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Blunt Chest Trauma Algorithm

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Cardiac Arrest from Blunt Chest Trauma

ED Thoracotomy indications:

  • Trauma patient, CPR, no signs of life (SOL) +:
    • Blunt trauma with CPR <10min
    • Penetrating trauma with CPR <15min
    • Penetrating trauma to neck/extremity < 5 min

No Signs of Life (SOL)

– No pulse
– No pupils
– No movement
– No breaths
– No PEA
– No cardiac motion (US)

Cardiac Arrest

  • Resuscitative Thoracotomy (Open the left chest)
    • Release tamponade and open resuscitation of heart ⇒ Control bleeding
    • Open Cardiac Resuscitation
    • Cross-clamp aorta → Shunt blood up
  • Right Chest Tube
    • Blood? → Clamshell thoracotomy to control bleeding

Survival rates:

Blunt Chest Trauma Algorithm
Blunt Chest Trauma Algorithm

Unstable Patient from Blunt Chest Trauma

1. Cardiac Tamponade

  • Cause
    • Blunt Cardiac Injury – Wall rupture,
    • Coronary injury
  • Clinical
    • May be asymptomatic or non-specific
    • Beck’s Triad: Distended neck veins, hypotension/shock, muffled hear sounds

Beck’s Triad

– Hypotension
– Distended neck veins
– Muffled heart sounds

  • Diagnosis
    • Bedside US: Pericardial effusion
      • Sensitivity 100% for detections of pericardial effusion in multiple studies
    • ECHO
  • Treatment
    • OR immediately for sternotomy
    • ER thoracotomy if too unstable for OR
    • Pericardiocentesis if unable to perform thoracotomy
    • Closed chest CPR ineffective

2. Pneumothorax

Clinical

  • Often asymptomatic
  • Dyspnea, tachypnea, absent breath sounds, poorly moving hemithorax, subcutaneous emphysema

Diagnosis

  • Upright CXR
    • PTX, deep sulcus sign, subcutaneous air
  • Lung Ultrasound (Essentials 2013 #49)
    • Diagnosis: Lung sliding, lung point
  • True PTX? vs skin folds, blebs, peritoneal contents?

Treatment

  • Chest tube: Unstable, hemothorax, multiple trauma
  • Heimlich valve: stable, large Pneumothorax (>3cm)
  • Observe & Oxygenate: stable, small-mod Pneumothorax (2-3cm; <20%)
  • Occult Pneumothorax + Positive Pressure Ventilation (PPV) → if stable, can be observed

Chest Tube Stat!

– Traumatic cardiac arrest
– No BP/Pulse during resuscitation
– Hypotension + ↑ Ppeak or difficult to bag
– Hypotension or Hypoxia + decreased breath sounds or SQ emphysema

Pneumothorax - an algorithm for management
Pneumothorax – an algorithm for management

Tension Pneumothorax

Presentation:

  • Classic presentation
    • Respiratory distress
    • Tachypnea
    • Deviated trachea
    • Hypotension/shock
    • Unilateral decreased breath sounds
  • Course
    • Hypoxia with progressive respiratory compromise → hypotension → cardiac failure, respiratory arrest
  • Ventilated patients
    • Sudden deterioration, hypoxia and hypotension (almost universal), increased Ppeak on vent, difficult to bag

Treatment: Tension Pneumothorax

  • Needle decompression (inconsistent and unreliable)
  • Immediate tube thoracostomy in mid-axillary line

Spontaneous Pneumothorax

Treatment

  • ACCP recommends small bore (14F or smaller) catheter or 16-22 F chest tube connected to Heimlich valve or water seal
  • If fails to re-expand → Chest tube
  • May also do volume controlled re-expansion → Suction 200ml/hr from Heimlich and reclamp

Re-expansion pulmonary edema (mortality up to 20%)

  • Risk factors: large size, long duration (>3days), rapid rate of re-expansion
  • Clinical: 64% have symptoms within one hour, coughing, tachypnea, tachycardia and hypoxia
  • Treatment: generally supportive, mechanical ventilation and hemodynamic support

Disposition: may discharge with Heimlich valve if lung fully expanded (large ptx should be admitted, observe 24h)

3. Hemothorax

Clinical

  • Often asymptomatic
  • Presentation: Dyspnea, tachypnea, hypovolemia, absent breath sounds, poorly moving hemithorax, dull on percussion

Diagnosis

  • Upright CXR: 150-200ml needed in pleural cavity to diagnose hemothorax
  • Supine CXR: Sensitivity of 40-60% in ruling out hemothorax
  • US: Can diagnose as little as 20ml of blood; Sensitivity of 96%

Treatment

  • Significant Hemothorax
    • Chest tube: Drainage of hemothorax
    • Tube size doesn’t matter? (J Trauma Acute Care Surg 2012;72(2):422)
      • Size of tube is not a factor in causing complications (28-32F is equivalent to 36-40F)
    • Auto-transfusion for large hemothorax
    • Antibiotics prior to tube insertion (Cefazolin 2g IV)
  • Unstable/Life threatening bleed
    • Urgent thoracotomy: (J Trauma 2011;70(2):510)
      • More than 1,500 ml of blood immediately evacuated by tube thoracostomy
      • Persistent bleeding from the chest, defined as 150 ml/h to 200 ml/h for 2 hours to 4 hours
      • Persistent blood transfusion is required to maintain hemodynamic stability
      • Clinical stability of patient should determine whether or not patient needs OR (persistent shock etc…)

Complications

  • Empyema – infection of retained hemothorax
  • Retained fibrothorax – trapped lung
    • Both may necessitate open thoracotomy and decortication

Stable Patint with Blunt Chest Trauma

1. Blunt Aortic Inury

  • Epidemiology:
    • Over 80% of patients die on scene
  • Mechanism:
    • Rapid deceleration from high speed MVA, falls from height >3m, ejection from vehicle/motorcycle, crush between two objects
  • Evaluation
    • All patients with significant mechanism of injury should have CT of mediastinum irrespective of CXR findings
    • CXR: not sensitive to rule out aortic injury
    • CT Chest: Normal CT essentially rules out aortic injury (J Trauma 1998;45(5):922)
    • CT angiogram: sensitivity and NPV of approx 100%
    • TEE: consider for patients too unstable for CT
  • Treatment:
    • Resuscitation
    • Maintain low SBP <90 (β-blockers)
    • Emergent surgical consultation

Blunt Aortic Inury CXR Findings

– Widened mediastinum (>8cm)
– Apical capping
– Depressed L mainstem bronchus
– Widened L paratracheal stripe
– Loss of aortic knob contour
– Deviated NG tube

2. Blunt Cardiac Injury

Spectrum

  • Structural Wall contusion (rarely clinically significant)
    • Wall rupture (die at scene)
    • Septal rupture (die at scene)
    • Valve disruption (die at scene)
    • Coronary injury (die at scene)
    • Conclusion: Clinically significant structural injuries very rare in survivors
  • Electrical: Arrhythmias (Crit Care Clin 2004;20:57–70)
    • Non-specific changes (50-70%):
      • Sinus tachycardia/bradycardia, PAC/PVC, conduction delays, ST-T wave changes
    • Atrial arrhythmias (4-30%)
      • Atrial fibrillation most common arrhythmia to require treatment
    • Ventricular arrhythmias (2-10%)

Blunt Cardiac Injury Spectrum

□ Free wall rupture
□ Septal rupture
□ Coronary artery injury
□ Cardiac failure
□ Complex arrhythmias
□ Minor EKG/cardiac enzyme abnormalities

Who is at risk?

  • All patients with severe chest injury
  • High risk mechanism: high speed, rapid deceleration, airbag, steering wheel damage, seatbelt restraint
  • Associated chest trauma: fracture, contusion, hemothorax/pneumothorax

Evaluation:

  • Controversial: many approaches to rule out Blunt Cardiac Injury
  • Serial troponin/EKG (J Trauma 2003;54:45-51)
  • Serial EKG/Trop at 0 and 8 hours → sensitivity 100%
  • If either positive → rule out ACS, 24h monitoring for arrhythmias, TTE
  • If all normal, can discharge home

3. Blunt Diaphragmatic Rupture

General:

  • 50-80% on left side, right side rupture associated with liver injury (50%)
  • Clinical symptoms are varied, subtle and non-specific
  • Other injuries? Isolated diaphragm injuries from blunt trauma are rare

Mechanism

  • Severe abdominal trauma → sudden, major increase of intra-abdominal pressure (MVC) → weak parts of diaphragm pull apart → +/- translocation of abdominal contents

Diagnosis:

  • CXR
    • Classic: bowel in chest wall (<50% translocation), elevated hemidiaphragm, displaced NG tube, box-like R hemidiaphragm
    • Usual: abnormal but non-specific
  • CT → high specificity, sensitivity still low
    • Collar sign on CT: Constriction of colon/stomach passing through tear
    • If high clinical suspicion, may need surgical evaluation
  • Delayed presentation:
    • Most diaphragmatic ruptures missed on initial trauma eval → present later with bowel obstruction/incarceration

4. Tracheobronchial Tree Injury

Upper Airway Injury

  • Usually straightforward diagnosis
  • Treatment: Relieve obstruction and secure definitive airway

Lower Airway Injury

  • Clinical Presentation
    • Rare and can be subtle (depending on size of defect, air leak, pleural communication)
    • Small defect:
      • Mediastinal air on CT, subcutaneous emphysema, hemoptysis
    • Large defect:
      • Dyspnea, Pneumothorax, Persistent Pneumothorax after chest tube, air leak after chest tube
      • May need 2nd chest tube
  • Diagnosis
    • CT
      • Difficult to ID on CT → usually within 2cm of carina (right mainstem bronchus or trachea)
    • Bronchoscopy
      • Locate injury to advance ETT beyond site of injury, possibly to unaffected mainstem bronchus
      • Diagnose location and size of injury → surgical repair
  • Treatment
    • High mortality from ventilation/oxygenation compromise
    • Thoracic Surgery for repair

5. Pulmonary Contusion

Mechanism

  • High-energy mechanisms of trauma with rapid deceleration, compression, shear, or inertial forces
  • MVC, falls from great heights, blast injuries

Pathophysiology

  • Lung parenchyma damage → alveoli filled with mucus and fluid → decreased compliance, decreased oxygen diffusion, ventilation-perfusion mismatch, and shunting

Clinical

  • May be asymptomatic
  • SOB (dyspnea), hypoxia and increased work of breathing proportional to the degree of contused lung
  • Symptoms progress over hours and usually peak at 72h

Diagnosis

  • CXR
    • Classical: infiltrates or consolidation
    • Normal CXR in 50% pts on arrival → then progress to classic CXR at 24h
  • CT scan
    • More sensitive than CXR → may have parenchymal changes on CT with normal CXR

Treatment

  • Mostly supportive
  • Oxygen, pulmonary toilet, ICU monitoring
  • Avoid over-hydration → may worsen lung edema
  • NPPV may help avoid intubation in selected patients
  • Intubation and PPV if other modalities fail
    • Goal: optimize oxygenation while minimizing further lung trauma
    • Low Vt (6ml/kg) and maintain low Ppl <30

6. Flail Chest

  • Cause
    • Anterior or lateral double fractures of 3 or more adjacent ribs
    • Flail segment moves in during inspiration
  • Diagnosis
    • CXR
    • Chest CT – in severe trauma to evaluate for pulmonary contusion or other associated injuries
  • Treatment
    • Continuous pulse oximetry/ABG
    • Analgesia
    • Mechanical ventilation for severe trauma

7. Rib Fractures

  • Diagnosis
    • CXR (costochondral junction fractures may not be seen)

  • Treatment
    • Mild-moderate pain: oral analgesics
    • Severe pain: IV pain medication or epidural
    • Incentive spirometry
  • Associated injuries
    • Pneumothorax / hemothorax
    • 1st three ribs: subclavian vessels or major bronchi
    • Pulmonary contusion / Blunt Cardiac Injury / Aortic rupture / Diaphragm rupture

Read Also : Penetrating Chest Trauma Algorithm

References

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