Emergency Department Evaluation And Management Of Blunt Chest And Lung Trauma (Trauma CME)

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction And Epidemiology
4. Critical Appraisal of the Literature
5. Anatomy And Pathophysiology
   1. Pulmonary Contusion
   2. Bony Injuries
   3. Pneumothorax
   4. Hemothorax
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Chest X-Ray
   2. Ultrasound
   3. Computed Tomography
   4. Laboratory Testing
10. Treatment
    1. Airway Management
    2. Rib Fracture And Flail Chest Management
    3. Pulmonary Contusion Management
    4. Pain Management
    5. Sternal And Scapular Fracture Management
    6. Sternoclavicular Dislocation Management
    7. Pneumothorax Management
       1. Needle Versus Finger Decompression
       2. Tube Thoracostomy For Pneumothorax
    8. Hemothorax Management
       1. Tube Thoracostomy For Hemothorax
11. Disposition
    1. Rib Fractures In Geriatric Patients
    2. Discharge
    3. Admission
12. Controversies
    1. Thoracic Imaging In Blunt Trauma
13. Summary
14. Risk Management Pitfalls In Managing Blunt Chest Trauma
15. Case Conclusions
16. Clinical Pathway For Imaging Patients With Blunt Chest Trauma
17. Tables and Figures
    1. Table 1. Differential Diagnosis In Blunt Chest Trauma
    2. Table 2. Mechanisms Predictive Of Significant Thoracic Injury
    3. Table 3. NEXUS Chest Decision Instrument
    4. Table 4. Estimated Number Of Chest CTs Needed To Cause 1 Radiation-Induced Cancer
    5. Table 5. The Battle Score For Prediction Of Complications From Rib Fracture
    6. Table 6. NEXUS Chest CT Major Rule
    7. Figure 1. Pneumothorax On Chest X-Ray And Computed Tomography
    8. Figure 2. Pneumothorax On Chest X-Ray With Deep Sulcus Sign
    9. Figure 3. Hemothorax On Chest X-Ray
    10. Figure 4. Ultrasound Of A Normal Versus An Injured Lung
    11. Figure 5. Link To Finger Thoracostomy Video
18. References

Abstract

The majority of blunt chest injuries are minor contusions or abrasions; however, life-threatening injuries, including tension pneumothorax, hemothorax, and aortic rupture can occur and must be recognized early. This review focuses on the diagnosis, management, and disposition of patients with blunt injuries to the ribs and lung. Utilization of decision rules for chest x-ray and computed tomography are discussed, along with the emerging role of bedside lung ultrasonography. Management controversies presented include the limitations of needle thoracostomy using standard needle, chest tube placement, and chest tube size. Finally, a discussion is provided related to airway and ventilation management to assist in the timing and type of interventions needed to maintain oxygenation.

Case Presentations

You are about to start a busy Monday afternoon shift when you hear a radio call from EMS for a high-speed motor vehicle crash. The dispatcher tells you that the patients are 5 minutes away. The first patient that arrives is an unrestrained 23-year-old male driver. The patient has severe right-sided chest pain with moderate respiratory distress. His blood pressure is 102/54 mm Hg, his heart rate is 112 beats/min, and the pulse oximeter reads 92% on room air. You are concerned for a pneumothorax but wonder what else could explain his abnormal vital signs...

The second patient is the unrestrained 27-year-old female passenger from the same accident, with a chief complaint of chest pain, difficulty breathing, and shortness of breath. Her blood pressure is 120/70 mm Hg, her heart rate is 85 beats/min, and the pulse oximeter reads 97% on room air. On exam, the patient has decreased breath sounds on the right side. Again, pneumothorax sounds likely as you wait for the portable x-ray; you wonder if a bedside ultrasound could facilitate making the diagnosis...

A third patient then walks into triage. He is a 79-year-old man who has come in after a fall from standing and is complaining of rib pain. He is in moderate distress. His blood pressure is 140/90 mm Hg, his pulse is 90 beats/min, and his oxygen saturation is 97% on room air. His only complaint is extreme pain to his left chest. He tells you that his medical history is positive for type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. He takes metformin, metoprolol, and inhaled tiotropium bromide. On physical exam, you see bruises to the left chest wall and can feel crepitus; you suspect multiple rib fractures and get ready to treat a third pneumothorax...

Introduction And Epidemiology

Traumatic injuries continue to be a major health concern in the United States. Unintentional injuries have become the fourth leading cause of death, now exceeding stroke.¹ Trauma is also the leading cause of death, morbidity, hospitalization, and disability in Americans aged 1 year to 45 years. Blunt chest injuries are a particular concern, occurring in 12 persons per 1 million per day, with approximately one-third requiring hospital admission. Blunt thoracic traumatic injuries are responsible for 20% to 25% of all blunt trauma deaths.²

Motor vehicle crashes account for 70% to 80% of blunt chest trauma cases.^3,4 Motor vehicle crashes can cause injury both by direct forces of impact as well as rapid deceleration from high speed. Other common causative mechanisms of blunt chest injuries include falls, blast injuries, barotrauma, and physical assault. In a review of 1696 patients with blunt chest trauma, injuries were considered to be minor in 710 patients (42%), intermediate in 740 (44%), and severe in 246 (15%).³ Global in-hospital mortality was low (5%), but increased to 37% when only patients with multiple severe injuries were considered. Thoracic skeletal fractures were present in 84% of these patients, while flail chest was diagnosed in 8%. Pulmonary contusion was diagnosed in 16% of the patients, diaphragmatic rupture was present in 2%, and tracheobronchial injury in 0.4%.³

Rib fractures are identified in up to two-thirds of chest trauma patients who receive radiographic imaging.^4-6 Rib fractures are some of the most common injuries in the elderly, accounting for approximately 12% of all fractures, with increasing incidence as this population gets older.⁷ Emergency clinicians must have a low threshold of suspicion for rib fractures and bony skeletal injury in patients with blunt thoracic trauma, as up to 50% of fractures may be undetected radiographically.⁶ This is important, as morbidity and mortality can be significant from chest wall injuries alone. One review of 77 elderly patients reported a 38% rate of respiratory complication, with 8% mortality, associated with isolated rib fractures.⁸ Mortality associated with a flail chest is as high as 16%.⁹

Sternal fractures occur in approximately 8% of severe blunt chest trauma patients,^10,11 90% of which are secondary to motor vehicle crashes.^11,12 One study of 200 patients with sternal fracture reported an estimated 30% incidence of concomitant chest injuries.¹² The significance of associated intrathoracic injury associated with sternal fractures is underscored by the fact that fractures of the sternum have been associated with cardiac contusion in 20% to 40% of cases.¹³

Pulmonary contusions, pneumothorax, and hemothorax occur in 30% to 50% of patients with severe blunt chest trauma managed in trauma centers. ^4,11,13-17 Diaphragmatic tears secondary to blunt trauma are uncommon, but they have potential for delayed complications (eg, diaphragmatic hernia) if not identified. Up to 6% of patients with blunt abdominal trauma have had traumatic diaphragmatic rupture diagnosed during exploratory laparotomy.¹⁸ Clinically significant tracheobronchial injuries are rarely identified in blunt chest trauma, and are reported in < 1% of cases.¹⁹

This issue of Emergency Medicine Practice provides an evidence-based review of blunt chest trauma with a focus on injuries involving the chest wall, lungs, and pleura. Best-practice recommendations are made to facilitate clinical decision-making and appropriate resource utilization.

Critical Appraisal Of The Literature

PubMed was searched using the following terms: blunt chest trauma, blunt chest injury, traumatic pneumothorax, traumatic hemothorax, pulmonary contusion, rib fractures, flail chest, clavicle fracture, scapula fracture, sternoclavicular dislocation, and sternum fracture. Articles were selected if they were relevant to emergency care and focused on adult patients. References from the papers were also utilized. Guidelines from the Eastern Association for the Surgery of Trauma (EAST) and the American College of Radiology (ACR) Appropriateness Criteria^® were included as found on the National Guideline Clearinghouse site at www.guideline.gov.

Review of the literature clearly demonstrated that there is a paucity of well-designed prospective studies; much of the evidence is based on retrospective analysis of databases and cohort studies. Consequently, much of the literature suffers from selection bias and from being underpowered.

Risk Management Pitfalls In Managing Blunt Chest Trauma

1. “My patient feels fine. There’s no way he had a thoracic injury.”
   Serious injury is less likely in a well-appearing patient with no complaints. However, significant mechanism of injury alone should raise suspicion for intrathoracic injury. Consequently, a high index of suspicion should be maintained after high-speed motor vehicle collisions (> 35 mph) or falls from > 15 feet.


2. “The CXR was normal, so I was certain he didn’t have an intrathoracic injury.”
   Many injuries are missed on plain CXR that are later seen on CT. Although these injuries are often not clinically significant, it is important to discuss the potential for missed injuries with your patient if you will not be performing additional evaluation. A CT should be strongly considered for severely injured patients or those in whom a missed injury would have severe consequences (eg, the elderly, patients with COPD, etc).


3. “She couldn’t have had a tension pneumothorax because there was no rush of air after needle decompression.”
   The failure rate after needle decompression is quite high. If suspicion for tension pneumothorax remains in the traumatic arrest patient despite needle decompression, an immediate, simple (finger) thoracostomy should be performed. This procedure could also be considered as a first-line intervention in the ED in the traumatic arrest patient.


4. “He looked so stable; I never thought he would decompensate at home.”
   More seriously injured patients (especially elderly patients) require a low threshold for admission. Early engagement of physical/ occupational therapy and social workers can be helpful, based on clinical situations. Getting the patient’s family involved early in the decision-making for evaluation of safety at home and establishing support for the patient is a must if and when the patient is to be discharged home.


5. “I admit all my elderly patients to the floor if they have stable vital signs.”
   Consider admitting elderly patients with multiple rib fractures to a monitored setting such as a step-down unit or ICU. There is a potential for respiratory failure and these patients require close attention.


6. “I thought he would be fine; it was just a rib fracture.”
   Many patients with isolated rib fractures will do quite well with appropriate pain management. However, some groups are at increased risk of complications (eg, pneumonia) and subsequent respiratory failure. It is prudent to consider admission for the elderly, patients with chronic respiratory disease (COPD or congestive heart failure), 3 or more rib fractures, or patients with respiratory compromise. If not admitting these patients, a careful discussion should take place regarding the signs of pneumonia and instructions to return for worsening symptoms. Patients should understand the risk and be willing and able to return immediately, if necessary.


7. “I didn’t get a CT because I was worried about radiation.”
   Medical radiation is clearly a concern, and conscientious physicians seek to limit the potential danger. However, it is important to not exaggerate the risk and to use shared decision making with patients, when possible. In these discussions, it is important to emphasize that the exact risk is not known, but is based on models.


8. “I always use a 36Fr chest tube in trauma patients.”
   Although a 36-40Fr chest tube has classically been used for traumatic hemothorax and pneumothorax, this large-sized tube has some drawbacks. Smaller tubes are less painful and easier to pass in patients with smaller intercostal spaces. Additionally, there is evidence that smaller tubes may even be adequate for hemothoraces.


9. “I scan the chest of all my trauma patients. Why not?”
   Imaging should be done when there is concern for thoracic injury. However, patients ruled out by NEXUS Chest CT Rule and patients at low risk of serious injury should not receive a CT. This will avoid unnecessary radiation, risks of intravenous contrast, and inappropriate resource utilization.


10. “I used a 5-cm needle for needle decompression. It should have worked.”
    A CT study showed that the chest wall at the second intercostal space in the midclavicular line is > 5 cm in 42.5% of patients. Consider finger thoracostomy as an alternative procedure.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

1. Kochanek KD, Murphy SL, Xu J, et al. Mortality in the United States, 2013. NCHS Data Brief. 2014(178):1-8. (National database review)
2. Allen GS, Coates NE. Pulmonary contusion: a collective review. Am Surg. 1996;62(11):895-900. (Review article)
3. Galan G, Penalver JC, Paris F, et al. Blunt chest injuries in 1696 patients. Eur J Cardiothorac Surg. 1992;6(6):284-287. (Observational study; 1696 patients)
4. Shorr RM, Crittenden M, Indeck M, et al. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg. 1987;206(2):200- 205. (Retrospective study; 515 patients)
5. Newman RJ, Jones IS. A prospective study of 413 consecutive car occupants with chest injuries. J Trauma. 1984;24(2):129- 135. (Prospective observational; 413 patients)
6. Simon BJ, Cushman J, Barraco R, et al. Pain management guidelines for blunt thoracic trauma. J Trauma. 2005;59(5):1256-1267. (Guideline)
7. Palvanen M, Kannus P, Niemi S, et al. Epidemiology of minimal trauma rib fractures in the elderly. Calcif Tissue Int. 1998;62(3):274-277. (Finland national database review)
8. Barnea Y, Kashtan H, Skornick Y, et al. Isolated rib fractures in elderly patients: mortality and morbidity. Can J Surg. 2002;45(1):43-46. (Retrospective review; 77 patients)
9. Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma. 1988;28(3):298-304. (Retrospective; 144 patients)
10. Collins J. Chest wall trauma. J Thorac Imaging. 2000;15(2):112- 119. (Review)
11. Sangster GP, Gonzalez-Beicos A, Carbo AI, et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol. 2007;14(5):297-310. (Review)
12. von Garrel T, Ince A, Junge A, et al. The sternal fracture: radiographic analysis of 200 fractures with special reference to concomitant injuries. J Trauma. 2004;57(4):837-844. (Retrospective; 200 patients)
13. Mayberry JC. Imaging in thoracic trauma: the trauma surgeon’s perspective. J Thorac Imaging. 2000;15(2):76-86. (Review)
14. Kang EY, Muller NL. CT in blunt chest trauma: pulmonary, tracheobronchial, and diaphragmatic injuries. Semin Ultrasound CT MR. 1996;17(2):114-118. (Review)
15. Zinck SE, Primack SL. Radiographic and CT findings in blunt chest trauma. J Thorac Imaging. 2000;15(2):87-96. (Review)
16. Farooq U, Raza W, Zia N, et al. Classification and management of chest trauma. J Coll Physicians Surg Pak. 2006;16(2):101-103. (Retrospective; 100 patients)
17. Mirvis SE. Imaging of acute thoracic injury: the advent of MDCT screening. Semin Ultrasound CT MR. 2005;26(5):305- 331. (Review)
18. Rees O, Mirvis SE, Shanmuganathan K. Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review of 12 cases. Clin Radiol. 2005;60(12):1280- 1289. (Retrospective; 12 patients)
19. Wintermark M, Schnyder P, Wicky S. Blunt traumatic rupture of a mainstem bronchus: spiral CT demonstration of the “fallen lung” sign. Eur Radiol. 2001;11(3):409-411. (Case report)
20. Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S351-S361. (Guideline)
21. Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma. 1997;42(5):973-979. (Review)
22. Hoth JJ, Stitzel JD, Gayzik FS, et al. The pathogenesis of pulmonary contusion: an open chest model in the rat. J Trauma. 2006;61(1):32-44. (Animal study)
23. Raghavendran K, Notter RH, Davidson BA, et al. Lung contusion: inflammatory mechanisms and interaction with other injuries. Shock. 2009;32(2):122-130. (Review)
24. Seitz DH, Perl M, Liener UC, et al. Inflammatory alterations in a novel combination model of blunt chest trauma and hemorrhagic shock. J Trauma. 2011;70(1):189-196. (Animal study)
25. Knoferl MW, Liener UC, Seitz DH, et al. Cardiopulmonary, histological, and inflammatory alterations after lung contusion in a novel mouse model of blunt chest trauma. Shock. 2003;19(6):519-525. (Animal study)
26. Leport T, Baudrit P, Potier P, et al. Study of rib fracture mechanisms based on the rib strain profiles in side and forward oblique impact. Stapp Car Crash J. 2011;55:199-250. (Post mortem autopsy study)
27. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975-979. (Retrospective; 711 patients)
28. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-874. (Review)
29. Rotondo MF, Cribari C, Smith RS, Committee on Trauma, American College of Surgeons. Resources for the optimal care of the injured patient 2014. Available at: https://www.facs.org/quality%20programs/trauma/vrc/resources. Accessed October 30, 2015. (Committee on Trauma manual)
30. Baker CC, Oppenheimer L, Stephens B, et al. Epidemiology of trauma deaths. Am J Surg. 1980;140(1):144-150. (Retrospective; 437 patients)
31. Esposito TJ, Sanddal ND, Hansen JD, et al. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma. 1995;39(5):955-962. (Retrospective)
32. Esposito TJ, Sanddal TL, Reynolds SA, et al. Effect of a voluntary trauma system on preventable death and inappropriate care in a rural state. J Trauma. 2003;54(4):663-669. (Retrospective; 347 patients)
33. Maio RF, Burney RE, Gregor MA, et al. A study of preventable trauma mortality in rural Michigan. J Trauma. 1996;41(1):83-90. (Retrospective; 155 patients)
34. Sanddal TL, Esposito TJ, Whitney JR, et al. Analysis of preventable trauma deaths and opportunities for trauma care improvement in utah. J Trauma. 2011;70(4):970-977. (Retrospective;)
35. Trunkey DD, Lim RC Jr, Blaisdell FW. Traumatic injury. A health care crisis. West J Med. 1974;120(1):92-94. (Communication)
36. Hedges JR, Sacco WJ, Champion HR. An analysis of pre-hospital care of blunt trauma. J Trauma. 1982;22(12):989-993. (Retrospective)
37. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178(9):1141-1152. (Prospective; 2867 patients)
38. Pepe PE, Maio RF. Evolving challenges in prehospital trauma services. Current issues and suggested evaluation tools. Prehosp Disaster Med. 1993;8(1 Suppl):25-34. (Review)
39. Pepe PE, Stewart RD, Copass MK. Prehospital management of trauma: a tale of three cities. Ann Emerg Med. 1986;15(12):1484-1490. (Prospective)
40. Hedges JR, Feero S, Moore B, et al. Factors contributing to paramedic onscene time during evaluation and management of blunt trauma. Am J Emerg Med. 1988;6(5):443-448. (Retrospective; 109 patients)
41. Lecky F, Bryden D, Little R, et al. Emergency intubation for acutely ill and injured patients. Cochrane Database Syst Rev. 2008(2):CD001429. (Review)
42. Haut ER, Kalish BT, Cotton BA, et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Ann Surg. 2011;253(2):371-377. (Retrospective; 776,734 patients)
43. Cotton BA, Jerome R, Collier BR, et al. Guidelines for pre-hospital fluid resuscitation in the injured patient. J Trauma. 2009;67(2):389-402. (Guideline)
44. Ball CG, Wyrzykowski AD, Kirkpatrick AW, et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010;53(3):184- 188. (Retrospective review; 9689 patients)
45. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005;22(11):788-789. (Prospective observational; 24 patients)
46. Gilligan P, Hegarty D, Hassan TB. The point of the needle. Occult pneumothorax: a review. Emerg Med J. 2003;20(3):293- 296. (Review)
47. Holcomb JB, McManus JG, Kerr ST, et al. Needle versus tube thoracostomy in a swine model of traumatic tension hemopneumothorax. Prehosp Emerg Care. 2009;13(1):18-27. (Animal study)
48. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9):813-818. (Retrospective; 680 patients)
49. Martin M, Satterly S, Inaba K, et al. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? J Trauma Acute Care Surg. 2012;73(6):1412- 1417. (Animal model)
50. Rathinam S, Bleetman A, Steyn RS. Needle thoracostomy in treatment of a tension pneumothorax in trauma patients. J Trauma. 2008;65(4):964. (Communication)
51. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care. 2009;13(1):14-17. (Retrospective; 110 patients)
52. Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008;64(1):111-114. (Retrospective; 774 patients)
53. Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care. 1998;2(2):132-135. (Prospective observational; 108 patients)
54. Salim A, Sangthong B, Martin M, et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg. 2006;141(5):468- 473. (Prospective observational; 1000 patients)
55. * Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS Chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg. 2013;148(10):940-946. (Prospective multicenter; 9905 patients)
56. Gonzalez KW, Ghneim MH, Kang F, et al. A pilot single-institution predictive model to guide rib fracture management in elderly patients. J Trauma Acute Care Surg. 2015;78(5):970-975. (Retrospective; 400 patients)
57. Ferraris VA, Bernard AC, Hyde B. The impact of antiplatelet drugs on trauma outcomes. J Trauma Acute Care Surg. 2012;73(2):492-497. (Retrospective; 11,374 patients)
58. Bonville DJ, Ata A, Jahraus CB, et al. Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery. 2011;150(4):861-868. (Retrospective review; 456 patients)
59. Millo NZ, Plewes C, Rowe BH, et al. Appropriateness of CT of the chest, abdomen, and pelvis in motorized blunt force trauma patients without signs of significant injury. AJR Am J Roentgenol. 2011;197(6):1393-1398. (Retrospective; 542 patients)
60. Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med. 2005;46(3):232- 236. (Prospective; 875 patients)
61. * Chung JH, Cox CW, Mohammed TL, et al. ACR appropriateness criteria blunt chest trauma. J Am Coll Radiol. 2014;11(4):345-351. (Guideline/review)
62. Kea B, Gamarallage R, Vairamuthu H, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma? Am J Emerg Med. 2013;31(8):1268-1273. (Observational; 791 patients)
63. Wisbach GG, Sise MJ, Sack DI, et al. What is the role of chest x-ray in the initial assessment of stable trauma patients? J Trauma. 2007;62(1):74-78. (Retrospective review; 1000 patients)
64. Barrios C, Malinoski D, Dolich M, et al. Utility of thoracic computed tomography after blunt trauma: when is chest radiograph enough? Am Surg. 2009;75(10):966-969. (Retrospective; 200 patients)
65. Hoffstetter P, Dornia C, Schafer S, et al. Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography. J Trauma Manag Outcomes. 2014;8:10. (Retrospective; 56 patients)
66. Hoffstetter P, Dornia C, Wagner M, et al. Clinical significance of conventional rib series in patients with minor thoracic trauma. Rofo. 2014;186(9):876-880. (Retrospective; 669 patients)
67. Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. AJR Am J Roentgenol. 2009;192(3):599-612. (Review)
68. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest. 2012;141(3):703-708. (Systematic review)
69. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17. (Systematic review)
70. Hyacinthe AC, Broux C, Francony G, et al. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012;141(5):1177-1183. (Prospective observational; 119 patients)
71. Leblanc D, Bouvet C, Degiovanni F, et al. Early lung ultrasonography predicts the occurrence of acute respiratory distress syndrome in blunt trauma patients. Intensive Care Med. 2014;40(10):1468-1474. (Prospective observational; 45 patients)
72. * Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. (Epidemiological review and theoretical model)
73. Mitchell AM, Kline JA, Jones AE, et al. Major adverse events one year after acute kidney injury after contrast-enhanced computed tomography. Ann Emerg Med. 2015. (Prospective observational; 633 patients)
74. * Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-2086. (Retrospective; 1119 patients)
75. Berrington de Gonzalez A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-2077. (Theoretic risk model study of cancer risk)
76. Livingston DH, Shogan B, John P, et al. CT diagnosis of rib fractures and the prediction of acute respiratory failure. J Trauma. 2008;64(4):905-911. (Retrospective; 388 patients)
77. * Rodriguez RM, Baumann BM, Raja AS, et al. Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations. Acad Emerg Med. 2014;21(6):644-650. (Prospective observational; 9905 patients)
78. Namias N, McKenney MG, Martin LC. Utility of admission chemistry and coagulation profiles in trauma patients: a reappraisal of traditional practice. J Trauma. 1996;41(1):21-25. (Prospective observational; 500 patients)
79. Tortella BJ, Lavery RF, Rekant M. Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med. 1995;2(3):190-194. (Retrospective review; 913 patients)
80. Asimos AW, Gibbs MA, Marx JA, et al. Value of point-of-care blood testing in emergent trauma management. J Trauma. 2000;48(6):1101-1108. (Prospective; 200 patients)
81. Odom SR, Howell MD, Silva GS, et al. Lactate clearance as a predictor of mortality in trauma patients. J Trauma Acute Care Surg. 2013;74(4):999-1004. (Prospective; 4742 patients)
82. Pal JD, Victorino GP, Twomey P, et al. Admission serum lactate levels do not predict mortality in the acutely injured patient. J Trauma. 2006;60(3):583-587. (Prospective; 5995 patients)
83. Herbert HK, Dechert TA, Wolfe L, et al. Lactate in trauma: a poor predictor of mortality in the setting of alcohol ingestion. Am Surg. 2011;77(12):1576-1579. (Retrospective; 1083 patients)
84. Manikis P, Jankowski S, Zhang H, et al. Correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med. 1995;13(6):619-622. (Retrospective; 129 patients)
85. Regnier MA, Raux M, Le Manach Y, et al. Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology. 2012;117(6):1276-1288. (Prospective observational; 586 patients)
86. Dezman ZD, Comer AC, Smith GS, et al. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg. 2015;79(4):580-585. (Retrospective; 3887 patients)
87. Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline)
88. Beckers SK, Brokmann JC, Rossaint R. Airway and ventilator management in trauma patients. Curr Opin Crit Care. 2014;20(6):626-631. (Review)
89. Richter T, Ragaller M. Ventilation in chest trauma. J Emerg Trauma Shock. 2011;4(2):251-259. (Review)
90. Gallagher JJ. Management of blunt pulmonary injury. AACN Adv Crit Care. 2014;25(4):375-386. (Review)
91. Chiumello D, Coppola S, Froio S, et al. Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med. 2013;39(7):1171-1180. (Meta-analysis; 5 studies, 219 patients)
92. Carrier FM, Turgeon AF, Nicole PC, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009;56(3):230-242. (Meta-analysis)
93. Yoshida H, Yaguchi S, Matsumoto A, et al. A modified paravertebral block to reduce risk of mortality in a patient with multiple rib fractures. Am J Emerg Med. 2015;33(5):e733-e734. (Case report)
94. Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care. 2011;17(4):323-327. (Review)
95. Mohta M, Verma P, Saxena AK, et al. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study. J Trauma. 2009;66(4):1096-1101. (Randomized controlled trial; 30 patients)
96. Tainter CR. An evidence-based approach to traumatic pain management in the emergency department. Emerg Med Pract. 2012;14(8):1-26. (Review)
97. Pieracci FM, Rodil M, Stovall RT, et al. Surgical stabilization of severe rib fractures. J Trauma Acute Care Surg. 2015;78(4):883-887. (Review)
98. Oyetunji TA, Jackson HT, Obirieze AC, et al. Associated injuries in traumatic sternal fractures: a review of the National Trauma Data Bank. Am Surg. 2013;79(7):702-705. (Retrospec¬tive; 23,985 patients)
99. Perez MR, Rodriguez RM, Baumann BM, et al. Sternal fracture in the age of pan-scan. Injury. 2015;46(7):1324-1327. (Retrospective; 292 patients)
100. Dua A, McMaster J, Desai PJ, et al. The association between blunt cardiac injury and isolated sternal fracture. Cardiol Res Pract. 2014;2014:629687. (Retrospective; 88 patients)
101. Baldwin KD, Ohman-Strickland P, Mehta S, et al. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma. 2008;65(2):430-435. (Retrospective case control; 12,181 patients)
102. Brown CV, Velmahos G, Wang D, et al. Association of scapular fractures and blunt thoracic aortic injury: fact or fiction? Am Surg. 2005;71(1):54-57. (Retrospective; 35,541 patients)
103. Glass ER, Thompson JD, Cole PA, et al. Treatment of sternoclavicular joint dislocations: a systematic review of 251 dislocations in 24 case series. J Trauma. 2011;70(5):1294-1298. (Systematic review; 24 case studies, 251 patients)
104. Clemency BM, Tanski CT, Rosenberg M, et al. Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehosp Disaster Med. 2015;30(3):249-253. (Meta-analysis)
105. Dominguez KM, Ekeh AP, Tchorz KM, et al. Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? Am J Surg. 2013;205(3):329- 332. (Prospective observational; 41 patients)
106. Fitzgerald M, Mackenzie CF, Marasco S, et al. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008;39(1):9-20. (Review)
107. Massarutti D, Trillo G, Berlot G, et al. Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. Eur J Emerg Med. 2006;13(5):276-280. (Prospective observational; 55 patients)
108. Deakin CD, Davies G, Wilson A. Simple thoracostomy avoids chest drain insertion in prehospital trauma. J Trauma. 1995;39(2):373-374. (Prospective observational; 45 patients)
109. Benns MV, Egger ME, Harbrecht BG, et al. Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions. J Trauma Acute Care Surg. 2015;78(2):386-390. (Retrospective review; 291 patients)
110. Rivera L, O’Reilly EB, Sise MJ, et al. Small catheter tube thoracostomy: effective in managing chest trauma in stable patients. J Trauma. 2009;66(2):393-399. (Retrospective; 565 patients)
111. Iepsen UW, Ringbaek T. Small-bore chest tubes seem to perform better than larger tubes in treatment of spontaneous pneumothorax. Dan Med J. 2013;60(6):A4644. (Retrospective; 104 patients)
112. Kulvatunyou N, Joseph B, Friese RS, et al. 14 French pigtail catheters placed by surgeons to drain blood on trauma patients: is 14-Fr too small? J Trauma Acute Care Surg. 2012;73(6):1423-1427. (Prospective observational; 36 patients)
113. Kulvatunyou N, Erickson L, Vijayasekaran A, et al. Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg. 2014;101(2):17-22. (Randomized controlled trial; 40 patients)
114. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422- 427. (Prospective observational; 353 patients)
115. Lee RK, Graham CA, Yeung JH, et al. Occult pneumothoraces in Chinese patients with significant blunt chest trauma: radiological classification and proposed clinical significance. Injury. 2012;43(12):2105-2108. (Retrospective; 36 patients)
116. Wilson H, Ellsmere J, Tallon J, et al. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Injury. 2009;40(9):928-931. (Retrospective; 1881 patients)
117. Kirkpatrick AW, Rizoli S, Ouellet JF, et al. Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces. J Trauma Acute Care Surg. 2013;74(3):747-754. (Randomized controlled trial; 90 patients)
118. Yadav K, Jalili M, Zehtabchi S. Management of traumatic occult pneumothorax. Resuscitation. 2010;81(9):1063-1068. (Systematic review)
119. Wells BJ, Roberts DJ, Grondin S, et al. To drain or not to drain? Predictors of tube thoracostomy insertion and outcomes associated with drainage of traumatic hemothoraces. Injury. 2015;46(9):1743-1748. (Retrospective cohort; 635 patients)
120. ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, International Working Group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013;74(5):1363-1366. (Guideline)
121. Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. 1982;196(4):481-487. (Retrospective 427 patients)
122. Alexander JQ, Gutierrez CJ, Mariano MC, et al. Blunt chest trauma in the elderly patient: how cardiopulmonary disease affects outcome. Am Surg. 2000;66(9):855-857. (Retrospective review; 62 patients)
123. Stawicki SP, Grossman MD, Hoey BA, et al. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. 2004;52(5):805-808. (Retrospective; 8648 patients)
124. Keller JM, Sciadini MF, Sinclair E, et al. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012;26(9):e161-e165. (Retrospective; 597 patients)
125. Battle CE, Hutchings H, James K, et al. The risk factors for the development of complications during the recovery phase following blunt chest wall trauma: a retrospective study. Injury. 2013;44(9):1171-1176. (Retrospective; 174 patients)
126. Shields JF, Emond M, Guimont C, et al. Acute minor thoracic injuries: evaluation of practice and follow-up in the emergency department. Can Fam Physician. 2010;56(3):e117-e124. (Retrospective; 447 patients)
127. Bulger EM, Arneson MA, Mock CN, et al. Rib fractures in the elderly. J Trauma. 2000;48(6):1040-1046. (Retrospective; 277 patients)
128. Battle C, Hutchings H, Lovett S, et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care. 2014;18(3):R98. (Retrospective and prospective observational decision instrument study; 511 patients)
129. Gupta M, Schriger DL, Hiatt JR, et al. Selective use of computed tomography compared with routine whole body imaging in patients with blunt trauma. Ann Emerg Med. 2011;58(5):407-416. (Observational study; 701 patients)
130. * Langdorf MI, Medak AJ, Hendey GW, et al. Prevalence and clinical import of thoracic injury identified by chest computed tomography but not chest radiography in blunt trauma: multicenter prospective cohort study. Ann Emerg Med. 2015;66(6):589-600. (Prospective observational; 5912 patients)
131. Rodriguez RM, Langdorf MI, Nishijima D, et al. Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLoS Med. 2015;12(10):e1001883. (Prospective; 11,477 patients)
132. * Caputo ND, Stahmer C, Lim G, et al. Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;77(4):534- 539. (Systematic review)
133. Van Vugt R, Keus F, Kool D, et al. Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients. Cochrane Database Syst Rev. 2013;12:CD009743. (Systematic Cochrane review)