Netherlands Journal of Critical Care

Copyright © 2010, Nederlandse Vereniging voor Intensive Care. All Rights Reserved. Received: July 2009; accepted: April 2010

Review

Blunt chest trauma in intensive care

J Textoris, F Michel, A Charvet, C Martin, M Leone

Department of Anaesthesiology and Critical Care Medicine, North Hospital, Assistance Publique – Hôpitaux de Marseille,  Unversity of Méditerranée, Marseilles, France

Abstract - Objective: To describe the management of blunt thoracic trauma patients admitted to the intensive care unit, and to provide a strategy for their management. Search strategy: The literature was reviewed using several sources: Pubmed, textbooks, guidelines of thoracic societies. Where available, data from patients admitted to intensive care units were assessed. Articles focusing on surgical techniques for chest trauma were discarded. Summary of findings: The assessment of the literature shows that chest trauma is the second most frequent and lethal injury in the modern era. The performance of computed tomography is excellent, which makes it pos- sible to diagnose most injuries without delay. In contrast, most management procedures rely on an empiric approach because of the weakness of the level of evidence in this field. Protective ventilation, safe procedures to insert a chest drain and adequate administration of analgesics are the basis of the management of patients with chest trauma. Worsening the outcome by an excessively aggressive ap- proach should be avoided. Conclusion: The injuries of patients with chest are presently well-depicted, but there is a need for randomized clinical trials in order to progress in their management.

Keywords - trauma, chest, thorax, contusion

Introduction effect. The aorta can be likened to a column of blood heavy with Thoracic injuries are responsible for approximately 20% of inertia that swings like the clanger of a bell within the thorax. This all trauma-related deaths. They are the second most common produces severe shear forces. An experimental cadaveric study cause of death in trauma patients. In Europe, thoracic injury is has shown that the deceleration recorded in the isthmus of the mostly caused by motor vehicle accidents or falls, resulting in aorta is always higher than that recorded in the [3]. This blunt trauma. Penetrating wounds represent less than 10% of may explain the blunt thoracic aortic rupture in the high speed chest trauma. In the intensive care unit (ICU), most patients with accident. Crushing is the second most common cause of injury. blunt chest trauma have multiple injuries including head trauma It is responsible for rib fractures, flail chest and visceral lesions. (58%), abdominal injury (41%), and long bone fractures (51%) [1]. Blast injuries are related to a sudden energy transfer. The blast Of those patients, 50-100% have pulmonary contusions, wave can cause occult trauma to the ocular, aural, pulmonary, 30-70% have a , 20-50% have a haemothorax cardiovascular, musculoskeletal and neurological systems. and 15-50% have rib fractures [1]. The prognosis of multiple The ears should be examined by means of direct otoscopy for trauma patients worsens with specific injuries including head primary blast injury-induced tympanic membrane perforation or and thorax [2]. The literature was reviewed using several sources: disruption of the ossicular chain [4]. Pubmed, textbooks, guidelines of thoracic societies. Where available, data from patients admitted to intensive care units Thoracic injuries were assessed. Articles focusing on surgical techniques for chest Trauma to the chest wall trauma were discarded. This review will attempt to describe from Rib fractures constitute a major part of chest trauma (Figure 1). the intensivist’s point of view, the management of blunt thoracic The exact incidence is unknown as many can be missed. In a trauma patients admitted to intensive care units, and to provide a cohort of patients with chest trauma admitted to ICU, unilateral strategy for their management. rib fractures were found in about 60% of cases. The number of fractured ribs depends on the mechanism of injury. The energy Pathophysiology required to induce a is conversely proportional to the In Europe, blunt thoracic injuries are related to three mechanisms. age of the victim. Fracture of the first rib is uncommon because it Rapid deceleration is the cause of injuries in most motor vehicle is one of the strongest, it is the shortest rib and is in a protected accidents. It produces the so-called intra-thoracic bell clanger position. This fracture is a marker of severe trauma [5]. An arterial abnormality is found in 14% of patients with a first rib fracture [6]. Correspondence Fractures of the last rib may be associated with abdominal injuries. A flail chest occurs when a segment of the chest wall M Leone breaks under stress and become detached from the rest of the E-mail: [email protected] chest wall. It requires multiple adjacent rib fractures in multiple

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Bluntchesttraumainintensivecare places, in order for a segment to be separated. This causes a these images. Multidetector CT scan should be used after paradoxical motion increasing respiratory work and pain during plain radiography. Abdominal ultrasound can provide valuable breathing. Flail chest is accompanied by information. Diaphragmatic herniation of liver, bowel or omentum and possibly by haemopneumothorax. has been well shown in sagittal and coronal magnetic resonance Sternal fractures are observed when victims of motor vehicle imaging that can be useful only in selected patients [14]. accidents impact on the steering wheel. This occurs in old cars without airbags [7]. Other causes are falls or direct blows. Rib Pleural effusion fractures, myocardial contusion and pulmonary contusion are Haemothorax is a collection of blood in the space between the associated with at least 30% of cases [8]. chest wall and the lung - the pleural cavity. It is present in about 50% of patients with chest trauma admitted to ICU [1]. It may be due to rib fractures, vertebral fractures or lung laceration. The In a post-mortem series, the incidence of diaphragmatic rupture classical signs of tachycardia, low blood pressure, pallor, sweating was 3.7% in patients with blunt trauma [9]. Blunt diaphragmatic and air hunger are diffi cult to interpret in ICU patients. The picture injuries are easily missed in the absence of other indications for can be that of a hypovolaemic . Chest radiograph and CT immediate surgery [10]. This can generate late complications [11]. scan confi rm the diagnosis. Chest radiographs identify a volume However, the use of multidetector computed tomography (CT) of blood above 200-300 mL. The sensitivity and specifi city of CT scan can improve the diagnosis performance [12]. In blunt scan are 100%. Ultrasound can easily detect haemothorax at the trauma, the right hemi-diaphragm is ruptured in 15-20%, and the bedside (Figure 2). left in 70-80% of cases [11]. Pneumothorax is a collection of air in the pleural cavity, Clinically, patients can be asymptomatic. They commonly occurring in about 70% of patients with chest trauma [1]. The experience dyspnoea, chest pain, abdominal pain, and vomiting. most common aetiology is the rib fracture which tears the A decrease in respiratory sounds is the primary fi nding. parietal pleura. Other causes are compressive tear of the lung Bowel sounds in the thorax are the pathognomonic fi nding of parenchyma, rupture of following barotraumas and intestinal herniation. In the ICU, a diaphragmatic rupture can leakage of air from the peritoneal cavity in a patient with a ruptured cause a failure of weaning from the ventilator [13]. Initial chest diaphragm and viscous injury. Tension pneumothorax is a life- radiograph arouses suspicion in only 20-34% of cases [13]. The threatening condition that results from a progressive deterioration hemi-diaphragms require careful scrutiny. A possible rupture and worsening of a simple pneumothorax associated with the of the hemi-diaphragm is suggested by several radiological formation of a one-way valve at the point of rupture in the lung. signs including: inability to delineate the full extent of the hemi- Air becomes trapped in the pleural cavity, putting pressure on the diaphragm, apparently elevated diaphragm, gas or air-fl uid levels in the lower chest, abrupt upward bulge of the hemi-diaphragm, basal soft tissue opacifi cation, mediastinal displacement, and a Figure 2. Ultrasound: normal lung in TM mode (A), pneumotho- nasogastric tube which the tip is above the normal diaphragmatic rax in TM mode (B), and haemothorax in bidimensional mode (C) position. Chest radiography should be repeated to obtain

Figure 1. Computed tomography showing most frequent inju- ries in blunt chest trauma

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lung and keeping it from infl ating fully. This leads to compression blunt chest trauma. Pulmonary contusion alters gas exchange, of the heart, decreasing the cardiac output due to the reduced and the extent of contusion volumes allows identifi cation of amount of diastolic fi lling of the ventricles, and also pressure patients at high risk of acute respiratory distress syndrome on the trachea. Because of the resulting increased intrathoracic (ARDS) [17,18]. Unilateral lung contusion rapidly leads to a pressure, venous return to the heart is impaired. generalized impairment of the entire lung [19]. Several signs including hyper-resonance on percussion, The history of a blunt chest trauma suggests its diagnosis. decreased breath sounds and subcutaneous emphysema Increased alveolar-arterial oxygen gradient, moist rales on suggest the diagnosis. Chest radiograph can confi rm it, with the auscultation and haemoptysis appear at a later stage. Extra- exception of occult anterior effusion. Chest ultrasound can easily thoracic injuries are present in 87% of cases. Pulmonary exclude occult pneumothorax and, in experienced hands, can be contusion may be absent on the initial chest radiograph [20]. In performed on admission of trauma patients [15-16] (Figure 2). As contrast, the CT scan reveals pulmonary contusions whatever for haemothorax, the sensitivity and specifi city of CT scan are their clinical expression. Three times as many lesions can be excellent (Figure 1). seen on CT scan than on chest radiograph [21]. Four types of lesions can be visualized by CT scan, each resulting from a Pulmonary contusion different mechanism [21]. These images should be differentiated Pulmonary contusion is a of the lung. As a result of damage from those of a lung collapse (Figure 1). to capillaries, blood and other fl uids accumulate in the lung Pulmonary contusion has been considered to be a relatively tissues. It is the chief aetiology of pulmonary dysfunction after benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma [22]. This statement should be modifi ed. In the short term, pneumonia is the most frequent Figure 3. Blunt thoracic aortic rupture (chest radiograph (A) and complication of lung contusion [17]. Its incidence in multiple computed tomography (B)) trauma with pulmonary contusion ranges from 25% to 33% [1,17,18, 20]. The incidence of ARDS in patients with pulmonary contusion ranges from 4.5% to 14% [1,18]. In the long term, six months after being discharged from the ICU survivors of multiple trauma with chest trauma have functional limitations, as attested by 70% of patients with impaired pulmonary function on testing. The obstructive pattern seemed overrepresented on comparison with the age- and sex-matched reference population. The pulmonary function limitation impacts on quality of life [1]. A ratio of arterial oxygen pressure to inspired oxygen fraction of less than 200 mmHg on admission may determine those patients at high risk of pulmonary complications [1].

Table 1. Clinical and radiological signs leading to high suspicion of blunt traumatic aortic rupture

CLINICAL CHEST rADIOGrAPH

Rapid deceleration Wide mediastinum Ejection from vehicle Left apical pleural cap Hypertension at the level of Blurring of the sharp aortic superior limbs knob contour Difference of pulse perception Tracheal or oesophageal or between the arms nasogastric tube shift to the right Precordial or paravertebral systolic Depression of the left main murmur bronchus greater than 40° (palpation) Left haemothorax Cardiac contusion Fracture of fi rst rib Unexplained hypotension Opacifi cation of the supramedial aspect of the left pleural apex

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Blunt thoracic aortic trauma angiography. It can be performed at the bedside. Its sensitivity Although traumatic rupture of the thoracic aorta occurs in only and specifi city are excellent although this procedure depends on 1% of victims of motor vehicle accidents, it accounts for 20% of the operator. Transoesophageal should be an all fatalities. Its incidence is twice as high in side impacts as in option in unstable patients who cannot undergo CT scan. These frontal ones. The risk increases with age and is reduced for belted procedures have been superseded by multidetector CT scan with occupants in frontal impacts. Multiple rib fractures, bilateral in use of contrast that has 100% sensitivity and 99.8% specifi city 68% of cases, are the most common injuries associated with a for diagnosing traumatic rupture of thoracic aorta [28] (Figure 2). traumatic rupture of the thoracic aorta [23]. In addition, CT scan makes it possible to diagnose associated Traumatic rupture of the thoracic aorta is usually caused injuries in multiple trauma patients. Hence, a study clearly shows by either a direct impact on the stationary sternum, rapid a major shift in the diagnosis of traumatic rupture of thoracic deceleration of the cranially or caudally moving body, or a aorta, with the widespread use of CT scan and the almost combination of these mechanisms [24]. However, this injury complete elimination of angiography and transoesophageal should be suspected whenever there is a signifi cant energy echocardiography [29]. transfer, regardless of direction. The most common causes of injury are falls from higher than 3 metres, motor vehicle crashes Injuries to the heart at speeds above 50 km per hour, drivers not wearing seat belts, The spectrum of is wide. However, the ejected passengers, and pedestrians struck by motor vehicle. clinical expression of heart injury remains infrequent in multiple Based on a landmark study, an estimated 85% of thoracic aortic trauma patients. Myocardial contusion is the most common ruptures are fatal at the scene of injury [25]. Criteria leading to a expression of heart trauma, usually located at the level of right high suspicion of aortic injury are shown in Table 1. ventricle. Its clinical expression mimics a . Clinical examination remains negative in about 50% of cases. Clinical signs of tamponade include cyanosis of the head, neck, Symptoms of traumatic rupture of the thoracic aorta include and upper chest with dilatation of jugular veins which increases chest pain, dyspnoea, back pain, dysphagia, and cough. In on inspiration. Occasionally its presentation is dramatic with the patients admitted to ICU, signs can include unexplained circulatory collapse. A paradoxical pulse has a 10-20 mmHg drop hypotension, upper limb hypertension, or acute coarctation at the end of the inspiration phase. This classical sign is rarely syndrome consisting of decreased lower limb pulses with normal found in the patients admitted to ICU. The picture is rather that upper limb pulses [26]. Other signs include left haemothorax, of a hypovolaemic shock with tachycardia and . The paraplegia, and cardiac tamponade. Associated injuries are electrocardiographic fi ndings are variable. The electrocardiogram common: these include brain trauma (15-20%), abdominal injuries (60%), pelvic fracture (35%), and long-bone fractures (65%) [26]. Chest radiograph is the initial step in the detection of Figure 4. Chest drain insertion. The safe triangle is the triangle blunt thoracic aortic rupture (Figure 3). Mediastinal abnormalities bordered by the anterior border of the latissimus dorsi, the that are the cornerstone for screening traumatic rupture of lateral border of the pectoralis major muscle, a line superior to thoracic aorta include widened mediastinum, abnormal aortic the horizontal level of the nipple, and an apex below the axilla. outline, opacifi cation of the aortopulmonary window, downward The procedure must be aseptic. shift of the left main stem bronchus, deviation of the trachea to the right of midline [27]. Up to now, angiography has been the gold standard imaging modality for diagnosing traumatic rupture of thoracic aorta. The presence of contrast outside the lumen of the aorta underlines a transmural laceration. The contrast may be contained in cases of pseudoaneurysm. Aortography is considered to be 98% specifi c with a sensitivity of 100%. Transoesophageal echocardiography is less invasive than

Table 2. Criteria for tracheal intubation in blunt chest trauma patients

Glasgow coma scale score < 9 Failure or contraindication of non-invasive ventilation Respiratory rate > 25 cycles per minute Acidosis (pH < 7.1)

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(ECG) may show non-specifi c ST and T wave changes. Bundle of the papillary muscle can result in myocardial infarction. This branch block is possible and may progress to complete heart leads to a severe volume overload on the pulmonary circulation. block and cardiac arrest. Cardiac contusion, independently of its Diagnosis is based on echocardiography. volume, can produce ventricular tachycardia. Echocardiography is the cornerstone of the management of patients with suspected Tracheobronchial injuries blunt heart trauma. In 22 patients diagnosed as having cardiac Tracheobronchial injuries are mostly related to penetrating contusion, transoesophageal echocardiography identifi ed 15 trauma. Most penetrating injuries are recognized at the time patients with right ventricular contusions, seven patients with of initial evaluation. In contrast, blunt tracheobronchial injuries left ventricular contusions, and two patients with both ventricles require careful scrutiny. More than 80% of injuries are located involved. The mortality of patients with contusion was 27% within 2.5 cm from the carina. Their incidence is low. The compared with the overall trauma group with a corresponding analysis of 1,178 autopsies of trauma patients showed 33 (2.8%) mortality of 9%. On ECG, cardiac contusions were not diagnosed tracheobronchial injuries, associated with 81% prehospital in 73% of patients [30]. If in-hospital cardiac monitoring is mortality [36]. Elsewhere, the mortality associated with necessary, the hospitalization period can be limited because bronchotracheal injuries in another series was 15% [37]. Delay nearly all (81–95%) life threatening ventricular in diagnosis is the one of the most important factors infl uencing and acute cardiac failures occur within 24-48 hours after the outcome [37]. trauma [31-33]. However, in our clinical practice, the incidence The most common signs and symptoms are dyspnoea, of cardiac contusion after chest trauma remains low. It should tachypnoea, subcutaneous emphysema, pneumothorax and be noted that after right-sided pulmonary contusion, myocardial pneumomediastinum. In the ICU patient, a tension pneumothorax performance is impaired probably due to depressed myocardial generating a continuous air leak despite adequate drainage contractility and increased right ventricular afterload. This occult and worsening of gas exchange after initiation of mechanical myocardial dysfunction may have a role in the progression to ventilation, suggest the diagnosis. Chest radiograph is abnormal cardiorespiratory failure even in the absence of direct cardiac in 90% of cases, showing a combination of signs including contusion [34]. emphysema, pneumomediastinum, pneumothorax or pleural Traumatic valvular insuffi ciency is a rare complication of effusion [38]. If a bronchus is torn completely, the lung may blunt trauma, with potentially serious complications. In the acute collapse outward towards the chest wall because it loses the phase of the injury, the traumatic lesion may go undetected. attachment to the bronchus which normally holds it toward the In the chronic phase many patients remain asymptomatic and centre. In a patient lying face-up, the lung collapses toward the others exhibit symptoms and signs of moderate to severe heart diaphragm and the back. This sign, described in 1969, is called failure [35]. Early diagnosis may lead to surgical treatment before fallen lung sign and is pathognomonic of tracheobronchial deterioration of the heart function. Complete or partial rupture injury [39-40]. However, it occurs only rarely. CT scan detects

Figure 5. Algorithm for managing chest drainage in haemothorax

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over 90% of tracheobronchial injuries resulting from blunt trauma haemothorax, pneumothorax, or haemopneumothorax has a but cannot replace bronchoscopy [38]. Bronchoscopy should be sensitivity of 58%, a specificity of 98%, and a positive predictive performed if there is any suspicion. Tracheal extubation for the value of 98%. Hence, a negative auscultation does not rule out procedure allows observation of the entire area. The oesophagus injury [48]. should be carefully examined if a tracheobronchial injury is Chest radiograph is carried out systematically as soon as the diagnosed. patient is admitted. It rules out significant pleural effusion and enables the detection of mediastinal injuries. The interpretation of Oesophageal injuries chest radiograph is neither influenced by the experience and the The incidence of oesophageal injuries ranges from 1.2% for blunt specialty of the physician nor by the use of a grid [49]. trauma to 10% for penetrating trauma. The site of injury can be The use of ultrasound at the bedside represents real progress cervical (56%), thoracic (30%), or abdominal (17%) [41]. Clinical in the management of trauma patients. The focused assessment symptoms are the exception in ICU patients. Pain and dysphagia sonography for trauma (FAST) is an accurate and efficient tool for can occur in the conscious patient. Fever and subcutaneous early detection of fluid collection [50]. It also makes it possible emphysema are the only signs reported in the patients under to assess the pleural space, heart injuries and vascular ruptures. sedative drugs. However, the best training for the non-radiologist remains The diagnosis of an oesophageal injury is frequently delayed, undetermined. either as an accidental finding at a surgical procedure being Multidetector CT is the modality of choice for rapid carried out for another cause, or secondary complications such assessment of chest trauma patients [51-52]. Contrast injection as dysphagia or pyopneumothorax. Chest radiograph is normal is mandatory. Multidetector CT makes it possible to visualize in 30% of cases [42]. Plain film findings include cervical or most injuries occurring in chest trauma patients, i.e. vascular mediastinal emphysema, pneumothorax, pneumopericardium injuries, pulmonary contusion, and pleural effusion. Detractors and pleural effusion. CT findings include mediastinal emphysema of routine CT use in trauma patients underline that blunt and show a communication between the air- or contrast-filled thoracic injuries detected by CT infrequently require immediate oesophagus and an adjacent mediastinal collection [43-44]. therapy [53]. However, the risk of blunt thoracic aortic injury, even A contrast oesophagogram is the standard procedure used to if classical chest radiograph findings are not present, supports confirm and localize an oesophageal perforation. A water soluble the routine use of CT after blunt chest trauma [54]. Of note, six contrast is used first followed by administration of barium in the months after the trauma, pathologic images are observed in 60% absence of leak. The false negative rate of an oesophagogram of the patients, including rib consolidations in 56% and areas is 10% [45]. Ideally, the procedure should be carried out on a of ground-glass opacification in 45%. These areas were limited, cooperative patient who is able to swallow - which is not the less than one pulmonary segment in most cases [1]. case in most ICU patients. Oesophagoscopy is probably a key investigation in patients admitted to ICU with suspected Treatment oesophageal injury following a trauma. The flexible endoscope Providing oxygen is an accurate and safe diagnostic tool with 96% sensitivity, The management of patients with chest trauma should always 99% negative predictive value, 100% specificity and positive include proper stabilization of the neck until a cervical fracture predictive value [46]. Risks accompanying this procedure are has been excluded. In addition, to achieve an alveolar pressure contusion and laceration. Only minimal insufflation is required in in oxygen at 80 mmHg, exogenous oxygen has to be provided if order to avoid a worsening of the injury. needed. The next step should be to exclude a pleural effusion and tension pneumothorax. Mechanical ventilation, using an invasive Strategy management or non-invasive method, is used if spontaneous ventilation Depending on the institutional organization, the following cannot ensure adequate oxygenation. Non-invasive ventilation treatments may take place either in the emergency department, should follow guidelines, and in particular not be implemented if a shock room is available, or in the ICU. Mechanical ventilation in non-conscious patients. If tracheal intubation is mandatory, requires the presence of an intensivist or anaesthesiologist. one should again underline that cervical spine immobilization is In all cases, diagnosis and initial treatment should involve a crucial. multidisciplinary trauma team. All the staff should be present in During mechanical ventilation, high end-inspiratory lung the shock room to avoid unnecessary delay in management. The volume results in a permeability type pulmonary oedema, called role of the advanced trauma life support (ATLS) guidelines is well- ventilator-induced lung injury. Using a protective strategy by

established in most industrialized countries [47]. limiting the levels of plateau pressure (under 30 cm H2O) and tidal volume (6 to 8 mL/kg) is recommended in those patients with Diagnosis pre-existing lung injury [55]. Tidal volume should probably be set Clinical examination is essential. Palpation, auscultation and differently in patients with head trauma in whom normocapnia is peripheral pulse detection are systematically performed on recommended. In our opinion, the limitation of plateau pressure admission of trauma patients. However, one should know the seems the more critical step in the management of these patients. limitation of the clinical assessment. Auscultation to detect

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Regarding the use of positive end-expiratory pressure (PEEP), its been used [66]. Thoracic paravertebral block is as effective as level should probably be set differently in the early and late phases thoracic epidural analgesia for pain management with unilateral of management. In the early phase, the use of PEEP should be fractured ribs [67]. However, unilateral fractured ribs remain a rare avoided because it may worsen the haemodynamics [56-57]. event in the ICU patient. Epidural analgesia given at the thoracic In a later period, an ARDS can occur. In this case, the baseline level has been associated with improved outcomes in at least ventilation should follow guidelines for ARDS management [58- two studies [68-69]. However, only about 10% of the screened 59]. High levels of PEEP have been associated with improved patients underwent inclusion due to stringent exclusion criteria. oxygenation in ARDS related to chest trauma [60]. This reflects the challenge encountered by physicians to perform In refractory hypoxaemia, prone positioning and extra- epidural analgesia at the bedside of trauma patients. In addition, corporeal membrane oxygenation support should be discussed. although patient-controlled analgesia (PCA) remains the reference The use of such strategies relies on a weak level of evidence. standard in the literature, nurse-driven protocols optimizing the Tracheal intubation is associated with a high prevalence administration of short half-life opioids provide better results of pulmonary infection that can increase the duration of than PCA in ICU [70]. In our experience, in a series of patients hospitalization [18-61]. Thus, institution of invasive mechanical with pain refractory to morphine used in PCA, administration of ventilation should be balanced against the possible harm that remifentanil or sufentanil in accordance with a target-controlled it can induce. Tracheal intubation criteria after chest trauma are infusion mode made it possible to relieve pain in all patients reported in Table 2. (personal data). For these reasons, the use of regional analgesia Non-invasive mechanical ventilation in pressure support with in patients admitted to ICU remains a matter of debate [71]. a positive end-expiratory pressure seems appealing. However, in the literature, we found only case reports relating success Anti-infective drugs in a single patient [62-63]. Non-invasive mechanical ventilation Injured pulmonary parenchyma is a good growing medium for should not be used in cases of agitation, shock, non-evacuated bacteria. This can be worsened by an associated head injury pneumothorax, non-conscious patients, head and facial trauma favouring aspiration. Selective digestive decontamination and tetraplegia. Thus, non-invasive ventilation can be started consists of the systematic administration of antibiotics in the only after effective analgesia. oropharyngeal area and gut of mechanically-ventilated patients. It has been associated with improved outcome in a large number Fluid expansion of patients [72]. In multiple trauma patients, selective digestive In trauma with shock, the first step of resuscitation is to restore decontamination appears especially effective [73-76]. haemodynamics by providing fluid. However, experimental data show that fluid restriction is associated with a reduction in Chest drain contusion volume. Use of colloids has been associated with a Chest drain insertion is a surgical procedure which is often reduction of total volume of fluid and improved outcome [64]. In performed by non-surgeon physicians. This procedure can be order to avoid severe hypovolaemia, fluid resuscitation should associated with complications. Before inserting a chest drain, be based on the results of careful monitoring with non-invasive all operators should have been adequately trained. Chest drain (transthoracic echocardiography examination, leg raising) and insertion is a painful procedure requiring high quality analgesia. invasive methods (central venous saturation in oxygen when Aseptic technique should be employed during drain insertion available, arterial pressure waveform analysis, etc.). Guided fluid (Figure 4). The risk of haemorrhage should be carefully assessed expansion therapy may keep patients dry and avoid pulmonary before insertion. The “safe triangle” is the triangle bordered by oedema in contusion areas, but there is a lack of clinically relevant the anterior border of the latissimus dorsi, the lateral border of the data to support this strategy. pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla. It should be determined Analgesia with the patient in the correct position, i.e. slightly rotated, with Analgesia is the basis of the management of patients with chest the arm on the side of the lesion behind the patient’s head to trauma. Treatment is individualized according to a pain scale that expose the axillary area (Figure 4). Correct positioning can be should be used in all conscious patients. Systemic use of opioids confirmed by echography. has traditionally been the cornerstone of acute pain management. Unless the clinical situation imposes immediate management However, due to the side effects of systemic opioids alternative (e.g. tension pneumothorax), chest radiographs are mandatory ways to relieve pain have been investigated. Multimodal therapy before and after chest drain insertion. The analysis of the literature is increasingly recognized as a critical pain management suggests more questions than answers. Drains should be inserted approach. It encompasses a wide range of procedures and in patients with haemothorax causing distress or occupying at medications, including regional analgesia, judicious use of short least one-third of the expected thoracic cavity. Those with a half-life morphinomimetic drugs, non-steroid anti-inflammatory smaller haemothorax should be observed by means of repeated agents, acetaminophen, ketamine or anxiolytics [65]. In order chest radiographs. Others justify an aggressive approach arguing to reduce the side effects of morphine, nebulized morphine that the morbidity associated with residual haemothorax justifies providing equivalent pain relief with less sedative effects has the risks associated with drain insertion [77]. A high volume of

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blood associated with haemodynamic instability occurring after multiple trauma patients with head trauma. In addition, preventive drainage, should lead to thoracotomy or aorta opacification for steroids possibly increase the incidence of ARDS in critically ill possible stenting of a vessel injury (Figure 5). adults [87]. In brief, the lack of clear evidences does not support Traditionally, all pneumothoraces in mechanically ventilated the use of steroids in patients with chest trauma. patients are an indication for chest drain insertion. In practice, Surfactant therapy has been assessed in acute lung injury. several studies have shown that pneumothoraces which were not However, there is little evidence to support its use in trauma. observed on chest radiograph, so-called occult pneumothorax, One randomized trial compared surfactant with placebo in do not require chest tube insertion [78,79]. They should be simply trauma patients with lung contusion and acute lung injury [88].

observed. They naturally resolve without complications in few Surfactant therapy was associated with higher PaO2/FiO2 ratio days. Tension pneumothorax should be drained without delay. and compliance than placebo. Mechanical ventilation duration Small catheters can be used to drain such air effusion. The British was also reduced. However, these promising results must be Thoracic Society guidelines for the insertion of a chest drain confirmed as only eight patients were included in each group. summarize the procedure steps [80]. In cases of massive air leak, Surgical stabilization of rib fractures may reduce ventilator lung isolation using either a double-lumen endotracheal tube or a requirement in patients with multiple rib fractures. In a retro­ bronchial blocker may be considered [81]. However, the literature spective study including 30 case patients and 30 matched on this topic is really scarce, making such treatment anecdotal in controls, surgical stabilization was associated with a reduced patients with chest trauma. number of ventilator days [89]. In antero-lateral flail chest injuries, early surgical restoration of chest wall integrity and respiratory Thoracotomy pump function may be cost effective through the prevention of The indications for urgent thoracotomy after blunt chest trauma are prolonged mechanical ventilation and restriction-related working based on the criteria used for penetrating injuries. As commonly incapacity [90]. depicted, thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours or a flow above 200 ml per hour Conclusion for four hours, regardless of injury mechanism [82]. However, the The management of patients with thoracic trauma requires level of evidence supporting this statement is weak. One study a multidisciplinary approach, including a trauma surgeon, made a point on this issue nicely [83]. The authors concluded that radiologist, anaesthesiologist, and intensivist. During the Golden thoracotomy after blunt trauma is associated with a high rate of Hour, depending on local organizations, an intensivist, trauma mortality. In contrast with penetrating trauma, urgent thoracotomy surgeon, or anaesthesiologist are candidates to lead this team. for blunt injury is rarely justified on the basis of chest tube output However, in the severely injured patient, the role of intensivists is alone [84]. Caution should be exercised when deciding whether always crucial because she or he is able to manage the airway, to proceed with thoracotomy based solely on chest tube output. mechanical ventilation, and haemodynamic failure. The chest radiograph is the cornerstone of the management. Other therapies It excludes all significant injuries requiring emergent treatments. Methylprednisolone before surgery may reduce pulmonary Ultrasound represents an interesting tool that can be used at the complications without increasing adverse events [85]. However, bedside. The CT scan is performed in all stable trauma patients. the number of trauma patients included in the studies assessed in The performance of CT scan is excellent in detecting most this meta-analysis is small. One should keep in mind that steroids injuries. Treatment consists of providing oxygen and making the are associated with increased mortality in patients with head pleural space free. It is crucial to avoid a worsening of injuries by trauma [86]. This suggests that their use should be excluded in inadequate treatment.

References

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