blunt chest wall injuries yury rabotnikov, m.d. pgy 1 advancing science, enhancing life weill...

Blunt Chest Wall Injuries

Yury Rabotnikov, M.D.PGY 1

ADVANCING SCIENCE, ENHANCING LIFEWeill Cornell Medical College

EPIDEMIOLOGY

• Rib Fx: 2/3 of admitted pts• Sternal Fx: 8% of blunt chest trauma, 18 of

multiple trauma• Scapular Fx about 1-2%

Initial Assesment

• Hx: mechanism, PMH, presentation• Physical: flail chest, Hypoxia, HD, Seat belt sign, pain, deformities, abd

tenderness

• Imaging: CXR, EKG, CT (if stable enough).

High Risk Chest Wall Injuries

• Scapula fracture• Flail chest• Multiple rib fractures (≥3) and displaced rib

fractures• Sternal fracture• Posterior sternoclavicular dislocation

• Asymptomatic PTX: less then 8mm – observe• Hemothorax: 300 cc needed to diagnose

36Fr chest tube. >1500cc surgery • Pulmonary contusion develop in 24 hours,

resolve in 1 week. (Irregular, nonlobular opacification ). Intubation only if hypoxic.

• Tracheobronchial injury 1%. Most diet at the sceene (R main Bronchus> L main )

Associated complication

• Pneumonia - ~6% of all hospitalized pt’s w rib fx– Elderly pts( >65 y.o.) => 30% incidence, 22%

mortality• Retained hemothorax – dx CT, tx VATS• Empyema :3-10% of pt’s w CT placed • Fracture nonunion • Respiratory failure

Associated Internal Injuries

• Blunt aortic and other mediastinal injury • Pneumothorax• Pulmonary contusion • Cardiac contusion• Myocardial rupture

Blunt Aortic Injury (BAI)Radiologic Findings:

• Wide mediastinum (supine CXR >8 cm; upright CXR >6 cm)• Obscured aortic knob; abnormal aortic contour• Left "apical cap" (ie, pleural blood above apex of left lung)• Large left hemothorax• Deviation of nasogastric tube rightward• Deviation of trachea rightward and/or right mainstem

bronchus downward• Wide left paravertebral stripe

Isolated Chest wall injury:

• Main goals =(1) Pain control(2) Expansion of pulmonary volume

• Hospitalization = any pt w 3 or more rib fx• ICU = elderly pt w 6 or more rib fx

Pain Control

• Regional anesthesia– Continuous epidural infusion => shorter duration

of mechanical ventilation and dec risk pneumonia– Paravertebral block = unilateral rib fx– Intercostal nerve blocks– Intrapleural infusion

• IV narcotics• IV NSAIDs (ex toradol)

Surgical Management

– Flail chest + failure to wean from ventilator– Painful, movable ribs refractory to pain

management strategies– Significant chest wall deformity– Chest wall instability due to fracture nonunion– Displaced rib fx found at thoracotomy– Internal Injuries.