• Clinical science

Blunt trauma

Abstract

Blunt trauma is most commonly due to motor vehicle accidents and is a major cause of morbidity and mortality in all age groups. The most common signs of significant abdominal trauma are pain, gastrointestinal hemorrhage, hypovolemia, and peritoneal irritation. The patterns of chest injury are highly dependent on the intensity of the trauma and may vary from harmless contusions to possible life-threatening injuries of the heart and/or the aorta. Management is initially focused on the ABCs (airway, breathing, circulation). FAST and CT imaging are used to detect intraabdominal bleeding and organ damage, while chest x-ray is the most important initial diagnostic tool in the assessment of blunt chest trauma. Treatment depends on the specific injury, as well as the hemodynamic status of the patient. Conservative management with close monitoring is indicated for hemodynamically stable patients. However, emergency surgery is often necessary. This learning card provides a brief overview of the clinical features and management of blunt trauma to the abdomen and chest.

For information on prehospital care and general principles of trauma management, see prehospital and hospital trauma care.
Penetrating trauma is discussed in its own learning card.

General

  • Etiology
    • Motor vehicle accidents (50–75%) (auto-auto or auto-pedestrian)
    • Falls; industrial or recreational accidents
  • Mechanism of injury
    • Rapid deceleration: results in shear forces that cause vascular tears, as well as hollow and solid organ contusions and ruptures
    • External compression and crushing

Blunt abdominal trauma

Possible injuries

Clinical features

  • Pain, tenderness
  • Abdominal distention; guarding or rigidity
  • Signs of abdominal bleeding: hemodynamic instability/shock (hypotension, tachycardia, cyanosis) , anxiety, flank discoloration

Approach to blunt abdominal trauma

  • Primary survey
  • Imaging to assess the location and extent of abdominal injury
    • FAST exam to detect hemoperitoneum
    • CT if FAST is inconclusive and patient is stabilized
    • X-ray: detects fractures, free intra-abdominal air, or large collections of blood; less useful than CT or FAST
  • Diagnostic peritoneal lavage: has been largely replaced by the rapid, noninvasive FAST exam, but useful for assessing hemodynamically unstable patients if FAST is inconclusive
    • If fecal matter or significant blood are detected (positive test) → emergent laparotomy is indicated
    • Highly sensitive, but invasive
  • Negative FAST/CT: identify extra-abdominal cause of hemodynamic instability
  • Laparotomy is indicated for patients with
    • Hemodynamic instability
    • Signs of peritonitis
    • Intra-abdominal bleeding detected on imaging
  • Conservative management
    • Depends on the location and extent of injury
    • Close monitoring of vital signs and serial examinations
    • Angiography and embolization (e.g., control bleeds, manage low retroperitoneal hematomas)
    • Management of pancreas injury: percutaneous drainage (with culture) and debridement to prevent complications (pseudocysts, abscess)
    • Management of duodenal injury: nasogastric suction and parenteral nutrition to allow healing; if patients remain unstable, laparotomy may be indicated.

The absence of pain does not rule out significant intra-abdominal injury! Imaging must be performed!

If FAST exam is not available, a hemodynamically unstable patient should be taken to the operating room immediately!

References: [1][2][3][4]

Blunt chest trauma

Possible injuries

Clinical features

Approach to blunt chest trauma

  • Primary survey: prehospital trauma care and preliminary trauma care in the hospital
  • Emergency assessment: : of hemodynamically unstable patients to rule out life-threatening conditions
  • Rapid diagnostic evaluation
    • Chest x-ray (initial test for all blunt chest trauma patients)
    • Ultrasound (extended FAST)
    • Echocardiography and ECG
    • Others: CT, transesophageal echocardiography (TEE), bronchoscopy, angiography
  • Management
    • Close monitoring of vital signs
    • Appropriate surgical repair after stabilization of vitals
    • Unstable patient: immediate surgery/explorative thoracotomy

Chest wall injury

Rib fracture

Sternal Fracture

Phrenic nerve paralysis

  • Etiology: trauma, iatrogenic, compression (e.g., malignancy)
  • Clinical features
    • Unilateral paralysis of the diaphragm often presents asymptomatically; ; possible (exertional) dyspnea
    • Bilateral paralysis leads to severe dyspnea.
  • Diagnostics
    • Auscultation: reduced respiratory movement, dull on percussion
    • Chest x-ray
  • Treatment
    • Ventilation may be required.
    • Possible implantation of a diaphragmatic pacemaker

References:[5][6][7][8]

Cardiovascular injury

Cardiac injury

Aortic injury and Aortic rupture

  • Typical location: aortic isthmus distal to the exit of the left subclavian artery (∼ 70%)
  • Severity: ranges from intimal lesions to aortic rupture
  • Clinical features
  • Diagnostics
    • Initial test: chest x-ray
    • Further tests
      • In hemodynamically stable patients → CT scan and contrast-enhanced CT angiography (high sensitivity and specificity; particularly useful if endovascular repair is being considered)
      • In hemodynamic unstable patients → transesophageal echocardiography (TEE) in the operating room
  • Treatment
    • Immediate IV fluids
    • If blood pressure is elevated (systolic blood pressure > 100 mm Hg): antihypertensive drugs
    • Definitive treatment: endovascular repair or open surgical repair
  • Prognosis: ∼ 80% of patients die before reaching the hospital.

References:[5][9][10]

Pulmonary injury

Pulmonary contusion

  • Clinical features
  • Diagnostics:
    • Chest x-ray: patchy alveolar infiltrates; ; diffuse opacity or 'white out' that develops over the first 24 hours after trauma and typically resolves within 1 week
    • CT if x-ray is inconclusive
  • Treatment
    • Monitor blood gases
    • Intubation: usually not necessary
  • Complications
  • Differential diagnosis: pneumothorax (ipsilateral reduced or absent breath sounds)

Tracheobronchial injury (TBI)

Diaphragmatic rupture

See diaphragmatic rupture for details.

References:[5][11][12][13][14]