REVIEW

CURRENT
OPINION Blunt thoracic trauma: recent advances and
outstanding questions
Neil G. Parry a,b,c, Bradley Moffat a,c, and Kelly Vogt a,c

Purpose of review
The treatment of blunt thoracic injuries is complex and evolving. The aim of this review is to focus on what
is new with ventilation for blunt chest trauma as well as an update on the current management strategies
for blunt aortic injury and rib fractures.
Recent findings
Early use of noninvasive ventilation appears to be well tolerated in select hemodynamically stable blunt
trauma patients. For those patients requiring intubation, airway pressure release ventilation is an excellent
mode to decrease the risk of posttraumatic acute lung injury. Endovascular repair of blunt thoracic aortic
injuries provides benefit over open repair and, if possible, delayed repair confers a mortality advantage.
Despite its increasing use, there continue to be conflicting results about the role of surgical rib fixation for
the treatment of flail chest.
Summary
Blunt thoracic injuries are commonly treated in the ICU and a solid knowledge of mechanical ventilation
strategies (both noninvasive and invasive) is essential. Blunt thoracic aortic injuries require early diagnosis
and aggressive blood pressure management. Not all such injuries need operative repair but those that do
benefit from an endovascular approach. The management of flail chest includes early aggressive
multimodal analgesia, adequate oxygen, and ventilatory support. Surgical rib fixation should be
considered in select patients.
Keywords
airway pressure release ventilation, blunt aortic injuries, flail chest, noninvasive ventilation

INTRODUCTION respiratory failure in patients with cardiogenic pul-

Due to the extensive anatomy, blunt traumatic
injuries can present with a host of simple or complex
injuries to the musculoskeletal thoracic cage
and/or major cardiovascular, pulmonary, or digestive
organs. Unfortunately, there is scant literature about
the incidence of blunt trauma admission to the ICU.
However, Veysi et al. [1] found that 37.5% of their
blunt trauma population were admitted to the ICU
and that their mortality rate was 18.7%. Their
mortality rate is consistent with other published
series [2,3]. These patients are often multiply injured
and may have competing treatment options.
The aim of this review is to focus on what is new
in ventilation with blunt chest trauma as well as an
update on the management strategies for blunt
thoracic aortic injury and multiple rib fractures.
MECHANICAL VENTILATION
Noninvasive ventilation
Although noninvasive ventilation (NIV) has been
well established and accepted for treatment of
monary edema and chronic obstructive pulmonary
disease, its role in managing respiratory failure in
trauma patients remains somewhat controversial
[4–7]. Recently, two systematic reviews have eval-
uated the safety and efficacy of NIV in blunt chest
trauma [8,9].
Chiumello et al. included 10 studies for a total
of 368 patients [four randomized controlled trials
(RCTs) as well as three prospective and three
a
Division of General Surgery, Department of Surgery, bDivision of Critical
Care, Department of Medicine and cTrauma Program, London Health
Sciences Centre, London, Ontario, Canada
Correspondence to Neil G. Parry, MD, FRCSC, FACS, Medical Director
of Trauma, London Health Sciences Centre, Site Chief of Surgery,
Victoria Hospital, London Health Sciences Centre Associate Professor
of Surgery and Critical Care Schulich School of Medicine and Dentistry,
Western University Rm E2-217, Victoria Hospital, London Health Scien-
ces Centre 800 Commissioners Rd E, London, Ontario N6A 5W9,
Canada. E-mail: Neil.Parry@lhsc.on.ca
Curr Opin Crit Care 2015, 21:544–548
DOI:10.1097/MCC.0000000000000251

www.co-criticalcare.com Volume 21
Number 6
December 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS

Early noninvasive mechanical ventilation is effective in
select awake, hemodynamically normal patients with
blunt chest trauma.

Early use of airway pressure release ventilation appears
to be as effective or perhaps better than low-tidal
volume ventilation to decrease acute lung injury and
acute respiratory distress syndrome.

Blunt thoracic aortic injuries require aggressive blood
pressure control and those that require surgery benefit
from an endovascular approach.

Management of flail chest requires aggressive
multimodal analgesia and select patients may benefit
from surgical rib fixation.
retrospective observational studies]. The majority of
respiratory failure was defined as impaired oxygen-
ation and increased respiratory rate. NIV was
defined as either the use of continuous positive
airway pressure, bilevel-positive airway pressure,
or noninvasive pressure support ventilation. The
relative risk (RR) for mortality if treated with NIV
compared with standard care was 0.26 [95% confi-
dence interval (CI) 0.09–0.71, P ¼ 0.003]. NIV was
also found to significantly reduce the intubation
rate (RR 0.32, 95% CI 0.12–0.86, P ¼ 0.023), overall
complications (RR 0.37, 95% CI 0.24–0.57,
P < 0.001), and ICU length of stay (weighted mean
difference 2.4, 95% CI 3.9 to 1.0, P ¼ 0.001).
Duggal et al. included nine articles (three RCTs,
four observational, and two retrospective cohort
studies) for a total of 407 patients diagnosed with
pulmonary contusions, rib fractures (including
flail), or sternal fractures. Interestingly, they
included three articles not studied by Chiumello
and omitted three articles included in the first
review. Also, Duggal et al. did not perform a meta-
analysis, as the included studies were deemed too
heterogeneous and of relatively poor quality. As a
result, their conclusions were not as emphatic as
Chiumello, as they stated only that there may be a
role for the early use of NIV in select blunt trauma
patients and that it should be instituted for only 48–
72 h.
NIV can recruit atelectatic, collapsed, and
poorly ventilated lungs while improving oxygen-
ation and decreasing the work of breathing. To date,
the literature would support that select hemody-
namically stable, neurologically intact trauma
patients with blunt chest trauma may benefit from
NIV if administered early before the onset of fulmi-
nant respiratory failure.
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Update on blunt thoracic trauma Parry et al.
Invasive ventilation
Many modes of mechanical ventilation have been
utilized in the management of blunt trauma patients;
however, the literature remains unclear as to which
mode is superior to prevent and treat posttraumatic
acute lung injury (ALI) or acute respiratory distress
syndrome (ARDS). The basic tenets of adequate
oxygenation, use of positive end expiratory pressure,
and low-tidal volume to decrease the risk of ARDS
still hold true [3,10]. However, there is a growing
body of literature that airway pressure release venti-
lation (APRV) may provide several advantages over
conventional ventilation of the injured lung.
APRV is a spontaneous breathing mode that
attempts to maximize recruitment (thereby improve
oxygenation and minimize alveolar shear stress)
through prolonged-positive pressure during the
inspiratory phase with brief expiratory releases
[11,12]. It is thought to be ‘lung protective’, in part,
because it has been shown to reduce alveolar micro-
&&
strain [13,14 ].
A RCT of 63 adult trauma patients with acute
respiratory failure found no difference in mean
ventilator days, ICU length of stay, complications,
or mortality between patients treated with APRV or
low-tidal volume ventilation [15]. APRV performed
at least as well as low-tidal volume, ARDS net-
like ventilation.
A recent systematic review by Andrews et al. [16]
evaluated the efficacy of early APRV in trauma
patients. They included eight retrospective and
eight prospective observational studies that
included 66 199 patients (one study was a retrospec-
tive analysis of the National Trauma Data Bank
which contributed 43 644 patients) [17]. They con-
cluded that the early application of APRV reduced
the incidence of ARDS and overall mortality in
ventilated trauma patients. Experimental models
also support that early application of APRV can
reduce the ALI and ARDS in normal lungs [18].
In summary, APRV is a very attractive mode of
ventilation for trauma patients as it appears to be at
least as well tolerated as and possibly better than low-
tidal volume ventilation to prevent posttraumatic
ALI and ARDS. Several ongoing clinical trials includ-
ing the acute lung injury ventilator evaluation trial
will hopefully shed more information on the role of
APRV with the traumatically injured [19].
Blunt thoracic aortic injury
Injury to the thoracic aorta is a rare but challenging
consequence of blunt trauma. Although the
majority of patients with injury to the thoracic aorta
will die on scene, 20% will survive to hospital and
&&
10% will survive the first 24 h in hospital [20 ].
Blunt thoracic aortic injury (BTAI) is not only a
www.co-criticalcare.com 545
Trauma
challenging injury to manage, but also an important
marker of the severity of injury and a potential
marker for other significant injuries, as demon-
strated by the high early hospital mortality rates
associated with this injury. Demetriades [21] recog-
nized the importance of this rare injury pattern in
2011 when he gave the Scudder Oration at the
American College of Surgeons Clinical Congress
on BTAI.
In 2015, the Eastern Association for the Surgery
of Trauma (EAST) updated their practice manage-
ment guidelines for the evaluation and manage-
&&
ment of blunt traumatic aortic injury [20 ]. The
guidelines addressed three specific questions: what
is the optimal diagnostic modality for BTAI; should
repair be performed using an endovascular or open
approach; and what is the optimal timing of repair?
The authors highlight that, as stated in the prior
iteration of these guidelines, any patient with chest
radiograph findings of widened mediastinum, loss
of aortopulmonary window, tracheal deviation, api-
cal cap, or depressed left mainstem bronchus, or
who was injured by a significant acceleration or
deceleration mechanism, or in whom there is
clinical suspicion of BTAI should undergo further
imaging for diagnosis [22]. Based on the currently
available evidence for diagnostic accuracy of both
computed tomography (CT) and conventional
angiography, the authors strongly recommend that
further imaging be completed with CT scan of the
chest with intravenous contrast.
For those that require intervention, the conven-
tional open repair was compared with endovascular
repair with respect to mortality, stroke, and para-
plegia. Recognizing that no Level I evidence exists to
guide decision-making, the guidelines are based on
45 observational studies that compared endovascu-
lar repair of the aorta (EVAR) to open repair. Despite
this low-quality evidence, the authors strongly
recommend the use of EVAR for patients without
contraindications, based on a demonstrated
reduction in mortality (RR 0.56, 95% CI 0.44–
0.73) and paraplegia (RR 0.36, 95% CI 0.19–0.71),
and a comparable rate of stroke (RR 1.48, 95% CI
0.67–3.27) when comparing EVAR to open repair.
The final topic covered in the updated EAST
guidelines is the optimal timing of repair of BTAI.
The seven studies comparing immediate versus
delayed repair again provided low-quality evidence;
however, the authors suggest delayed repair in the
absence of contraindications such as active extrav-
asation of contrast on CT scan. This is based on a
demonstrated survival benefit (RR 2.07, 95% CI
1.03–4.15) and reduced rates of paraplegia (RR
5.90, 95% CI 1.51–22.97) with delayed repair,
although it is important to recognize that there is
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
moderate heterogeneity in the studies combined to
provide these estimates. The majority of the benefit
conferred with delayed repair likely relates to the
need for resuscitation and immediate management
of other life threatening injuries prior to the aortic
repair, and, therefore, no clear recommendations
can be made in patients presenting without associ-
ated injuries. With delayed repair, antihypertensive
medications are advocated to maintain a SBP less
than 120 mmHg prior to repair.
The Society of Vascular Surgery classifies trau-
matic aortic injuries as follows: type I represents an
intimal tear; type II represents an intramural hem-
atoma; type III represents a pseudoaneurysm; and
type IV represents a rupture [23]. There is increasing
interesting in defining which of these injuries can
&
be managed nonoperatively. DuBose et al. [24 ]
recently published their retrospective multicenter
study encompassing data from nine Level I trauma
centers in the United States. Of the 382 patients,
32% of patients underwent an initial trial of non-
operative management (NOM). The majority of the
patients in the NOM group had Grade I or II injuries,
and only two failures occurred requiring eventual
EVAR. There was, however, a 10% aorta-related
mortality among the NOM group, as compared with
5% in the operatively managed group. Some of this
may be related to time to OR, and questions still
arise with respect to correctly identifying the
patients in need of immediate rather than delayed
&&
operative repair. Rabin et al. [25 ] from Shock
Trauma attempted to define a more clinically useful
grading system to guide therapy in their retrospec-
tive cohort study. In their study, grade I represented
an intimal tear of intramural hematoma, grade II
represented a small pseudoaneurysm, grade III
represented a large pseudoaneurysm, and grade IV
represented a rupture or transection of the aorta.
They also took into account secondary signs of
injury on CT chest, which included pseudocoarcta-
tion, mediastinal hematoma with mass effect,
and/or a large left hemothorax. In their series,
46% of patients underwent NOM, most of whom
had Grade I or II injuries. Of these, 31% died of
associated injuries, and there were no reported
aorta-related deaths. The authors concluded that
patients with Grade I, II injuries are amenable to
medical management with beta-blocker therapy to
control blood pressure. They recommend that Grade
III injuries should undergo repair, and the urgency
of repair should be dictated by the presence of
secondary signs of injury. Finally, they recommend
that all Grade IV injuries undergo immediate repair.
The presence of multiple grading systems, and con-
founding introduced by associated injuries makes a
strict determination of the optimal patient for NOM
Volume 21
Number 6
December 2015

difficult to define. None the less, for patients deter-
mined by the surgeon to be a candidate for either
NOM or delayed operative management, the
importance of strict blood pressure control using
an agent that will decrease shear forces on the aortic
wall such as a beta-blocker cannot be underscored
&&
[25 ].
In summary, BTAI is a relatively rare injury in
patients surviving to hospital after blunt trauma.
When it is identified, however, patients should be
immediately considered for operative repair. In
patients deemed candidates for immediate operative
intervention, EVAR appears to provide benefit over
open repair, although long-term outcomes of this
strategy are not yet known. If possible, delayed
operative repair should be considered, as this
appears to correlate with improved outcomes when
blood pressure is strictly controlled preoperatively.
Not all patients with BTAI require operative repair,
and for those deemed to be candidates for NOM, SBP
should be controlled below 120 mmHg, preferably
with a beta-blocking agent.
Multiple rib fractures and flail chest
In contrast to BTAI, rib fractures are extremely com-
mon in patients incurring blunt trauma. Although
rarely immediately life threatening, rib fractures are
associated with significant pain and disability not
only in the early posttrauma period, but also up to
at least two years after injury [26,27]. Flail chest,
generally defined as the fracture of three or more ribs
in two or more places, represents the most severe
form of rib fractures [28]. Flail injuries are associated
with mortality rates of up to 40% in patients with
associated pulmonary contusions, in part related
to the inability to adequately oxygenate and/or
ventilate the underlying contused lung [28,29].
The management of rib fractures begins with
analgesia. Although nonsteroidal antiinflammato-
ries, acetaminophen, and narcotics all play a role,
these are often not sufficient to provide the amount
of analgesia required to control pain and to normal-
ize respiratory function. Epidural analgesia is advo-
cated by many as the ideal modality for pain control
in patients with multiple rib fractures and/or flail
chest [28,30]. Gage et al. [31] recently published a
retrospective cohort study using data from the
National Study on Cost and Outcomes of Trauma
database to evaluate the efficacy of epidural analge-
sia in the United States. Of the 836 patients with
three or more rib fractures determined to be poten-
tial candidates for epidural placement, 100 actually
had an epidural placed. The authors comment that
the variability in results of published studies evalu-
ating pain control with epidural use for rib fractures
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Update on blunt thoracic trauma Parry et al.
likely contributes to the low rates of usage. None the
less, in patients who had an epidural placed, multi-
variable analysis adjusting for demographic and
injury data as well as trauma center status demon-
strated significantly lower odds of mortality com-
pared with those who did not at 30 days (adjusted
odds ¼ 0.08, 95% CI 0.01–0.43), 90 days (adjusted
odds 0.09, 95% CI 0.02, 0.42), and one year
(adjusted odds 0.12, 95% CI 0.04–0.42). Interest-
ingly, similar multivariable analysis failed to dem-
onstrate an effect of epidural associated with rates of
pneumonia or empyema.
Given the lack of success with even the most
aggressive analgesia, there has been renewed inter-
est in recent years in the operative management of
flail chest. In 2012, the EAST guidelines suggested
that, despite definitive evidence of improved out-
comes with surgical fixation, patients with flail
chest who fail to wean from the ventilator or who
are undergoing thoracotomy should be considered
for fixation [30]. Two recent reviews have addressed
this topic in patients requiring intubation and
mechanical ventilation. In 2013, Slobogean et al.
[32] published their systematic review and meta-
analysis of nine observational studies and two RCTs
comparing surgical fixation to NOM for flail chest.
Surgical fixation was found to be superior to NOM
with respect to ventilator days, odds of developing
pneumonia and sepsis, the need for tracheostomy,
and mortality. In 2015, a Cochrane Database Review
was published representing the results from three
&&
RCTs totalling 123 patients [33 ]. The meta-analysis
failed to demonstrate a reduction in mortality (risk
ratio 0.56, 95% CI 0.13–2.42); however, the analysis
was underpowered to detect a meaningful differ-
ence. They did, however, demonstrate surgical man-
agement to be superior with respect to pneumonia
(RR 0.36, 95% CI 0.15–0.85), chest deformity (RR
0.13, 95% CI 0.03–0.67), and tracheostomy (RR
0.38, 95% CI 0.14–1.02). Although not able to be
assessed in this meta-analysis, at least one RCT
demonstrated that surgical fixation is associated
with a decrease in the duration of ventilation [27].
Despite these successes, physicians caring for
patients with multiple rib fractures, however, rec-
ognize that not all patients who meet the criteria for
flail chest require operative fixation. It is hoped that
an ongoing multicenter randomized controlled trial
being coordinated in Canada will help to clarify who
will most benefit from surgical fixation, as nonven-
tilated patients are also being enrolled in this trial
[34].
In summary, multiple rib fractures and flail
chest are associated with a significant risk of morbid-
ity and mortality. Early aggressive analgesia, includ-
ing the use of epidural analgesia, should be pursued
www.co-criticalcare.com 547
Trauma
in all patients. Consideration should be given to
surgical rib fixation in patients requiring mechan-
ical ventilation, and patients who are not yet intu-
bated should be considered for inclusion in ongoing
clinical trials.
CONCLUSION
Blunt thoracic injuries are commonly treated in the
ICU and a solid knowledge of mechanical venti-
lation strategies (both noninvasive and invasive)
is essential. Blunt thoracic aortic injuries require
early diagnosis and aggressive blood pressure man-
agement. Not all such injuries need operative repair
but those that do benefit from an endovascular
approach. The management of flail chest includes
early aggressive multimodal analgesia, adequate
oxygen, and ventilatory support. Surgical rib fix-
ation should be considered in select patients.
Acknowledgements
None.
Financial support and sponsorship
This work received no financial support.
Conflicts of interest
There are no conflicts of interest.
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READING
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been highlighted as:
& of special interest
&& of outstanding interest
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