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KEY POINTS

KEY POINTS

  • Only 7% (blunt trauma) to 15% (penetrating trauma) of patients with thoracic trauma will require a thoracotomy.

  • The ribs are flexible, the sharpest angle of the rib occurs posteriorly at the tubercle, and the ribs are furthest apart from one another anteriorly.

  • Currently available classification systems for rib fractures include the Organ Injury Scale–Chest, Rib Fracture Score, Chest Trauma Score, and RibScore.

  • Both acetaminophen and nonsteroidal anti-inflammatory drugs have been shown to provide comparable analgesia to oral narcotics in trauma patients and should be given routinely to patients with injury to the chest wall.

  • Surgical stabilization of rib fractures is currently recommended for patients with a flail segment and a poor response to nonoperative therapy or associated respiratory failure, patients with multiple displaced rib fractures, and patients with multiple nondisplaced fractures that undergo interval displacement and worsening clinical status.

  • Prolonged (ie, 7–10 days) trials of nonoperative management in patients with multiple displaced rib fractures increase the risk of pulmonary compromise.

  • A large pneumothorax seen on computed tomography, but not detected on a chest x-ray, is most often anterior.

  • Indications for a thoracotomy for a hemothorax include initial chest tube drainage (15–30 minutes) of 1200 to 1500 mL or 200 mL/h for 2 to 4 hours.

  • Significant injuries to the lung, particularly those from gunshot wounds and away from the hilum, are often best treated with pulmonotomy and selective vascular ligation.

  • A “persistent” air leak after 5 to 7 days of drainage of the pleural cavity can be treated with autologous blood pleurodesis, a commercially available sealant, an endobronchial one-way valve, a Heimlich valve, or a thoracotomy.

INTRODUCTION

Injuries to the chest wall and lung are common following both blunt and penetrating trauma. Blunt thoracic injuries are responsible for approximately 8% of all trauma admissions and contribute to 25% of trauma deaths in the United States, with motor vehicle crashes as the most common mechanism.1-4 The most common injury following blunt chest trauma is rib fractures.5 In comparison, penetrating chest trauma accounts for 7% of all trauma admissions and 16% of penetrating trauma admissions overall.6

The first task in managing patients with injuries to the chest wall and lung is determining the need for emergency intervention. Conditions typically needing emergency intervention are related to either bleeding or a pneumothorax. The majority of patients continue to be successfully managed nonoperatively or with minor procedures. Between 18% and 40% of patients sustaining thoracic trauma can be effectively managed with tube thoracostomy alone, and thoracotomy will be required for only 7% to 15% of patients. Even among those with penetrating chest trauma, only 14% of patients with stab wounds and 20% of patients with gunshot wounds to the chest require emergent thoracotomy.6

When emergent operation is required, approximately 30% of patients undergoing thoracotomy require a pulmonary resection. Mortality varies between 5% and 45%.3 This wide ...

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