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Blunt Thoracic Trauma
1
How often do patients with isolated blunt chest trauma need an emergent operation?
Rarely. The majority of injuries can be managed with aggressive pain control, mechanical ventilation, tube thoracotomy, and other simple supportive care. Only 5% of patients with isolated blunt injury to the chest require thoracotomy, as operative injuries to pulmonary, vascular, and mediastinal structures are surprisingly rare.
2
In a patient with a hemothorax after blunt chest injury, what is the most important guide for the decision to operate?
The hemodynamic status of the patient. Hemothorax after blunt injury is most often the result of nonoperative lesions of the lung and chest wall. In a stable patient, therefore, evacuation of the hemothorax, reexpansion of the lung, and correction of coagulopathy, hypothermia, and acidosis should be the initial focus. Chest tube output should be noted, as initial output >1500 mL is an indication for operative management, but is not the principle consideration.
3
What is a tension pneumothorax?
Trapped air in the pleural space as a result of a one-way valve mechanism. In contrast to simple pneumothorax, tension pneumothorax causes hemodynamic compromise. This is a life-threatening condition because marked elevations in intrapleural pressure leading to impaired ventilation capacity, central venous return, and right ventricular filling produces circulatory collapse if left undiagnosed and untreated.
4
What are the clinical signs of tension pneumothorax?
Hypotension, hyperresonance with absent breath sounds on the involved side, tachypnea, and distended neck veins.
5
How is tension pneumothorax treated?
Immediate decompression through a hole in the chest. Tension pneumothorax should be treated on clinical suspicion and without delay for radiographic confirmation. For prehospital care, needle decompression via the second intercostal space in the midclavicular line. In the hospital setting, however, an experienced physician can completely decompress the pleural space just as rapidly with a tube thoracostomy.
6
Does it matter how many ribs are broken?
Yes. Some studies indicate that the presence of three or more fractures is associated with significantly higher risk of mortality and six or more fractures indicate a higher risk of pneumonia and adult respiratory distress syndrome (ARDS), particularly in elderly patients.
7
What is a flail chest?
A flail chest occurs when at least three consecutive ribs are fractured in two or more places resulting in loss of bony continuity with the rest of the chest. This results in the chest wall moving paradoxically (“flails”) with respiration.
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