Blunt chest injuries (blunt aortic, blunt cardiac, chest wall)

Initial mangement

• RSI is the safest and most effective method to secure the airway.
• Induction in the exsanguinating patient can be fatal. Provide ongoing volume resuscitation during RSI in these patients.
• Do not delay induction for arterial or central access in patients in extremis.
• Resuscitate and treat immediately life-threatening injuries before Aortic repair.
• Control Blood Pressure (SBP <120mmHg) with intravenous anti- hypertensive (whilst awaiting repair or under observation).
• CT is diagnostic modality of choice.

Timing

• Repair early (<24hrs) in the following situations:
• Absence of other serious non aortic injuries requiring intervention
  • Grade III/IV injuries
  • Pseudocoarctation
  • Substantial risk of rupture (based upon imaging and clinical findings).
• Delay repair until life and limb threatening injuries have been treated though aim to repair immediately thereafter.
• TEVAR is treatment of choice unless contra-indicated or poor anatomy.

Special Considerations in TEVAR for Trauma

• Use systemic heparin at a lower dose than elective TEVAR in patients with brain injury or solid organ injury at risk of bleeding
• Heparin has and can be safely omitted dependent on risk/benefit
• Prophylactic spinal drainage is not indicated
• Consider a spinal drain only if symptoms of spinal cord ischemia develop.

• Admit all patients with chest wall trauma new ECG abnormalities.
• Admit all patients with a raised troponin and perform serial troponins.
• Perform Echocardiography if haemodynamic instability or persistent new arrhythmia.
• Cardiac CT/MRI may differentiate between acute MI and Blunt cardiac injury.
• If severe cardiac valvular regurgitation is associated with cardiac failure consider a diagnosis of traumatic cardiac valvular rupture, especially if the valvular regurgitation can be shown to be new. It is treated by surgical cardiac valve replacement.

Sternal Fractures

Indications for admission:

• Evidence of blunt cardiac injury (as above)
• inadequate pain control
• Severely displaced (which rarely may be considered for fixation)
• Significant associated injuries
• Important co-morbidities.

Rib Fractures

Clear pathways which encompass early identification, imaging, multimodal analgesia including paravertebral or epidural analgesia combined with surgical fixation in appropriate groups have been shown to reduce morbidity and length of stay. The following guideline should be used when the patient arrives in the ED:

Co-existent Pulmonary Contusions

Once adequately resuscitated, unnecessary fluid administration should be meticulously avoided.