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Blunt Chest Wall Injuries. Yury Rabotnikov , M.D. PGY 1. Weill Cornell Medical College. ADVANCING SCIENCE, ENHANCING LIFE. EPIDEMIOLOGY. Rib Fx : 2/3 of admitted pts Sternal Fx : 8% of blunt chest trauma, 18 of multiple trauma Scapular Fx about 1-2%. Initial Assesment.

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blunt chest wall injuries

Blunt Chest Wall Injuries

YuryRabotnikov, M.D.

PGY 1

Weill Cornell Medical College

ADVANCING SCIENCE, ENHANCING LIFE

epidemiology
EPIDEMIOLOGY
  • Rib Fx: 2/3 of admitted pts
  • Sternal Fx: 8% of blunt chest trauma, 18 of multiple trauma
  • Scapular Fx about 1-2%
initial assesment
Initial Assesment
  • Hx: mechanism, PMH, presentation
  • Physical: flail chest, Hypoxia, HD, Seat belt sign, pain, deformities, abd tenderness
  • Imaging: CXR, EKG, CT (if stable enough).
high risk chest wall injuries
High Risk Chest Wall Injuries
  • Scapula fracture
  • Flail chest
  • Multiple rib fractures (≥3) and displaced rib fractures
  • Sternal fracture
  • Posterior sternoclavicular dislocation
slide5

Asymptomatic PTX: less then 8mm – observe

  • Hemothorax: 300 cc needed to diagnose 36Fr chest tube. >1500cc surgery
  • Pulmonary contusion develop in 24 hours, resolve in 1 week. (Irregular, nonlobularopacification ). Intubation only if hypoxic.
  • Tracheobronchial injury 1%. Most diet at the sceene (R main Bronchus> L main )
associated complication
Associated complication
  • Pneumonia - ~6% of all hospitalized pt’s w rib fx
    • Elderly pts( >65 y.o.) => 30% incidence, 22% mortality
  • Retained hemothorax – dx CT, tx VATS
  • Empyema :3-10% of pt’s w CT placed
  • Fracture nonunion
  • Respiratory failure
associated internal injuries
Associated Internal Injuries
  • Blunt aortic and other mediastinal injury 
  • Pneumothorax
  • Pulmonary contusion 
  • Cardiac contusion
  • Myocardial rupture
b lunt a ortic i njury bai radiologic findings
Blunt Aortic Injury (BAI)Radiologic Findings:
  • Wide mediastinum (supine CXR >8 cm; upright CXR >6 cm)
  • Obscured aortic knob; abnormal aortic contour
  • Left "apical cap" (ie, pleural blood above apex of left lung)
  • Large left hemothorax
  • Deviation of nasogastric tube rightward
  • Deviation of trachea rightward and/or right mainstem bronchus downward
  • Wide left paravertebral stripe
isolated chest wall injury
Isolated Chest wall injury:
  • Main goals =

(1) Pain control

(2) Expansion of pulmonary volume

  • Hospitalization = any pt w 3 or more rib fx
  • ICU = elderly pt w 6 or more rib fx
pain control
Pain Control
  • Regional anesthesia
    • Continuous epidural infusion => shorter duration of mechanical ventilation and dec risk pneumonia
    • Paravertebral block = unilateral rib fx
    • Intercostal nerve blocks
    • Intrapleural infusion
  • IV narcotics
  • IV NSAIDs (ex toradol)
surgical management
Surgical Management
  • Flail chest + failure to wean from ventilator
  • Painful, movable ribs refractory to pain management strategies
  • Significant chest wall deformity
  • Chest wall instability due to fracture nonunion
  • Displaced rib fx found at thoracotomy
  • Internal Injuries.