Diagnostic Dilemmas and Current Controversies in Blunt Chest Trauma

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Blunt chest injuries are common encounters in the emergency department. Instead of a comprehensive review of the management of all chest injuries, this review focuses on injuries that can be difficult to diagnose and manage, including blunt aortic injury, cardiac contusion, and blunt diaphragmatic injury. This review also discusses some recent controversies in the literature regarding the use of prophylactic antibiotics for tube thoracostomy and the optimal management of occult pneumothorax. The article concludes with a discussion of the management of rib fractures in the elderly.

Section snippets

Blunt aortic injury

Blunt aortic injury is the second most common cause of death in blunt trauma patients [1]. Common mechanisms that induce blunt aortic injury are rapid deceleration injuries from motor vehicle or motorcycle crashes, falls, and crush injuries [2]. Blunt aortic injuries result in nearly 8000 deaths a year in the United States [3]. Classically, over 80% of patients who suffer blunt aortic injuries die on scene, whereas 13% to 15% of patients who survive the initial injury make it to the hospital

Blunt cardiac injury

Blunt cardiac injury is usually sustained in rapid deceleration injuries with direct blows to the chest. There is no standard definition of blunt cardiac injury and no straightforward or accurate way to establish the diagnosis. The exact incidence of blunt cardiac injury is unknown but is estimated to range from 8% to 71% of all blunt chest injured patients. This large variation in incidence and the lack of agreement between researchers as to the definition of blunt cardiac injury make

Blunt diaphragmatic rupture

Blunt diaphragmatic rupture most often occurs as a result of severe blunt chest and abdominal trauma resulting from motor vehicle crashes or vehicles striking pedestrians, as well as falls from a height of 10 ft or more. The reported incidence of blunt diaphragmatic rupture ranges from 0.5% to 8% of patients admitted to the emergency department as a result of automobile crashes or undergoing exploratory laparotomy for trauma [37], [38], [39]. Fifty percent to 80% of blunt diaphragmatic ruptures

The role of antibiotics in chest tube thoracostomy

Chest tube placement in blunt chest trauma is a common procedure. More than 100,000 chest tubes are placed annually in trauma patients [48]. Large-bore chest tubes (36-F or higher) are often placed to drain traumatic hemothorax, traumatic pneumothorax, or in traumatic arrest. Complications with chest tube insertion are well known, and they include intra-abdominal tube placement, intrathoracic misplacement, lung parenchyma injury, intercostal artery or nerve injury, or post-procedural infectious

Summary

The management and evaluation of blunt chest trauma is an ever changing field. The use of helical CT scans has allowed for rapid diagnosis and exclusion of blunt aortic injury. The evaluation of blunt myocardial injury is difficult; however, a normal EKG in a patient with blunt chest trauma essentially rules out a significant risk of blunt myocardial injury. Blunt diaphragmatic injury is a relativity rare occurrence but carries a high morbidity and mortality if diagnosis is significantly

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