Management of Blunt Trauma Chest Injuries

I’m Ed Smith, a Sacramento Chest Trauma Lawyer. Patients who seem clinically stable and have no apparent injury but have suffered a high energy blunt trauma injury from rapid deceleration, such as in an automobile accident, are at risk of having severe injury to the chest. A portable chest x-ray is part of the initial evaluation. If this is normal and there are no other injuries, a regular chest x-ray including lateral x-ray should be performed. A CT scan of the chest is done if there are any findings of suspicion on chest x-ray.

An EKG is performed on all patients who have sustained chest trauma to the front of the chest, patients who have a history of heart disease, and in the elderly. Patients who have no findings on any of the above evaluations and are otherwise stable, may be sent home. They should be told of the possibility of delayed issues and told to return to the emergency department immediately if they develop problems breathing, lightheadedness, or severe pain in the chest.

Cardiac Injuries

A cardiac contusion should be evaluated with an EKG in patients who have sustained a blunt trauma to the chest and have the following findings:

Fracture of the sternum
Pain or tenderness over the mid-chest area
A history of heart disease
Rollover, high speed collision, or a fatality in the accident
Signs of ongoing heart disease

If there are cardiac arhythmias, the patient should be watched via cardiac monitoring and may need an echocardiogram.

Myocardial Rupture

Most people who have a severe blunt injury to the heart do not survive to reach the emergency department. Many of those who do survive suffer from low blood pressure that can lead to rupture as the fluids given will raise the blood pressure.

Nonspecific signs usually make it difficult to diagnose an injury to the heart. If there is low blood pressure and distended veins in the neck or muffled heart sounds, this may mean there is a cardiac tamponade and serious heart injury. A bedside echocardiogram should be done in those who have unexplained shock despite aggressive resuscitative efforts. A pericardiocentesis should be done if an echocardiogram is unavailable.

An emergency department thoracotomy may need to be done rather than a pericardiocentesis if the patient can’t be moved to surgery. Delay the intubation just before cutting into the sternum because this might make low blood pressure worse.

Myocardial Infarction

This is an uncommon complication of having blunt trauma to the chest. It can be caused by dissection of a coronary artery or a blood clot in a coronary artery. The most common artery involved is the left anterior descending artery. A rapid EKG should be done in a chest wall trauma to screen for MI or cardiac contusion.

Pneumothorax

Pneumothorax is common after blunt trauma to the chest, especially if a rib is fractured. Common symptoms are shortness of breath, low oxygenation, chest pain and absent breath sounds. The best way to identify this is to do a chest x-ray while the person is lying down, although an ultrasound can help.

Patients with historical findings or examination findings should have a chest x-ray during inspiration and expiration or a CT scan of the chest. A repeat chest x-ray can be done if there is suspicion but no findings on x-ray.

Silent pneumothorax can be seen on CT scan. This happens about 5-10 percent of the time. The greatest risk of these hidden pneumothoraxes are that they might get bigger when you intubate the patient and put air into the lungs under pressure. Most of these can be treated through observation rather than using a chest tube. Not all trauma surgeons recommend chest tubes in these cases.

Hemothorax

This involves bleeding into the chest space. It can come from rupture of the heart, aortic rupture or other chest structures. It takes about 300 milliliters of fluid in order for it to show up on a chest x-ray. An ultrasound may be a better test.

This is treated usually with a chest tube that will drain the blood. If about 1500 milliliters of fluid come out, this usually means doing an open surgical procedure to identify and treat the cause. If both blood and air are in the chest space, a chest tube can usually take care of the problem.

Pulmonary Contusion

This is a bruising of the lungs. It usually takes about 24 hours to manifest itself and goes away after a week. It can be seen on x-ray. About a third of the time it cannot be seen on initial chest x-ray but a CT scan will show the problem. The main treatment is to control pain and prevent pneumonia. It only needs to be treated with intubation if the person is short of breath or has low oxygen levels. Common complications of this type of bruising are adult respiratory distress syndrome and pneumonia.

Tracheobronchial Injury

This is uncommon, happening in only about one percent of patients with blunt trauma to the chest. Most of these people die at the scene. The trachea is relatively protected because it is elastic and protected behind the sternum and vertebral column. Injury to the cervical part of the trachea can result from a direct blow to the trachea. Lower injuries need a high energy trauma, such as a motor vehicle accident or crush injury.

It is often difficult to diagnose this type of injury and it is often a delayed diagnosis. It often shows as a pneumothorax or a pneumo-mediastinum that keeps on happening after putting in a chest tube. There is air in the tissues, hoarseness, and shortness of breath.

It takes a bronchoscopy evaluation to make the definitive diagnosis. Sometimes a CT scan can diagnose a tracheal laceration but it may not be sensitive. If a rupture of the trachea is suspected, a thoracic surgeon should be contacted to do a bronchoscopy. If a rupture is detected, it can be repaired surgically or just observed if it isn’t very serious.

Esophageal Rupture

This is rare after blunt trauma to the chest. There are very few specific symptoms and often there are other serious injuries associated with this injury. Injuries may be seen in any part of the esophagus. Signs of injury include blood in the nasogastric tube, air in the tissues, and a neck blood clot.

X-ray will show air in the mediastinum, a gas bubble in the nasogastric tube, or fluid in the lung space. Endoscopy can be done to make the diagnosis or esophagography with a water soluble contrast. CT scan can also help make the diagnosis.

I’m Ed Smith. A Sacramento Chest Trauma attorney. Call me anytime for free, friendly advice at 916-921-6400 in Sacramento.

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Management of Blunt Trauma Chest Injuries