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Blunt chest trauma

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Updated 2024 ACEP guidelines for the evaluation and management of acute blunt trauma.

Background

Overview

Definition
Blunt chest trauma refers to a non-penetrating injury to the chest, often resulting from high-energy impact or forceful direct blow.
1
Pathophysiology
The pathophysiology of blunt chest trauma involves a variety of mechanisms, including direct impact, rapid deceleration, compression, and blast waves. These mechanisms can lead to a wide range of injuries to the thoracic structures, including fractures of the ribs and sternum, lung contusions, pneumothorax, hemothorax, cardiac contusions, and aortic injuries.
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Epidemiology
Blunt chest trauma accounts for over 10% of all trauma cases presenting to the emergency department.
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Risk factors
Risk factors for blunt chest trauma include involvement in road traffic accidents, violent falls, interpersonal aggression, and high-risk sports.
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Disease course
Clinically, patients with blunt chest trauma may present dyspnea, chest pain, and cough. Physical examination may reveal abnormal breath sounds, subcutaneous emphysema, and signs of respiratory distress. In some cases, cardiac conduction abnormalities may occur due to the trauma.
4
Prognosis and risk of recurrence
The prognosis of blunt chest trauma is influenced by several factors. The overall mortality rate is 15%, with the highest rate observed within the first 24 hours post-trauma.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of blunt chest trauma are prepared by our editorial team based on guidelines from the American College of Emergency Physicians (ACEP 2024), the European Association of Urology (EAU 2024), the European Society of Cardiology (ESC 2024), the Society of Thoracic Surgeons (STS/EACTS 2024), the Surgical Infection Society Europe (SIS-E/GAIS/WSES/WSIS/AAST 2024), the ...
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Diagnostic investigations

Initial evaluation
As per ACEP 2024 guidelines:
Use clinical judgment and hospital-specific protocols to decide between selective CT and whole-body CT in hemodynamically stable adult patients with blunt trauma.
B
Take into account age (> 65 years) for triage of older adult patients with trauma, as they have increased morbidity and mortality compared with similarly injured adults.
B
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  • Evaluation for pneumothorax/hemothorax

  • Evaluation for rib fracture

  • Evaluation for cardiac injury (ECG)

  • Evaluation for cardiac injury (cardiac biomarkers)

  • Evaluation for cardiac injury (imaging)

  • Evaluation for aortic injury

  • Evaluation for renal injury

Respiratory support

Noninvasive ventilation: as per ERS 2017 guidelines, consider initiating noninvasive ventilation in patients with chest trauma and acute respiratory failure.
C
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  • Mechanical ventilation

Medical management

Management of pain: as per EAST 2016 guidelines, consider administering epidural analgesia over nonregional modalities of pain control (IV or enteral analgesics, such as opioids, acetaminophen, and NSAIDs) for the management of pain in adult patients with blunt thoracic trauma.
C
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  • Management of pneumothorax (oxygen supplementation)

  • Management of pneumothorax (drainage)

  • Management of hemothorax

  • Management of pulmonary contusion (fluid resuscitation)

  • Management of pulmonary contusion (respiratory support)

  • Management of pulmonary contusion (diuretics)

  • Management of pulmonary contusion (corticosteroids)

  • Management of pulmonary contusion (analgesics)

  • Management of pulmonary contusion (chest physiotherapy)

  • Management of rib fracture (surgical stabilization)

  • Management of rib fracture (analgesics)

  • Management of aortic injury (setting of care)

  • Management of aortic injury (expectant management)

  • Management of aortic injury (anti-impulse therapy)

  • Management of aortic injury (aortic repair, indications)

  • Management of aortic injury (aortic repair, timing)

  • Management of aortic injury (aortic repair, choice of approach)

  • Management of aortic injury (aortic repair, technical considerations)

  • Management of aortic injury (left subclavian artery revascularization)

  • Management of aortic injury (resuscitative thoracotomy)

  • Management of aortic injury (resuscitative endovascular balloon aortic occlusion)

  • Management of aortic injury (surveillance imaging)

  • Antibiotic prophylaxis

Therapeutic procedures

Technical considerations for chest drainage, analgesic premedication
As per BTS 2010 guidelines:
Consider administering analgesia as premedication to reduce pain associated with chest drains.
E
Administer local lidocaine 1% before the procedure, paying particular attention to the skin, periosteum, and pleura.
E
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  • Technical considerations for chest drainage (antibiotic prophylaxis)

  • Technical considerations for chest drainage (insertion technique)

  • Technical considerations for chest drainage (care of inserted drains)

  • Technical considerations for chest drainage (follow-up imaging)

  • Blood product transfusion

Surgical interventions

Indications for surgery
As per EAST 2011 guidelines:
Decide on the surgical intervention based on patient physiology rather than absolute numbers of initial or persistent output.
B
Consider performing surgical exploration in case of 1,500 mL via a chest tube in any 24-hour period, regardless of mechanism.
C
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Specific circumstances

Pediatric patients
As per EAST/PTS/WTA 2023 guidelines:
Consider performing emergency department thoracotomy following emergency adjuncts, including ultrasound and thoracostomies, to determine injury location and/or reversible causes of shock in pediatric patients presenting pulseless to the emergency department after blunt injury with signs of life.
C
Do not perform emergency department thoracotomy in pediatric patients presenting pulseless to the emergency department after blunt injury without signs of life.
D
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