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.

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