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Emergency Department Evaluation and Management of Blunt Chest June 2016 Emergency Department Volume 18, Number 6 Authors Evaluation And Management Of Eric J. Morley, MD, MS Associate Professor of Clinical Emergency Medicine, Associate Residency Director, Department of Emergency Medicine, Stony Brook Blunt Chest And Lung Trauma Medicine, Stony Brook, NY Scott Johnson, MD Associate Professor of Clinical Emergency Medicine, Residency Abstract Director, Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY The majority of blunt chest injuries are minor contusions or Evan Leibner, MD, PhD Department of Emergency Medicine, Stony Brook Medicine, Stony abrasions; however, life-threatening injuries, including tension Brook, NY pneumothorax, hemothorax, and aortic rupture can occur and Jawad Shahid, MD must be recognized early. This review focuses on the diagnosis, Department of Emergency Medicine, Stony Brook Medicine, Stony management, and disposition of patients with blunt injuries to Brook, NY the ribs and lung. Utilization of decision rules for chest x-ray and Peer Reviewers computed tomography are discussed, along with the emerging Ram Parekh, MD role of bedside lung ultrasonography. Management controversies Assistant Clinical Professor, Emergency Department, Elmhurst Hospital presented include the limitations of needle thoracostomy us- Center, Icahn School of Medicine at Mount Sinai, New York, NY Christopher R. Tainter, MD, RDMS ing standard needle, chest tube placement, and chest tube size. Assistant Clinical Professor, Department of Emergency Medicine, Finally, a discussion is provided related to airway and ventilation Department of Anesthesiology, Division of Critical Care, University of management to assist in the timing and type of interventions California San Diego, San Diego, CA needed to maintain oxygenation. Prior to beginning this activity, see “Physician CME Information” on the back page. This issue is eligible for 4 Trauma CME credits. Editor-In-Chief Daniel J. Egan, MD Eric Legome, MD Robert Schiller, MD International Editors Associate Professor, Department Chief of Emergency Medicine, Chair, Department of Family Medicine, Andy Jagoda, MD, FACEP Peter Cameron, MD of Emergency Medicine, Program King’s County Hospital; Professor of Beth Israel Medical Center; Senior Professor and Chair, Department of Academic Director, The Alfred Director, Emergency Medicine Clinical Emergency Medicine, SUNY Faculty, Family Medicine and Emergency Medicine, Icahn School Emergency and Trauma Centre, Residency, Mount Sinai St. Luke's Downstate College of Medicine, Community Health, Icahn School of of Medicine at Mount Sinai, Medical Monash University, Melbourne, Roosevelt, New York, NY Brooklyn, NY Medicine at Mount Sinai, New York, NY Director, Mount Sinai Hospital, New Australia York, NY Nicholas Genes, MD, PhD Keith A. Marill, MD Scott Silvers, MD, FACEP Giorgio Carbone, MD Assistant Professor, Department of Research Faculty, Department of Chair, Department of Emergency Associate Editor-In-Chief Emergency Medicine, University Medicine, Mayo Clinic, Jacksonville, FL Chief, Department of Emergency Emergency Medicine, Icahn School Medicine Ospedale Gradenigo, Kaushal Shah, MD, FACEP of Medicine at Mount Sinai, New of Pittsburgh Medical Center, Associate Professor, Department of Pittsburgh, PA Corey M. Slovis, MD, FACP, FACEP Torino, Italy York, NY Professor and Chair, Department Emergency Medicine, Icahn School Suzanne Y.G. Peeters, MD Charles V. Pollack Jr., MA, MD, of Emergency Medicine, Vanderbilt of Medicine at Mount Sinai, New Michael A. Gibbs, MD, FACEP Emergency Medicine Residency FACEP University Medical Center, Nashville, TN York, NY Professor and Chair, Department Director, Haga Teaching Hospital, of Emergency Medicine, Carolinas Professor and Chair, Department of Emergency Medicine, Pennsylvania Ron M. Walls, MD The Hague, The Netherlands Editorial Board Medical Center, University of North Professor and Chair, Department of Hospital, Perelman School of Hugo Peralta, MD Carolina School of Medicine, Chapel Emergency Medicine, Brigham and Saadia Akhtar, MD Medicine, University of Pennsylvania, Chair of Emergency Services, Hospital Hill, NC Women's Hospital, Harvard Medical Associate Professor, Department of Philadelphia, PA Italiano, Buenos Aires, Argentina Emergency Medicine, Associate Dean Steven A. Godwin, MD, FACEP School, Boston, MA for Graduate Medical Education, Professor and Chair, Department Michael S. Radeos, MD, MPH Dhanadol Rojanasarntikul, MD Program Director, Emergency of Emergency Medicine, Assistant Assistant Professor of Emergency Critical Care Editors Attending Physician, Emergency Medicine Residency, Mount Sinai Medicine, Weill Medical College Medicine, King Chulalongkorn Dean, Simulation Education, William A. Knight IV, MD, FACEP Beth Israel, New York, NY of Cornell University, New York; Memorial Hospital, Thai Red Cross, University of Florida COM- Associate Professor of Emergency Jacksonville, Jacksonville, FL Research Director, Department of Thailand; Faculty of Medicine, William J. Brady, MD Emergency Medicine, New York Medicine and Neurosurgery, Medical Chulalongkorn University, Thailand Professor of Emergency Medicine Gregory L. Henry, MD, FACEP Hospital Queens, Flushing, NY Director, EM Midlevel Provider and Medicine, Chair, Medical Clinical Professor, Department of Program, Associate Medical Director, Stephen H. Thomas, MD, MPH Ali S. Raja, MD, MBA, MPH Emergency Response Committee, Emergency Medicine, University Neuroscience ICU, University of Professor & Chair, Emergency Vice-Chair, Emergency Medicine, Medical Director, Emergency of Michigan Medical School; CEO, Cincinnati, Cincinnati, OH Medicine, Hamad Medical Corp., Massachusetts General Hospital, Management, University of Virginia Medical Practice Risk Assessment, Weill Cornell Medical College, Qatar; Boston, MA Scott D. Weingart, MD, FCCM Medical Center, Charlottesville, VA Inc., Ann Arbor, MI Associate Professor of Emergency Emergency Physician-in-Chief, Hamad General Hospital, Doha, Qatar John M. Howell, MD, FACEP Robert L. Rogers, MD, FACEP, Medicine, Director, Division of ED Calvin A. Brown III, MD FAAEM, FACP Clinical Professor of Emergency Critical Care, Icahn School of Medicine Edin Zelihic, MD Director of Physician Compliance, Assistant Professor of Emergency Medicine, George Washington at Mount Sinai, New York, NY Head, Department of Emergency Credentialing and Urgent Care Medicine, The University of University, Washington, DC; Director Medicine, Leopoldina Hospital, Services, Department of Emergency Maryland School of Medicine, Medicine, Brigham and Women's of Academic Affairs, Best Practices, Senior Research Editors Schweinfurt, Germany Inc, Inova Fairfax Hospital, Falls Baltimore, MD Hospital, Boston, MA James Damilini, PharmD, BCPS Church, VA Alfred Sacchetti, MD, FACEP Clinical Pharmacist, Emergency Peter DeBlieux, MD Shkelzen Hoxhaj, MD, MPH, MBA Assistant Clinical Professor, Room, St. Joseph’s Hospital and Professor of Clinical Medicine, Chief of Emergency Medicine, Baylor Department of Emergency Medicine, Medical Center, Phoenix, AZ Interim Public Hospital Director College of Medicine, Houston, TX Thomas Jefferson University, of Emergency Medicine Services, Philadelphia, PA Joseph D. Toscano, MD Louisiana State University Health Chairman, Department of Emergency Science Center, New Orleans, LA Medicine, San Ramon Regional Medical Center, San Ramon, CA Case Presentations mortality was low (5%), but increased to 37% when only patients with multiple severe injuries were You are about to start a busy Monday afternoon shift considered. Thoracic skeletal fractures were present when you hear a radio call from EMS for a high-speed in 84% of these patients, while flail chest was diag- motor vehicle crash. The dispatcher tells you that the pa- nosed in 8%. Pulmonary contusion was diagnosed tients are 5 minutes away. The first patient that arrives is in 16% of the patients, diaphragmatic rupture was 3 an unrestrained 23-year-old male driver. The patient has present in 2%, and tracheobronchial injury in 0.4%. severe right-sided chest pain with moderate respiratory Rib fractures are identified in up to two-thirds of distress. His blood pressure is 102/54 mm Hg, his heart chest trauma patients who receive radiographic imag- 4-6 rate is 112 beats/min, and the pulse oximeter reads 92% ing. Rib fractures are some of the most common on room air. You are concerned for a pneumothorax but injuries in the elderly, accounting for approximately wonder what else could explain his abnormal vital signs... 12% of all fractures, with increasing incidence as this 7 The second patient is the unrestrained 27-year-old fe- population gets older. Emergency clinicians must male passenger from the same accident, with a chief com- have a low threshold of suspicion for rib fractures and plaint of chest pain, difficulty breathing, and shortness bony skeletal injury in patients with blunt thoracic of breath. Her blood pressure is 120/70 mm Hg, her heart trauma, as up to 50% of fractures may be undetected 6 rate is 85 beats/min, and the pulse oximeter reads 97% radiographically. This is important, as morbidity and on room air. On exam, the patient has decreased breath mortality can be significant from chest wall injuries sounds on the right side. Again, pneumothorax sounds alone. One review of 77 elderly patients reported a likely as you wait for the portable x-ray; you wonder if a 38% rate of respiratory complication, with 8% mortal- 8 bedside ultrasound could facilitate making the diagnosis... ity, associated
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