Dr Titiosi Adegbija – Emergency Medicine Registrar
Blunt Aortic Injury is the 2nd commonest cause of death in BCT patients – 80% on scene
The mechanisms involved in BAI include 1) Osseous pinch 2) Water-hammer effect 3) Stretching/ shearing and 4) Torsion
Management is either open surgery or endovascular repair
Blunt Myocardial Injury occurs in 13% BCT patients
Myocardial rupture is commonest in the right atrium with septal/ valvular injury occurring most commonly in the aortic valve
ECG is used as screening tool and further specific diagnostic and therapeutic measures are limited to cases where cardiac complications develop
Indication for Surgical thoracotomy in Blunt Chest Trauma – immediate drainage of >20ml/kg or shock + persistent, substantial bleeding (>3ml/kg/hr)
Rib fractures occur in 67% of MVC patients with BCT
- ≥6 rib #s – double incidence of pneumonia & ARDS
- ≥45y + ≥4 rib #s = longer intubation, ICU stay, hospital stay
Indications for Rib Plating:
– flail segment + failure to wean
– Painful, moveable ribs refractory to pain management
– Significant chest wall deformity or tissue defect
– Instability due to non-union
Contraindication: – severe pulmonary contusion
Lung expansion modalities include: 1) Deep breathing & Incentive spirometry 2) Intermittent Positive Pressure Breathing 3) Continuous Positive Airway Pressure
CT remains gold standard for investigation of blunt chest trauma
For Blunt aortic injury, if CT is equivocal, then Angiogram may be done as more specific (though not as sensitive) than CT scan.
NEXUS Chest Decision instrument may safely reduce need for chest imaging (SN 98.8%, NPV 98.5%, SP 13.3%)
Advantages of Epidural Analgesia
– Significantly improves subjective pain perception
– Significantly improves critical PFTs
– causes less respiratory depression, somnolence, GI symptoms
– Safe, negligible mortality
– improves outcomes of ventilator days, ICU & hospital LOS
Types of Intercostal blocks include: 1) Intercostal block 2) Intrapleural anaesthesia 3) Thoracic paravertebral block
TAKE HOME PEARLS…
- Maintain a high index of suspicion for lethal injuries!
- If the patient has ≥3 OR high (ribs 1-3) #s: 1) search rigorously for other lethal intrathoracic injuries 2) consider admission especially if elderly
- Actually give the physiotherapist a call!
- Involve APMS early if challenging pain control anticipated
- Kea, Bory, et al. “What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?” The American journal of emergency medicine8 (2013): 1268-1273.
- McGillicuddy, Daniel, and Peter Rosen. “Diagnostic dilemmas and current controversies in blunt chest trauma.” Emergency medicine clinics of North America3 (2007): 695-711.
- Neschis, David G., et al. “Blunt aortic injury.” New England Journal of Medicine16 (2008): 1708-1716.
- Rodriguez, Robert M., et al. “NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma.” JAMA surgery10 (2013): 940-946.
- Simon, Bruce J., et al. “Pain management guidelines for blunt thoracic trauma.” Journal of Trauma and Acute Care Surgery5 (2005): 1256-1267.
- Traub, Matthias, et al. “The use of chest computed tomography versus chest X-ray in patients with major blunt trauma.” Injury1 (2007): 43-47.