During your assessment of a patient with blunt chest trauma, you note that the patient has shallow breathing and paradoxical movement of the left chest wall. You should:

• A. Administer oxygen by NRB
• B. Monitor him and transport
• C. Transport rapidly
• D. Assist ventilations with a BVM

Answer: (D)

When there is blunt chest trauma with shallow breathing and paradoxical chest wall movement, you’re seeing a flail chest that compromises ventilation. The priority is to support breathing and oxygenation. Assisting ventilations with a bag-valve mask delivers positive pressure to help expand the lungs, reduce the work of breathing, and stabilize the injured chest wall enough to improve tidal volume. Use a good seal and provide breaths at a rate that maintains chest rise, delivering high-flow oxygen for a better FiO2.

Oxygen by NRB is helpful, but it won’t fix the inadequate ventilation caused by the flail segment. Merely monitoring and delaying ventilation, or rushing transport without addressing the airway and breathing, can allow hypoxia to worsen. Rapid transport remains important, but it should be done with the patient’s airway supported and ventilations being assisted as needed.