Blunt Chest Trauma Guidelines

Updated: Jul 07, 2016
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Guidelines

EAST Guidelines for ED Thoracotomy

In 2015, the Eastern Association for the Surgery of Trauma (EAST) published a practice management guideline on patient selection for emergency department (ED) thoracotomy. [16] The following recommendations are pertinent to blunt chest trauma:

  • Patients presenting pulseless to the ED with signs of life after blunt injury - Conditional recommendation in favor of ED thoracotomy (moderate-quality evidence) 
  • Patients presenting pulseless to the ED without signs of life after blunt injury - Conditional recommendation against ED thoracotomy (low-quality evidence)
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EAST Guidelines for Blunt Aortic Injury

In 2015, the EAST published a practice management guideline on evaluation and management of blunt traumatic aortic injury (BTAI), [30] which included the following recommendations:

  • Patients with suspected BTAI - Strong recommendation in favor of computed tomography (CT) of the chest with intravenous contrast for diagnosis of clinically significant BTAI (low-quality evidence)
  • Patients diagnosed with BTAI - Strong recommendation in favor of using endovascular repair in patients without contraindications for such repair (low-quality to moderate-quality evidence)
  • Patients diagnosed with BTAI - Suggestion in favor of delayed repair as opposed to immediate repair (very-low-quality to high-quality evidence)
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EAST Guidelines for Pulmonary Contusion and Flail Chest

In 2012, the EAST published a practice management guideline on management of pulmonary contusion and flail chest. [17]  Recommendations were stratified as follows:

  • Level 1 - Convincingly justifiable on the basis of the available scientific evidence alone
  • Level 2 - Reasonably justifiable on the basis of the available scientific evidence and strongly supported by expert opinion
  • Level 3 - Supported by the available data but lacking adequate scientific evidence

No level 1 recommendations were made.

Level 2 recommendations included the following:

  • Patients should not be excessively fluid-restricted but should be resuscitated as necessary; once this is done, unnecessary fluid administration should be avoided
  • A pulmonary artery catheter may be useful
  • In the absence of respiratory failure, obligatory mechanical ventilation solely for overcoming chest-wall instability should be avoided
  • Patients needing mechanical ventilation should be supported according to institutional and physician preference and separated from the ventilator as soon as possible; positive end-expiratory pressure (PEEP)/continuous positive airway pressure (CPAP) should be included
  • Optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure and ensuing ventilatory support
  • Steroids should not be used

Level 3 recommendations included the following:

  • A trial of mask CPAP should be considered in alert, compliant patients with marginal respiratory status in combination with optimal regional anesthesia
  • Paravertebral analgesia may be considered in certain situations when epidural analgesia is contraindicated
  • Independent lung ventilation may be considered in severe unilateral PC when shunt cannot be otherwise corrected or when crossover bleeding is problematic
  • High-frequency oscillatory ventilation (HFOV) should be considered for patients failing conventional ventilatory modes
  • Diuretics may be used in the setting of hydrostatic fluid overload or in the setting of known concurrent congestive heart failure
  • Surgical fixation of flail chest may be considered in severe cases when patients cannot be weaned from the ventilator or when thoracotomy is required for other reasons
  • Rib plating or wrapping devices are likely superior to intramedullary wires for surgical fixation of rib fractures, and these should be preferred for this purpose
  • Self-activating multidisciplinary protocols for the treatment of chest-wall injuries should be considered where feasible
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EAST Guidelines for Screening for Blunt Cardiac Injuries

In 2012, the EAST published a practice management guideline on screening for blunt cardiac injury (BCI). [15]  Recommendations were stratified as follows:

  • Level 1 - Convincingly justifiable on the basis of the available scientific evidence alone
  • Level 2 - Reasonably justifiable on the basis of the available scientific evidence and strongly supported by expert opinion
  • Level 3 - Supported by the available data but lacking adequate scientific evidence

The single level 1 recommendation was that electrocardiography (ECG) should be performed at admission on all patients in whom BCI is suspected (no change)..

Level 2 recommendations included the following:

  • If the admission ECG reveals a new abnormality, the patient should be admitted for continuous ECG monitoring; if the patient has preexisting abnormalities, comparison should be made to a previous ECG to determine need for monitoring
  • In patients with a normal ECG result and normal troponin I level, BCI is ruled out; patients with normal ECG results but elevated troponin I level should be admitted to a monitored setting
  • For patients with hemodynamic instability or persistent new arrhythmia, an echocardiogram should be obtained; if optimal transthoracic echocardiography (TTE) cannot be performed, transesophageal echocardiography (TEE) should be performed
  • The presence of a sternal fracture alone does not predict the presence of BCI and thus should not prompt monitoring in the setting of normal ECG result and troponin I level
  • Creatinine phosphokinase with isoenzyme analysis should not be performed
  • Nuclear medicine studies should not be routinely performed

Level 3 recommendations included the following:

  • Elderly patients with known cardiac disease, unstable patients, and patient with an abnormal admission ECG result can safely undergo surgery if appropriately monitored; placement of a pulmonary artery catheter may be considered
  • With suspected BCI, troponin I should be routinely measured; if elevated, patients should be admitted to a monitored setting and troponin I followed up serially
  • Cardiac CT or magnetic resonance imaging (MRI) can help differentiate acute myocardial infarction (AMI) from BCI in trauma patients with abnormal ECG results, cardiac enzymes, or echocardiograms to determine need for cardiac catheterization or anticoagulation
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