Approach to blunt chest injury: Clinical sciences

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Introduction0:00–1:01

Blunt chest injury commonly occurs from motor vehicle accidents, falls, and assault, and can range in severity from mild to life-threatening.
Most of the blunt chest injuries are mild and can be managed non-surgically. However, severe injuries can become rapidly fatal, so timely diagnosis and immediate surgical intervention is key.
These life-threatening injuries include tension pneumothorax, massive hemothorax, and aortic rupture, as well as cardiac tamponade and thoracic vertebral fracture.
Other urgent but less serious injuries include rib fractures, flail chest, sternal fracture, thoracic vertebral fractures, and tracheobronchial and esophageal injuries, in addition to parenchymal lung injuries, hemopneumothorax, blunt aortic injury, and diaphragmatic injury.

Acute Management1:01–2:10

Alright, your first step in evaluating a patient presenting with blunt chest injury is to perform the primary survey using the ABCDE assessment.
First, secure the Airway while stabilizing the cervical spine. Have a low threshold for endotracheal intubation or a surgical airway, especially if the patient cannot protect or maintain their own airway.
Once you’ve secured the airway, ensure adequate Breathing or ventilation by providing supplemental oxygen. Next, assess Circulation and obtain 2 large bore IVs or IO access while continuously monitoring vitals, such as heart rate and blood pressure.
Then, assess Disability and neurologic status by calculating their GCS and examining the pupils and spine, as well as for sensory and motor deficits.
Make sure to ensure spine immobilization until spinal injury has been ruled out. Finally, Expose the patient and remove all clothing to assess for any other associated injuries, and cover the patient with warm blankets to prevent hypothermia.

Unstable Patient2:10–2:38

Once you’ve determined your patient is unstable, your next step is to quickly perform the secondary survey, which is a head-to-toe exam, and adjunctive tests like an e-FAST exam to look for any life-threatening injuries and signs of impending hemodynamic collapse.
Keep in mind, unstable patients might not be able to report symptoms or provide a history. Luckily, the majority of life-threatening conditions can be detected on physical exam and adjunctive tests.

Tension Pneumothorax2:38–3:26

Let’s dive into our first diagnosis, tension pneumothorax. This occurs when a tear in the pleural lining causes air to accumulate in the pleural space, compressing the lung and pushing upon other mediastinal structures like the heart and trachea.
On exam, you can expect to find hypotension, jugular venous distention, tracheal deviation, absent lung sounds on auscultation, along with resonance on percussion of the chest wall.
These are classic findings of a tension pneumothorax and obstructive shock. Needle decompression or a tube thoracostomy should be performed immediately to relieve the pneumothorax.
Our next life-threatening injury is massive hemothorax. This occurs when an injury to the heart, thoracic aorta, or great vessels leads to a large volume of blood accumulating in the thoracic cavity.

Massive Hemothorax3:26–4:16

Physical exam will show hypotension, absent breath sounds and dullness on percussion over the affected side. Additionally, you might see fluid within the pleural cavity on e-FAST, leading you to consider a hemothorax.
Then, place a tube thoracostomy to relieve the blood and reinflate the lung. If there’s an immediate output of blood greater than 1500 cc, your diagnosis of a massive hemothorax is confirmed.
This is an indication for emergent operative intervention. Next up we have aortic rupture.

Aortic Rupture4:16–5:07

This injury is often associated with a high force and speed mechanism, and most patients die before arriving at a hospital.
Those who make it to the hospital might present after losing vitals on the field with CPR ongoing. Patients are likely to be unresponsive and hypotensive, often in extremis.
However, if they show signs of life, an emergency or resuscitative should be performed immediately at the bedside. The goal of the thoracotomy is to directly visualize the injury and provide temporizing measures as fast as possible.
Visualization of the ruptured aorta will establish your diagnosis of aortic rupture. Of note, even if the injury is repaired, mortality rates remain high.
Now let’s move on to cardiac tamponade. This injury occurs when blunt trauma causes bleeding into the pericardial sac.

Cardiac Tamponade5:07–5:47

As blood accumulates, it restricts the heart, causing obstructive shock. On physical exam, you can expect to see hypotension, JVD, and muffled heart sounds, also known as the Beck triad.
If, on e-FAST, you can see abnormal fluid within the pericardial sac, your diagnosis is confirmed. Pericardiocentesis or pericardial window should be performed to drain the pericardial space.
Our last life-threatening condition is thoracic vertebral fracture. This occurs after high impact mechanisms of injury.

Thoracic Vertebral Fracture5:47–6:30

Exam will typically reveal bony step-offs and tenderness on palpation of the spine, with associated motor or sensory deficits.
On chest x-ray, you can see a fracture of the thoracic vertebrae. Make sure to immobilize the spine in these patients at all times until definitive treatment is provided.
Here’s a clinical pearl! If the patient is stable, the diagnosis of a thoracic vertebral fracture should be confirmed with dedicated spine x-rays or CT.

Stable Patients6:30–7:09

Now that unstable patients are taken care of, let’s talk about stable patients. Unlike immediately life-threatening conditions that are typically recognized during the primary survey, injuries in a stable patient might not be as obvious.
So, your next step is to perform a thorough secondary survey and obtain adjunctive tests, such as a full set of trauma labs including type and screen, ABG, CBC, CMP, lactate, urinalysis, pregnancy test, and urine tox screen.
Additionally, diagnostic tests such as chest x-ray, e-FAST, and CT chest can help narrow down your differential. First up, we have rib fractures.

Rib Fracture7:09–7:54

This is a common injury that can happen after low impact traumas, like a fall, or high-impact, like motor vehicle collisions.
Patients typically report localized chest pain that’s worse on inspiration, and exam will reveal chest wall tenderness on palpation.
Chest x-ray showing a fracture line on the rib is diagnostic. Here’s a clinical pearl!
If the patient has fractures of the lower ribs, so ribs 9 through 12, look for underlying solid visceral organ injuries like the spleen on the left and the liver on the right.
Next, we have flail chest. This occurs when 3 adjacent ribs are fractured in two places.

Flail Chest7:54–8:25

This causes the classic paradoxical chest wall motion, where the flail segment moves inward during inspiration and expands during expiration.
In these patients, a chest x-ray will show fractures on three contiguous ribs, in two places per rib, confirming the diagnosis.
Now, let’s discuss sternal fractures. Patients typically report pain in the middle of the chest and show tenderness over the sternum on physical exam.

Sternal Fracture8:25–9:01

The initial chest x-ray might show a fracture line in the sternum, (Image confirming your diagnosis. Here’s another clinical pearl!
Although the incidence of blunt cardiac injury associated with sternal fractures are low, if there are any concerns, obtain an ECG and troponin levels.
A normal ECG and negative troponin rules this out. Next, let’s explore aerodigestive tract injuries, meaning injuries to the thoracic tracheobronchial tree and esophagus.

Tracheobronchial and Esophageal Injury9:01–9:57

These are typically seen in high-impact or high-speed traumas like acceleration-deceleration injuries. On physical exam, you might see crepitus around the face, neck, or chest; with hemoptysis or cyanosis in extreme cases.
Chest x-ray will reveal pneumomediastinum and subcutaneous emphysema, which should lead you to consider an aerodigestive tract injury.
Your next step is to order bronchoscopy or contrast esophagram. Direct visualization of main airway injury on bronchoscopy is diagnostic of tracheobronchial injuries; while extravasation of contrast from the esophagus on the esophagram confirms an esophageal injury.

Parenchymal Lung Injury (Pulmonary contusions)9:57–10:45

Let’s move on to pulmonary parenchymal injury, which can range from a minor contusion to severe crush injury. On physical exam, patients often exhibit chest wall tenderness as well as increasing oxygen requirements.
This occurs from the pulmonary edema that develops as a sequelae of parenchymal injury. Chest x-ray will typically show bilateral patchy airspace opacities, and other clues like rib fractures may also be present.
On CT, you can expect to see focal areas of patchy opacities. These findings combined support your diagnosis of a parenchymal lung injury, also known as pulmonary contusions.

Aortic Injury10:45–11:38

Next we have blunt aortic injury. Aortic injuries are associated with rapid deceleration mechanisms and most commonly occur at the aortic isthmus just distal to the takeoff of the left subclavian artery.
Exam typically reveals chest wall tenderness and asymmetric upper extremity blood pressures. The e-FAST might show a disruption in the wall of the aorta with some periaortic or mediastinal fluid; while chest x-ray shows a widened mediastinum.
On CT chest, you might see an aortic intimal flap, or you may see either a contained or ruptured pseudoaneurysm, which would have accompanying mediastinal hematoma.
All of these findings confirm a blunt aortic injury. Our final diagnosis is diaphragmatic injury.

Diaphragmatic Injury11:38–12:15

Although more common in penetrating injuries, diaphragmatic injuries can occur with high impact or sudden deceleration of the thoracoabdominal region.
Of note, diaphragm injuries most commonly occur on the left side because the liver protects the right dome of the diaphragm.
On exam, you might hear bowel sounds on chest auscultation. Chest x-ray revealing gastric bubble or loops of bowel in the thorax is diagnostic.
Alright, as a quick recap… Blunt chest injury often occurs from motor vehicle collisions, falls, and assault. Your first step is to perform a primary survey to determine if the patient is stable or unstable.

Review12:15–12:55

In an unstable patient, look for life-threatening injuries such as tension pneumothorax, massive hemothorax, aortic rupture, cardiac tamponade and thoracic vertebral fractures.
In stable patients, injuries include rib fracture, flail chest, sternal fracture, tracheobronchial or esophageal injury, and parenchymal lung injury,