Blunt chest trauma
Blunt chest trauma is a significant source of mortality and morbidity. Blunt injury to the chest can affect any
one of the components of the chest wall and thoracic cavity. By far the most common cause of significant
blunt chest trauma is MVA, accounting for 70-80% of these injuries.
Primary survey
 Rapid review of ABCDE
 Airway – control may be required early in case of significant chest injury to maintain adequate
oxygenation and ventilation or management of the multi-trauma victim
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Breathing
o Ventilate with 100% oxygen
o Check thorax and neck
o Deviated trachea
o Tension pneumothorax (intervention—needle decompression)
o Chest wounds and chest wall motion
o Sucking chest wound (intervention—occlusive dressing)
o Neck and chest crepitation
o Multiple broken ribs
o Fractured sternum
o Pneumothorax
o Listen for breath sounds
o Correct tracheal tube placement?
o Hemopneumothorax?
o Chest tube(s)—38-Fr
o Collect blood for autotransfusion
By far the most important assessment in cases of blunt chest trauma
Assess and treat presence of any of the following
 Tension pneumothorax
 Massive hemothorax
 Open pneumothorax
 Cardiac tamponade
 Flail chest
Some conditions may require increased positive pressure ventilation to improve oxygenation
and
In cases of spontaneous decompensation in a previously stable victim, review may be
necessary to rule out development of any of the above conditions
Circulation
 Apply pressure to sites of external exsanguination
 Assure that two large-bore IVs established
o Begin with rapid infusion of warm crystalloid solution
 Assess for blood volume status
o Radial and carotid pulse, BP determination
o Jugular venous filling
o Quality of heart tones
 Beck triad present? – low BP, JV distension and distant muffled heart
sounds
o Pericardiocentesis or echocardiogram
o Decompress tamponade
o Pericardiocentesis
o Thoracotomy with pericardiotomy
Disability
 Brief neurologic examination
o Pupil size and reactivity
o Limb movement
o Glasgow Coma Scale
Exposure
 Completely disrobe the patient
 Logroll to inspect back
Continuing and monitoring resuscitation
LIMITS
 Lines – ETT/NGT/IVx2/IDC
 Investigations – bloods/ ABG/ ECG/ X-ray/ FAST
 Monitoring – O2/ ETCO2/ ECG/ NBP/ Neuro/ BSL/ Temp
 IV therapy – fluids/analgesia/ antibiotics/ blood
 Teams/transfer – inform cardiothoracic/vascular teams early
 Stabilize ABCDE before secondary survey
Secondary survey
 Usual head to toe examination with close detailed examination of chest for
o Rib fractures and flail chest
o Pulmonary contusion
o Simple pneumothorax
o Simple hemothorax
o Blunt aortic injury
o Blunt myocardial injury
Physical examination includes:
 Look
o Determine the respiratory rate and depth
o Look for chest wall asymmetry. Paradoxical chest wall motion
o Look for bruising, seat belt or steering wheel marks,
penetrating wounds
 Feel
o Feel for the trachea for deviation
o Assess whether there is adequate and equal chest wall
movement
o Feel for chest wall tenderness or rib 'crunching' indicating rib
fractures
o Feel for subcutaneous emphysema
 Listen
o Listen for normal, equal breath sounds on both sides.
o Listen especially in the apices and axillae and at the back of the
chest (or as far as you can get while supine).
 Percuss
o Percuss both sides of the chest looking for dullness or
resonance (more difficult to appreciate in the trauma room).
Monitoring adjuncts
 Oxygen saturation
 End-tidal carbon dioxide
o Confirmation of tube placement and dislodgement
o Diagnosing sudden changes in ventilatory pattern e.g. pneumothorax associated with PPV
Diagnostic adjuncts
 Chest X-ray – single most important initial tool in evaluation of any chest injury and preferable
conducted at the end of primary survey
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FAST examination
o Look for free fluid (blood) in peritoneum, pericardium or hemothorax
Arterial blood gas analysis
o To diagnose and monitor pulmonary function/resuscitation status
Further investigations:
 CT scan chest and abdomen
 Angiography
 Oesophagoscopy/ Oesophagram
 Bronchoscopy
Definitive care/ disposition may include:
 Chest drain
 Thoracostomy
 Transfer to critical care/ retrieval to tertiary centre
Complications of Blunt chest trauma
Pneumothorax
 Simple pneumothorax is a non-expanding collection of air around the lung
 Lung is collapsed to a variable extent
 Diagnosis may be difficult on clinical examination –
o reduced air entry, resonance to percussion
o Adjunct signs – subcutaneous emphysema and rib fractures
 Chest x-ray usually diagnostic – but may miss small pneumothoraces especially if patient supine.
o Presence of rib fractures should raise suspicion
o Non-congruent x-ray lucency
o Deep sulcus sign
o Flat meniscus with hemopneumothorax
 CT scanning more sensitive than plain chest x-ray – but use of this sensitivity questionable since small
pneumothoraces may not need ICD even with PPV
 Ultrasound – recently gained more popularity in diagnosing chest conditions
o Loss of lung sliding and Comet tail artifacts on US
 Management
o Placement of intercostal chest drain is definitive treatment in most cases
o Expectant management of small pneumothoraces practical
o Indications for ICD placement include:
 Multiply injured trauma patient
 Hemodynamically unstable with need for close control on ABC
 Need for prolonged anesthesia
 Need for prolonged or air transfer
 Situations where detection of worsening may be difficult or delayed
Tension pneumothorax
 Progressive buildup of air within the pleural space, usually due to a lung laceration which allows air to
escape into pleural space with a “one-way valve” effect
 Displacement of mediastinum to the opposite hemithorax → obstructing venous return to heart →
traumatic arrest
 Classic signs
o Deviation of trachea away from side of tension
o Hyper-expanded chest
o Increased percussion noted
o Hyper-expanded chest that moves little with respiration
o Raised CVP if no hypovolemia present
 Other signs
o Tachycardia, tachypnea and hypoxia
o Circulatory collapse with hypotension
o Traumatic arrest with pulseless electrical activity
 Chest x-ray findings
o Deviation of trachea away from the side of the tension
o Shift of the mediastinum
o Depression of the hemi-diaphragm
 Management
o Needle thoracostomy
 Emergent chest decompression with needle thoracostomy
 14-16g IV cannula inserted into the second rib space in mid-clavicular line
 Controversy regarding placement before imaging
 Prone to blockage, kinking, dislodging and falling out
 In absence of hemodynamic compromise, may be prudent to wait for results of an
emergent CXR
 Needle decompression can be associated with complications
 It should not be used lightly
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o
Never be used just because there are no breath sounds BUT
In clear cut cases: shock with distended neck veins, reduced breath sounds,
deviated trachea, it could be life-saving
Chest drain placement
 Definitive treatment of traumatic pneumothorax
 Preferred over blind needle thoracostomy if patient stable enough to tolerate the
wait
 Blunt dissection to enter the pleura – relieves tension even before chest tube is
placed
Open pneumothorax
 Occurs when there is a pneumothorax associated with a chest wall defect.
 Negative intrathoracic pressure during inspiration drains air into the chest through the wound
because the chest wall wound is shorter that trachea → inadequate oxygenation and ventilation
 May tension if flap has been created acting as an ‘one-way-valve’.
 Diagnosis
o Primary survey – sucking chest wound visibly bubbling
o Reduced expansion of hemithorax with reduced breath sounds and increased percussion
note
o Rapid, labored and shallow breathing
o All the signs may be difficult to appreciate in a noisy trauma room
 Management
o 100% oxygen via facemask
o Intubation early when airway and breathing inadequate
o Do not delay placement of chest tube and closure of wound
o Definitive treatment – occlusive dressing over wound and immediate placement of IC drain
o If ICD not available as occurs at scene – application of three sided bandage
Haemothorax
 Collection of blood in the pleural space and may be caused by blunt or penetrating trauma
 Most result from rib fractures, lung parenchymal and minor venous injuries
 Less commonly there is arterial injury requiring surgical repair
 Physical examination –
o External bruising or lacerations
o Palpable crepitus indicating rib fractures
o Penetrating injury over affected hemithorax
o Examine the back!!!
o Classic signs are
 Decreased chest expansion
 Dullness to percussion
 Reduced breath sounds on affected side
 Diagnosis
o Most haemothoraces not identified on examination will be picked up by CXR, US or CT
o CXR –
 Erect film is usually standard – classical fluid meniscus
 400-500mls of blood required to obliterate the costo-phrenic angle
 Supine film – blood lies posteriorly causing diffuse opacification of hemithorax
o FAST ultrasound
 Can detect even smaller hemothoraces (<200mls)
 Presence of pneumothoraces and subcutaneous air can make it inaccurate
 Significance of small hemothoraces not known
o CT Chest
 Even more sensitive than US
 Invaluable in determining presence and significance of hemothoraces in supine
patients with significant other injuries
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Can more reliably differentiate pulmonary contusion and aspiration from
hemothorax in supine patient
Management
o Chest drain
 First step in management of traumatic hemothorax
 Smallest size 32F but preferably 36F to be able to drain clots
 For drainage of hemothorax tube placed posteriorly unlike pneumothoraces
 But placed anteriorly if significant rib fractures and associated pneumothorax
present to avoid kinking and development of tension pneumothorax
o Thoracotomy
 Required in under 10% of thoracic trauma patients
 Indications for thoracotomy (s/o arterial injury)
 Immediate drainage of 1000-1500mls
 Obvious ongoing arterial bleeding – colour
 Continuing drainage after 4-5hrs since insertion – 200-250mls/hr
Rib fractures and flail chest
Chest wall injury is very common following blunt chest trauma.
Complications of rib fractures:
 The most important complication of multiple rib fractures is the occurrence of pulmonary contusion.
 Fractures of lower ribs may be associated with diaphragmatic tear, liver and splenic injury.
 Injuries to the upper ribs may be associated with injuries to adjacent great vessels, especially the first
rib. The first rib due to its size and position requires significant amount of force to fracture and thus
indicates a major energy transfer.
 Fracture of first rib associated with
o 20% aortic injury
o Bronchial fracture in 80%
o Mortality of 20%
Flail chest occurs when a segment of thoracic cage is separated from rest of the chest wall.
 Defined as at least two fractures per rib in at least two ribs.
 Segment of chest wall is unable to contribute to lung expansion.
 Large flail segments may disrupt pulmonary function severely enough to require mechanical
ventilation
 Main significance of flail segment is the indication of likelihood for underlying pulmonary contusion
Diagnosis
 Bruising, grazes or seat belt signs on inspection
 Crepitus and tenderness on palpation and movement or respiration in conscious patients
 Chest x-ray and CT scan may both reveal extent of rib fractures
o CXR will not identify all rib fractures
o CXR more likely to miss lateral or anterior fractures on AP view
o Dedicated ribs views not indicated in trauma patients
 Clinically a flail chest is identified as paradoxical movement of a segment of the chest wall – indrawing
on inspiration and moving outwards on expiration.
 Pediatric patients rib fractures may be absent despite significant pulmonary contusion
Management
 Directed towards protecting underlying lung and allowing adequate oxygenation, ventilation and
pulmonary toilet.
 Secondary goal is to prevent development of significant atelectasis and secondary pneumonia.
 100% O2 initally
 Analgesia
o PCA of opioids best option in conscious and cooperative patients
o Additional NSAID therapy may help further
o NSAID withheld if risk of bleeding significant
o Best analgesia for severe chest injury – continuous epidural infusion of local anesthetic +/opioid
o Posterior rib blocks may be appropriate for one or two isolated rib fractures – last 4-24hrs
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Intubation and ventilation
o Needed when significant contusions complicate injury
o Increasing analgesia requirement with significant risk for respiratory depression may
sometimes necessitate PPV
Chest tube insertion
o Patients with significant rib fractures and requiring PPV will most often get prophylactic chest
tubes due to increased risk of pneumothoraces with PPV
o Need for chest tube also dictated by the presence of other injuries
Rib fracture fixation
o Rarely needed these days since intubation and ventilation of patient with multiple injuries
usually provides internal stabilization and results in good fixation by the time the contusion
heals
Traumatic Aortic injury
 16% of MVA fatalities due to TAI, 85-90% prior to arrival to ED
 30% die within 6hrs of presentation, 50% by 24hrs, 72% die within 8days, 90% die within 4months
 Most common site of injury aortic root in patients who die prior to arrival, in survivors 90% injury at
isthmus
 CT aortography most sensitive tool to diagnose aortic injury, though most CXR with aortic injury are
abnormal
 Aortography gold standard with 94% sensitivity and 96% specificity
Bronchial tear
 Present in 1.5% of major chest trauma patients
 80% of injuries within 2.5cm of carina
 Commonly missed
 Persistent or progressive pneumothorax or pneumomediastinum despite chest drain – fallen lung sign
 Definitive diagnosis with bronchoscopy
Thoracic spine injury
 Critical zone for injury – T9 to T11
 Thoracic facets face inward and lumbar facets face outwards → weak point of transition between T9
and T11
 Symptoms can simulate thoracic transection and high degree of suspicion to be maintained
 Management as with other spinal fractures
Diaphragm rupture
 Are common and commonly missed
 Most common location is the central tendon, extending posterolaterally
 5% of blunt chest trauma, 90% left-sided, 70% initially missed
 CXR signs – mediastinal shift, elevated hemidiaphragm, hemothorax and bowel gas in chest wall
 False negative results likely with CT unless sagittal reconstructions done
Esophageal rupture
 Rare injury, most commonly in upper oesophagus
 Commonly present as pneumomediastinum
 CXR shows air along diaphragm and paravertebral are forming a “V”.
 Confirmatory diagnosis with oesophagram
Cardiac injury
 Myocardial contusion accounts for 50% of cardiac injuries in blunt chest trauma
 Less common cardiac injuries include
o Pericardial laceration
o Myocardial rupture
o Aortic valve rupture
o Coronary artery laceration
 Consider cardiac injury in any patient with enlarged heart or sudden development of pulmonary
edema
 2D-ECHO most sensitive test for diagnosis
Cardiac contusion
 Difficult diagnosis due to non-specific symptoms and lack of ideal test
 Can cause life threatening arrhythmias and cardiac failure
 Symptoms
o Palpitations or precordial pain
 ECG findings
o Non-specific abnormalities
 Pericarditis changes
 Prolonged QT interval
o Myocardial injury
 New Q waves
 ST-T segment elevation or depression
o Conduction disorders
 RBBB
 Fascicular block
 AV nodal disorder
o Arrhythmias – any possible
 Troponin T or I: need to be done at presentation and 4-6hrs post trauma and if raised may be serially
measured
 Echocardiography
o Features similar to myocardial infarction
o Valvular lesions
o Pericardial effusion or tamponade
o Ventricular dilatation
 Nearly all (81-95%) life threatening ventricular arrhythmias and acute cardiac failures occur within 2448 hrs from admission
 Treatment is mainly supportive except in case of anatomic disruption of structures
Malposition of tubes and catheters
Tube
Desired position
Common malposition
Endotracheal tube
Trachea
Esophagus, mainstem
CV Catheter
SVC
Pleural space or artery
NGT
Stomach
Bronchus
Chest drain
Pleura
Chest wall
Investigations in blunt chest trauma
A: Aortography
B: Bronchoscopy
C: CT
D: Drink barium
E: Esophogram
G: CT upright or decubitus film
H: Echocardiography
I: Inject dye