Chest Trauma: Diagnosis and Management
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The distance between the ETT and carina ranged between 1. No patient was at immediate risk of endobronchial intubation. Pak et al in and Hunyady et al in developed similar assessments of optimal ETT placement. The average of the 3 scores Pak, Hunyady, and Chula is nearly identical to the Chula formula. The Blast Lung Injury Severity Score stratifies primary blast lung injuries into 3 categories to guide ventilator treatment. 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.
Use the BLI Severity Score in patients who have sustained blast injury and have respiratory symptoms eg, cough, cyanosis, dyspnea, hemoptysis. Intubated patients require the following ventilation management:. The study evaluated 15 patients with primary BLI after explosions on 2 civilian buses.
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 PaO 2 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.
- Vascular injuries after blunt chest trauma: diagnosis and management;
- Chest Trauma: An Overview - MedCrave online.
- Microquasars: Proceedings of the Third Microquasar Workshop Granada Workshop on Galactic Relativistic Jet Sources Granada, Spain, 11–13 September 2000.
In comparison, Avidan et al, in , 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.
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. Eric J. Date of Original Release: June 1, Date of most recent review: May 10, Termination date: June 1, Physicians should claim only the credit commensurate with the extent of their participation in the activity. AAFP accreditation begins July 1, 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. 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.
The information received is as follows: Dr. Morley, Dr. Johnson, Dr. Leibner, Dr. Shahid, Dr.
Anesthesia & Critical Care: Open Access
Parekh, Dr. Tainter, Dr. Jagoda, Dr. Shah, Dr. Damilini, Dr. A methodical approach to the radiograph is necessary to evaluate the airway and bilateral hemithoraces, the cardio-mediastinal silhouette, the diaphragmatic contours. Bony disruption and subcutaneous emphysema are readily diagnosed on anteroposterior AP radiograph. The appropriate placement of the endotracheal tube and access lines must be confirmed and the presence of foreign bodies identified.
In hemodynamically stable patients, chest CT offers higher resolution imaging and is far more sensitive in diagnosis of small anterior pneumothoraxes, lung contusions and lung lacerations, as well as bony injury of the sternum, scapula, ribs and spine. The increased diagnostic yield however, may only matter to clinical management in a few instances. CT remains is the gold standard in the evaluation of the cervico-thoracic spine.
Chest Trauma. Diagnosis and Management : Critical Care Medicine
Additionally, in patients with a severe energetic mechanism or widened mediastinum, CT may help definitively diagnose aortic injury 6 , 7. Lastly, for stable patients with extensive chest wall injuries the use of 3D reconstruction is often helpful to operative planning for potential rib fixation. Operative reduction and fixation ORIF of the chest wall has been evolving as an additional method of chest wall stabilization. Those who are candidates for operative fixation generally have significant pain that is difficult to control, and respiratory impairment from the impact of the flail segment on the mechanics of the chest wall.
Over the years, many attempts have been made to fashion devices to stabilize the chest wall. These devices have evolved from simple silk suture fixation to measured plates in anatomical configuration and bracketed fixators. The simple idea behind these devices has been to stabilize the chest wall to improve pain and respiratory mechanics.
Multiple randomized controlled trials have indicated decreased rates of pneumonia and shorter time on the ventilator when patients with rib fractures are treated with surgical fixation 16 - Two randomized controlled trial deserve mention. Tanaka et al. The control group was managed with internal stabilization with positive end-expiratory pressure PEEP , synchronous intermittent mandatory ventilation SIMV and pressure support.
Long-term outcomes for return to work also heavily favored operative stabilization A more contemporary study by Marasco et al. Two recent a meta-analysis has evaluated surgical fixation. The second meta-analysis by Kasotakis et al. This included both retrospective and three randomized controlled trials including Tanaka and Marasco.
The data had a wide variety of surgical techniques including struts, wires and plates; as well as, significant heterogeneity in the conservative management strategies of intubation, tracheostomy and fluid management. Only one study evaluated pain as an outcome and incorporated 37 patients.
Surgical rib stabilization demonstrated consistent improvement in duration of mechanical ventilation, ICU and HLOS, pneumonia rates and need for tracheostomy Although the available evidence is not without its limitations, there is randomized controlled prospective data supporting surgical fixation in appropriately selected patients 13 , 14 , 16 , 19 - 25 , 27 , 28 see Table 1. There have been several techniques described to stabilize the rib, and currently there is no evidence to support one method of fixation over another.
Previously, wire cerclage was used to secure anterior metal plates to bridge the fracture. Given the propensity for fracture of the wire itself and subsequent dislodgement of the plate, uni- and bi-cortical screws have now replaced wire cerclage as fixation points for the anterior plate. Bi-cortical screws are generally sized for the thickness of the rib, and care is taken to avoid placing screws through the posterior cortex and into the pleura.
Judet struts, which are placed without screw fixation and similar U-plates with locking screws provide similar fixation without the need for a long span of healthy rib to anchor the device, but carry a theoretical risk of intercostal nerve impingement from the inferior portion of the hardware locking around the rib. Fixation should aim to immobilize the fracture enough to allow pain relief and healing, but leave room for micromovement at the fracture site to promote osteoclast activity and callous formation.
Fractures of ribs 3—10 are considered for repair due to the difficulty in reaching ribs 1 and 2, and minimal contribution of these and ribs 11 and 12 to respiratory mechanics. Attempts should be made to stabilize both fracture lines, however, if additional exposure is necessary it may be sufficient to stabilize one fracture line without impairment in pain control or pulmonary function Posterior fractures within 2. Furthermore, the generation muscular support and stability afforded in this region usually obviates the need for fixation close to the spine. Additionally, techniques have been described to fix anterior fractures to the costal cartilage or sternum but are currently off label uses of the available products Figures 1,2.
The treatment of the unstable chest injury has evolved significantly.
Mandatory mechanical ventilatory support solely for chest wall stabilization has been abandoned. Increased use of noninvasive strategies involves intensive pulmonary toilet and involvement of respiratory therapy for volume expansion with incentive spirometry, noninvasive positive airway pressure, and cough-assist. High flow nasal cannula oxygen alone may be able to allow patients to avoid or delay mechanical ventilation.
Two meta-analyses supported the use of noninvasive ventilation NIV in chest trauma. Roberts et al. Both included three randomized controlled trials.
Although there was significant heterogeneity in terms of injury severity, level of hypoxemia and timing of intervention, NIV was safe with no increased morbidity and mortality. Chiumello et al. Overall arterial oxygen saturations were significantly higher with a significant reduction in intubation Interestingly, no meta-analysis has shown a significant reduction in mortality with NIV 34 - If patients are requiring high flow oxygen or non-invasive ventilation close observation should be undertaken in the intensive care setting to monitor for acute decompensation or need for invasive ventilation.
Attention to patients with concomitant intracranial injuries is required as these patients necessitate a higher arterial oxygen levels and hypoxemia should not be tolerated in this population. The most severe forms of chest trauma warrant endotracheal intubation and mechanical ventilation for impending or manifest hypoxemic or hypercapnic respiratory failure. The insult of pulmonary contusion and subsequent alveolar-capillary leak can lead to poor lung compliance.
The use of PEEP to recruit alveoli and decreased shunting is advised, and continuous positive airway pressure can be used to improve compliance. Several modes of ventilation have been studied, and no single mode has been proven more effective for patients with flail chest or pulmonary contusion 38 , Management of ventilator modes should be left to provider comfort and familiarity. Independent lung ventilation can be useful in the situation where a patient has a discrepant injury burden to each side of the chest resulting in a severely injured lung and a relatively normal contralateral lung.
This allows lower tidal volumes and lung rest for the injured lung, which optimizing gas exchange with the healthy lung. There are few well-established indications for independent lung ventilation for trauma as the incidence is relatively rare. One such indication is the demonstration of paradoxical PEEP, which is hyperinflation of the healthy lung causing a fall in PaO 2 and increased shunting to the injured lung.