Skip to Main Content

++

Introduction

++

Objectives

  1. Discuss the clinical presentation of patients with both blunt and penetrating chest trauma.

  2. Discuss the use of mask continuous positive airway pressure and noninvasive ventilation for patients with chest trauma.

  3. Discuss the initial ventilator settings for patients with chest trauma.

  4. Describe the monitoring of mechanically ventilated patients with chest trauma.

  5. Discuss the weaning of chest trauma patients from ventilatory support.

++

Although the chest wall can absorb significant amounts of trauma without serious injury to the patient, chest trauma is a frequent indication for critical care and mechanical ventilation. Unlike other disease states requiring mechanical ventilation (eg, chronic obstructive pulmonary disease [COPD]), patients suffering chest trauma are typically young and previously healthy and an increasing number are being managed with noninvasive approaches.

++

Overview

++

Blunt Chest Trauma

++

With blunt chest trauma, there are often no exterior signs or symptoms of injury to the chest. Clinical entities associated with blunt chest trauma include fractures, pulmonary contusion, tracheobronchial injury, myocardial and vascular injury, esophageal perforation, and diaphragmatic injury. Fractures can involve the ribs, sternum, vertebrae, clavicles, or scapulae. Of these, rib fractures are the most common. Rib fractures without flailing can be painful, resulting in splinting, atelectasis, and hypoxemia due to ventilation/perfusion mismatching. Isolated rib fractures almost never necessitate mechanical ventilation unless they are associated with other injuries such as pulmonary contusion. Flail chest is a loss of stability of the rib cage caused by multiple rib fractures, which frequently results in significant ventilatory disturbances due to underlying damage to the lung parenchyma, inefficient expansion of the thorax due to paradoxical movement of the chest wall, and pain leading to hypoventilation. Until recently, it was common practice to internally stabilize the rib cage in patients with flail chest by use of positive pressure ventilation and positive end-expiratory pressure (PEEP). Many patients with flail chest are now adequately managed without intubation and mechanical ventilation. This is particularly the case with appropriate pain control and noninvasive ventilation (NIV). It is now generally accepted that mechanical ventilation is only required for patients with flail chest if one of the following is present: shock, closed head injury, need for immediate operation, severe pulmonary dysfunction, or deteriorating respiratory status.

++

Pulmonary contusion results from high impact blunt chest trauma, which produces leakage of blood and protein from the vascular to the interstitial and alveolar space of the lungs. Clinically, pulmonary contusion is similar in presentation and treatment to acute respiratory distress syndrome (ARDS). If the contusion is localized, high levels of PEEP may produce a paradoxical decrease in arterial oxygenation because blood may be diverted from normal to the injured lung increasing shunt fraction. Mild to moderate forms of pulmonary contusion may not require intubation, and hypoxemia can be adequately treated with oxygen and mask continuous positive airway pressure (CPAP) or NIV.

++

Tracheobronchial injuries most often occur near the trachea or ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.