{"id":5409,"date":"2011-09-06T15:55:35","date_gmt":"2011-09-06T15:55:35","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5409.htm\/"},"modified":"2018-08-03T14:30:50","modified_gmt":"2018-08-03T18:30:50","slug":"thoracic-trauma","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/system\/thoracic-trauma.htm\/","title":{"rendered":"Thoracic Trauma"},"content":{"rendered":"

<\/span>EAST Guidelines for Pneumo\/Hemothorax<\/span><\/h2>\n

(The Journal of TRAUMA 2011;70(2):510)<\/p>\n

Diagnosis<\/strong><\/p>\n

1. Ultrasound can reliably be used to identify pneumothorax and pleural effusion (Level 2).<\/p>\n

2. CT of the chest is indicated in patients with persistent opacity on chest radiograph after tube thoracostomy to determine whether significant undrained fluid exists (Level 2)<\/p>\n

3. Primary VATS of stable penetrating thoracoabdominal wounds is safe and effective for the diagnosis and management of selected diaphragm and pulmonary injuries<\/p>\n

(Level 2).Management of Massive Hemothorax1. Patient physiology should be the primary indications forsurgical intervention rather than absolute numbers of initial or persistent output (Level 2).2. 1500 mL via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgicalexploration (Level II). Management of Hemothorax1. All hemothoraces, regardless of size, should be consideredfor drainage (Level 3).2. Attempt of initial drainage of hemothorax should be witha tube thoracostomy (Level 3).3. Persistent retained hemothorax, seen on plain films, afterplacement of a thoracostomy tube should be treated withearly VATS, not a second chest tube (Level 1). 4. VATS should be done in the first 3 days to 7 days ofhospitalization to decrease the risk of infection and conversionto thoracotomy (Level 2).5. Intrapleural thrombolytic may be used to improve drainageof subacute (6-day to 13-day duration) loculated orexudative collections, particularly patients where risks ofthoracotomy are significant (Level 3).Management of Occult Pneumothorax1. Occult pneumothorax, those not seen on chest radiograph, may be observed in a stable patient regardless of positivepressure ventilation (Level 3).<\/p>\n

3. Scoring systems are not accurate in predicting whichpatients will need a tube thoracostomy for occult pneumothorax(Level 3).4. A persistent air leak on postinjury day 3 should prompt aVATS evaluation (Level 2)<\/p>\n

patho of tension<\/a>
\nmore pathophys of tension<\/a><\/p>\n

<\/span>Tube Drainage Indications for Thoracotomy<\/span><\/h2>\n

20 cc per kilo initially or 5 cc\/kg\/hr or 25 cc\/kg total to OR<\/p>\n

1.5 liters initially or 350\u00a0 (200) cc\/hr or 2 1\/2 liters total.<\/p>\n

The presence of more than 1500 mL of blood in the initial chest tube drainage, drainage of more than 200 mL an hour for 2-4 hours, or ongoing transfusion requirements mandate surgical exploration with open thoracotomy<\/p>\n

 <\/p>\n

CT Chest is useful (J Am Surgeon 2001;67:660-664)<\/p>\n

<\/span>West Study on Retained Hemothorax<\/span><\/h2>\n

RH <=300 cc and pneumothorax as initial indication for trauma thoracostomy tube placement.<\/p>\n

The Journal of Trauma and Acute Care Surgery 72(1), 2012,\u00a0p 11\u201324<\/div>\n
<\/div>\n
High rate of empyema with retained hemothorax (J Trauma 2012;73:752)<\/div>\n
n<\/div>\n
Journal of Trauma and Acute Care Surgery
\nIssue: Volume 84(3), March 2018, p 454\u2013458<\/div>\n

<\/span>“The Box”<\/span><\/h2>\n

Notch and Clavicles (roof), Nipple line are lateral (sides), Costal Margins (bottom)<\/p>\n

Echo initially and repeat in 6 hours.\u00a0 C-XR initially and in 6 hours.\u00a0 Can use helical CT to evaluate for pericardial fluid, just as good.<\/p>\n

\"\"<\/a>\"\"<\/a>\"\"<\/a>\"\"<\/a>\"\"<\/a><\/p>\n

 <\/p>\n

\"\"<\/a><\/p>\n

\u0093The box:\u0094 definition of proximity to the heart for penetrating injuries. X = wounds that produced cardiac injuries (Nagy KK, J Trauma 1995)<\/p>\n

<\/span>Thoracoabdominal<\/span><\/h2>\n

Nipple Line to costal margins\/below the scapula<\/p>\n

Both cavities and worry about the diaphragm<\/p>\n

DPL is good here, use low cut-off 5000 RBCs per cc<\/p>\n

 <\/p>\n

7% risk of occult<\/strong> diaphragmatic injury (J Trauma 2003;55(4):646)<\/p>\n

 <\/p>\n

\n
J Trauma. 1997 Oct;43(4):624-6.Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries.<\/strong> OBJECTIVE: The objective of this study was to (1) determine the incidence of diaphragmatic injuries in penetrating left thoracoabdominal trauma and (2) evaluate the role of laparoscopy in detecting clinically occult diaphragmatic injuries. PATIENTS AND METHODS: One hundred nineteen consecutive patients with penetrating injuries to the left thoracoabdominal region presenting to Los Angeles County-University of Southern California Medical Center were prospectively evaluated during an 8-month period. Either celiotomy (with hemodynamic instability or peritonitis) or laparoscopy was performed. Results of the clinical examination and roentgenographic findings were recorded preoperatively. RESULTS: One hundred seven patients were fully evaluated. Fifty patients required emergent celiotomy. Fifty-seven patients underwent laparoscopy. The overall incidence of diaphragmatic injuries was 42% (59% for gunshot wounds, 32% for stab wounds). Among the 45 patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had a normal chest roentgenogram, and 49% had an associated hemopneumothorax. Fifteen of the patients undergoing laparoscopy (26%) had occult diaphragm injuries. CONCLUSION: (1) The incidence of diaphragmatic injuries in association with penetrating left thoracoabdominal trauma is high. (2) The clinical and roentgenographic findings are unreliable at detecting occult diaphragmatic injuries. (3) Laparoscopy is a vital tool for detecting occult diaphragmatic injuries among patients who have no other indications for formal celiotomy.<\/dd>\n<\/dl>\n

 <\/p>\n

<\/span>Rib Fx<\/span><\/h2>\n

X-Ray if ribs 1-2, 9-12, pathological fx, or elderly<\/p>\n

1st or 2nd rib is fx along with another rib-get angio<\/p>\n

Flail-3 ribs in two places<\/p>\n

Traumatic Asphyxia<\/p>\n

Pulmonary Contusion<\/p>\n

Epidural analgesia probably reduces vent days and nosocomial pneumonia (J Surg 2004;136(2):426)<\/p>\n

 <\/p>\n

A Prospective Randomized Trial of Nebulized Morphine Compared with Patient-Controlled Analgesia Morphine in the Management of Acute Thoracic Pain [Original Articles] Fulda, Gerard J. MD, FACS, FCCM; Giberson, Frederick MD, FACS; Fagraeus, Lennart MD, PhD From the Departments of Surgical Intensive Care (F.G. and G.J.F.) and Anesthesia (L.F.), Christiana Care Health Services, Newark, Delaware. Submitted for publication October 26, 2004. Accepted for publication May 10, 2005. Presented at the 63rd Annual Meeting of the American Association of the Surgery of Trauma, September 29\u0096October 2, 2004, Maui, Hawaii. Address for reprints: Gerard J. Fulda, MD, FACS, FCCM, Director, Surgical Intensive Care, Associate Director of Trauma, Christiana Care Health Services, Room 2325, 4755 Ogletown-Stanton Road, Newark, DE 19718; email: gfulda@christianacare.org. Abstract Background: Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain. Methods: This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (0\u00963), total drug administration, and systematic side effects were recorded. Results: Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 \u00b1 3.4 mg for NMS and 6.22 \u00b1 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 \u00b1 11 bpm versus 92 \u00b1 12 bpm; p < 0.001) and were less sedated ( 0.33 \u00b1 0.7 versus 0.56 \u00b1 0.9; p = 0.03). The mean pain level (VAS) was 3.38 \u00b1 1.8 for NMS and 3.84 \u00b1 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao 2. Conclusion: Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects. Treatment and Dosing All patients had, at baseline, pulmonary function assessments before study initiation. Pulmonary function assessments consisted of forced expiratory volume in 1 second (FEV 1), maximum spirometric capacity, vital capacity, pulse oximetry, arterial blood pressure, and heart rate. Each patient then received an intravenous loading dose of morphine sulfate 0.07 mg\/kg (approximately 5 mg). This was to provide all patients with a baseline level of pain control. Patients then received a continuous intravenous infusion of study medication, either morphine 1 mg\/h (PCA group) with no on-demand morphine or an equivalent amount of 0.9% saline solution via PCA (NMS group). Both groups also received a nebulized study drug of either 0.9% saline solution (PCA group) or morphine sulfate 8 mg\/mL Normal Saline (NSS) (NMS group) every 4 hours around the clock (ATC). In summary, the PCA group received nebulized saline every 4 hours with PCA morphine, and the NMS Group received nebulized morphine every 4 hours with PCA saline. The rational for the initial doses and interval was based on published pharmacokinetic data. 4,5 This data suggest that inhaled morphine administered every 4 hours follows similar kinetics and elimination as a single intravenous injection. However, the dose of nebulized morphine needs to exceed twice the intravenous dose to provide similar bioavailability and half-life. Nebulized morphine was prepared and administered as follows. Morphine and placebo vials were prepared and blinded by the pharmacist. Standard injectable morphine sulfate with preservative was used (Abbott Labs, Chicago, IL). The patient’s nurse provided the correct dosage of study medication to the respiratory therapist. The nurse and therapist were responsible for ensuring that normal saline was added to the study medication to equal a 3 ml total volume. The solution was nebulized using a Respirguard II nebulizer system with the Acorn II nebulizer (Vital Signs, Inc., Totowa, NJ). This system produces an aerosol with a mass median aerodynamic diameter of 1.67 \u00b5m with an output of 0.34 mL\/min at 8 L\/min. The patient received the nebulizer treatment for 10 to 12 minutes. (J Trauma 2005;59(2)<\/p>\n

 <\/p>\n

OLD Folks do poorly with Rib Fractures<\/h4>\n

Bergeron E et al: Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 54:478, 2003;<\/p>\n

 <\/p>\n

 <\/p>\n

Small RCT shows NIV staves off intubation (CHEST January 2010 vol. 137 no. 1 74-80 )<\/cite><\/p>\n

Chest.<\/a> 2010 Jan;137(1):74-80. Epub 2009 Sep 11.Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial. Hernandez G<\/a>, Fernandez R<\/a>, Lopez-Reina P<\/a>, Cuena R<\/a>, Pedrosa A<\/a>, Ortiz R<\/a>, Hiradier P<\/a>.Critical Care Medicine, Hospital Virgen de la Salud, Toledo, Mezquite n degrees 12, 6 degrees A, 28045, Madrid, Spain. ghernandezm@telefonica.netBACKGROUND: Guidelines for noninvasive mechanical ventilation (NIMV) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia. This recommendation is rated only by level C evidence because randomized controlled trials in this specific population are lacking. Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia. METHODS: This was a single-center randomized clinical trial in a nine-bed ICU of a level I trauma hospital. Inclusion criteria were patients with Pao(2)\/Fio(2)<200 for >8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma. Patients were randomized to remain on high-flow oxygen mask or to receive NIMV. The interface was selected based on the associated injuries. Thoracic anesthesia was universally supplied unless contraindicated. The primary end point was intubation; secondary end points included length of hospital stay and survival. Statistical analysis was based on multivariate analysis. RESULTS: After 25 patients were enrolled in each group, the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients (10 [40%] vs 3 [12%], P = .02). Multivariate analysis adjusted for age, gender, chronic heart failure, and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation (odds ratio, 0.12; 95% CI, 0.02-0.61; P = .01). Length of hospital stay was shorter in NIMV patients (14 vs 21 days P = .001), but no differences were observed in survival or other secondary end points. CONCLUSION: NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia.PMID: 19749006 [PubMed – indexed for MEDLINE]<\/p>\n

 <\/p>\n

<\/span>Pneumothorax<\/span><\/h2>\n

32-40 French<\/p>\n

Thoracotomy-20 cc\/kg of initial blood, >7cc\/kg\/hr, decompensation, increased hemothorax<\/p>\n

If you get supine AP x-ray, look for deep sulcus sign<\/p>\n

1.25% of percent of Pneumo spontaneously absorbed each day, more c 100% O2<\/p>\n

Can get a delayed Pneumo up to 4 days post line placement<\/p>\n

Normally film 6 hours after initial chest x-ray in trauma, but article suggests 3 hours sufficient (JEM 20:3) and a second prospective trial (J Trauma 65(3):549)<\/p>\n

Spontaneous Pneumothoraces<\/p>\n

One shot of manual aspiration is supported and efficacious.\u00a0 If it fails, don\u0092t try again, move on to chest tube or Heimlich valve (Am J Resp Crit Care Med 165:1240, 2002)<\/p>\n

 <\/p>\n

Author, country, date Patient group Study type Outcomes Key results Study weaknesses<\/p>\n

\n

Garramone et al<\/em>, 1991, USA 26 trauma patients aged 14\u009665 with occult pneumothorax (OPTX) on abdominal CT. Classified as <5×80 mm or > = 5×80 mm Retrospective chart review Complications of OPTX, respiratory or haemodynamic compromise No patient had haemodynamic or respiratory complications. Retrospective Small numbers Of 18 with small OPTX: 2 had chest drains for increasing subcutaneous emphysema, 1 for increasing PTX. Of 13 patients with larger OPTX 4 had prophylactic chest drains, 3 for increasing subcutaneous emphysema 2 for increasing effusion Collins et al<\/em>, 1992, USA 23 patients aged 18\u009682 with occult pneumothorax Retrospective chart review Length of hospital stay (mean) 13.4 days vs 8.8 days Small study Retrospective Length if ICU stay 6.3 days vs 3.3 days Not randomised Immediate chest tube (n = 12) vs observation (n = 11) Complications 1 pt in immediate chest tube group: had laceration of intercostal artery. 2 observed pts had eventual chest tubes for enlarging pneumothorax or haemothorax Enderson et al<\/em> 1993 USA 40 adult trauma patients PRCT Length of hospital stay 12.9 vs 17.6 days Small study Randomized to immediate chest tube (n = 19) or observation (n = 21) Length of ICU stay 2.8 vs 3.2 days Complications Immediate chest tube: 1 pneumonia, 8 atelectasis. Observation group 3 tension pneumothorax, 5 progression pneumothorax, 1 pneumonia, 1 empyema, 3 atelectasis Wolfman et al<\/em> 1998 , USA 44 pts aged 17 months \u009670 yrs with occult pneumothorax, classified according to size into miniscule, anterior or anterolateral. Chest tube inserted dependent on size and at trauma surgeons discretion Prospective non-randomized Complications 15\/16 with miniscule observed, 2 had delayed chest drain for pneumothorax progression. 12\/20 anterior observed 1 developed tension pneumothorax. 8 with anterolateral had immediate chest drain, no complications Small numbers Both adults and children Brasel et al<\/em> 1999 , USA 39 adult patients with occult pneumothorax randomised to chest tube (n = 18) or observation (n = 21) PRCT Respiratory distress 1 pt with chest tube was intubated for stridor. 3 observed pts had resp distress with pneumothorax progression Only 39 of 86 eligible pts recruited Holmes et al<\/em>2000 , USA 11 children <16yrs with occult pneumothorax presenting to level 1 trauma centre. 1 had chest tube, 10 observed Prospective observational cohort study Complications No haemodynamic or respiratory complications Small numbers paediatric population
\nJ Trauma. 1993 Nov;35(5):726-9; discussion 729-30.Links Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville. Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.<\/p>\n

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Prospective multicenter of occult pneumo (J Trauma 2011;70:1019)<\/p>\n

Only 14% failed obs approach on mech vent<\/p>\n

no patient developed tension or decompensation<\/p>\n

<\/span>True Pathophysiology of Tension<\/span><\/h3>\n

Emerg Med J 2005;22:8\u201316.<\/p>\n

 <\/p>\n

<\/span>Hemothorax<\/span><\/h2>\n

Can Respir J.<\/a> 2008 Jul-Aug;15(5):255-8.Links<\/a><\/p>\n

Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury.<\/p>\n

Karmy-Jones R, Holevar M, Sullivan RJ, Fleisig A, Jurkovich GJ.<\/p>\n

Department of Surgery, Harborview Medical Center, Seattle, Washington 98664, USA. rkarmyjo@swmedicalcenter.com<\/p>\n

BACKGROUND: Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies. OBJECTIVE: To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema. METHODS: A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score. RESULTS: A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4+\/-26) versus those who did not (22.6+\/-13; P=0.03). CONCLUSIONS: The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach.<\/p><\/blockquote>\n

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Small hemothoraces can probably be left undrained (< 1.5 cm), if there is a coincident pneumo, then probably put it in (Am J of Surgery 2006;192:722)<\/p>\n

Risk of post-traumatic empyema in pt’s with retained hemothorax (J Trauma 2012;73:752) 26.8% rate of empyema. Go after the blood.<\/p>\n

but newer study disagrees<\/p>\n

Journal of Trauma and Acute Care Surgery
\nIssue: Volume 84(3), March 2018, p 454\u2013458<\/p>\n

<\/span>Cardiovascular Trauma<\/span><\/h2>\n

<\/span>Myocardial Concussion<\/span><\/h3>\n

Brief dysrhythmia, hypotension or LOC c no lasting effects, no autopsy evidence<\/p>\n

<\/span>Myocardial Contusion<\/span><\/h3>\n

Most commonly from mva<\/p>\n

Autopsy evidence<\/p>\n

Can cause vasospasm or thromboembolism<\/p>\n

Pericardial effusion +- friction rub, S3 gallop, rales, elevated CVP<\/p>\n

2 mechanisms of injury:\u00a0 transient reduction in bloodflow and transient dysrhythmias<\/p>\n

70% of pts have tachycardia<\/p>\n

EKG is the screening exam, if negative, do not have to admit<\/p>\n

Common ekg abnormalities are PVCs, 1st degree av block, RBBB (Right ventricle is closest to anterior chest wall)<\/p>\n

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It is possible to have problems 12-72 hours after injury<\/p>\n

If available, gated radionucleotide angiography is excellent test<\/p>\n

Thalium also good<\/p>\n

Monitor for 12 hours then can send home, b\/c no life threatening problems seen after this time<\/p>\n

If decreased cardiac output, can use dobutamine or IABP<\/p>\n

Send 1 Troponin and get EKG:\u00a0 both normal, young patient, send home (Journal of Trauma 50:237 2001) 100% sensitivity<\/p>\n

Another study used 0 and 8 hour trops (J Trauma <\/em>2003;54:45-51.)<\/p>\n

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Abnormal Admit to Tele Bed<\/p>\n

If the patient is unstable, get an echo<\/p>\n

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troponin specific but insensitive for myo injury in trauma (Anesthesiology 2004;101:1262)<\/p>\n

 <\/p>\n

Excellent Blunt Cardiac Injury Review (Crit Care Clin 2004;20:57)<\/p>\n

\"\"<\/a>\"\"<\/a><\/p>\n

<\/span>New Guidelines from EAST<\/span><\/h3>\n
Summary from the Amazing Trauma Professionals Blog – Practice Guideline – Blunt Cardiac Injury (BCI)<\/div>\n
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The Eastern Association for the Surgery of Trauma recently released an update of their practice guideline for screening for blunt cardiac injury. Although the bulk of the guideline remains the same, a few areas have been updated to reflect advances since its original 1998 release.<\/p>\n

Here is a quick summary of the new guidelines. Level 1 (best data):<\/p>\n