Guideline sources The following summarized guidelines for the evaluation and management of blunt chest trauma are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the American Heart Association (AHA/ACC 2022), the European Association of Urology (EAU 2022), the Society of Interventional Radiology (SIR 2020), the American College of Radiology (ACR 2020; 2019), the European Respiratory Society (ERS 2017), the Eastern Association for the Surgery of Trauma (EAST 2017; 2016; 2015; 2012; 2011), the British Thoracic Society (BTS 2017; 2010), the Society of Critical Care Medicine (SCCM 2016), the American Urological Association (AUA 2014), the European Society of Cardiology (ESC 2014), and the Society for Vascular Surgery (SVS 2011). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Calculator Calculator Blast Lung Injury severity score NEXUS criteria for chest X-ray in https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 1/10 6/29/23, 3:20 AM Blunt chest trauma Pathway Guidelines 1. Diagnostic investigations Evaluation for pneumothorax/hemothorax: consider obtaining trauma ultrasound to identify pneumothorax and pleural effusion. C Evaluation for rib fracture: Obtain a CXR as the initial imaging in patients with suspected rib fractures in the following situations: minor blunt trauma (injury confined to ribs) after CPR pathologic fracture. B Obtain chest CT without IV contrast or whole body technetium-99m bone scan as complementary to the CXR in patients with suspected pathologic rib fracture. B Evaluation for cardiac injury (electrocardiogram): Obtain an ECG on admission in all patients with suspected blunt cardiac injury. A Admit patients with a new abnormality (arrhythmia, ST changes, ischemia, heart block, or unexplained ST changes) for continuous ECG monitoring. Compare the results to a previous ECG to determine the need for monitoring in patients with preexisting abnormalities. B Evaluation for cardiac injury (cardiac biomarkers): obtain troponin I level measurement routinely in patients with suspected blunt cardiac injury. Admit patients to a monitored setting and obtain serial laboratory monitoring if the troponin I level is elevated. B Show 2 more Evaluation for cardiac injury, imaging: As per ACR 2020 guidelines: Obtain a CXR, TTE, and chest CT with IV contrast or chest CT angiography as complementary first-line imaging modalities in hemodynamically stable patients with suspected cardiac injury following blunt chest trauma. B Obtain a CXR, TTE, chest CT with IV contrast, chest CT angiography, and cardiac CT with IV contrast as complementary imaging modalities in hemodynamically unstable patients with suspected cardiac injury following blunt chest trauma. B As per SCCM 2016 guidelines, consider obtaining a bedside TTE to exclude significant pericardial effusion in hemodynamically unstable patients with blunt chest trauma. C As per EAST 2012 guidelines: Obtain a TTE in patients with hemodynamic instability or persistent new arrhythmia. Obtain a TEE if an optimal TTE cannot be obtained. B Obtain cardiac CT or MRI to help differentiate acute myocardial infarction from blunt cardiac injury in trauma patients with abnormal ECG, cardiac enzymes, and/or abnormal https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 2/10 6/29/23, 3:20 AM Blunt chest trauma Pathway echocardiography. B Evaluation for aortic injury: As per EAST 2015 guidelines, obtain contrast-enhanced chest CT in patients with suspected blunt traumatic aortic injury. A As per ESC 2014 guidelines, obtain CT in patients with suspected traumatic aortic injury. B Consider obtaining a TEE if CT is not available. B Evaluation for renal injury: As per EAU 2022 guidelines, obtain multiphase CT in patients with a rib fracture and suspected kidney trauma. A As per AUA 2014 guidelines, obtain IV contrast-enhanced CT in stable patients with trauma with a mechanism of injury or physical examination findings concerning renal injury (such as rapid deceleration, rib fracture, or penetrating injury of the lower chest). B 2. Respiratory support Noninvasive ventilation: As per ERS 2017 guidelines, consider initiating noninvasive ventilation in patients with chest trauma and acute respiratory failure. C Updated evidence: OptiTHO In adult patients admitted to the ICU within 48 hours after high-risk blunt chest trauma, non- severe hypoxemia, and no evidence of acute respiratory failure, early noninvasive ventilation and high-flow nasal oxygen therapy were not superior to late noninvasive ventilation and conventional oxygen therapy with respect to endotracheal intubation for delayed respiratory failure. C dric Carri et al. Crit Care. 2023 Apr 26. As per EAST 2012 guidelines: Consider initiating a trial of mask CPAP in combination with optimal regional anesthesia in alert, compliant patients with marginal respiratory status. C Consider initiating high-frequency oscillatory ventilation in certain cases of blunt chest trauma when other modalities have failed. Consider initiating high-frequency oscillatory ventilation in patients failing conventional ventilatory modes. C Mechanical ventilation: avoid initiating obligatory mechanical ventilation in the absence of respiratory failure solely for the purpose of overcoming chest wall instability. D Show 2 more 3. Medical management https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 3/10 6/29/23, 3:20 AM Blunt chest trauma Pathway Management of pain: As per EAST 2016 guidelines, consider administering epidural analgesia over nonregional modalities of pain control (IV or enteral analgesics, such as opioids, acetaminophen, and NSAIDs) for the management of pain in adult patients with blunt thoracic trauma. C Show 2 more As per EAST 2012 guidelines: Administer optimal analgesia to minimize the likelihood of respiratory failure and ensuing ventilatory support. Use epidural catheter as the preferred mode of analgesia delivery in patients with a severe flail chest injury. B Insufficient evidence regarding the effectiveness of paravertebral analgesia in patients with trauma. Consider administering paravertebral analgesia in certain situations where epidural analgesia is contraindicated. I Management of pneumothorax (oxygen supplementation): Aim at an oxygen saturation of 94-98% in most cases of pneumothorax if the patient is not at risk of hypercapnic respiratory failure. B Use high-concentration oxygen (15 L/min flow rate via reservoir mask) in patients with pneumothorax under hospital observation without drainage unless the patient is at risk of hypercapnic respiratory failure. B Management of pneumothorax (drainage): consider observing stable patients with occult pneumothorax (not seen on CXR), regardless of positive pressure ventilation. C Show 2 more Management of hemothorax: consider draining all hemothoraces, regardless of size. C Show 4 more Management of pulmonary contusion (fluid resuscitation): Administer fluid resuscitation with isotonic crystalloid or colloid solution as necessary to maintain signs of adequate tissue perfusion in patients with pulmonary contusion-flail chest. Avoid administering unnecessary fluid once adequately resuscitated. B Consider placing a pulmonary artery catheter to avoid fluid overload during resuscitation. C Management of pulmonary contusion (respiratory support): consider initiating a trial of mask CPAP in combination with optimal regional anesthesia in alert, compliant patients with marginal respiratory status. C Show 4 more Management of pulmonary contusion (diuretics): consider administering diuretics in the setting of hydrostatic fluid overload, as evidenced by elevated pulmonary capillary wedge pressures, in hemodynamically stable patients or in the setting of known concurrent congestive HF. C Management of pulmonary contusion (corticosteroids): do not use corticosteroids in the management of patients with pulmonary contusion. D Management of pulmonary contusion (analgesics): https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 4/10 6/29/23, 3:20 AM Blunt chest trauma Pathway Administer optimal analgesia to minimize the likelihood of respiratory failure and ensuing ventilatory support. Use epidural catheter as the preferred mode of analgesia delivery in patients with a severe flail chest injury. B Insufficient evidence regarding the effectiveness of paravertebral analgesia in patients with trauma. Consider administering paravertebral analgesia in certain situations where epidural analgesia is contraindicated. I Management of pulmonary contusion (chest physiotherapy): offer aggressive chest physiotherapy to minimize the likelihood of respiratory failure and ensuing ventilatory support. B Management of rib fracture, surgical stabilization: As per EAST 2017 guidelines: Consider performing surgical reduction and internal fixation of rib fracture to decrease mortality, shorten the duration of mechanical ventilation, ICU and hospital length of stay, the incidence of pneumonia, and the need for tracheostomy in adult patients with flail chest after blunt trauma. C Insufficient evidence to recommend surgical reduction and internal fixation of rib fractures in adult patients with non-flail rib fractures after blunt trauma. I As per EAST 2012 guidelines: Consider performing surgical fixation of the flail chest in patients with severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. C Insufficient evidence to recommend any type of proprietary implant for surgical fixation of rib fractures. Consider using rib plating or wrapping devices over intramedullary wires. I Management of rib fracture, analgesics: As per AOTA/EAST 2023 guidelines: Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture. C Insufficient evidence to recommend for the preference of selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs. I As per EAST 2012 guidelines, administer optimal analgesia to minimize the likelihood of respiratory failure and ensuing ventilatory support. Use epidural catheter as the preferred mode of analgesia delivery in patients with a severe flail chest injury. B Management of aortic injury (setting of care): manage and treat patients with blunt traumatic thoracic aortic injury at a trauma center with the facilities and expertise to treat aortic pathology. B Management of aortic injury, expectant management: As per AHA/ACC 2022 guidelines: Offer nonoperative management and follow-up imaging in patients with grade 1 blunt traumatic thoracic aortic injury. B Consider offering nonoperative management and follow-up surveillance imaging in patients with grade 2 blunt traumatic thoracic aortic injury without high-risk imaging features. C https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 5/10 6/29/23, 3:20 AM Blunt chest trauma Pathway As per SVS 2011 guidelines, consider offering expectant management with serial imaging in patients with type I aortic injuries (intimal tear). C Management of aortic injury, anti-impulsive therapy: As per AHA/ACC 2022 guidelines, initiate anti-impulse therapy to reduce the risk of injury extension and rupture in patients with blunt traumatic thoracic aortic injury, except with hypotension or hypovolemic shock. B As per SIR 2020 guidelines, initiate antihypertensive and anti-impulse medications with close symptomatic and/or radiographic follow-up in patients with grade 1-2 aortic injuries (minimal aortic injury). B Management of aortic injury, TEVAR, indications: As per AHA/ACC 2022 guidelines: Perform an aortic intervention in patients with grade 3-4 blunt traumatic thoracic aortic injury and nonprohibitive comorbidities or injuries. B Consider performing an aortic intervention in patients with grade 2 blunt traumatic thoracic aortic injury with high-risk imaging features. C As per SIR 2020 guidelines, perform an aortic intervention in patients with anatomically favorable grade 3-4 aortic injuries. B Management of aortic injury, TEVAR, timing: As per EAST 2015 guidelines, consider performing delayed repair in patients diagnosed with blunt traumatic aortic injury while ensuring effective BP control with antihypertensive medications. C As per SVS 2011 guidelines, consider performing urgent (< 24 hours) repair at the latest before hospital discharge. C Management of aortic injury, TEVAR, choice of approach: As per AHA/ACC 2022 guidelines, perform TEVAR over open repair in patients with blunt traumatic thoracic aortic injury with appropriate anatomy meeting indications for repair. B As per SIR 2020 guidelines, perform emergent TEVAR in patients with anatomically favorable grade 3-4 aortic injuries. B As per EAST 2015 guidelines, perform endovascular repair in patients with blunt traumatic aortic injury without contraindications to endovascular repair. A As per ESC 2014 guidelines, perform TEVAR over open surgery in patients with traumatic aortic injury with suitable anatomy requiring intervention. B As per SVS 2011 guidelines, consider performing endovascular repair over open surgical repair or nonoperative management in patients with traumatic thoracic aortic injuries requiring intervention. Consider performing endovascular repair regardless of age if anatomically suitable. C Management of aortic injury (TEVAR, technical considerations): Consider using the femoral access technique. C https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 6/10 6/29/23, 3:20 AM Blunt chest trauma Pathway Avoid performing routine spinal drainage. D Management of aortic injury (left subclavian artery revascularization): consider performing selective revascularization of the left subclavian artery. C Management of aortic injury (resuscitative thoracotomy): Consider performing emergency department thoracotomy in patients presenting pulseless to the emergency department with signs of life after blunt injury. C Avoid performing emergency department thoracotomy in patients presenting pulseless to the emergency department without signs of life after blunt injury. D Management of aortic injury (surveillance imaging): Consider obtaining surveillance imaging at intervals appropriate for the repair approach and location after aortic repair in patients with blunt traumatic aortic injury. C Consider obtaining surveillance CT at 1 month, 6 months, and 12 months after the diagnosis and, if stable, at appropriate intervals thereafter (depending on the type and extent of the injury) in patients with unrepaired blunt traumatic aortic injury. C 4. Therapeutic procedures Technical considerations for chest drainage (analgesic premedication): Consider administering analgesia as premedication to reduce pain associated with chest drains. E Administer local lidocaine 1% before the procedure, paying particular attention to the skin, periosteum, and pleura. E Technical considerations for chest drainage (antibiotic prophylaxis): consider administering antibiotic prophylaxis in trauma patients requiring chest drains, especially after penetrating trauma. B Technical considerations for chest drainage (insertion technique): perform pleural aspirations and chest drain insertions in a clean area using a full aseptic technique, E including gowns, drapes, sterile gloves, and skin cleansing. B Show 16 more Technical considerations for chest drainage (care of inserted drains): do not clamp the bubbling chest tube. D Show 4 more Technical considerations for chest drainage, follow-up imaging: As per EAST 2011 guidelines, obtain chest CT to determine whether significant undrained fluid exists in patients with persistent opacity on CXR after tube thoracostomy. B As per BTS 2010 guidelines, do not obtain CXRs after a simple pleural aspiration unless air is withdrawn, the procedure is difficult, multiple attempts are required, or the patient becomes symptomatic. D https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 7/10 6/29/23, 3:20 AM Blunt chest trauma Pathway 5. Surgical interventions Indications for surgery: Decide on the surgical intervention based on patient physiology rather than absolute numbers of initial or persistent output. B Consider performing surgical exploration in case of 1,500 mL via a chest tube in any 24-hour period, regardless of mechanism. C Clinical findings Symptoms Past events Chest pain Blunt chest trauma Shortness of breath Motor vehicle accident Vital signs Vascular exam Signs of shock Hypovolemia Tachypnea Respiratory exam O2 saturation Chest wall crepitus Neurological exam Chest wall tenderness Altered mental status Flail chest Paradoxical movement of the chest wall Integument exam Chest wall ecchymosis Lab findings Seatbelt sign serum troponin I ECG findings serum troponin T Cardiac arrhythmias Imaging findings St-segment changes Hemothorax Pericardial effusion Pleural effusion Pneumothorax Rib fracture Studies 2023 OptiTHO In adult patients admitted to the ICU within 48 hours after high-risk blunt chest trauma, non-severe hypoxemia, and no evidence of acute respiratory failure, early noninvasive ventilation and high-flow https://web.pathway.md/diseases/recgbkpqWjLA9ypLs 8/10 6/29/23, 3:20 AM Blunt chest trauma Pathway nasal oxygen therapy were not superior to late noninvasive ventilation and conventional oxygen therapy with respect to endotracheal intubation for delayed respiratory failure. 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