What is the management of blunt trauma to the chest?

From the Guidelines

Blunt trauma to the chest should be managed with a systematic approach, prioritizing the ABCs (airway, breathing, circulation) of trauma care, and considering surgical stabilization of rib fractures (SSRF) in appropriate cases, as it has been shown to improve outcomes in patients with severe chest wall injuries 1. The initial assessment should focus on identifying life-threatening injuries such as tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and cardiac tamponade.

• Supplemental oxygen should be provided to maintain oxygen saturation above 94%, and patients may require intubation if respiratory distress is severe.
• Pain control is essential using medications like morphine (2-4 mg IV every 5-10 minutes as needed), fentanyl (25-50 mcg IV every 30 minutes as needed), or ketorolac (15-30 mg IV/IM every 6 hours).
• For pneumothorax, needle decompression using a 14-16 gauge needle in the second intercostal space at the midclavicular line may be necessary, followed by chest tube placement (28-40 French tube) in the 4th-5th intercostal space at the anterior axillary line.
• Hemothorax requires chest tube drainage and possibly surgical intervention if bleeding exceeds 1500 mL initially or continues at >200 mL/hour.
• Rib fractures should be managed with adequate analgesia, which may include intercostal nerve blocks with 0.25% bupivacaine or thoracic epidural analgesia for severe cases, and consideration of SSRF in patients with flail chest or multiple and displaced rib fractures, as recommended by the World Journal of Emergency Surgery 1.
• Pulmonary contusions require supportive care with oxygen, careful fluid management, and possibly ventilatory support. Serial chest imaging and continuous monitoring of vital signs are crucial as some injuries may develop or worsen over 24-48 hours after the initial trauma, and CT chest with IV contrast may be useful in identifying the source of bleeding and ruling out concomitant cardiovascular injury 1. Additionally, echocardiography can be useful in patients with signs of heart failure or abnormal heart sounds to diagnose the cause of dysfunction and identify other injuries requiring intervention or monitoring for arrhythmia 1.

From the Research

Management of Blunt Trauma to the Chest

The management of blunt trauma to the chest involves several key aspects, including:

• Initial patient assessment and acute care priorities 2
• Pain management to improve ventilatory function, such as continuous epidural fentanyl analgesia (CEFA) 3
• Mechanical ventilation strategies to prevent further injury and support respiratory function, including noninvasive ventilation, airway pressure release ventilation, and high-frequency oscillatory ventilation 4
• Individualized treatment based on the magnitude, location, and type of lung or chest injury 5

Ventilatory Management

Ventilatory management in patients with blunt chest trauma is crucial to prevent further injury and support respiratory function. This may include:

• The use of CEFA to improve ventilatory function and provide effective pain relief 3
• The application of mechanical ventilation strategies, such as airway pressure release ventilation and high-frequency oscillatory ventilation, to recruit and stabilize alveoli at low pressures 4
• The importance of preventing ventilator-induced lung injury and optimizing oxygenation 5

Special Considerations

In certain cases, special considerations may be necessary, such as:

• The performance of out-of-hospital chest escharotomy in patients with circumferential chest burns to restore chest expansion and ventilation 6
• The use of systematic care pathways to improve outcomes for patients with blunt mechanism chest wall injury 2