- Clinical science
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 .
is discussed in its own learning card.
- Motor vehicle accidents (50–75%)
- 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
- Most common: and liver injury (e.g., hematoma, laceration)
- Severe bleeding
- Pancreatic contusion, laceration, or rupture (through direct epigastric impact, e.g., handlebar injury)
- Duodenal damage and hematoma: common injury in children who suffer blunt abdominal trauma
- Pain, tenderness
- Abdominal distention; guarding or rigidity
- Signs of abdominal bleeding: hemodynamic instability/shock (hypotension, tachycardia, cyanosis) , anxiety, flank discoloration
Imaging to assess the location and extent of abdominal injury
- exam to detect hemoperitoneum (Collection of blood in the peritoneal cavity)
- 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
: 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
- 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!
- Chest wall injuries: rib fracture, flail chest, sternal fracture
- Aortic injury (highest lethality rate!)
- Cardiac contusion and
- Pulmonary contusion
- Tracheobronchial injury
- Chest pain
- Hypotension, tachycardia, hypoxia
- Diminished breath sounds in pneumothorax
- Jugular venous distention could suggest pericardial effusion or cardiac contusion
- 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
- Close monitoring of vital signs
- Appropriate surgical repair after stabilization of vitals
- Unstable patient: immediate surgery/explorative thoracotomy
- Etiology: mostly blunt trauma, pathologic fractures, nonaccidental trauma (child abuse)
- Pain on inspiration
- Focal chest wall tenderness
- Chest wall deformity
Flail chest: multiple (≥ 3) rib fractures in 2 or more places, resulting in a floating section of ribs and soft tissue within the chest wall
- Paradoxical movement: the floating segment moves inward during inspiration and outward during expiration
- Respiratory distress, tachypnea, and shallow breaths
- Usually no surgery necessary
- Intubation with positive pressure ventilation in severe flail chest (bridge to surgery)
- In case of pneumothorax or hemothorax: thoracic drainage and thoracic surgical intervention
- Indications for surgery
- Anatomical course of the nerve: : originates as a branch from the cervical plexus of C3–C5 → passes ventrally on the anterior scalene muscle before descending into the chest wall → between pleura and pericardium accompanied by pericardiacophrenic artery and vein → motor innervation of the diaphragm + sensory innervation of the pericardium, parietal pleura (mediastinal and diaphragmatic part), and peritoneum
- Clinical features
Unilateral phrenic nerve paralysis
- Auscultation: reduced respiratory movement, dull on percussion
- Chest x-ray
- Paradoxical elevation of the paralyzed hemidiaphragm on respiration or on asking the patient to sniff (sniff test)
- Bilateral phrenic nerve paralysis
- Unilateral phrenic nerve paralysis
- Ventilation may be required.
- Possible implantation of a diaphragmatic pacemaker
- Cardiac contusion: Clinical features depend on the extent of the injury.
Myocardial rupture: hypotension, muffled heart sounds
- Most patients die before reaching the hospital.
- Septal or valvular injury
- Cardiac monitoring
- Cardiac rupture: immediate surgery
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
- Initial test: chest x-ray
- Further tests
- Prognosis: ∼ 80% of patients die before reaching the hospital.
- Clinical features
- Chest x-ray: patchy alveolar infiltrates; ; diffuse opacity or 'white out'
- CT if x-ray is inconclusive
- Monitor blood gases
- Intubation: usually not necessary
- Differential diagnosis: pneumothorax (ipsilateral reduced or absent breath sounds)
Tracheobronchial injury (TBI)
- Clinical features
- Chest x-ray: air in surrounding soft tissue
- Bronchoscopy: visualization of the lesion
- TBI vs tension-pneumothorax: TBI usually does not feature midline shift and distended neck veins.
- Complications: chylothorax, chylopericardium, chylomediastinum
- Treatment: mostly surgical repair