This is structured terribly but okay here are some things I am going to tell you a lil bit about:
First of all we will talk about simple rib fractures and the ways that they can present. Mentions of blunt trauma vs. penetrating trauma to the thoracic cavity ftw.
Then we will talk about simple and tension pneumothoraxes, which is when your lungs get involved, and how they present, and what you can do to save the lives of your characters.
Are usually caused by blunt force trauma to the chest. Might be common if your character is wearing armour so that they don’t get the actual bullet and/or knife wounds, just the force of the blow. Most common rib fractures are to the 7th and 10th ribs.
Can be really bad, can be not so bad. It could go either way.
The main life-threatening complication of broken ribs is that they can poke into your lungs, but they don’t have to and we’ll talk about that later, sit down.
Also, if you have lower rib fractures they might poke into you diaphragm and cause a diaphragmatic hernia. Gross.
Visually, looking at the chest you might see what is called a flail segment, if the rib was broken in more than one place, or if multiple ribs were broken multiple times. A flail segment looks like a little floaty piece of chest that moves more than the rest of the chest and it’s pretty cool. Here is a video of what flail chest looks like when someone is breathing. I would probably tag it as body horror, but there is no blood or anything, just weirdness.
Otherwise, have a feel (if the character is not too much of a wuss, or too stubborn, that they won’t let you), and if it hurts when you poke it, that’s probably a rib fracture. Worse if there is instability.
Don’t push on it if its unstable IDJIT!
Other things your character will feel/symptoms:
Pain! P. bad pain. Especially on inspiration (when they breathe in) or with movement. They might describe it as sharp or stabbing.
In fact, the character is probably going to be breathing quite shallowly (even if their lungs haven’t been directly affected) just because to breathe too deeply is painful for them. That means they’ll also have an increased respiratory rate, to compensate.
If you ask the person to take a deep breath or lift their arms they are going to cry because it’ll hurt like the fire of a thousand Archdemons. If they are p. tough they might just wince tho. I would probably cry.
Other vital signs that will change are an increase in heart rate and blood pressure, as part of a normal pain response and due to the increased respiratory effort.
Also you’ll have bruising from the mechanism, even early on, because the force required to crack adult ribs is not something to be laughed at.
More serious rib fractures might be accompanied by a low pulse oximetry (SpO2) reading, which means low levels of oxygen in your blood. And the lack of oxygen (hypoxia) can cause a person to act confused or agitated, because their brain isn’t getting as much oxygen as it wants. Also, they might have slightly paler skin or a low capillary refill time because peripheral perfusion will decrease to compensate.
Don’t worry if that made no sense. It’s only pertinent if you have a modern day medical setting. Like really, if you are a spirit healer in Thedas then “what the fuck is a pulse oximeter? Why do I need it? Magic!”
And even if you are in a modern day setting where you just don’t have access to medical equipment then four for you, your writing will be much easier. But feel free to consult me, yeah? I love you.
Right so there you go. Rib fractures.
A&P (don’t skip this)
I want to teach you also about simple and tension pneumothoraxes, because I think it’s a pretty cool condition to describe and there is a pretty cool intervention that will save your characters life that would be awesome to write and if I read a fanfic where there was a chest decompression, I will be so happy. I demand that you tag me.
But first, I’m going to have to give you a beginner’s guide on the anatomy and physiology of the lungs.
Lungs are made of millions of little alveoli that are the site of gas exchange and what-not. Alveoli are kind of like the functional unit of the lungs. They are basically just tiny bags of air with blood vessels (capillaries) around them. The alveoli fill with air when you breathe in and the blood in the capillaries take up the oxygen and let go of the carbon dioxide and then the blood goes off to look after the rest of your body. There are bronchioles and bronchi and the trachea that are the tubes that carry air from your mouth and nose into the alveoli and back. You don’t really need to know this for anything though. Here’s a picture of lungs that I found on google images:
It is generally assumed that the lungs breathe in and out with the help of loads of muscles, which is true (especially when breathing becomes very difficult) but it isn’t the main mechanism. Mostly breathing is controlled by pressure gradients.
When your diaphragm pulls down during inspiration it increases the area in your lungs. So you now have the same amount of air in your lungs, but the gas is now swimming around in a lot more area. So, the pressure that all the gas particles exert on the walls of your lungs becomes less. I hope that makes sense here is a picture that I prepared earlier.
You can probably see that the only thing that changes is the size of the container, which is applicable to your lungs.
If you are into physics then you are probably familiar with a dude named Boyle and his law which states that “as volume increases, the pressure of the gas decreases in proportion. Similarly, as volume decreases, the pressure of the gas increases,” which is p. much what I was trying to draw. Also increasing temperature can increase pressure but I don’t want to talk about that I don’t like maths.
The other important thing is that air will always travel from an area of high pressure to an area of low pressure if it can, so air will go from outside of your body (higher pressure) into your lungs (lower pressure), and then you have inspiration. Expiration is a passive process, which means it happens without your say-so. With expiration, your lungs are full of air after inspiration and the pressure is high, so the air will just mosey on back out to put the pressure gradient back at equilibrium.
Lungs are attached to your ribs at the front and back (kindof) and your diaphragm at the bottom. I say kindof because they are not /really/ attached. There is no connective tissue or anything. Instead you have two membranes, one on the lungs and one on the ribs/diaphram, and in between these two membranes there is the pleuritic cavity which is full of pleural fluid which sticks the lungs to the ribs and hey presto your lungs expand with your chest. There is no air in this space. This space is sacred. It’s not sticky like glue, its more watery. The way two pieces of paper will stick together if you put water between them.
Here is a picture I found on google images:
It’s important that you have no leaks in your pleural cavity (the space between the two membranes), because then that space can lose its stickiness, or fill up with air or blood, and breathing becomes super hard. Do you see where I am going with this?
If you get a lot of air or blood in your pleural cavity, then that puts pressure on your lungs and it screws up all those pressure gradients that we talked about earlier.
Right so, yep. Rib fractures, like we said, are usually caused by blunt trauma to the chest. The thing is that broken ribs can be sharp so they can still poke into your lungs.
But also penetrating trauma, like a knife or a bullet or a star picket can get in there and do the job with much more efficiency, if you ask me. Only usually if you have penetrating trauma you will get what is called a sucking chest wound, which is also called an open chest wound as opposed to the closed chest wounds caused by blunt trauma. And no it’s not called that cause it sucks to have one, but because the wound will literally be sucking air and it will make a funny slurpy sound. I’ve never heard one irl I just watch videos on the internet here is one but it has more gore than the last video and you should not watch this if you don’t like blood or gross deformity and such.
TYPES OF PNEUMOTHORAXES
Simple and Tension
A simple pneumo is less serious than a tension pneumo. It is when you have a collection of air or blood in your pleural cavity, but it’s not expanding. The lung might be partially collapsed, but you are still getting air entry. It’s caused by a two-way valve, so air can get into the pleural cavity, but it can also wander back out, which means you don’t get heaps of pressure build-up.
If you have a simple pneumo, the diagnosis is difficult, but not impossible.
If your character has access to a stethoscope, that is a start. There will be reduced air entry on one side of the chest. Normal breath sounds are a nice healthy whoosh, so if you are getting a softer whoosh or no sound at all in some lung fields then that’s bad. If you have a feel of the chest wall (a nice excuse to have one character grope another character’s sweaty, naked chest, queue feelings of: oh no, I shouldn’t be having sexy feelings at a time like this!), anyway, if they have a feel (palpate) then they might feel what is called subcutaneous emphysema which is pretty hard to describe, but if you’ve ever felt lung tissue, I imagine it would be something like that. Tiny, tiny, teensy little bubbles under the skin. And also, another clue is that you have the rib fractures and bruises. But all in all it’s pretty hard to diagnose without x-rays. Only you have to watch it really close because they can easily develop into the dreaded TENSION PNEUMOTHORAX!
A pneumothorax will tension if you have a one-way valve and air or blood gets trapped in your pleural cavity and can’t get out but it just keeps building up and up and up in the pleural space and then it puts loads of pressure on your lung and on your heart.
And then your lung will probs collapse, or even the excessive pressure on your heart can cause occlusion of the vessels that supply your heart muscle with blood (coronary arteries) and then you will have a heart attack too.
The same thing can happen with blood but it is called a haemopneumothorax, which is blood and air. Cool beans.
Here’s a picture to explain:
Okay so obviously your character is gonna be short of breath, they will have chest pain (though I wouldn’t expect them to describe it because talking would be hard enough without confusion and passing out et al) they might have that subcutaneous emphysema that we talked about earlier, they will also have diminished breath sounds on the affected side, a high heart rate and maybe an elevated blood pressure because holy shit your heart is panicking and at this point your body is trying to compensate for the lack of ventilation and the hypoxia (low oxygen). So it’s gonna constrict your peripheral blood vessels (fingers, toes, arms, legs, kidneys, etc) to try and keep all the blood and all the precious oxygen for just the heart and lungs and brain, which is a short term compensatory mechanism to protect the more vital structures.
You know it is getting really serious when your patient begins to have an altered level of consciousness: confusion, agitation, drowsiness, etc. You might also get pale skin or cyanosis (blue skin).
A big change though is when you start to get HYPOTENSION! Hypotension happens because the pressure on your heart and your lungs and your vena cava (big low-pressure vein in your chest) makes it harder for your heart to pump and harder for your pulmonary vessels and your vena cava to keep travelling blood to your heart. So then, if your heart receives less blood (preload) then it is not going to put out as much blood (cardiac output), then your blood pressure will drop.
At this point your radial pulses (pulse on the inside of your wrist) will be very weak. But your heart rate should still be pretty high. If your heart rate starts to drop (bradycardia: under 60bpm) then I’d say you are pre-arrest, so get ready to do some CPR! ^-^
Other things you might see include jugular vein distension (JVD), your JV is a big vein in your neck, and when it becomes distended it is a sign that blood is not effectively getting taken to the heart so you get a backlog of blood in the jugular vein it sounds gross to me.
There is also tracheal deviation, which, I don’t know if you know but the trachea is the big air tube that travels from the back of your throat all the way down into your lungs until it branches off into the bronchi. So, with the excessive pressure from your huge lung and your expanding pneumothorax, it pushes your trachea to the side. This is a really late stage phenomenon and your character is probably about to die. They are also probably unconscious because their brain has no oxygen.
Do you know how on TV you see people holding a bag-valve mask on someone’s face and squeezing the bag to breathe for them? Probably don’t do that for a tension pneumothorax, because you might overinflate the lung and cause it to collapse. But you want to put them on a high flow oxygen mask because whatever oxygen they can get into the blood, they are going to need. Just, don’t increase the pressure in their lungs. Cause pressure is super important I think you know this now.
Chest decompression (in the prehospital setting at least) is for tension pneumothoraxes only!! You can’t decompress a simple pneumothorax. Don’t do it.
But yo, actually don’t try to decompress a tension pneumothorax in real life with the shell of a pen because I know it has happened in a film or book somewhere but don’t do it I’m warning you. Writing it and doing it are totally different things. And if you did do it and then you say: “but Bram told me it was okay to do, I was totally educated on this procedure,” that will not work. Call an ambulance instead. But you are probably never gonna see a real life tension pneumo cause we just don’t get nice trauma now that people wear seatbelts all the time etc.
Okay, procedure then:
Chest decompression involves putting the biggest needle you have into the pleural cavity, thereby releasing the pressure, and preventing the further expansion of the pneumothorax.
Here is where you stab the dude.
So the landmarks that you are looking for when you are about to do the stabbing are the second intercostal space (between the second and third ribs) Ribs are pretty easy to feel on skinny people or if you are pushing hard enough, so have a grope of your own chest ;D
When you find the second intercostal space, then make sure you are in line with the middle of the clavicle. The clavicle is your collar bone that runs from your shoulder to the hollow of your throat. Find the middle of that bone and trace down until you get to the second intercostal space. Draw a big X here.
Here are a few other pictures that I think you will enjoy more:
maybe I drew that one a bit high though.
If only I could palpate their ribs. FOR SCIENCE!
But I digress… Q__Q
NOW, get a big needle. You will need to use at least a 14gauge canulla for this procedure to work at all, and you could easily go bigger if you have bigger needles.
Make sure to swab the skin with an alcohol swab. We want aseptic procedures please.
Be careful because directly below each rib you have a neurovascular bundle which you do not want to stab. So make sure you are stabbing as close to the top of the third rib as you can.
Stab away! Until you feel a sudden loss of resistance. This means you are in the pleural cavity. Now remove the sharp bit of the needle (stylet) and advance the canulla (the plastic tubey bit) until it is flush with the skin.
Now have another listen to the chest and generally re-evaluate your character’s vital signs to make sure you got it in the right place, which you did. Because we don’t make mistakes (just happy accidents). Also we can take liberties with fiction.
Then you tape that down cause you don’t want it accidentally getting pulled out.
(EDIT: This bit’s been changed a bit sorry guys. Thanks gayaspinkink!)
You can put a square bandage over open chest wounds to reduce the risk of foreign particles being sucked into the chest but make sure you leave one side of the bandage open and un-taped (flutter valve) so that air can still escape.
Also at hospital they can do a thing called a chest drain but other than that when I drop people at the hospital I leave them there and I’m not sure what witch docterey goes on in those places except there is free coffee.
Also, guys I am still a student for the rest of this year so remember that I am allowed to be fallible and I probably am totally fallible, so if you notice and mistakes or can think of anything else to add, then let me know. I love learning! Also I am a poor editor of my own work so yeah.