Which initial radiographic findings would the nurse expect in a patient with a pulmonary contusion?

Reports of chest trauma from ancient, medieval, Renaissance, and even the modern eras reflect both an appreciation for and a therapeutic frustration in caring for patients with chest injuries. Blunt injuries with flail chest and hemoptysis were described in the Smith Papyrus (written in Egypt in approximately 1600 bc and thought to probably represent a copy of an earlier missive written circa 3000 bc), in the Iliad circa 850 bc, and by Hippocrates in the fifth century bc.1 However, these early writings did not describe effective treatment strategies for patients with chest injuries. Effective treatment of chest injuries was made possible by the development of general anesthesia and positive-pressure ventilation. By the early 1900s, thoracoscopy and thoracotomy were both being performed, and the advent of antibiotics allowed the treatment of infection, thereby reducing a major postoperative risk. Throughout the 20th century, advances in thoracic, trauma, and critical care surgery attempted to keep pace with the increasing volume and complexity of cases.

The most significant advances in the treatment of blunt chest trauma from the later part of the 20th century involve a better understanding of acute respiratory failure, creative and flexible ventilator treatment strategies, directed pneumonia and empyema treatments, the diagnosis and treatment of aortic and great- vessel injury, remarkable advances in imaging techniques, and operative strategies that have become more conservative in scope and intervention. Although only perhaps 10% of blunt chest trauma cases require an operation, these patients typically present a challenging treatment dilemma, demanding rapid yet thoughtful decision-making, comprehensive anatomic understanding, and often prompt operative intervention. In this monograph, we hope to provide a broad and contemporary summary of the treatment of patients with blunt chest trauma, an important and changing component of trauma care.

Incidence

Calhoon and Trinkle2 have noted that in the United States alone, trauma is responsible for 100,000 deaths and more than 9,000,000 disabling injuries annually and that 25% of blunt traumatic fatalities are a direct consequence of chest injury, whereas in as many as another 50%, chest injury plays a major contributing role. Blunt thoracic injuries are responsible for approximately 8% of all trauma admissions, with motor vehicle crashes (MVCs) the dominant injury mechanism.3 A 4-year review of

Prehospital care

Treatment of many thoracic injuries can begin in the prehospital setting. The basic principles of prehospital care, including maintaining a patent airway, supplying supplemental oxygen and breathing support, establishing intravenous access, and pressure control of obvious hemorrhage, are likewise essential components of chest trauma treatment. Tracheal intubation and chest needle decompression are part of the armamentarium of many prehospital care providers, and some programs even allow

Incisions and positioning

The choice of operative approach is influenced primarily by the required exposure but must also take into account likely injuries, patient stability, available equipment, and experience of the surgeon (Figure 2). The initial exposure may prove to be inadequate, and recognizing this and making modifications or closing and repositioning are far better than continuing to struggle. At the same time, particularly in unstable patients, one should not be paralyzed by indecision in trying to choose

Rib fractures

Rib fractures are common, yet they often appear trivial in the setting of major multisystem injury. The incidence of chest trauma ranges from 4% to 10% of all trauma admissions (the higher numbers being seen in dedicated trauma centers), although the true incidence is probably higher, since up to 50% of rib fractures may be missed on initial CXRs.68, 69 Chest wall trauma is also a marker of significant associated injury, including an increased risk for intra-abdominal injuries.69 The incidence

Hemothorax

The treatment of patients with ongoing hemorrhage has been described earlier, and the approach to those who are stable and have a retained hemothorax will be discussed in later, but the acute treatment of patients who present with hemothorax without immediately obvious indications for operation deserves consideration. For simplicity, patients can be considered to be in 1 of 2 extremes. The first set includes those patients who are stable, with minimal respiratory distress, who do not require

History and mechanism

The first reported cases of blunt cardiac injury (in which valvular rupture was noted) may have been in 1676 by Borch294 and subsequently by Berard in 1826,193, 194, 195, 196 but it was not until 1955 that the first successful repair of a rupture (at the right atrial-superior vena cava junction) was reported by Desforges and colleagues.197 Blunt cardiac injury manifests as a variety of clinical conditions, usually in association with multiple injuries of other organs and difficult treatment

Traumatic rupture of the thoracic aorta

The treatment of aortic rupture has significantly evolved from the mid-portion of the last century when aortic injuries were thought to be fatal in essentially all cases unless immediately operated on, through an evolution of early recognition based on mechanism and physical signs, improved imaging, varied operative approaches (including the “clamp- and-sew” versus “bypass” controversy), to the current era of selective operative repair, nonoperative repair, and the emergence of endovascular

Great-vessel injury

Blunt injuries involving the intrathoracic great vessels are difficult to diagnose and treat and are commonly associated with significant associated injuries (including the airway, heart, brachial plexus, and central nervous system) that impact the outcome. As with aortic injury, the incidence and location of blunt injury of the great vessels differ between autopsy and clinical series. It has been argued that the majority of patients who suffer blunt disruption of the great vessels die at the

Tracheobronchial injury

The first description of tracheobronchial rupture from blunt trauma may be from an 1874 article by W.H. Winslow, as quoted by Mills and colleagues471:

The cook was preparing two of them (canvas back ducks) for baking, when she notice [sic] something abnormal in one of them, and called my attention to it. On examination, it was evident that at some previous remote period the left bronchus of the duck had been ruptured on the outer side, where it joined the trachea at the bifurcation…yet in this

Conclusion

In conclusion blunt chest injury continues to pose a significant burden on trauma systems and requires aggressive diagnostic and therapeutic approaches. Patients often have multiple injuries that compete for priority, and in a large proportion these injuries may not be operable. Ongoing research into biomechanics offers some hope in reducing both the incidence and severity of injuries. Other clinical research efforts are introducing newer diagnostic modes to our armamentarium, as well as

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