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trauma in adults
Author: Eric Legome, MD
Section Editor: Maria E Moreira, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jul 2020. | This topic last updated: May 27, 2020.
INTRODUCTION
Blunt chest trauma puts multiple structures at risk of injury. In addition to direct
trauma, rapid deceleration and other mechanisms can cause injury to thoracic
structures. Major concerns include chest wall injury, such as rib fractures or flail
chest; cardiovascular injury, such as blunt aortic injury (BAI) or cardiac contusion;
and pulmonary injury, such as contusions or lacerations. BAI is the most lethal
injury of the thorax if untreated.
This topic will review the epidemiology, diagnosis, and initial management of
injuries sustained in adults from blunt thoracic trauma (BTT). Fundamentals of
initial trauma management, thoracic trauma in children, and other injuries
sustained from trauma are discussed separately. (See "Initial management of
trauma in adults" and "Thoracic trauma in children: Initial stabilization and
evaluation" and "Initial evaluation and management of rib fractures" and "Initial
evaluation and management of chest wall trauma in adults" and "Cardiac injury
from blunt trauma" and "Initial evaluation and management of blunt abdominal
trauma in adults".)
EPIDEMIOLOGY
Motor vehicle collisions (MVCs) represent the most common cause of major
thoracic injury among emergency department (ED) patients [1,2]. Several factors
are associated with a higher risk of thoracic injury:
● High speed
● Not wearing a seatbelt [3-5]
● Extensive vehicular damage
● Steering wheel deformity [6,7]
Studies of chest trauma are often based upon data from trauma registries that
catalog admitted trauma patients. Patients with minor injuries or isolated rib
fractures are often discharged and do not appear in such registries, leading to
substantial bias in the trauma literature toward more seriously injured patients
[10].
● Blunt aortic injury – The majority of blunt trauma patients who sustain a major
aortic injury die immediately. Of those who reach the hospital alive, the
majority either die during initial management or are unable to undergo aortic
repair due to their injuries, both intra- and extrathoracic [12].
• Front- or near-side MVC (RR 3.1; 95% CI 1.9-5.1 and RR 4.3; 95% CI 2.6-7.2,
respectively)
• Abrupt deceleration ≥40 km/hour (RR 3.8; 95% CI 2.6-5.6)
• Crushing of the vehicle (ie, ≥40 cm) (RR 4.1; 95% CI 2.7-6.3)
• Intrusion ≥15 cm (RR 5.0; 95% CI 3.5-7.3)
The risk of injury to the thoracic aorta is also greater among passengers
traveling in a car struck by a sports utility vehicle (RR 1.7; 95% CI 1.2-2.3).
Anatomy and physiology — The rib cage, intercostal muscles, and costal cartilage
form the basic structure of the chest wall (figure 1). In addition, neurovascular
bundles comprised of an intercostal nerve, artery, and vein run along the inferior
aspect of each rib. The inner lining of the chest wall is the parietal pleura. Visceral
pleura covers the major thoracic organs. Between the two is a potential space
normally containing a small amount of lubricating fluid, but blood or air can
accumulate there following injury. The anterior chest wall also contains the
sternum (figure 2) and pectoralis major and minor muscles, as well as the clavicle
at its superior border. Posteriorly, the scapula provides added protection to the
superior thorax. The scapula (figure 3) is a dense bone encased in muscle, and
significant force is necessary to fracture it or the sternum.
The chest wall has two important functions: to assist in the mechanics of
respiration and to protect the intrathoracic organs. Adequate ventilation is
accomplished by creating negative intrathoracic pressure during inspiration and
positive pressure during expiration. During inspiration, a combination of
diaphragmatic excursion and contraction of the intercostal muscles to raise the
ribs in a "bucket-handle" fashion increases intrathoracic volume and decreases
intrathoracic pressure, which then pulls air passively into the lungs. In expiration,
this process is reversed: all the muscles relax and intrathoracic pressure passively
increases and volume decreases, forcing air out of the lungs.
The chest wall protects against devastating injuries to the intrathoracic structures
(figure 4 and figure 5 and figure 6). In fulfilling this role, the chest wall is commonly
injured. While generally not life-threatening, chest wall injuries can be extremely
painful and can lead to significant morbidity if not recognized and treated
appropriately. (See "Initial evaluation and management of chest wall trauma in
adults".)
With blunt trauma, the most common isolated mediastinal injury involves the aorta
(figure 10). Hemorrhage from other nearby structures, such as venous lacerations
or fractures of the ribs, sternum, or vertebra, can manifest as mediastinal blood,
raising concern for aortic injury (algorithm 1). Aortic injuries are mainly transverse
tears with relatively smooth margins. The underlying injury ranges from a simple
subintimal hemorrhage, with or without intimal laceration, to complete aortic
transection [19].
The diaphragm constitutes the floor of the thoracic cavity (figure 11). The
diaphragm exhibits substantial movement with inspiration and expiration, and
thus, posttraumatic pain in the lower thorax may reflect intraabdominal as well as
intrathoracic injury.
Aortic tears usually occur from high-energy injuries to the thorax, often following
rapid deceleration. Several theories for the mechanism of aortic disruptions have
been proposed, and it is likely that a number of factors are involved. These
theories are discussed separately. (See "Clinical features and diagnosis of blunt
thoracic aortic injury", section on 'Pathophysiology of injury'.)
PREHOSPITAL MANAGEMENT
Clinicians first assess and stabilize the patient's airway, breathing, and circulation,
in that order (ABCs; ie, primary survey). The one caveat to this principle in patients
with respiratory distress following chest trauma is that breathing may take priority
over airway. If the patient is in respiratory distress due to a tension pneumothorax,
the clinician should relieve the pneumothorax before performing endotracheal
intubation, if needed. Positive-pressure ventilation following intubation will
exacerbate a pneumothorax.
After addressing the patient's ABCs, the clinician continues the initial evaluation
taking into account vital signs, the initial presentation, and the mechanism of
injury. Mechanism is less predictive of injury severity and ultimate disposition than
abnormal vital signs in the setting of blunt trauma [22]. Ultrasound examination
(extended Focused Assessment with Sonography for Trauma [eFAST]), including
assessment for pericardial effusion and pneumothorax, is performed as part of
the examination. (See "Emergency ultrasound in adults with abdominal and
thoracic trauma".)
For any patient with unstable vital signs, hypoxia, or obvious severe injury (eg, flail
chest, multiple rib fractures, large open wounds), the clinician performs a rapid
search with concurrent management of immediate life-threatening injuries of the
head, cervical spine, abdomen, chest, and pelvis. Immediate surgical consultation
should be obtained. (See "Initial management of trauma in adults", section on
'Primary evaluation and management'.)
● Tension pneumothorax
● Cardiac tamponade from myocardial injury (see "Cardiac tamponade")
● Aortic injury (see "Clinical features and diagnosis of blunt thoracic aortic
injury")
● Hemothorax with severe, active bleeding (see 'Hemothorax' below)
● Tracheobronchial disruption (see "Identification and management of
tracheobronchial injuries due to blunt or penetrating trauma")
Patients with cardiac tamponade may initially appear stable if the rate of bleeding
is slow or the pericardium periodically decompresses by emptying blood into the
pleural space. Some patients may complain of shortness of breath. Beck's triad
(hypotension, jugular venous distension [JVD], muffled heart sounds) can be
difficult to detect and may not be present. In hypovolemic patients, JVD may be
absent. Ultimately, tamponade physiology causes diminished cardiac output,
leading to a decrease in systolic blood pressure and narrowing of the pulse
pressure. (See "Cardiac tamponade", section on 'Clinical presentation'.)
Given the resources required and risks entailed in EDT, we recommend hospitals
develop policies to determine the circumstances under which the procedure is to
be performed. A trauma or thoracic surgeon should be readily available if EDT is
performed: immediate surgical intervention may be necessary if the patient is to
survive. The subset of blunt trauma patients most likely to survive an EDT
neurologically intact includes the following:
● Patients who lose vital signs in the ED and appear to have no obvious
nonsurvivable injury (eg, massive head trauma, multiple severe injuries)
● Patients with cardiac tamponade rapidly diagnosed by ultrasound, with no
obvious nonsurvivable injury
EDT in blunt trauma patients appears to be futile in any one or more of the
following circumstances:
Some observational data suggest that no blunt trauma patient who requires more
than five minutes of CPR survives neurologically intact [27]. A systematic review of
27 observational studies involving 1369 blunt trauma patients reported an overall
survival rate with good neurologic outcome of only 1.5 percent [30]. All surviving
patients (n = 21) had either measurable vital signs at the scene or in the ED and a
maximum duration of cardiopulmonary resuscitation of 11 to 15 minutes.
The clinician first determines whether the patient is at low or high risk for
significant injury. This determination is based on the vital signs, the mechanism
and potential for injury, and the patient's complaints and general clinical
appearance [1,2,8-10]. Of note, according to a systematic review of studies of
aortic injury from blunt trauma, many patients present with normal vital signs, and
thus, hemodynamic stability does not rule out aortic injury [31].
Studies suggest the history and physical examination are insensitive for detecting
intrathoracic injury. This insensitivity stems in part from the nature of the studies,
which often include a heterogeneous mix of patients and injuries, a low number of
positive findings, and a lack of follow-up.
The risk of serious injury is low among alert patients without discomfort, dyspnea,
or tenderness [32-35]. Hypoxia and abnormal lung sounds are the most specific
signs for pneumothorax or hemothorax, while chest pain and tenderness are most
sensitive, albeit nonspecific [36]. Normal lung sounds showed a high negative
predictive value (NPV) for pneumothorax in one prospective, observational study,
but the number of patients with abnormal findings was too low to draw definitive
conclusions [34]. Important examination findings associated with life-threatening
intrathoracic injuries that should be noted during the primary survey are described
above. (See 'Primary survey and initial management' above.)
Chest radiograph — The chest radiograph (CXR) is the initial test for all patients
with BTT who warrant imaging [37]. The CXR is inexpensive, noninvasive, and easy
to obtain, and in many instances, it reveals useful information. For these reasons,
we suggest a CXR be obtained in all patients who have sustained BTT of any
significance, unless the patient requires immediate surgery or warrants immediate
chest CT. Patients with minor trauma whose clinical evaluation reveals no signs of
injury may not require a CXR; a decision instrument to help determine whether to
forego a CXR is described at the end of this section.
The CXR is systematically reviewed for evidence of hemothorax (image 6),
pneumothorax (image 1 and image 2 and image 3), pulmonary contusion (image
7), fractures (image 8), and aortic injury. Studies to determine CXR findings
suggestive of blunt aortic injury (BAI) are limited by their observational design and
the small number of injuries [38-40]. Nevertheless, although no single finding on
CXR possesses high sensitivity or specificity for BAI, the following findings on a
plain CXR increase the likelihood of BAI and indicate a need for further
investigation:
● 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
Normal PA and lateral chest radiographs in a low-risk patient obviate the need for
additional studies to rule out intrathoracic or chest wall injury. Rib films are rarely
needed. They may provide more information about fractures but rarely change
management. The clinician can treat patients likely to have sustained a rib fracture
on the basis of symptoms and signs, despite the absence of radiographic
evidence [43-45]. (See "Initial evaluation and management of rib fractures".)
The NEXUS Chest Decision Instrument studies evaluated the utility of chest
imaging in the assessment of blunt trauma. In practice, the instrument is used
most often to determine the need for chest CT, but it may also be used to help
determine the need for CXR (algorithm 3). The NEXUS investigations include a
prospective validation study involving 9905 patients that reported on the tool's
effectiveness for identifying blunt trauma patients at low risk of intrathoracic injury
[46]. The instrument uses seven simple criteria:
Pending further study, we believe the decision to obtain a chest CT for BTT should
be based upon the clinical findings. In addition to the physical examination, these
include a plain CXR when one is obtained, the patient's mental status and
distracting injuries, the mechanism of injury and any other relevant history,
available resources, clinician judgment, institutional tolerance for delayed
diagnosis (eg, forgoing a CT in favor of serial examinations and close
observation), and other relevant factors.
The NEXUS research group has developed and prospectively validated decision
instruments to help determine which adults with BTT can safely forego CT
imaging of the chest [46,52,53]. The criteria and use of the NEXUS instruments are
summarized in the following graphic (algorithm 3). It bears emphasizing that the
purpose of the NEXUS guidelines is to help determine which patients can safely
forego imaging; clinical judgment retains an important role in determining which
patients should be imaged. (See 'NEXUS decision rules' below.)
The use of chest CT for trauma evaluation has increased dramatically; in many
centers, patients involved in high-energy trauma are sent almost immediately for
CT before a CXR can be performed. Patients with a low-risk mechanism, minor
injuries by examination, and normal CXRs generally do not require CT imaging,
which may be overused in these circumstances [47,54-56]. However, findings from
some observational studies suggest that a substantial number of patients may
sustain clinically significant intrathoracic injuries that are identified by CT but do
not manifest abnormal findings on plain CXR [49,57]. Conversely, abnormalities
apparent on a plain radiograph strongly suggest the presence of a clinically
significant injury [58]. We believe that it is reasonable to obtain a chest CT in
patients with concerning clinical findings (eg, severe pain or marked chest
tenderness, hypoxia, dyspnea, tachypnea) despite an unremarkable plain CXR or
ultrasound, and in patients with an abnormal plain CXR despite the absence of
obvious clinical signs of injury. This approach is consistent with the NEXUS
guidelines.
NEXUS decision rules — We believe the NEXUS instruments can provide useful
guidance to clinicians and help to decrease the number of unnecessary CT scans
obtained [46,52,53]. These instruments are highly sensitive and useful tools when
applied appropriately. The criteria for all three NEXUS instruments are included
with the following algorithm for imaging blunt chest trauma (algorithm 3).
While the absence of all criteria indicates low risk, the presence of any one
criterion does not necessarily indicate high risk and the need for CT. In general, the
clinician should have decided that imaging may be appropriate and useful, and
then should apply the NEXUS criteria to determine whether imaging can be
foregone safely without missing injury.
The first iteration of the NEXUS decision instrument (NEXUS Chest) includes the
following criteria [46]:
If all criteria are absent, the patient has a very low risk for intrathoracic injury, and
chest imaging of any kind is not indicated. The first validation study of this
instrument included 9905 patients over the age of 14, evaluated at nine trauma
centers, whose initial workup for blunt chest trauma included a plain CXR, chest
CT, or both, which revealed 363 major injuries [46]. In this study, NEXUS Chest
demonstrated a sensitivity of 98.8 percent and specificity of 13.3 percent for any
thoracic injury seen on chest imaging.
While all the NEXUS decision rules have demonstrated high sensitivity for major
injury (approximately 99 percent), Chest CT-All had a specificity of 20.8 percent
(95% CI 19.2-22.4) and an NPV of 99.8 percent (95% CI 98.9-100) for major injury,
while for either major or minor injury, the rule demonstrated a specificity of 25.5
percent (95% CI 23.5-27.5%) and an NPV of 93.9 percent (95% CI 91.5-95.8). Chest
CT-Major had a specificity of 31.7 percent (95% CI 29.9-33.5) and an NPV of 99.9
percent (95% CI 99.3-100) for major injury.
In a follow-up study of the 269 BTT patients who sustained major injuries,
researchers noted that except for an abnormal plain CXR, the risk for major injury
remained low in the presence of any one criterion [58]. By contrast, the sensitivity
and specificity of an abnormal plain radiograph for major injury were relatively high
(73.7 [95% CI 68.1-78.6] and 83.9 [95% CI 83.6-84.2], respectively), highlighting the
importance of carefully assessing any plain CXR obtained. Clinicians should not
hesitate to obtain imaging studies if they have concerns based upon their clinical
assessment, regardless of the decision instrument used.
SUBSEQUENT MANAGEMENT
SPECIFIC INJURIES
Aortic injury
Aortic injury is unlikely in patients with a truly normal CXR, no sign of significant
injury on examination, and a mechanism that does not involve rapid deceleration
[41,47,55,66]. No further testing is needed in such patients.
Chest CT has great sensitivity and specificity for BAI and is used most often to
make the diagnosis [70-73]. CT also enables detection of other intrathoracic
injuries.
Among patients with abnormal CXR findings, chest CT identifies injuries that
would not otherwise be found, resulting in significant changes in management
between 20 and 30 percent of the time [47,74,75]. Among patients without
abnormal CXR findings in whom chest CT is performed solely based on
mechanism, the study leads to changes in management only 5 percent of the time.
An equivocal CT scan should be followed by angiography to exclude aortic injury
[66,69].
Most studies that assess the use of CT in chest trauma involve critically ill or
multiply injured patients. Therefore, it is difficult to draw conclusions about the
appropriate use of CT in patients without evidence of severe injury, based solely on
mechanism. (See 'Chest computed tomography' above.)
TEE is an excellent modality to assess for BAI in patients too unstable for chest
CT. TEE has high sensitivity and specificity for BAI, can be performed in the ED or
the operating room, requires no contrast, and provides information about cardiac
injury and function.
TEE is operator dependent and suffers in some studies from loss of sensitivity as
the interposition of the air-filled trachea between the aorta and esophagus creates
a blind spot, precluding adequate evaluation of the distal ascending aorta and
proximal arch. It should not be performed in patients with unstable cervical spine
injuries or esophageal injuries.
TEE compares favorably with angiography or CT scan in the majority of cases and
diagnoses some intimal tears not seen on corresponding angiography, although
the clinical significance of these tears is unclear [76-78]. It also has utility in
diagnosing valvular injuries and pericardial effusions. Unlike transesophageal
imaging, transthoracic echocardiography, while excellent for diagnosing significant
pericardial effusions, cannot reliably diagnose BAI [76,77].
Management — Patients with BAI awaiting transport to the operating room or a
monitored setting for medical management require careful control of their blood
pressure and heart rate. The medical management of patients with blunt thoracic
injury is discussed in detail separately. (See "Management of blunt thoracic aortic
injury", section on 'Anti-impulse therapy'.)
Options for surgical treatment of aortic injury include open repair (via
thoracotomy) or endovascular repair. These are reviewed separately. (See
"Surgical and endovascular repair of blunt thoracic aortic injury".)
In some cases, emergency surgery is not feasible. The relative risks and benefits
of immediate versus delayed repair are discussed separately. (See "Management
of blunt thoracic aortic injury", section on 'Approach to management'.)
Cardiac injury
The supine chest radiograph has high specificity for diagnosing a pneumothorax
from blunt injury, but its sensitivity is variable. Ultrasound may be a more sensitive
initial screening tool. (See 'Ultrasound' above and 'Chest radiograph' above.)
Debate continues about the need for tube thoracostomy in patients with occult
pneumothorax who require positive-pressure ventilation, reflecting the conflicting
data [91-94]. One randomized trial found that such patients are at significant risk
of developing a life-threatening tension pneumothorax [91]; a subsequent
randomized trial reported that observation of such patients, without chest tube
placement, was not associated with an increased incidence of pneumothorax
progression [94]. Both trials involved few patients; thus, it is difficult to draw
meaningful conclusions.
However, not all trauma surgeons advocate tube thoracostomy in such cases.
Practice guidelines from the Eastern Association for the Surgery of Trauma state
that observation is an acceptable option [87]. If tube thoracostomy is not
performed in patients requiring mechanical ventilation, careful monitoring looking
for signs that the pneumothorax may be expanding is critical.
Hemothorax — Injuries leading to massive hemothorax include aortic rupture,
myocardial rupture, and injuries to hilar structures. Other causes include injuries to
the lung parenchyma and intercostal or mammary blood vessels. A volume of 300
mL is needed for hemothorax to manifest on an upright CXR. In skilled hands,
ultrasound can diagnose hemothorax accurately. (See 'Ultrasound' above.)
Pain control and pulmonary toilet are the mainstays of treatment. Prophylactic
endotracheal intubation is unnecessary, but patients with hypoxia or difficulty
ventilating require airway management. While opinions vary, fluid resuscitation
with crystalloid to euvolemia appears appropriate. Common complications include
pneumonia and acute respiratory distress syndrome (ARDS). (See "Acute
respiratory distress syndrome: Clinical features, diagnosis, and complications in
adults" and "Acute respiratory distress syndrome: Supportive care and oxygenation
in adults".)
Radiographs generally reveal marked air in local soft tissue (ie, subcutaneous
emphysema). If tracheal disruption occurs, the larynx can rise, allowing the hyoid
bone to ascend above the level of the third cervical vertebra, an unusual finding
otherwise. Fractures of the first three ribs are associated with intrathoracic injury
[100,101]. Other radiologic findings on plain film include persistent pneumothorax
with a dependent lung (image 12), interstitial air in the wall of the trachea or
mainstem bronchus, abnormal location of the endotracheal tube (ETT), and a
distended ETT cuff due to protrusion of the trachea. Of note, an isolated finding on
CXR of air outlining the trachea or mainstem bronchus due to
pneumomediastinum or occult pneumomediastinum seen on CT does not
correlate significantly with tracheobronchial rupture and does not require
extensive evaluation [101,102].
Diaphragm injury may be associated with epigastric and abdominal pain, referred
shoulder pain, shortness of breath, vomiting, dysphagia, or shock. The initial CXR
is normal or nondiagnostic in up to 50 percent of patients. Nevertheless, the CXR
may reveal diagnostic findings, such as abdominal viscera in the hemithorax, a
nasogastric tube in the thorax, or a focal constriction of herniated viscera at the
site of the tear, producing circumferential compression (collar sign). CXR may also
reveal nonspecific findings such as atelectasis, pleural effusion, loss of the usual
hemidiaphragm contour, eventration of the diaphragm, and pneumothorax or
hemothorax, although none of these are sensitive or specific for diaphragm injury.
Serial CXRs may be useful, especially in patients in whom positive-pressure
ventilation has prevented bowel herniation [101,109]. Because many studies do
not differentiate between penetrating and blunt injuries, plain CXR may have
greater accuracy in detecting injuries due to blunt trauma than has been thought.
The extent of sternal fracture displacement correlates with the risk for associated
intrathoracic injury, although even nondisplaced fractures carry a substantial risk
and significant extrathoracic injuries can also occur [117,120,121]. Common
associated injuries include cranial injury (including intracranial hemorrhage), rib
fracture, pulmonary contusion, spinal fracture, retrosternal hematoma,
pneumothorax and hemothorax, and extremity trauma [119]. If a thoracic spine
fracture occurs concomitantly, it may be an unstable burst fracture and should be
investigated [122]. Other important albeit less common associated injuries include
hemopericardium, cardiac contusion, and aortic tear. (See "Evaluation of thoracic
and lumbar spinal column injury".)
Rib fracture — Patients with three or more rib fractures, especially older adult
patients, are at significant risk for complications such as pulmonary contusion and
pneumonia, even in the absence of other injuries, and should be admitted for
observation. Rarely, healthy, younger individuals with three rib fractures, having
undergone a thorough clinical and radiographic evaluation by clinicians
experienced in trauma management and an appropriate period of observation,
may be discharged from the ED. The management and disposition of patients with
rib fractures and no other injuries is discussed separately. (See "Initial evaluation
and management of rib fractures", section on 'Disposition' and "Inpatient
management of traumatic rib fractures".)
Flail chest — Flail chest occurs when three or more adjacent ribs are each
fractured in two places, creating one floating segment comprised of several rib
sections and the soft tissues between them (figure 12). This unstable section of
chest wall exhibits paradoxical motion (ie, it moves in the opposite direction of the
uninjured, normal-functioning chest wall) with breathing and is associated with
significant morbidity from pulmonary contusion. Abnormal motion can be difficult
to detect, making the diagnosis difficult.
Initial management of flail chest consists of oxygen and close monitoring for early
signs of respiratory compromise, ideally using both pulse oximetry and
capnography in addition to clinical observation. Stabilization of the segment with
manual or object pressure restricts chest wall expansion, thereby interfering with
proper respiratory mechanics, and is no longer used. Use of noninvasive positive
airway pressure by mask may obviate the need for endotracheal intubation in alert
patients. Patients with severe injuries, respiratory distress, or progressively
worsening respiratory function require endotracheal intubation and mechanical
ventilatory support. (See "Inpatient management of traumatic rib fractures",
section on 'Flail chest'.)
Plain radiographs are not sensitive for detecting SC dislocation. While special
views can be obtained to improve sensitivity (eg, "serendipity view" with beam
angled approximately 45 degrees cephalad), it is best to obtain a contrast-
enhanced CT of the chest if there is any suspicion for posterior dislocation or
internal injury [127]. This study enables evaluation for both bony and vascular
injury.
Initial treatment of SC dislocation depends upon the type of dislocation and the
severity of associated symptoms. Anterior subluxations require no immediate
treatment. However, a true anterior dislocation should be reduced within 12 to 24
hours. This can often be done as an outpatient by orthopedic surgery.
● Clinicians managing BTT first assess and stabilize the patient's airway,
breathing, and circulation (ABCs). The one caveat to this principle is that
breathing may take priority over airway if a tension pneumothorax is present. In
this case, the clinician should relieve the pneumothorax before performing
tracheal intubation, if needed. (See 'Primary survey and initial management'
above.)
● When determining the likelihood of severe injury from BTT, abnormal vital
signs are more important than mechanism of injury. Immediate life-threatening
injuries from blunt chest trauma include:
• Aortic injury
• Tension pneumothorax
• Hemothorax with severe, active bleeding
• Pericardial tamponade from myocardial injury
• Tracheobronchial disruption
• 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
BAI is discussed in detail above. (See 'Aortic injury' above.)
● BTT is capable of causing a wide range of injuries, some of which are difficult
to detect by physical examination or with plain radiographs. Common and
important injuries are discussed in the text. (See 'Specific injuries' above.)
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