The most significant advances in the treatment of blunt chest trauma from the later part of the 20th century involve a better understanding of acute respiratory failure, creative and flexible ventilator treatment strategies, directed pneumonia and empyema treatments, the diagnosis and treatment of aortic and great- vessel injury, remarkable advances in imaging techniques, and operative strategies that have become more conservative in scope and intervention. Although only perhaps 10% of blunt chest trauma cases require an operation, these patients typically present a challenging treatment dilemma, demanding rapid yet thoughtful decision-making, comprehensive anatomic understanding, and often prompt operative intervention. In this monograph, we hope to provide a broad and contemporary summary of the treatment of patients with blunt chest trauma, an important and changing component of trauma care. Show
Section snippetsIncidenceCalhoon and Trinkle2 have noted that in the United States alone, trauma is responsible for 100,000 deaths and more than 9,000,000 disabling injuries annually and that 25% of blunt traumatic fatalities are a direct consequence of chest injury, whereas in as many as another 50%, chest injury plays a major contributing role. Blunt thoracic injuries are responsible for approximately 8% of all trauma admissions, with motor vehicle crashes (MVCs) the dominant injury mechanism.3 A 4-year review of Prehospital careTreatment of many thoracic injuries can begin in the prehospital setting. The basic principles of prehospital care, including maintaining a patent airway, supplying supplemental oxygen and breathing support, establishing intravenous access, and pressure control of obvious hemorrhage, are likewise essential components of chest trauma treatment. Tracheal intubation and chest needle decompression are part of the armamentarium of many prehospital care providers, and some programs even allow Incisions and positioningThe choice of operative approach is influenced primarily by the required exposure but must also take into account likely injuries, patient stability, available equipment, and experience of the surgeon (Figure 2). The initial exposure may prove to be inadequate, and recognizing this and making modifications or closing and repositioning are far better than continuing to struggle. At the same time, particularly in unstable patients, one should not be paralyzed by indecision in trying to choose Rib fracturesRib fractures are common, yet they often appear trivial in the setting of major multisystem injury. The incidence of chest trauma ranges from 4% to 10% of all trauma admissions (the higher numbers being seen in dedicated trauma centers), although the true incidence is probably higher, since up to 50% of rib fractures may be missed on initial CXRs.68, 69 Chest wall trauma is also a marker of significant associated injury, including an increased risk for intra-abdominal injuries.69 The incidence HemothoraxThe treatment of patients with ongoing hemorrhage has been described earlier, and the approach to those who are stable and have a retained hemothorax will be discussed in later, but the acute treatment of patients who present with hemothorax without immediately obvious indications for operation deserves consideration. For simplicity, patients can be considered to be in 1 of 2 extremes. The first set includes those patients who are stable, with minimal respiratory distress, who do not require History and mechanismThe first reported cases of blunt cardiac injury (in which valvular rupture was noted) may have been in 1676 by Borch194 and subsequently by Berard in 1826,193, 194, 195, 196 but it was not until 1955 that the first successful repair of a rupture (at the right atrial-superior vena cava junction) was reported by Desforges and colleagues.197 Blunt cardiac injury manifests as a variety of clinical conditions, usually in association with multiple injuries of other organs and difficult treatment Traumatic rupture of the thoracic aortaThe treatment of aortic rupture has significantly evolved from the mid-portion of the last century when aortic injuries were thought to be fatal in essentially all cases unless immediately operated on, through an evolution of early recognition based on mechanism and physical signs, improved imaging, varied operative approaches (including the “clamp- and-sew” versus “bypass” controversy), to the current era of selective operative repair, nonoperative repair, and the emergence of endovascular Great-vessel injuryBlunt injuries involving the intrathoracic great vessels are difficult to diagnose and treat and are commonly associated with significant associated injuries (including the airway, heart, brachial plexus, and central nervous system) that impact the outcome. As with aortic injury, the incidence and location of blunt injury of the great vessels differ between autopsy and clinical series. It has been argued that the majority of patients who suffer blunt disruption of the great vessels die at the Tracheobronchial injuryThe first description of tracheobronchial rupture from blunt trauma may be from an 1874 article by W.H. Winslow, as quoted by Mills and colleagues471:
ConclusionIn conclusion blunt chest injury continues to pose a significant burden on trauma systems and requires aggressive diagnostic and therapeutic approaches. Patients often have multiple injuries that compete for priority, and in a large proportion these injuries may not be operable. Ongoing research into biomechanics offers some hope in reducing both the incidence and severity of injuries. Other clinical research efforts are introducing newer diagnostic modes to our armamentarium, as well as First page previewOpen this preview in PDF  Click to open first page preview Open this preview in PDF References (523)
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Moreover, after nonpenetrating chest trauma, cardiac tamponade is very rare and occurs in less than 1 of 1000. To date, we read with great interest an article by Dr. S. Vanwynsberghe and colleagues for sharing their first case report of perforation of the right cardiac ventricle due to direct mechanical effect of the sharp, bony sternal fragment as a late complication of a displaced sternal fracture following blunt trauma, which occurred 5 days after blunt chest trauma. Fortunately, the patient recovered after aggressive surgical intervention and critical care. 2020, Chinese Journal of Traumatology - English Edition Show abstractNavigate Down Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods. 2019, American Journal of Surgery Show abstractNavigate Down Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI. We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients. BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32–5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50–5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80–11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05–7.40, p < 0.001). SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI. Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor. Management of rib fractures2017, Journal Europeen des Urgences et de Reanimation Show abstractNavigate Down Les fracture de côtes sont fréquentes, isolées ou associées à des lésions viscérales dans le cadre d’un polytraumatisme. Un patient ayant des fractures de côtes même isolées doit faire l’objet d’une surveillance à la recherche de signes cliniques susceptibles d’évoluer vers une détresse respiratoire. L’échographie pulmonaire permet de faire le bilan des lésions secondaires au traumatisme et d’en assurer le suivi au lit du patient. Un volet thoracique peut entraîner une défaillance respiratoire et peut faire l’objet d’une fixation chirurgicale. Une fracture de côtes est toujours douloureuse et relève donc d’une stratégie analgésique adaptée incluant la réalisation précoce de blocs analgésiques comme le bloc paravertébral. Rib fracture is a common entity after thoracic trauma that could be isolated or associated to visceral lesions in polytrauma patients. Patients having rib fractures should be evaluated repeatedly for signs and symptoms of respiratory failure. Ultrasonography is worth performing at bedside to check for visceral lesions and their follow-up. Flail chest may induce respiratory failure and may require surgical fixation. A rib cage fracture is always painful and requires adapted pain control strategy including the use of continuous paravertebral block. Full tracheal rupture associated with posterior thoracic duct injury to blunt chest trauma: A case report2017, Revista Chilena de Cirugia Show abstractNavigate Down La rotura traqueal completa y la lesión de conducto torácico representan complicaciones raras del trauma torácico cerrado. Se presenta el caso de un paciente con rotura completa de la tráquea asociada a rotura del conducto torácico que fue operado en el Hospital del Trabajador. La identificación y el manejo oportuno de estas lesiones disminuyen la morbimortalidad asociada a trauma. Tracheal rupture and thoracic duct lesion are rare complications of blunt thoracic trauma. We present in this article the case of a patient with complete tracheal rupture and thoracic duct lesion treated in Hospital del Trabajador. Early identification and prompt management of this conditions reduce morbimortality associated with trauma. Traumatic heart disease2017, Cardiology Secrets Research article The Annals of Thoracic Surgery, Volume 102, Issue 3, 2016, pp. e201-e203 Show abstractNavigate Down We report the case of a 39-year-old man presenting with an acute right-sided traumatic pneumothorax secondary to migration of a hypodermic needle fractured during intravenous drug use. We discuss the unusual passage of this foreign body from the left groin to the right ventricular wall and into the mediastinum, ultimately presenting with a right pneumothorax 1 year later. Research article Imaging of Blunt Thoracic TraumaSeminars in Roentgenology, Volume 51, Issue 3, 2016, pp. 203-214 Research article Spectrum and Outcome of Patients Who Have Undergone Implantation of an Implantable Cardioverter Defibrillator After Aborted-Sudden Cardiac ArrestThe American Journal of Cardiology, Volume 121, Issue 2, 2018, pp. 149-155 Show abstractNavigate Down Most of implantable cardioverter defibrillator (ICD) secondary prevention studies have been published 2 decades ago. We aimed to describe a contemporary cohort of patients who have undergone implantation of an ICD after an aborted-sudden cardiac arrest (SCA). We retrospectively evaluated consecutive patients referred to our centers between 2005 and 2013. Predictors of overall mortality or heart transplant were analyzed using Cox proportional hazards models. A total of 250 patients (76.4% male, 48.7 ± 16.7 years) were included (mean follow-up = 49.6 ± 35 months). The presence of a structural heart disease (SHD) was considered as the primary cause of the aborted-SCA in 160 patients (64%). In 90 patients (36%), no SHD was observed, with patients much younger (40.9 ± 16.2 years vs 53.0 ± 15.5 years in the SHD group, p < 0.0001). The 5-year estimated rates of death or heart transplant were 14.3% and 5.2% in the group with and without SHD, respectively (hazard ratio = 4.65, 95% confidence interval 1.40 to 15.6, p = 0.014). The 5-year estimated rates of appropriate ICD therapy in the ventricular fibrillation zone were 16.7% and 25.1% in patients without and with SHD (p = 0.24), respectively. Only left ventricular ejection fraction remained independently associated with mortality or heart transplant (hazard ratio = 0.94, 95% confidence interval 0.90 to 0.97, p = 0.0004). Overall, 69 patients (27.6%) experienced at least 1 ICD-related complication. In conclusion, compared with secondary prevention pivotal studies, the current patients who have undergone implantation of an ICD after aborted-SCA are younger, with a high proportion of structurally normal hearts. Compared with patients without SHD, who depicted a relatively favorable outcome, patients with SHD present a fourfold higher risk of death during follow-up. Reduced left ventricular ejection fraction remains the major influencing factor. Research article Outcomes of endovascular repair for blunt thoracic aortic injuryJournal of Vascular Surgery, Volume 58, Issue 6, 2013, pp. 1483-1489 Show abstractNavigate Down Consistent long-term follow-up data of thoracic endovascular repair (TEVAR) for acute blunt thoracic aortic injury (BTAI) are largely absent at this time. The late outcomes of TEVAR for BTAI are the focus of this study to evaluate the durability of this type of repair. The records of 46 consecutive cases of TEVAR for BTAI from November 2000 to August 2012 were reviewed. Patient demographics, lesion characteristics, procedure details, and outcomes were recorded. We performed a clinical and body computed tomography angiography follow-up at 1, 6, and 12 months after the intervention; thereafter, it was done on a yearly basis if device-related defects were ruled out. There were 35 (76.1%) males. Mean age was 39 ± 18 years (range, 17-92). Indications for intervention were BTAI at the aortic isthmus in 73.9% (n = 34) of the cases, and in the proximal one-half of the descending thoracic aorta in the remaining 26.1% (n = 12). Pseudoaneurysm or free rupture accounted for 44 (95.6%) cases. Primary technical success was obtained in all cases. All patients survived the intervention, open conversion was never required, and no patient required reintervention. In-hospital mortality was 6.5% (n = 3). Mean follow-up was 66 ± 46 months (range, 1-144; median, 72). No patient was lost during this period. All patients who were discharged from the hospital are still alive. Aortic hematoma or hemothorax were completely reabsorbed in 42 (97.7%) cases. Endoleak or modifications of the native aorta were never detected; endograft-related complication was observed in one (2.3%) case only. An asymptomatic collapse was observed at a 36-month follow-up and was managed conservatively. Midterm follow-up of TEVAR for acute BTAI is feasible with satisfactory late outcomes. In our experience, TEVAR is a durable and definitive treatment for BTAI. Research article Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort StudyAnnals of Emergency Medicine, Volume 66, Issue 6, 2015, pp. 589-600 Show abstractNavigate Down Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries. Research article Admission of elderly blunt thoracic trauma patients directly to the intensive care unit improves outcomesJournal of Surgical Research, Volume 219, 2017, pp. 334-340 Show abstractNavigate Down Blunt thoracic trauma in the elderly has been associated with adverse outcomes. As an internal quality improvement initiative, direct intensive care unit (ICU) admission of nonmechanically ventilated elderly patients with clinically important thoracic trauma (primarily multiple rib fractures) was recommended. A retrospective review of the trauma registry at a level 1 trauma center was performed for patients aged ≥65 y with blunt thoracic trauma, admitted between the 2 y before (2010-2012) and after (2013-2015) the recommendation. There were 258 elderly thoracic trauma admissions post-recommendation (POST) and 131 admissions pre-recommendation (PRE). Their median Injury Severity Score (13 versus 12, P = ns) was similar. The POST group had increased ICU utilization (54.3% versus 25.2%, P < 0.001). The POST group had decreased unplanned ICU admissions (8.5% versus 13.0%, P < 0.001), complications (14.3% versus 28.2%, P = 0.001), and ICU length of stay (4 versus 6 d, P = 0.05). More POST group patients were discharged to home (41.1% versus 27.5%, P = 0.008). Of these, the 140 POST and 33 PRE patients admitted to the ICU had comparable median Injury Severity Score (14 versus 17, P = ns) and chest Abbreviated Injury Score ≥3 (66.4% versus 60.6%, P = ns). The POST-ICU group redemonstrated the above benefits, as well as decreased hospital length of stay (10 versus 14 d, P = 0.03) and in-hospital mortality (2.9% versus 15.2%, P = 0.004). Admission of geriatric trauma patients with clinically important blunt thoracic trauma directly to the ICU was associated with improved outcomes. What are 3 types of chest injuries?damage to the heart, for example, blunt injury to the heart, or injury to the aorta — the main artery that delivers blood to the rest of your body. damage to the lungs — for example, bruising (pulmonary contusion) penetrating chest wounds — these can damage the chest wall and any of the internal organs within the chest.
What are some different types of injuries that result from chest trauma?As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries.
What are the two types of chest trauma?Chest trauma can be penetrating or blunt. If the injury pokes through the skin (stabbing, gunshot wound, an arrow through the heart, etc.) we call it penetrating chest trauma. If a sharp object tearing deep into skin and muscle isn't the main cause of tissue damage, consider it blunt chest trauma.
What's the 6 immediate life threats in chest trauma?The Lethal Six (airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest) are immediate, life-threatening injuries that require evaluation and treatment during primary survey.
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