Blunt Chest Injuries

Types of blunt chest injuries include myocardial and pulmonary contusions and rib and sternal fractures. Such fractures can be simple, multiple, displaced, or jagged. Chest injuries account for one-fourth of all trauma deaths in the United States.

Causes

Most blunt chest injuries result from motor vehicle crashes. Other causes include sports, fights, and blast injuries.

Diagnostic tests

Chest X-rays may confirm rib and sternal fractures, pneumothorax, flail chest, pulmonary contusions, lacerated or ruptured aorta, tension pneumothorax (mediastinal shift), diaphragmatic rupture, lung compression, or atelectasis with hemothorax.

With cardiac damage, an ECG may show right bundle-branch block. In myocardial contusions, arrhythmias, conduction abnormalities, and STT wave changes may occur.

Serum levels of aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase (CK), and the isoenzyme CK-MB are elevated.

Angiography reveals aortic laceration or rupture. Contrast studies and liver and spleen scans detect diaphragmatic rupture.

Echocardiography, computed tomography scans, and nuclear heart and lung scans show the extent of injury.

Treatment

Blunt chest injuries call for controlling bleeding and maintaining a patent airway, adequate ventilation, and fluid and electrolyte balance. Further treatment depends on the specific injury and complications:

• Single fractured ribs are managed conservatively with mild analgesics and follow-up examinations to check for indications of a pneumothorax or hemothorax. To prevent atelectasis, the patient should perform incentive spirometry, deep breathing, and coughing for lung expansion. Intercostal nerve blocks may help with more severe fractures.
• Treatment for a pneumothorax involves inserting a spinal, 14G, or 16G needle into the second intercostal space at the midclavicular line to release pressure. Then the doctor inserts a chest tube in the affected side to normalize pressure and reexpand the lung. The patient also receives oxygen and l.V. fluids. The patient may require intubation and mechanical ventilation.
• Shock related to hemothorax calls for l.V. infusion of lactated Ringer's or normal saline solution. If the patient loses more than 1 ,500 ml of blood or more than 30% of circulating blood volume, he'll also need a transfusion of packed red blood cells or an auto-transfusion. He may also require intubation, mechanical ventilation, and possible thoracotomy. Chest tubes are inserted into the fifth or sixth intercostal space at the midaxillary line to remove blood.
• Treatment of flail chest may include endotracheal intubation and mechanical ventilation with positive pressure. The patient also may receive l.V. muscle relaxants. If the patient requires controlled ventilation, he'll receive a neuromuscular blocking agent. If an air leak occurs, the patient may need operative fixation of the flail chest.

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