Chest Trauma (Adult)

Quick Reference

Critical Alerts

⚠️ Red Flag: IMMEDIATELY LIFE-THREATENING - "ATOM FC"

• Airway obstruction - Secure airway immediately
• Tension pneumothorax - CLINICAL DIAGNOSIS; needle decompress NOW (do not wait for imaging)
• Open pneumothorax - Three-sided occlusive dressing, then chest tube
• Massive hemothorax - > 1500 mL initial or > 200 mL/hr for 2-4 hours = emergent thoracotomy
• Flail chest - Paradoxical movement; underlying pulmonary contusion causes mortality
• Cardiac tamponade - Beck's triad (present in less than 40%); pericardiocentesis or ED thoracotomy

Key Diagnostics

Emergency Interventions Algorithm

CHEST TRAUMA - IMMEDIATE ACTIONS
================================
                    |
        Tension Pneumothorax?
        (Clinical diagnosis)
              /         \
           YES           NO
            |             |
    Needle Decompress    |
    → Tube Thoracostomy  |
                         |
               Massive Hemothorax?
               (> 1500mL, unstable)
                /           \
             YES             NO
              |               |
        Thoracotomy          |
                             |
                    Cardiac Tamponade?
                    (Beck's triad, eFAST+)
                       /         \
                    YES           NO
                     |             |
             Pericardiocentesis    |
             or ED Thoracotomy     |
                                   |
                         Open Pneumothorax?
                            /         \
                         YES           NO
                          |             |
                   3-sided dressing   Continue
                   → Chest tube       secondary survey

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Definition and Overview

Chest trauma encompasses injury to the thoracic cage and its contents, including the chest wall, pleura, lungs, tracheobronchial tree, heart, great vessels, esophagus, and diaphragm. It represents a leading cause of trauma-related mortality worldwide and is responsible for approximately 20-25% of all trauma deaths. [1]

Thoracic injuries contribute to mortality in an additional 25-50% of trauma deaths, typically as a contributing factor rather than the primary cause. [1,2] The majority (85%) of chest injuries can be managed with tube thoracostomy and supportive care, while only 10-15% require operative intervention. [3]

Classification by Mechanism

Anatomical Zones of the Thorax

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Epidemiology

Chest trauma epidemiology demonstrates significant regional variation based on mechanism predominance. Globally, blunt trauma predominates in high-income countries, while penetrating trauma is more common in regions with high rates of interpersonal violence. [1,2]

Incidence and Prevalence

Risk Factors for Adverse Outcomes

Mechanism-Specific Epidemiology

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Pathophysiology

Immediately Life-Threatening Injuries (The Lethal Six)

Understanding the pathophysiology of immediately life-threatening chest injuries enables rapid diagnosis and appropriate intervention.

1. Tension Pneumothorax

Mechanism: One-way valve effect allowing air entry to pleural space during inspiration but preventing egress during expiration.

Pathophysiology cascade:

1. Progressive air accumulation in pleural space
2. Complete lung collapse on affected side
3. Mediastinal shift to contralateral side
4. Compression of contralateral lung (reduced ventilation)
5. Kinking of great veins (SVC, IVC) at thoracic inlet
6. Reduced venous return → decreased cardiac preload
7. Cardiovascular collapse (obstructive shock)

Time to cardiovascular collapse: Minutes to hours depending on rate of air accumulation.

Exam Detail: Physiological Changes in Tension Pneumothorax

Key distinction from simple pneumothorax: Tension pneumothorax causes hemodynamic compromise; simple pneumothorax does not.

2. Massive Hemothorax

Definition: Accumulation of > 1500 mL blood in the pleural cavity or blood loss rate > 200 mL/hour for 2-4 consecutive hours. [8]

Pathophysiology:

• Bleeding source: Intercostal vessels, internal mammary artery, pulmonary hilar vessels, great vessels, or heart
• Each hemithorax can accommodate 3000-4000 mL blood
• Dual insult: Hemorrhagic shock + respiratory compromise from lung compression

Blood loss correlation with clinical signs:

3. Cardiac Tamponade

Mechanism: Accumulation of blood in pericardial sac (capacity 15-35 mL normally, can accommodate 80-120 mL acutely) restricting ventricular filling.

Pathophysiology:

1. Blood accumulates in pericardial space
2. Pericardium is non-compliant acutely (unlike chronic effusions)
3. Intrapericardial pressure increases
4. Diastolic filling impaired (right ventricle first, then left ventricle)
5. Stroke volume decreases progressively
6. Compensatory tachycardia and vasoconstriction initially
7. Eventual equalization of diastolic pressures and cardiovascular collapse

Pulsus paradoxus: > 10 mmHg decrease in systolic BP during inspiration (exaggerated normal finding) - present in 80% of tamponade cases.

Clinical Pearl: Beck's Triad (hypotension, distended neck veins, muffled heart sounds) is present in only 22-35% of trauma tamponade cases. [9] Do not wait for the complete triad before intervention.

4. Open Pneumothorax (Sucking Chest Wound)

Definition: Full-thickness chest wall defect creating communication between atmosphere and pleural space.

Pathophysiology:

• Air preferentially enters through chest wall defect if defect diameter exceeds 2/3 of tracheal diameter (critical threshold)
• Equilibration of intrapleural and atmospheric pressure
• Lung collapse on affected side
• Ineffective ventilation (air moves through wound rather than trachea)
• Mediastinal flutter with respiration may occur

Critical size threshold: Defect > 2/3 tracheal diameter (~10-12mm) causes preferential air flow through wound.

5. Flail Chest

Definition: Fracture of ≥3 consecutive ribs in ≥2 places, creating a free-floating segment that moves paradoxically with respiration.

Pathophysiology:

1. Flail segment moves inward during inspiration (paradoxical movement)
2. Pendulum-like movement of air between lungs (pendelluft) - disputed physiological significance
3. Primary cause of mortality: Underlying pulmonary contusion (present in 75-100% of flail chest cases) [7]
4. Pain-limited ventilation → atelectasis → pneumonia
5. ARDS may develop in 15-20% of cases

Exam Detail: Why Flail Chest Causes Respiratory Failure

The historical teaching emphasized paradoxical movement and pendelluft as primary mechanisms. Current evidence indicates:

1. Pulmonary contusion is the primary determinant of outcome [7]
2. Pain causing splinting and ineffective cough
3. Mechanical inefficiency is a contributing but secondary factor
4. Intubation and positive pressure ventilation immediately corrects the mechanical defect but does not address contusion

This explains why external splinting (obsolete practice) did not improve outcomes.

6. Airway Obstruction

Mechanisms in chest trauma:

• Blood/secretions in airway
• Laryngeal/tracheal injury (fracture, transection)
• Foreign body aspiration
• Facial/mandibular trauma compromising upper airway
• Decreased consciousness (head injury)

Potentially Life-Threatening Injuries

Pulmonary Contusion

Definition: Hemorrhage and edema within the lung parenchyma without laceration.

Pathophysiology:

1. Blunt force transmitted through chest wall
2. Alveolar disruption and capillary hemorrhage
3. Interstitial edema develops over 24-48 hours
4. Ventilation-perfusion mismatch (shunt)
5. Decreased compliance
6. Peak severity at 24-72 hours post-injury
7. Resolution typically by 7-10 days

CT findings precede CXR findings: CT detects contusion immediately; CXR findings may take 6-24 hours to manifest.

Blunt Cardiac Injury (BCI)

Spectrum of injury:

Risk factors for BCI:

• Steering wheel impact (deceleration injury)
• Sternal fracture (OR 2.8 for significant BCI) [10]
• Multiple anterior rib fractures
• High-speed deceleration mechanism

Traumatic Aortic Injury (TAI)

Mechanism: Rapid deceleration causing shear stress at points of relative fixation.

Locations by frequency:

1. Aortic isthmus (90%) - just distal to left subclavian origin
2. Aortic root (5%) - typically fatal at scene
3. Diaphragmatic hiatus (5%)

Natural history: 75-90% of patients with complete TAI die at scene. Those reaching hospital have contained rupture with intact adventitia. [11]

Diaphragmatic Injury

Mechanism:

• Blunt trauma: Sudden increase in intra-abdominal pressure
• Penetrating trauma: Direct violation

Left vs Right:

• Left-sided 3x more common clinically (liver protects right, pericardial rupture often obscures right-sided injury)
• Right-sided injuries more commonly missed

Esophageal Injury

Mechanism: Penetrating injury most common; blunt rupture rare (severe epigastric blow against closed glottis).

Clinical significance: Mediastinitis if not recognized early; mortality increases 2% per hour of delay in diagnosis. [12]

Tracheobronchial Injury

Location: Within 2.5 cm of carina (80% of cases)

Clinical features:

• Massive persistent air leak after chest tube placement
• Failure of lung to re-expand despite adequate drainage
• Pneumomediastinum, deep cervical emphysema

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Clinical Presentation

Primary Survey (ATLS Approach)

Airway Assessment

Breathing Assessment

Inspection:

• Respiratory rate and effort
• Asymmetric chest movement
• Paradoxical movement (flail segment)
• Penetrating wounds (entry/exit, location in "cardiac box")
• Contusions, seat belt sign

Palpation:

• Crepitus (surgical emphysema, rib fractures)
• Tracheal position (deviation indicates tension)
• Chest wall tenderness
• Flail segment identification

Percussion:

Auscultation:

Circulation Assessment

Classic Presentations by Pathology:

Clinical Pearl: "Flat and Shocked vs. Full and Shocked"

• Flat neck veins + hypotension = Hemorrhagic shock (hemothorax, abdominal injury)
• Distended neck veins + hypotension = Obstructive shock (tension pneumothorax, tamponade)

This distinction guides immediate intervention.

Beck's Triad for Cardiac Tamponade

1. Hypotension
2. Distended neck veins (JVD)
3. Muffled heart sounds

Sensitivity: Only 22-35% in trauma [9]

• Muffled heart sounds often difficult to appreciate in noisy trauma bay
• JVD may be absent if concurrent hypovolemia

Waddell's Triad for Rib Fractures by Location

Secondary Survey Findings

Chest wall examination:

• Palpate entire chest wall systematically
• Document number and location of rib fractures
• Assess for sternal fracture (deceleration injury marker)

Associated injuries to consider:

• Clavicle fractures (concurrent thoracic injury)
• Scapular fractures (high-energy mechanism)
• Thoracic spine fractures (neurological examination)

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Red Flags and Time-Critical Interventions

⚠️ Red Flag: ### IMMEDIATE INTERVENTION REQUIRED

Indications for Emergency Department Thoracotomy

ED thoracotomy (EDT) should be considered in specific circumstances with defined survival expectations: [13]

Penetrating Trauma

Blunt Trauma

*Signs of life: pupillary response, spontaneous movement, cardiac electrical activity, measurable blood pressure

Exam Detail: Technique Overview: ED Thoracotomy

1. Left anterolateral thoracotomy (5th intercostal space)
2. Extend across sternum if needed (clamshell)
3. Open pericardium anterior to phrenic nerve
4. Evacuate clot and identify injury
5. Control cardiac hemorrhage (digital pressure, stapling, suture)
6. Cross-clamp descending aorta if profound hypotension
7. Internal cardiac massage if arrested

Goals of EDT:

• Relieve tamponade
• Control hemorrhage
• Cross-clamp aorta to redistribute blood to coronary and cerebral circulation
• Internal cardiac massage

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Differential Diagnosis

Hypotension in Chest Trauma

Respiratory Distress in Chest Trauma

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Diagnostic Approach

Extended Focused Assessment with Sonography for Trauma (eFAST)

The eFAST examination adds thoracic views to the traditional FAST examination and is now considered standard in trauma assessment. [14]

Standard Views

Pneumothorax Detection

Sensitivity for pneumothorax: 78-98% (superior to supine CXR 36-75%) [14] Specificity: 94-100%

Clinical Pearl: eFAST Limitations

• Operator-dependent
• Body habitus affects quality
• Subcutaneous emphysema obscures lung sliding
• Cannot differentiate cause of absent lung sliding (pneumothorax vs mainstem intubation vs ARDS)
• Hemothorax less than 200 mL may be missed

Chest Radiography

Supine CXR in trauma: Standard initial imaging for hemodynamically stable patients.

Key Findings and Interpretation

Exam Detail: Widened Mediastinum: Causes and Approach

CTA indications for suspected aortic injury:

• Widened mediastinum
• Abnormal aortic contour
• First/second rib fractures
• High-energy deceleration mechanism
• Hemodynamic instability without other source

Computed Tomography

CT with IV contrast is the gold standard for stable patients with significant chest trauma. [15]

Indications

CT Findings in Specific Injuries

Electrocardiogram in Blunt Cardiac Injury

Screening for BCI: ECG should be obtained in all patients with significant blunt chest trauma. [10]

Algorithm for BCI screening [10]:

High-risk mechanism (steering wheel impact, sternal fracture)
                    |
              Obtain ECG
               /        \
          Normal        Abnormal
            |              |
      Observe 24h     Troponin + Echo
      (monitor PRN)     /       \
                   Normal    Abnormal
                     |          |
               Observe 24h   ICU monitoring
                             Consider echo

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Management

Tension Pneumothorax

KEY PRINCIPLE: This is a CLINICAL diagnosis. Do NOT delay treatment for imaging.

Needle Decompression (Temporizing Measure)

Preferred site: 4th-5th intercostal space, anterior axillary line [16] Alternative site: 2nd intercostal space, midclavicular line

Clinical Pearl: Anterior Axillary Line vs Midclavicular Line

The 4th/5th ICS anterior axillary line is now preferred over the traditional 2nd ICS midclavicular line because: [16]

• Thinner chest wall at lateral position
• Higher success rate (79% vs 58%)
• Avoids mediastinal structures
• Same triangle of safety used for chest tube

Tube Thoracostomy (Definitive Treatment)

Technique - Finger Thoracostomy with Tube Insertion:

1. Position: Supine, arm abducted 90 degrees
2. Landmark: 4th-5th ICS, anterior axillary line (triangle of safety)
3. Preparation: Sterile prep, local anesthesia (if patient conscious)
4. Incision: 3-4 cm horizontal incision over rib below insertion point
5. Dissection: Blunt dissect through subcutaneous tissue and intercostal muscles
6. Entry: Puncture pleura with finger or clamp over superior rib border
7. Finger sweep: Confirm entry to pleural space, sweep for adhesions
8. Tube insertion: 28-32 Fr directed posterosuperiorly for pneumothorax
9. Connection: Underwater seal or one-way valve
10. Confirmation: Fogging, swing, bubbling, CXR

Procedure Detail: Triangle of Safety for Chest Drain Insertion

Boundaries:

• Anterior: Lateral border of pectoralis major
• Posterior: Lateral border of latissimus dorsi
• Inferior: Horizontal line at nipple level (5th ICS)
• Superior: Base of axilla

This zone avoids:

• Breast tissue
• Internal mammary vessels
• Long thoracic nerve
• Major muscle masses

Simple Pneumothorax

Occult pneumothorax (CT-detected only): May observe if small, but tube required if positive pressure ventilation needed. [17]

Massive Hemothorax

Initial Management

1. Large-bore IV access (2 x 16G or larger)
2. Activate massive transfusion protocol if indicated
3. Tube thoracostomy: 32-36 Fr, posterior placement
4. Autotransfusion if available and blood less than 6 hours old

Indications for Emergent Thoracotomy

Evidence Debate: Thoracotomy Thresholds: The "1500/200" Rule

The traditional thresholds (> 1500 mL initial or > 200 mL/hr) come from retrospective studies. However: [8]

• Some surgeons use lower thresholds (> 1000 mL initial) in certain contexts
• Absolute numbers less important than hemodynamic response to resuscitation
• Trending output more valuable than single measurement
• Patient factors (elderly, anticoagulated) may warrant earlier intervention

EAST Guidelines (2011): Recommend early thoracotomy for massive output but acknowledge individual clinical judgment. [8]

Open Pneumothorax

Immediate management:

1. Cover wound with occlusive dressing taped on three sides
   • Creates flutter-valve effect (air out, not in)
2. Insert chest tube remote from wound
   • Not through the wound (contamination, inadequate seal)
3. Monitor for tension conversion if all four sides taped

Definitive management: Wound debridement and formal closure in OR

Cardiac Tamponade

Pericardiocentesis (Temporizing)

Indication: Hemodynamically unstable patient with confirmed or strongly suspected tamponade

Technique (Subxiphoid Approach):

1. Position patient 45 degrees upright if possible
2. Needle entry 1-2 cm below xiphoid, left of midline
3. Advance at 45 degrees toward left shoulder tip
4. Continuous aspiration
5. ECG monitoring (ST elevation indicates epicardial contact)
6. Even 20-50 mL removal provides significant relief

Echo guidance: Strongly preferred if available; increases success, decreases complications.

Clinical Pearl: Blood from pericardiocentesis will NOT clot (it has been defibrinated by cardiac motion). If aspirated blood clots, you may be in the ventricle - withdraw and redirect.

Definitive Management

Flail Chest and Pulmonary Contusion

Conservative Management (First-Line for Most Patients)

Analgesia is the cornerstone of management: [7]

Respiratory support:

• Supplemental oxygen to maintain SpO2 > 94%
• Incentive spirometry (hourly when awake)
• Chest physiotherapy
• Non-invasive ventilation (CPAP/BiPAP) if tolerated
• Avoid fluid overload (increases contusion severity)

Intubation Indications

Surgical Rib Fixation

Emerging evidence supports surgical stabilization for select patients: [19]

Evidence Debate: Surgical Fixation for Flail Chest

A 2013 meta-analysis of 11 studies (538 patients) found that surgical fixation reduced: [19]

• Duration of mechanical ventilation
• ICU stay
• Pneumonia rate
• Mortality (OR 0.31)

However, most studies were small and heterogeneous. The CWIS-1 trial (2020) and ongoing trials are providing higher-quality evidence. Current practice: Consider fixation for select patients, particularly those with chest wall deformity or prolonged ventilator dependence.

Rib Fractures

Risk Stratification

Number of rib fractures predicts outcomes: [5]

Age-adjusted risk: Each additional decade over 45 increases mortality risk significantly. Patients > 65 with ≥3 fractures should be admitted. [5]

Multimodal Analgesia Protocol

RIB FRACTURE PAIN MANAGEMENT LADDER
====================================
Level 1: Paracetamol 1g QID + NSAID (if no contraindication)
         |
Level 2: Add weak opioid (tramadol/codeine) or low-dose strong opioid
         |
Level 3: IV PCA morphine/fentanyl
         |
Level 4: Regional technique (intercostal block, serratus plane block)
         |
Level 5: Epidural analgesia (gold standard for multiple fractures)
         |
Level 6: Consider surgical fixation if refractory

Blunt Cardiac Injury

Management algorithm based on initial findings: [10]

Traumatic Aortic Injury

Initial Management

Blood pressure control is critical to prevent rupture: [11]

Clinical Pearl: Why Beta-Blocker First? Vasodilators alone cause reflex tachycardia, which increases dP/dt (rate of rise of aortic pressure) - this increases wall stress and rupture risk. Always establish rate control with beta-blocker before adding vasodilator.

Definitive Management

Damage Control Resuscitation

For patients with hemorrhagic shock from chest trauma, damage control resuscitation principles apply: [20]

Massive Transfusion Protocol:

• 1:1:1 ratio (RBC:FFP:Platelets)
• Target: Avoid crystalloid overload
• Permissive hypotension: SBP 80-90 mmHg until hemorrhage control (except TBI)
• TXA within 3 hours of injury (CRASH-2 evidence)

Targets during resuscitation:

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Complications

Early Complications (0-7 days)

Late Complications

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Disposition and Prognosis

ICU Admission Criteria

Floor/Monitored Bed

Discharge Criteria

Prognosis

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Special Populations

Elderly Patients (> 65 years)

Key considerations [5]:

• Lower physiological reserve
• Pre-existing cardiopulmonary disease
• Osteoporotic ribs fracture more easily
• Each rib fracture increases mortality by 19% and pneumonia risk by 27%
• Lower threshold for ICU admission
• Aggressive pain management (epidural if possible)
• Early surgical fixation may benefit this group particularly

Clinical Pearl: "The Elderly Rule of Fives" - Admit patients > 65 years with:

• ≥5 rib fractures, or
• Age + rib fractures ≥70 (e.g., 65 years + 5 ribs, or 70 years + 0 ribs)

This is an approximate guide - clinical judgment supersedes.

Anticoagulated Patients

Pregnant Patients

Pediatric Considerations

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Exam-Focused Content

Common Viva Questions

Viva Point: Q: "A 35-year-old male arrives after a high-speed MVA. He has absent breath sounds on the left, tracheal deviation to the right, and JVD. BP 70/40. What is your immediate management?"

Model Answer: "This clinical picture is consistent with left-sided tension pneumothorax causing obstructive shock. This is a clinical diagnosis and does not require radiological confirmation.

My immediate action is needle decompression - I would insert a 14-gauge needle, minimum 5 cm length, in the 4th or 5th intercostal space in the anterior axillary line, above the rib to avoid the neurovascular bundle. I expect a hiss of air and improvement in hemodynamics.

This is a temporizing measure only. I would immediately proceed to tube thoracostomy with a 28-32 French tube in the triangle of safety, connected to an underwater seal drain. After stabilization, I would obtain a chest radiograph to confirm position and assess for other injuries, and complete the trauma primary and secondary survey."

Viva Point: Q: "What are the indications for emergency department thoracotomy?"

Model Answer: "ED thoracotomy is a resuscitative procedure with the goal of relieving tamponade, controlling hemorrhage, and providing internal cardiac massage.

For penetrating trauma, it is indicated when a patient has signs of life and witnessed arrest within 15 minutes, or profound refractory hypotension with suspected tamponade. Survival rates are approximately 10-35% for stab wounds to the heart.

For blunt trauma, outcomes are significantly worse. I would consider EDT only in witnessed arrest within 10 minutes with signs of tamponade. Survival is 1-2%.

Signs of life include: pupillary response, spontaneous movement, organized cardiac electrical activity, and any measurable blood pressure.

EDT is not indicated for blunt trauma without signs of life, or any arrest exceeding the time thresholds, as survival approaches zero."

Viva Point: Q: "Describe the management of flail chest."

Model Answer: "Flail chest is defined as three or more consecutive ribs fractured in two or more places, creating a segment that moves paradoxically with respiration.

Importantly, the mortality from flail chest is primarily due to the underlying pulmonary contusion, present in 75-100% of cases, rather than the mechanical defect of paradoxical movement.

Initial management focuses on:

1. Analgesia - this is the cornerstone. Epidural analgesia is the gold standard as it reduces pneumonia and mortality, particularly in elderly patients. Alternatives include paravertebral block, serratus anterior plane block, and IV PCA.

2. Respiratory support - supplemental oxygen, incentive spirometry, chest physiotherapy, and non-invasive ventilation if tolerated.

3. Avoiding fluid overload - which worsens pulmonary contusion.

Intubation is indicated for respiratory failure, inability to achieve adequate oxygenation despite maximum support, or requirement for surgery.

Surgical rib fixation is an emerging option with evidence showing reduced ventilator days and ICU stay. I would consider this for patients with persistent chest wall deformity, failure to wean from ventilation, or refractory pain."

Common Mistakes That Fail Candidates

⚠️ Red Flag: AVOID THESE ERRORS

1. Waiting for CXR in tension pneumothorax - This is a clinical diagnosis; decompress immediately
2. Using the wrong site for needle decompression - 4th/5th ICS anterior axillary line preferred over 2nd ICS MCL
3. Forgetting the needle length matters - Must be ≥5 cm; 8 cm preferred for reliability
4. Stating Beck's triad is always present - Only present in 22-35% of trauma tamponade
5. Not understanding flail chest pathophysiology - Pulmonary contusion, not paradoxical movement, causes death
6. Ordering troponin as first-line for BCI - ECG is the screening test
7. Starting vasodilator before beta-blocker in aortic injury - Reflex tachycardia increases rupture risk
8. Forgetting age-adjusted rib fracture risk - Elderly patients have dramatically worse outcomes
9. Ignoring occult pneumothorax before intubation - Can convert to tension with positive pressure
10. Discharging elderly patients with multiple rib fractures - High complication rate; admit liberally

Key Numbers to Remember

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References

1. Mancini MC, Salas MD. Blunt chest trauma. J Trauma Acute Care Surg. 2021;91(3):546-552. doi:10.1097/TA.0000000000003195

2. Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43(1):8-17. doi:10.1016/j.injury.2011.01.004

3. Kulshrestha P, Munshi I, Wait R. Profile of chest trauma in a level I trauma center. J Trauma. 2004;57(3):576-581. doi:10.1097/01.TA.0000091107.00699.C7

4. Chrysou K, Halat G, Hoksch B, Schmid RA, Kocher GJ. Lessons from a large trauma center: impact of blunt chest trauma in polytrauma patients-still a relevant problem? Scand J Trauma Resusc Emerg Med. 2017;25(1):42. doi:10.1186/s13049-017-0384-y

5. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040-1047. doi:10.1097/00005373-200006000-00007

6. Wutzler S, Wafaisade A, Maegele M, et al. Lung organ failure score (LOFS): screening for adult respiratory distress syndrome in polytrauma patients. World J Emerg Surg. 2011;6:37. doi:10.1186/1749-7922-6-37

7. Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(2):462-468. doi:10.1097/TA.0000000000000086

8. Mowery NT, Gunter OL, Collier BR, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70(2):510-518. doi:10.1097/TA.0b013e31820b5c31

9. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. doi:10.1056/NEJMra022643

10. Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. doi:10.1097/TA.0b013e318270193a

11. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027

12. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77(4):1475-1483. doi:10.1016/j.athoracsur.2003.08.037

13. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363. doi:10.1097/TA.0b013e318270d2df

14. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma. 2004;57(2):288-295. doi:10.1097/01.TA.0000133565.88871.E4

15. Brink M, Deunk J, Dekker HM, et al. Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management. AJR Am J Roentgenol. 2008;190(6):1591-1598. doi:10.2214/AJR.07.3277

16. Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011;71(5):1099-1103. doi:10.1097/TA.0b013e31822d9618

17. Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma. 1993;35(5):726-730. doi:10.1097/00005373-199311000-00012

18. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136(2):426-430. doi:10.1016/j.surg.2004.05.019

19. Cataneo AJ, Cataneo DC, de Oliveira FH, Carneiro AF, Ruiz RL Jr, Gomes MJ. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev. 2015;(7):CD009919. doi:10.1002/14651858.CD009919.pub2

20. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. doi:10.1001/jama.2015.12

21. DuBose J, Inaba K, Okoye O, et al. Development of posttraumatic empyema in patients with retained hemothorax: results of a prospective, observational AAST study. J Trauma Acute Care Surg. 2012;73(3):752-757. doi:10.1097/TA.0b013e31825c1616

22. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23(3):374-378. doi:10.1016/s1010-7940(02)00813-8

23. Karmy-Jones R, Jurkovich GJ, Shatz DV, et al. Management of traumatic lung injury: a Western Trauma Association multicenter review. J Trauma. 2001;51(6):1049-1053. doi:10.1097/00005373-200112000-00004

24. Rodriguez RM, Hendey GW, Marek G, Dery RA, Bjoring A. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med. 2006;47(5):415-418. doi:10.1016/j.annemergmed.2005.10.001

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