Blunt chest injuries

Initial management

• 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. CT is diagnostic modality of choice
• Resuscitate and treat immediately life threatening injuries before aortic repair
• Control Blood Pressure (SBP <120mmHg) with intravenous antihypertensive (whilst awaiting repair or under observation
• CT is diagnostic modality of choice
• Resuscitate & treat immediately life threatening injuries before aortic repair
• Control Blood Pressure (SBP<120mmHg) with intravenous antihypertensives (whilst awaiting repair or under observation) 

Timing

• Repair early (<24hrs) in the following situations
• Absence of other serious non aortic injuries requiring intervention
  • Grade III/IV injuries
  • Pseudocoarctation
  • High 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 

Sternal fractures

Indications for admission:

• Evidence of blunt cardiac injury (as above)
• Inadequate pain control
•  Severely displaced (which rarely may be considered for fixation) 

Rib Fractures
Clear pathways which encompass early identification, imaging, multimodal analgesia including paravertebral or epidural analgesia combined with surgical fixaiton 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.

Chest Wall Analgesia Guide

Adult (16 yrs+) Chest Wall Trauma Management Guideline