Background
- Common injuries and may be very significant
- Complications often due to inadequate analgesia/ventilation (atelectasis)
- Substantial ↑ risk in elderly and pre-existing lung disease
- Beware occult neighbouring injuries (e.g. vertebral # in blunt injury)
| Risk score | Probability mean ± SD |
|---|---|
| 0 - 10 | 13% ± 6 |
| 11 - 15 | 29% ± 8 |
| 16 - 20 | 52% ± 8 |
| 21 - 25 | 70% ± 6 |
| 26 - 30 | 80% ± 6 |
| 31+ | 88% ± 7 |
| From Battle C, Hutchings H, Lovett S, et al. (below) | |
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Estimate complication risk and management advice.
Clinical
Causes
- Blunt e.g. MVAs, falls
- Penetrating
- Coughing spells
- Non accidental injury
- Stress fractures in athletes
Symptoms
- Pleuritic pain
- Pain worse on movement
- SoB
- Haemoptysis
Signs
- Localized pain/tenderness
- Hypoxia, resp. distress
- ↑RR, accessory muscles
- Palpable/visible deformity
- Paradoxical rib movements
- Tracheal deviation (v late)
- Surgical emphysema
- Percussion Δ
Complications
- Flail chest affects respiratory mechanics and increases work of breathing
- Haemothorax
- Pneumothorax
- Pulmonary Contusions evolve over the first 48 to 72 hours
- Superior vena caval obstruction
- Hepatosplenic injury - high degree of suspicion in lower rib fractures
- Cardiac contusions
- Mediastinal/Great vessel injury - particularly fractures of the scapula, first or second rib, or the sternum suggest a significant force of injury
- Oesophageal injury
- Diaphragmatic injury
- Atelectasis and Pneumonia which can be a consequence of inadequate analgesia and sputum clearance
Differential / Consider
- Abdominal Trauma
- Crying Child / NAI
- Domestic Violence / Elder Abuse
- Oesophagitis
- Fractures, Clavicle / sternal / vertebral etc
- Mechanical Back Pain
- Pneumothorax
- Pulmonary Embolism (PE)
- Upper Genitourinary Trauma
Investigations
- CXR
- Bedside US
- CT
- CT Angiogram
- Bone Scan
- MRI
- OGD or Bronchoscopy
Management
- Manage analgesia as above
- Complete a comprehensive tertiary survey for other injuries
- Early mobilistaion and stationary bike exercise are important
- Early incentive spiromerty and practical advice