling?
To remove air from the pleural space.

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111. What is observed in the water-seal chamber?
Air fluctuations (tidaling) and bubbling.

112. What is a possible cause if tidaling (rising with inspiration and falling with expiration in the spontaneously breathing patient) is not observed?
The drainage system is blocked, lungs are re-expanded, or system is attached to suction.

113. What is a possible cause if bubbling increases?
There may be an air leak in the drainage system or a leak from the patient (bronchopleural leak).

114. What measures should be taken if there is a system leak and bubbling is continuous?
Re-tape tubing connections. Ensure that dressing is air-occlusive. If the leak persists, briefly clamp chest tube at the patient’s chest. If the leak stops, air is coming from the patient. If air leak persists, briefly move the clamps down tubing away from the patient until air leak stops. The leak will then be present between the last two clamp points.

115. What happens if chest tube stays clamped?
Can cause a tension pneumothorax and mediastinal shift.

Final Thoughts

Chest trauma is a type of injury that occurs to the thoracic region and can range from mild to severe. As a respiratory therapist, it’s important to be aware of the signs and symptoms so that you can recommend or provide the appropriate treatment.

If you enjoyed this content, we have similar guides on pneumothorax and hemothorax, which are topics that are closely related to chest trauma. Thanks for reading!

Written by:

John Landry, BS, RRT

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.


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  • Davignon, K. “Pathophysiology and Management of the Flail Chest.” PubMed, Apr. 2004, pubmed.ncbi.nlm.nih.gov/15173695.
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  • “Management of Traumatic Flail Chest in Intensive Care Unit: An Experience from Trauma Center ICU.” PubMed Central (PMC), July 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6625290.

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