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
“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.
“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).
“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.
“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.
“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.
“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.
“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.
“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.
“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.
“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.
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* 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)
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* 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)
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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)
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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)
Beckers SK, Brokmann JC, Rossaint R. Airway and ventilator management in trauma patients. Curr Opin Crit Care. 2014;20(6):626-631. (Review)
Richter T, Ragaller M. Ventilation in chest trauma. J Emerg Trauma Shock. 2011;4(2):251-259. (Review)
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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)
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)
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)
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)
Tainter CR. An evidence-based approach to traumatic pain management in the emergency department. Emerg Med Pract. 2012;14(8):1-26. (Review)
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)
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)
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)
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)
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)
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)
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)
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)
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)
Fitzgerald M, Mackenzie CF, Marasco S, et al. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008;39(1):9-20. (Review)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
Yadav K, Jalili M, Zehtabchi S. Management of traumatic occult pneumothorax. Resuscitation. 2010;81(9):1063-1068. (Systematic review)
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)
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)
Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. 1982;196(4):481-487. (Retrospective 427 patients)
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)
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)
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)
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)
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)
Bulger EM, Arneson MA, Mock CN, et al. Rib fractures in the elderly. J Trauma. 2000;48(6):1040-1046. (Retrospective; 277 patients)
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)
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)
* 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)
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)
* 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)
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)
Emergency Department Evaluation And Management Of Blunt Chest And Lung Trauma - Calculated Decisions - Trauma CME
The Endotracheal Tube (ETT) Depth and Tidal Volume Calculator estimates depth of optimal ETT placement and target tidal volume by height. The Blast Lung Injury Severity Score stratifies primary blast lung injuries into 3 categories to guide ventilator treatment.
Endotracheal tube (ETT) depth is measured based on the patient’s front teeth rather than the molars.
Larger tidal volumes may be temporarily required for patients with severe metabolic acidosis.
Why and When to Use, and Next Steps H4
Why to Use
Placing the ETT too deep may cause right mainstem intubation, hypoxemia, and pneumothorax. However, placing the ETT too shallow may risk injury to the vocal cords and accidental extubation. Standard approaches to verify ETT depth (eg, bilateral auscultation) are insensitive. Use of lower tidal volumes appears to prevent the development of acute respiratory distress syndrome, even in patients who do not have lung injury.
When to Use
Use in adult patients (aged > 20 years) requiring orotracheal intubation.
Next Steps
ETT position should still be verified with a chest radiograph for patients who will remain intubated for an extended period of time.
For tidal volume, 6 to 8 mL/kg ideal body weight is generally a safe initial setting, but further ventilator adjustment may be required, depending on the adequacy of ventilation and airway pressures.
Obtain chest radiograph and measurement of CO2 level (eg, end-tidal CO2 or blood gas analysis) to confirm ETT position and adequacy of ventilation.
Evidence Appraisal
The Chula formula was developed and validated by Techanivate et al (2005) at King Chulalongkorn Memorial Hospital in Thailand. The authors prospectively validated the use of this formula among 100 patients in Thailand. Patients were intubated and the ETT placed according to the formula. Subsequently, a bronchoscope was used to determine the relationship among the ETT, carina, and vocal cords. The distance between the ETT and carina ranged between 1.9-7.5 cm. No patient was at immediate risk of endobronchial intubation. The upper border of the ETT cuff was always > 1.9 cm below the vocal cords, avoiding risk of laryngeal trauma or inadvertent extubation.
Pak et al in 2010 and Hunyady et al in 2008 developed similar assessments of optimal ETT placement. The average of the 3 scores (Pak, Hunyady, and Chula) is nearly identical to the Chula formula.
Primary blast injury (PBI) occurs when a blast wave accelerates and decelerates while traveling through tissues of varying density. Thus, PBI affects organs with greater air-tissue interfaces such as auditory, pulmonary, and gastrointestinal systems.
Primary blast lung injury (BLI) is radiological and clinical evidence of acute lung injury occurring after blast injury that is not due to secondary or tertiary blast injury. The pathophysiology is thought to be due to capillary rupture within alveoli leading to hemorrhage and pulmonary edema, which then reduces gas exchange, causing hypoxia and hypercarbia.
Clinical suspicion of primary BLI should be high after blast injury within an enclosed space, as the blast wave becomes amplified as it reflects off of the structural walls (Leibovici 1996).
A characteristic chest x-ray shows bilateral diffuse opacities in a “butterfly” pattern. Patients present with hypoxemia with associated pneumothoraces, bronchopleural fistulae, or hemoptysis.
In the studies, patients diagnosed with BLI were intubated immediately or within 2 hours of presentation due to respiratory decompensation. Thus, patients breathing spontaneously and adequately 2 hours after injury are unlikely to require mechanical ventilation because of BLI alone (Pizov 1999, Avidan 2005).
Why and When to Use, and Next Steps
Why to Use
The Blast Lung Injury (BLI) Severity Score is useful in guiding triage decisions in the setting of mass casualties, determining ventilation treatment, and predicting outcomes. BLI severity correlates with the likelihood of developing acute respiratory distress syndrome (ARDS), and can be helpful to delineate patients who will require more aggressive and potentially unconventional respiratory care (eg, nitric oxide, high-frequency jet ventilation, independent lung ventilation, or extracorporeal membrane oxygenation).
When to Use
Use the BLI Severity Score in patients who have sustained blast injury and have respiratory symptoms (eg, cough, cyanosis, dyspnea, hemoptysis).
Next Steps
Screening chest x-rays for asymptomatic patients are not recommended (Zara 2015), as patients with BLI present either immediately or early with hypoxemia. Contrary to previous belief that the clinical picture of BLI may develop over 24 to 48 hours, studies have shown that patients do not present with a delay in manifestation of lung injury (Pizov 1999, Avidan 2005).
Similarly, it was previously suggested that tympanic membrane rupture, the most common primary blast injury, was a marker for increased risk of development of BLI. Studies have shown that tympanic membrane perforation is in fact poorly correlated with BLI (Leibovici 1999, Ballivet de Regloix 2017).
Low inspiratory pressure with avoidance of positive end-expiratory pressure (PEEP) is ideal in BLI in order to avoid secondary barotrauma, arterial air embolism, or pneumothorax. However, patients with blast lung often have injury patterns similar to ARDS and require positive pressure ventilation and PEEP.
Other treatment considerations include avoiding aggressive intravenous hydration after physiology capture, as it can worsen pulmonary edema, and considering the need for a prophylactic thoracostomy tube before air transportation.
Intubated patients require the following ventilation management:
Mild BLI patients will usually require volume-controlled or pressure support ventilation modes and PEEP ≤ 5 cm H2O.
Moderate BLI patients require conventional ventilation modes, including inverse ratio ventilation as needed, with PEEP 5 to 10 cm H2O.
Severe BLI patients require conventional ventilation modes, and commonly require unconventional therapies such as nitric oxide, high-frequency jet ventilation, independent lung ventilation, or extracorporeal membrane oxygenation. The PEEP requirement is > 10 cm H2O.
Calculator Review Author
Jennie Kim, MD
Department of Surgery
Maimonides Medical Center, Brooklyn, NY
Travis Polk, MD
Commander, Medical Corps, U.S. Navy
Los Angeles County+USC Medical Center
Los Angeles, CA
Evidence Appraisal
The original BLI Severity Score was proposed in 1999 by Pizov et al. The study evaluated 15 patients with primary BLI after explosions on 2 civilian buses. BLI Severity scores were compared to Murray scores for acute lung injury at 6 and 24 hours after injury; at 24 hours, there was good correlation between the proposed BLI score and the modified Murray score.
Three of the 3 patients (100%) with severe BLI who were still alive after 24 hours (1 patient died within 24 hours from intrapulmonary hemorrhage after being placed on extracorporeal membrane oxygenation) and 2 of 6 patients (33%) with moderate BLI developed acute respiratory distress syndrome (ARDS) (Murray score > 2.5). None of the 5 patients with mild BLI developed ARDS. Other unconventional respiratory therapies such as independent lung ventilation, high-frequency jet ventilation, and nitric oxide were used in patients with severe BLI with improvements in their PaO2 levels. When comparing mortality rates, 4 patients with severe BLI died, all 6 patients with moderate BLI survived, and 1 of the 5 patients with mild BLI subsequently died from a traumatic head injury.
One year after the study by Pizov et al, Hirshberg et al conducted a follow-up study of the 11 surviving original patients. None of the 11 survivors had pulmonary-related complaints, and lung physical examinations were normal with complete resolution of chest radiograph findings.
In comparison, Avidan et al, in 2005, evaluated 29 patients with primary BLI, and only 1 patient had died (death occurred 24 days after admission from sepsis and multiple organ failure). The authors concluded that death because of BLI in patients who survived the explosion is unusual. Although these 29 patients were not categorized by BLI severity scores, there were 7 patients with PaO2 / FiO2 ratios < 60, 4 patients requiring positive end-expiratory pressure (PEEP) > 10 cm H2O, and 3 patients requiring unconventional therapies such as high-frequency ventilation or nitric oxide inhalations. The decreased mortality rate compared to Pizov et al, despite the presence of patients with characteristics of severe BLI, may be attributed to improvements in critical care and respiratory management.
The study also assessed long-term outcomes by contacting 21 of 28 survivors (75%) from 6 months to 21 years after discharge. Sixteen patients (76%) were free of respiratory symptoms and did not require respiratory therapy. Five patients (24%) reported respiratory symptoms but 2 of the 5 had a past medical history of asthma and another 2 of the 5 were contacted less than 1 year after injury.
Upon completion of this article, you should be able to:
Summarize the work-up, disposition, and immediate treatment of blunt thoracic trauma patients;
Assess the benefits and pitfalls of different imaging modalities; and
Describe different methods of thoracic decompression of pneumothorax and hemothorax and select patients who require admission.
Physician CME Information
Date of Original Release: June 1, 2016. Date of most recent review: May 10, 2016. Termination date: June 1, 2019.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2015. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
ABIM Accreditation: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 4 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Objectives: Upon completion of this article, you should be able to: (1) summarize the work-up, disposition, and immediate treatment of blunt thoracic trauma patients; (2) assess the benefits and pitfalls of different imaging modalities; and (3) describe different methods of thoracic decompression of pneumothorax and hemothorax and select patients who require admission.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Morley, Dr. Johnson, Dr. Leibner, Dr. Shahid, Dr. Parekh, Dr. Tainter, Dr. Jagoda, Dr. Shah, Dr. Damilini, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
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