blunt thorasic truama
The chest radiograph (CXR) is the initial test for all patients with blunt thoracic trauma who warrant imaging. following findings on a plain CXR increase the likelihood of blunt aortic injury (BAI) and indicate a need for further investigation: ●Wide mediastinum (supine CXR >8 cm; upright CXR >6 cm) ●Obscured aortic knob; abnormal aortic contour ●Left "apical cap" (ie, pleural blood above apex of left lung) ●Large left hemothorax ●Deviation of nasogastric tube rightward ●Deviation of trachea rightward and/or right mainstem bronchus downward ●Wide left paravertebral stripe. Further study, usually CT of the chest, is performed if CXR abnormalities consistent with aortic injury are identified.
Bedside ultrasound is a critical tool for the diagnosis of traumatic pericardial tamponade. Ultrasound is more sensitive for diagnosing pneumothorax than CXR and is also useful for diagnosing hemothorax. We suggest a chest CT be obtained if any concerning findings are identified on CXR, the patient has persistent chest pain or dyspnea, or the patient is unable to undergo a thorough clinical examination because of an extrathoracic injury. Patients who appear clinically stable, without apparent injury, without a concerning mechanism, and without abnormal findings on standard PA and lateral CXR require no further evaluation, with the possible exception of an electrocardiogram (ECG). An ECG is performed in all patients with anterior chest trauma, the elderly, and patients with a history of coronary heart disease
The sternoclavicular (SC) joint is a diarthrodial, saddle-type, synovial joint that can sublux or dislocate anteriorly or posteriorly. The usual mechanism is a direct, high velocity blow to the medial clavicle or medial compression of the shoulder girdle. If the shoulder and arm are posterior to the plane of the body during compression, an anterior dislocation results; if the shoulder and arm are anterior, a posterior dislocation results.
Although uncommon, posterior SC joint dislocations can cause significant internal injury. Posterior displacement of the clavicle can cause breathing difficulty from tracheal compression, lacerate or occlude the subclavian or brachiocephalic vessels, damage the lung parenchyma causing a pneumothorax, or injure the laryngeal nerve (hoarseness). Patients commonly present with anterior chest and shoulder pain exacerbated by arm movement, but may also complain of dyspnea, dysphagia, or upper extremity paresthesias depending upon the internal injury sustained. Examination may reveal a prominence at the SC joint with anterior dislocation, but a corresponding depression may be difficult to detect with a posterior dislocation.
Tracheobronchial injury The trachea is protected from injury by its position relative to the mandible, sternum and vertebral column, and its relative elasticity. Injury of the cervical trachea is uncommon but can occur from a direct blow, which may be of low energy; injury of the intrathoracic trachea results from high-energy trauma, generally MVCs and sometimes crush injuries. Most tracheal or bronchial injuries occur as part of multiple trauma, including additional injuries to the lungs and chest wall. The right main bronchus is involved most often, generally within 1 to 2 cm of the carina, followed by the left main bronchus.
Diagnosis is difficult and often delayed. Intrathoracic injury can be subtle and indolent, presenting with retained secretions, recurrent pneumothoraces, and obstruction. The sine qua non of intrathoracic tracheobronchial injury is a significant air leak and pneumothorax or pneumomediastinum that reaccumulates despite tube thoracostomy. A cervical injury may present without a significant air leak, if the tear or rupture is contained by the adventitia. Signs of cervical tracheal injury include dyspnea, hoarseness, and subcutaneous emphysema.
Diaphragm rupture — Penetrating trauma accounts for most diaphragm ruptures but also in some blunt. Left-sided rupture occurs twice as often as right sided in blunt trauma patients. Anatomic differences account for this discrepancy: the posterolateral aspect of the left hemidiaphragm is relatively weak and the bowel and stomach provide less protection than the liver. dx is easiest in left sided injuries when bowel enters the thoracic cavity. Severe concomitant injuries occur in most cases of diaphragmatic rupture. Injuries to the spleen and liver are relatively common, as are hemothorax and pneumothorax. Pelvic and long bone fractures, closed head injuries, and blunt aortic injury can also occur. Diaphragmatic injuries are often diagnosed incidentally during laparotomy or thoracotomy to treat coexistent injuries.
Diaphragmatic injury may be associated with epigastric and abdominal pain, referred shoulder pain, sob, vomiting, dysphagia, or shock. The initial CXR is normal or nondiagnostic in many Nevertheless, the CXR may reveal diagnostic findings, such as abdominal viscera in the hemithorax, a nasogastric tube in the thorax, or a focal constriction of herniated viscera at the site of the tear, producing circumferential compression (collar sign). CXR may also reveal nonspecific findings such as atelectasis, pleural effusion, loss of the usual hemidiaphragm contour, eventration of the diaphragm, and pneumothorax or hemothorax. Serial CXRs may be useful, especially in patients in whom positive pressure ventilation has prevented bowel herniation
Cardiac contusion — Clinicians should obtain an ECG on all blunt trauma patients with any of the following: ●Pain and tenderness directly over the mid-anterior chest ●Sternal fracture ●History suggestive of cardiac disease (eg, accident precipitated by syncope, severe chest pain, or shortness of breath) ●Active symptoms or signs suggestive of cardiac disease ●Major mechanism of injury (eg, rollover, high speed, fatality at scene).
Findings such as unexplained persistent tachycardia, new bundle branch block, or dysrhythmia raise concern for cardiac contusion and patients with such findings should be admitted for cardiac monitoring and possibly echocardiography.
Complications, of rib fractures such as pneumonia, can occur as a result of atelectasis, caused by splinting from inadequate analgesia. Delayed complications (eg, pneumothorax, pulmonary contusion, pneumonia) occur, but are rare with minor injuries. Return to work or sport depends upon the activity involved and the level of pain. Heavy labor and intensive training for athletes with stress fractures are not recommended for the first three weeks. Once there is no longer any pain at rest, the patient can begin to increase their activity level, but this should be done gradually. Most rib fractures heal within six weeks. Some athletes engaged in contact sports can return to play as soon as one week after acute injury, provided the fractured rib is protected with a flak jacket or similar device. The jacket should be worn for six to eight weeks.
Flail chest occurs when 3 or more adjacent ribs are each fractured in two places, creating one floating segment comprised of several rib sections and the soft tissues between them. This unstable section of chest wall exhibits paradoxical motion (ie, it moves in the opposite direction of the uninjured, chest wall) with breathing, and is assoç significant morbidity from pulmonary contusion. Abnormal motion can be difficult to detect making the diagnosis difficult. Initial management of flail chest consists of oxygen and close monitoring for early signs of respiratory compromise, ideally using both pulse oximetry and capnography in addition to clinical observation. Use of noninvasive positive airway pressure by mask may obviate the need for endotracheal intubation in alert patients. Patients with severe injuries, respiratory distress, or progressively worsening respiratory function require endotracheal intubation and mechanical ventilatory support.
it is best to obtain a contrast-enhanced CT of the chest if there is any suspicion for posterior dislocation or internal injury. Initial treatment of SC dislocation depends upon the type of dislocation and the severity of associated symptoms. Anterior subluxations require no immediate treatment.
However, a true anterior dislocation should be reduced within 12 to 24 hours. This can often be done as an outpatient by orthopedic surgery. Posterior SC dislocations become increasingly difficult to reduce after 24 hours so timely diagnosis and treatment is important. Many can be reduced under procedural sedation in the ED.
Pericardial tamponade, most likely from myocardial rupture, is detected by ultrasound as the first study of the standard FAST (Focused Assessment with Sonography for Trauma). Pericardiocentesis is performed immediately in patients with a pericardial effusion and significant hypotension. In patients requiring transport to another hospital, a catheter should be placed when pericardiocentesis is performed. The catheter allows for drainage during transport should fluid reaccumulate and cause hypotension.
If hemodynamic compromise is severe and tamponade cannot be relieved by percutaneous drainage or if the patient develops cardiac arrest while being resuscitated, emergency department thoracotomy (EDT) may be necessary. Hemothorax is treated with tube thoracostomy using a large chest tube. Immediate bloody drainage of ≥20 mL/kg is generally considered an indication for thoracotomy in the operating room. Vital signs, fluid resuscitation requirements, and concomitant injuries are also considered when determining the need for thoracotomy. Hypoxia and abnormal lung sounds are the most specific signs for pneumothorax or hemothorax, while chest pain and tenderness are most sensitive, albeit nonspecific
cxr generally reveal marked air in local soft tissue (ie, subcutaneous emphysema). If tracheal disruption occurs, the larynx can rise, allowing the hyoid bone to ascend above the level of the C3, an unusual finding otherwise. Fractures of the first three ribs are associated with intrathoracic injury. Other radiologic findings on plain film include: persistent pneumothorax, interstitial air in the wall of the trachea or mainstem bronchus, abnormal location of the endotracheal tube (ETT), and a distended ETT cuff due to protrusion of the trachea.Definitive diagnosis is made in the operating room or by bronchoscopy.
If tracheobronchial injury is suspected, obtain a MDCT or consult a thoracic surgeon for evaluation and possible bronchoscopy. The need for surgical repair is generally based on the risk for airway obstruction, massive air leak, or mediastinitis
Myocardial rupture — Most patients with severe blunt cardiac injury do not reach the ED alive. Of those who do, hypotension may have reduced pressure on the injured myocardium, which may subsequently rupture as fluid resuscitation restores systemic pressure. Signs such as hypotension associated with distended neck veins and muffled heart sounds suggest tamponade, which often occurs with severe cardiac injury.
Immediate bedside ultrasound (US) by a skilled ultrasonographer can reveal the diagnosis rapidly. The clinician should perform or obtain bedside echocardiography in any patient with unexplained shock out of proportion to apparent injuries or despite aggressive resuscitation. When immediate bedside US is unavailable and the clinician strongly suspects tamponade, pericardiocentesis should be performed.
Hemothorax — Injuries leading to massive hemothorax include aortic rupture, myocardial rupture, and injuries to hilar structures. Other causes include injuries to the lung parenchyma and intercostal or mammary blood vessels. A volume of 300 mL is needed for hemothorax to manifest on an upright CXR. ultrasound can diagnose hemothorax accurately. Hemothorax is treated with tube thoracostomy using a large chest tube.
Immediate bloody drainage of ≥ 1500 mL is generally considered an indication for surgical thoracotomy. Shock and persistent, substantial bleeding (generally >3 mL/kg/hour) are additional indications. Vital signs, fluid resuscitation requirements, and concomitant injuries are considered when determining the need for thoracotomy.
Pulmonary contusion — Pulmonary contusion is another common consequence of blunt chest trauma. Pulmonary contusions generally develop over the first 24 hours and resolve in about one week. Irregular, nonlobular opacification of the pulmonary parenchyma on chest radiograph is the diagnostic hallmark. About one-third of the time the contusion is not evident on initial radiographs. Chest CT provides better resolution, but rarely alters management, unless other injuries are found
Pain control and pulmonary toilet are the mainstays of treatment. Prophylactic endotracheal intubation is unnecessary, but patients with hypoxia or difficulty ventilating require airway management. While opinions vary, fluid resuscitation with crystalloid to euvolemia appears appropriate. Common complications include pneumonia and acute respiratory distress syndrome (ARDS).
Clinicians first assess and stabilize the patient's airway, breathing, and circulation, in that order (ABCs). If the patient is in respiratory distress due to a tension pneumothorax, the clinician should relieve the pneumothorax before performing endotracheal intubation, if needed. Positive pressure ventilation following intubation will exacerbate a pneumothorax. For any patient with unstable vital signs, hypoxia, or obvious severe injury (eg, flail chest, multiple rib fractures, large open wounds), the clinician performs a rapid search for ●Aortic injury ●Tension pneumothorax ●Hemothorax with severe, active bleeding ●Pericardial tamponade from myocardial injury ●Tracheobronchial disruption.
Patients with respiratory distress, marked hemodynamic instability, or severe injury are intubated. Rapid sequence intubation is the preferred approach whenever possible, avoiding pretreatment and induction agents with the potential to cause hypotension. Suspected tension pneumothorax is treated with immediate tube thoracostomy or needle decompression using a large angiocatheter. If needle decompression is performed first, it is followed by tube thoracostomy soon afterwards. If the patient stabilizes in the emergency department (ED) and does not require emergent operative treatment, a chest CT with contrast is performed to define the extent of thoracic injury and exclude aortic rupture. If the patient is unable to undergo CT, due to the need for immediate operation, transesophageal echocardiography can be performed in the ED or operating room to assess the aorta and heart.
Esophageal rupture — Blunt trauma patients rarely sustain esophageal rupture. Esophageal injury lacks specific symptoms and generally occurs in multiple trauma making it difficult to diagnose. Injuries may be seen in the cervical, thoracic, and distal esophagus. Signs of injury may include: blood in the nasogastric aspirate, subcutaneous cervical air, and neck hematoma
Plain radiograph may reveal pneumomediastinum, pleural effusion, mediastinal contour changes (which progress with inflammation), or a gas bubble in the nasogastric tube or esophagus, if a tracheoesophageal communication exists. Diagnosis is made by endoscopy or esophagography using water-soluble contrast.
Rib fracture — Patients with three or more rib fractures, especially elderly patients, are at significant risk for complications, such as pulmonary contusion and pneumonia, even in the absence of other injuries, and should be admitted for observation. Rib fractures are common injuries that occur most often following blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs), child abuse, and bone metastases. Concomitant injuries and complications range from mild discomfort to life-threatening conditions, such as pneumothorax, splenic laceration, and pneumonia.
Rib fractures in victims of blunt trauma are generally identified clinically or by chest radiograph. Frequently, they can localize the pain to one or two ribs and give a history that is consistent with the area of discomfort. A deep breath typically elicits pain at the fracture site. Rib stress fractures present with a gradual onset of activity-related chest wall pain. Standard posterior-anterior (PA) and lateral chest radiographs are adequate to identify most rib fractures. If these studies cannot be readily obtained, a simple anterior-posterior (AP) chest radiograph can provide useful information. Ultrasound may be useful for diagnosis of rib fractures and potential complications (eg, pneumothorax). A skeletal survey should be obtained in infants suspected of being abused. Findings consistent with abuse include the presence of multiple rib fractures in various stages of healing.
Treatment of rib fractures should be focused on early and adequate pain relief to avoid complications from splinting and atelectasis, primarily pneumonia. To provide analgesia, clinicians most often use NSAIDs(single rib fracture) with or without opioids. Intercostal nerve blocks (severe injuries, particularly if ventilation is compromised), are another effective approach for some patients.
Rib stress fractures are treated similarly to other low-risk stress fractures. Treatment begins with restriction of the inciting activity for four to six weeks, followed by a gradual return to the activity as tolerated. Patients with one or two nondisplaced rib fractures found on imaging studies, or focal tenderness over one or two ribs but no evidence of fracture on CXR and who are assumed to have a rib fracture, may be treated with analgesics and discharged without a period of observation, assuming there are no other injuries of concern. Appropriate follow-up should be arranged. Patients with clinical or radiographic evidence of one or two rib fractures who are discharged must be warned to return immediately to the ED for any concerning symptoms, such as shortness of breath, increasing pain, or signs of pneumonia (eg, cough, fever).
Sternal fracture — Sternal fractures usually result from a high-energy direct blow to the anterior chest wall. Typically these fractures occur during a MVC when the driver's chest strikes the steering column or rapid deceleration causes an occupant's chest to slam against their cross-shoulder seatbelt. Common associated injuries include: cranial injury (including intracranial hemorrhage), rib fracture, pulmonary contusion, spinal fracture, retrosternal hematoma, pneumothorax and hemothorax, and extremity trauma
Scapular fracture — Scapular fractures occur from trauma involving significant force and raise concern for further injury. High-speed MVCs and falls from heights are common mechanisms. Associated injuries include intrathoracic injuries, clavicle fractures, rib fractures, spine fractures, spleen and liver injuries, and tibial fractures (usually in pedestrians struck by motor vehicles. We obtain a chest CT in most patients with a scapular fracture following significant blunt chest trauma because of the forces involved and the risk of concomitant injury. If the chest CT and workup for extrathoracic trauma reveal no injuries, and no concerns exist about analgesia, comorbidities, or the patient's social circumstances, patients with scapular fractures may be discharged
Aortic injury:- Approach — Patients involved in high-energy blunt trauma involving rapid deceleration (eg, fall over 3 m [10 feet], motor vehicle collision (MVC) at speeds over 65 km/40 miles per hour) are at significant risk for blunt aortic injury (BAI). Almost 80 percent of BAIs cause immediate death from aortic transection. In a minority of patients the adventitia and mediastinal structures contain the rupture, allowing the patient to survive transport to the hospital. If BAI goes undiagnosed, these patients generally sustain an aortic rupture within 24 hours. Prompt ED diagnosis is crucial and may be lifesaving in some patients
The initial study is a chest radiograph (CXR), which should be closely scrutinized for any signs of aortic injury. Any abnormality on CXR should be followed by a computed tomography (CT) scan of the chest. A normal CT scan essentially rules out BAI. If the clinician has a strong suspicion for BAI, CT scan should be obtained, regardless of CXR appearance. angiography is the traditional gold standard. Transesophageal echo (TEE) is an excellent modality to assess for BAI in patients too unstable for chest CT. TEE has high sensitivity and specificity for BAI, can be performed in the emergency department or the operating room, requires no contrast, and provides information about cardiac injury and function. TEEshould not be performed in patients with unstable cervical spine injuries or esophageal injuries.
Pneumothorax is a common complication of blunt trauma, often sustained from a fractured rib. Patients may manifest tachypnea, chest pain, hypoxia, unilateral diminished or absent breath sounds, or unilateral hyperresonance to percussion, depending on the extent of the pneumothorax. The supine chest radiograph has high specificity for diagnosing a pneumothorax from blunt injury, but its sensitivity is variable. Ultrasound may be a more sensitive initial screening tool. Patients with historical features (eg, pleuritic pain, dyspnea) or examination findings (eg, rib fracture) that place them at risk for pneumothorax should be evaluated with an upright PA chest radiograph using inspiratory and expiratory views or a CT scan of the chest. if cxrZ does not reveal a pneumothorax but who are at risk repeat the radiograph in six hours.
pneumohemothorax is treated with drainage by tube thoracostomy. Small, clinically insignificant collections may be treated with needle aspiration or drainage. Occult pneumothorax is one not visible on a plain cxr but seen on cervical, chest, or abdominal CT. In some, occult pneumothoraces expand and become clinically significant, in some cases into a tension pneumothorax. The potential risk of an expanding pneumothorax is greater in patients receiving positive pressure ventilation. mx occult pneumothoraces less than 8 mm in length (as determined by CT) with observation alone. close monitoring for signs of an expanding or tension pneumothorax is critical.
Increased mortality and morbidity is associated with multiple rib fractures, increased age, and higher injury severity scores High risk group's include •Age ≥60 •Front-seat occupancy •Not wearing a seatbelt.
pneumothorax is a common complication of thoracic trauma. rib fractures occur in almost two-thirds patients with chest trauma
