Continuing Education Activity

Chest trauma has quickly risen to the second most common traumatic injury in non-intentional trauma. Trauma to the chest comes with the highest mortality; in some studies, up to 60%. Quick thinking and early interventions are key factors for evaluations, management, and survival. This activity reviews the cause and presentation of chest trauma and highlights the role of the interprofessional team in its management.

Objectives:

• Review the etiology of chest trauma.
• Describe the presentation of chest trauma.
• Summarize the management of chest trauma.
• Outline improving care coordination among interprofessional team members to improve outcomes for patients affected by chest trauma.

Introduction

Chest trauma has quickly risen to the second most common traumatic injury in non-intentional trauma. Trauma to the chest comes with the highest mortality; in some studies, up to 60%. [1] Quick thinking and early interventions are key factors for evaluations, management, and survival.

Etiology

Chest trauma can be a result of penetrating or blunt trauma. Blunt trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-threatening. It is essential to know the mechanism as management may be different.[2][3] Most blunt trauma is managed non-operatively, whereas penetrating chest trauma requires operative intervention.

Epidemiology

All age ranges are at risk for chest trauma. After head and extremity trauma, chest trauma is the third most common blunt injury and quickly rises to second. Motor vehicle injuries are the most common of these. However, this is declining with the advent of improved vehicle safety.[3][4][5][6][7]

Evaluation

Early recognition of trauma to the chest is a priority. The first 3 steps of trauma evaluation involve evaluation, recognition, and intervention of potential injuries to “the box.” Following a routine method of evaluation reduces missed injuries. Injuries to the heart and lungs are primary and vital since they have the highest mortality if missed. Injuries to other thoracic structures also need to be considered; ribs, clavicle, trachea, bronchi, esophagus, and arteries including the aorta and veins need to be evaluated in the secondary and tertiary survey.

The primary survey serves as a time to identify immediately life-threatening injuries. These injuries should be addressed at the time of identification.

Potential injuries that should be ruled out are:

• Large hemothorax
• Large pneumothorax
• Pericardial effusion with or without tamponade

Once the initial exam is complete and adjunct imaging is complete, a secondary survey may reveal:

• Rib fractures
• Small hemothorax
• Small pneumothorax
• Pulmonary contusion
• Chest wall contusion

There are physical exam findings that increase suspicion of chest trauma. Contusions of the chest wall in the pattern of seatbelts, point tenderness over the ribs, decreased breath sounds over the hemothorax, tachypnea, hypoxia, alone or in conjunction with other findings suggest thoracic trauma. The mechanism should also be considered. If the mechanism warrants a high level of suspicion, an ECG should be done to evaluate cardiac contusion.[5][7]

Diagnostics

While chest radiography prevails, it does have limitations. Since chest radiography is achieved in the supine position, small and medium-sized pneumothoraces and hemothorax may be missed.[8][9][10]

The extended-Focused Assessment with Sonography in Trauma (eFAST) may be done with the primary survey, especially in the unstable patient. This can help quickly identify places with air and or blood and direct, definitive management. Compared to supine chest radiography, bedside eFAST is more sensitive to evaluate for pneumothorax. [11][12][13][14]

The 4 views of the traditional Focused Assessment with Sonography in Trauma (FAST) exam include the cardiac (subxiphoid) window, right upper quadrant (RUQ, or Morrison’s pouch), left upper quadrant (LUQ), and suprapubic (bladder) window. The presence of a black collection outside of an organ, viscera, or pericardia suggests a +FAST exam.

The eFAST includes pulmonary views to evaluate for pneumothorax and hemothorax, in addition to the traditional four views. eFAST should be started in the area where there is the highest suspicion for injury. If the thorax is of concern, then this is where the eFAST should begin. This includes anterior chest wall evaluation between ribs for pneumothorax and looking for the continuation of the spinal stripe caudal to the diaphragm in the RUQ and LUQ windows to evaluate for hemothorax. The spinal stripe can be present in cases of pleural effusion. Similar to a positive FAST exam, any presence of fluid in the trauma patient is assumed to be blood.

Computed tomography (CT) is more sensitive and specific. However, this requires the patient to be stable enough for transport.

Other adjuncts include endoscopy, bronchoscopy, and electrocardiography to complete evaluation when warranted. [15][16]

Treatment / Management

Once the ABCs (airway, breathing, circulation) have been addressed, injury-specific interventions should be undertaken.

Immediate life-threatening injuries require prompt intervention, such as emergent tube thoracostomy for large pneumothoraces and initial management of hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted thoracoscopic surgery.[15][17]

The majority of thoracic trauma can be managed non-operatively. However, operative management should not be delayed when appropriate. Operative exploration of thoracic injuries should be considered if tube thoracostomy drainage exceeds 1000-1500mL immediately, about 200 mL per hour for 2 to 4 hours, or ongoing resuscitation (blood transfusion, persistent hypotension) with no other discernable cause.

Admission

Minor injuries may require close monitoring and pain control. Care should be taken in the young and the elderly. Patients with 3 or more rib fractures, a flail segment, and any number of rib fractures with pulmonary contusions, hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at an advanced level of care.

Pain Control

Pain control significantly affects mortality and morbidity in patients with chest trauma.[18]  Pain leads to splints which worsen or prevent healing. In many cases, it can lead to pneumonia. Early analgesia should be considered to decrease splinting.  In the acute setting, push doses of short-acting narcotics should be used.

Other pain control options include intrapleural nerve blocks, transdermal patches, intravenous patient control analgesia (PCA), and epidural analgesia.

Nonnarcotic transdermal patches are safe pain management options for many patients. It should be considered for patients with persistent chest wall pain despite lack of confirmed rib fractures, the patient's being discharged, or as an adjunct while admitted.

Antibiotics

Prophylactic antibiotics administration for tube thoracostomy for blunt thoracic trauma did not reduce the incidence of empyema or pneumonia when placed with sterile technique.[19]

It should be considered in cases of grossly contaminated wounds or where the sterile technique was broken.

Following steps should be considered in managing pulmonary contusion due to chest trauma.

Operative Management of Rib Fractures

Open reduction and internal fixation (ORIF) has been shown to decrease mortality in patients with flail chest, shorten the duration of mechanical ventilation, reduce hospital length of stay, and reduce intensive care length of stay.[20]

Most pulmonary contusions require supportive therapy until the contusion heals. Because contusions can gradually evolve over the first 24-48 hours after trauma, close monitoring is required. The goal of therapy is to prevent respiratory insufficiency, failure, and complications.[21] There should be appropriate pain control to prevent splinting of chest muscles secondary to injury and allow lung expansion. 

Supportive care like postural drainage, suctioning, chest physiotherapy, incentive spirometry, encouraging coughing, and deep breathing can be tried to prevent atelectasis. Positive pressure ventilation using CPAP and BiPAP may be used.[22]It is of utmost importance to provide minimum positive end-expiratory pressure (PEEP) to maintain the lungs open, recruit maximum alveoli, and prevent barotrauma.[23]Prone positioning of the patient with contusion reduces stress on the diaphragm, and positioning of the contused lung in a non-dependent position helps in recruiting alveoli. Noninvasive ventilation can cause gastric distention and aspiration significantly if the level of consciousness is impaired. If positive pressure ventilation fails, invasive ventilation is required. Large tidal volume can have adverse effects; hence the use of low tidal volume is suggested. Patients with severe hypoxia and poor response to other therapies can benefit from nitric oxide. Diuretics can be used in a contusion to reduce pulmonary venous resistance and pulmonary capillary hydrostatic pressure.[5] If fluid therapy is required to maintain euvolemia, measuring pulmonary artery pressure is recommended to avoid pulmonary edema.

Surgical stabilization may be required in the case of multiple rib fractures/ flail chest to correct pulmonary mechanics. Patients refractory to all conventional therapies have been successfully managed by extracorporeal gas exchange (ECMO).[24]

Differential Diagnosis

A complete primary, secondary, and tertiary survey should be completed to avoid missed or confounding injuries.

Pearls and Other Issues

Special Populations

Geriatric patients have higher mortality compared to younger patients with the same injuries.

Elderly patients with a single rib fracture have twice the mortality as their younger counterparts with the same injury. Mortality increases by 19% for each additional rib and the risk of pneumonia by 27%.[25][26]

Enhancing Healthcare Team Outcomes

Chest trauma is a common problem encountered by emergency department physicians. Because there are usually many other organs involved in chest trauma, the condition is best managed by an interprofessional team that consists of a trauma surgeon, nurse practitioner, anesthesiologist, thoracic surgeon, ICU nurses, and cardiac surgeon. In many cases, it takes enormous force to cause injury to the organs inside the chest cavity and associated organ injury is common. 

Depending on the extent of injury, the outcomes of chest trauma vary. For isolated rib fractures, the prognosis is good, but if the aortic has been disrupted or there is lung or cardiac contusion, the recovery is often prolonged. The highest morbidity following chest trauma is seen in very young and very old patients.[27][28] [Level 5]