Blunt Chest Wall Injuries YuryRabotnikov, 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 • 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 • Scapula fracture • Flail chest • Multiple rib fractures (≥3) and displaced rib fractures • Sternal fracture • Posterior sternoclavicular dislocation
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 • 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 • Blunt aortic and other mediastinal injury • Pneumothorax • Pulmonary contusion • Cardiac contusion • Myocardial rupture
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: • 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 • 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 • 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.