Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries)

Abstract

This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.

Lessons from a large trauma center: impact of blunt chest trauma in polytrauma patients—still a relevant problem?

“…As Lesquen et al [10] mentioned in their review, all traumatic pneumothoraces and symptomatic traumatic hemothoraces should be considered for chest tube insertion in the first 48 h following blunt chest trauma. However, observation is possible for selected patients without respiratory disease or the need for positive pressure ventilation presenting with small unilateral pneumothoraces [11].…”

Blunt Thoracic Injury Mortality and Clinical Presentation

“…Therefore, proper evaluation of thoracic injury complications could prevent delayed treatment consequences and reduce mortality and morbidity rates (17,18). Blunt chest trauma patients, who present no immediate life-threatening respiratory complications, are at a high risk of developing respiratory failure (19).…”

“…Early diagnosis and treatment of blunt thoracic trauma is also essential although the treatment is complex and evolving (17,18). According to current search and knowledge, a few studies were done about this important topic in Iran.…”

“…Therefore, proper evaluation of thoracic injury complications could prevent delayed treatment consequences and reduce mortality and morbidity rates (17,18). Blunt chest trauma patients, who present no immediate life-threatening respiratory complications, are at a high risk of developing respiratory failure (19).Early diagnosis and treatment of blunt thoracic trauma is also essential although the treatment is complex and evolving (17,18). According to current search and knowledge, a few studies were done about this important topic in Iran.…”

The role for surgery in pre-hospital care

“…Whilst most traumatic pneumothoraces will be treated with tube thoracostomy within the first 48 h of hospital admission, 15,16 there is no role for this intervention in PHC for uncomplicated cases. However, tension pneumothorax is the leading cause of preventable death following thoracic injury and can be rapidly fatal.…”