Asymptomatic PTX: less then 8mm – observe Hemothorax: 300 cc needed to diagnose 36Fr chest tube. >1500cc surgery Pulmonary contusion develop in 24 hours, resolve in 1 week. (Irregular, nonlobular opacification ). Intubation only if hypoxic. Tracheobronchial injury 1%. Most diet at the sceene (R main Bronchus> L main )
Associated complication Pneumonia - ~6% of all hospitalized pt’s w rib fx – Elderly pts( >65 y.o.) => 30% incidence, 22% mortality Retained hemothorax – dx CT, tx VATS Empyema :3-10% of pt’s w CT placed Fracture nonunion Respiratory failure
Associated Internal Injuries Blunt aortic and other mediastinal injury Pneumothorax Pulmonary contusion Cardiac contusion Myocardial rupture
Blunt Aortic Injury (BAI) Radiologic Findings: Wide mediastinum (supine CXR >8 cm; upright CXR >6 cm) Obscured aortic knob; abnormal aortic contour Left "apical cap" (ie, pleural blood above apex of left lung) Large left hemothorax Deviation of nasogastric tube rightward Deviation of trachea rightward and/or right mainstem bronchus downward Wide left paravertebral stripe
Isolated Chest wall injury: Main goals = (1) Pain control (2) Expansion of pulmonary volume Hospitalization = any pt w 3 or more rib fx ICU = elderly pt w 6 or more rib fx
Pain Control Regional anesthesia – Continuous epidural infusion => shorter duration of mechanical ventilation and dec risk pneumonia – Paravertebral block = unilateral rib fx – Intercostal nerve blocks – Intrapleural infusion IV narcotics IV NSAIDs (ex toradol)
Surgical Management – Flail chest + failure to wean from ventilator – Painful, movable ribs refractory to pain management strategies – Significant chest wall deformity – Chest wall instability due to fracture nonunion – Displaced rib fx found at thoracotomy – Internal Injuries.