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  • • Simple rib fracture is most common thoracic injury

    • Spectrum from simple rib fracture to fracture with hemothorax to flail chest with associated pulmonary contusion

    • Flail chest occurs when a portion of the chest wall becomes separated from the rib cage by multiple fractures and moves opposite to the rib cage with rib inspiration and expiration decreasing respiratory efficiency

    • Early deaths commonly due to:

    • -Airway obstruction

      -Flail chest

      -Open pneumothorax

      -Massive hemothorax

      -Tension pneumothorax

      -Cardiac tamponade

    • Late deaths are due to:

    • -Respiratory failure

      -Sepsis

      -Unrecognized injuries

    • 85% of chest injuries do NOT require open thoracotomy

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Epidemiology

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  • • Accounts directly or contributes to 50% of deaths from trauma

    • 80% of blunt thoracic injuries are related to motor vehicle accidents

    • Penetrating injury nearly as frequent as blunt injury

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Symptoms and Signs

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  • • Pain on inspiration

    • Decreased ventilation

    • Cyanosis, ashen or gray facies may indicate upper airway obstruction

    • Stridor

    • Poor respiratory excursion

    • Retraction of supraclavicular, suprasternal, intercostal, or epigastric regions

    • Paradoxic chest wall movement indicates flail chest

    • Tracheal shift, dullness to percussion and absence of breath sounds unilaterally with flat neck veins can indicate massive hemothorax

    • Tracheal shift, tympany to percussion and absence of breath sounds unilaterally with distended neck veins may indicate tension pneumothorax

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Laboratory Findings

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  • • Hypoxemia

    • Hypercapnea

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Imaging Findings

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  • Chest film or CT scan:

    • -Rib fractures

      -Pneumothorax

      -Hemothorax

      -Tension pneumothorax (does not need chest film to diagnose)

      -Wide mediastinum

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  • • Associated injuries in abdomen may dictate therapy

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Rule Out

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  • • Airway obstruction

    • Tension pneumothorax

    • Flail chest

    • Massive hemothorax

    • Cardiac tamponade

    • Open pneumothorax

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  • • Physical exam

    • Chest x-ray

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  • • Adequate analgesia

    • Intubation and mechanical ventilation as needed

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Surgery

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  • • Rarely, external fixation of chest wall

    • Operative repair specific for injury

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Treatment Monitoring

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  • • Serial ABG measurements

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Complications

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  • • Atelectasis

    • Hypercapnea

    • Hypoxia

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Prognosis

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  • • Hospital mortality of isolated thoracic injury is 4-8%, but rises to 10-15% with 1 other organ system involved and to 35% if multiple organs involved

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Prevention

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  • • Seatbelt use

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References

Bergeron E et al: Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 2003;54:478.  [PubMed: 12634526]
Cothren C et al: Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma 2002;53:483.  [PubMed: 12352485]
Dulchavsky SA et al: Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001;50:201.  [PubMed: 11242282] ...

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