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Blunt trauma

Last updated: November 6, 2023

Summarytoggle arrow icon

Blunt trauma is any nonpenetrating injury caused by the impact of a blunt object against the body, resulting in damage to underlying structures. Common causes include motor vehicle collisions and falls from height. Clinical features and diagnostic studies vary based on the type and location of blunt trauma. Assessment of patients with blunt trauma follows the systematic evaluation outlined in the advanced trauma life support (ATLS) algorithm: primary survey, transfer to a trauma center (if indicated), secondary survey, and tertiary survey. Management involves treating immediately life-threatening injuries and surgical repair of traumatic injuries.

See also “Management of trauma patients” and “Penetrating trauma.”

Overviewtoggle arrow icon

Management of blunt trauma is based on the type and location of the injury. Recommendations in this article are consistent with the 2018 guidelines on ATLS. [1]

Types of blunt trauma [1][2]

Blunt trauma injuries by mechanism [1][2]

The most common causes of blunt trauma injuries include motor vehicle collisions, vehicle-pedestrian collisions, falls from height, and bicycling injuries. [3]

Blunt trauma injuries by mechanism [1][2]
Mechanism Typical injuries
Motor vehicle collisions (MVC)

Frontal impact

Rear impact
Side impact
Rollover
  • Complex injury patterns
Ejection from vehicle
  • Complex injury patterns
MVC-related trauma mechanisms Windshield-related trauma
Seatbelt-related trauma
Airbag-related trauma
Motor vehicle–pedestrian collision Low-speed collision
High-speed collision
Motorcycle collisions [4]
Bicycle collisions [5]
Falls from a height [6] Vertical impact
Horizontal impact
Ground-level falls
Battery

Blunt trauma injuries by location [1]

Blunt trauma by body region [1]

Location
Potential injuries Management
Head

Neck

Chest

Abdomen and pelvis

Extremities

Blunt chest traumatoggle arrow icon

Approach to blunt chest trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

Clinical features [1]

Esophageal injuries may be missed initially; suspect esophageal rupture in a patient with left-sided pneumothorax without apparent rib fracture. [1]

Diagnostics [1][7][8]

Clinical decision tools can help identify patients who do not require imaging. See “Urgent diagnostics for trauma patients” for a comprehensive approach to trauma imaging.

NEXUS chest decision instrument for blunt chest trauma [9][10]

The NEXUS chest decision instrument for blunt chest trauma is a clinical decision tool to identify patients with a very low risk of thoracic injury who do not require thoracic imaging (e.g., CXR, chest CT).

NEXUS chest decision instrument for blunt chest trauma [9][10]
Criteria Points
Age > 60 years 1
Rapid deceleration mechanism, e.g., fall from > 20 ft/6 m or MVC > 40 mph (64 km/h) 1
Chest pain 1
Intoxication 1
Altered mental status 1
Distracting injury 1
Chest wall tenderness 1
  • Total score 0: Thoracic imaging (e.g., CXR, CT) is not required.
  • Total score ≥ 1: Thoracic imaging (e.g., CXR, CT) may be required.

NEXUS chest CT-all decision instrument for blunt chest trauma [11]

The NEXUS chest CT-all decision instrument for blunt chest trauma is a clinical decision tool to identify patients at very low risk of thoracic injuries who do not require a chest CT.

NEXUS chest CT-all decision instrument for blunt chest trauma [11]
Criteria Points

Abnormal CXR

1

Distracting injury

1

Chest wall, sternum, thoracic spine, or scapular tenderness 1
Rapid deceleration mechanism, e.g., fall from > 20 ft/6 m or MVC > 40 mph (64 km/h) 1
  • Total score 0: Chest CT is not required.
  • Total score ≥ 1: Chest CT may be required.

Management [1][2]

Bedside interventions

The following bedside interventions may be performed during the primary survey:

Further management

Further management depends on the type and extent of associated injuries.

Chest wall injurytoggle arrow icon

Rib fracture [1][12]

Etiology

Clinical features

Diagnostics [2][8][13]

Treatment [2][15]

Disposition [15][16]

Complications

Other chest wall injuries

Cardiovascular injurytoggle arrow icon

Blunt cardiac injury (BCI) [1][17][18]

Cardiac injuries from blunt trauma most commonly occur after high-speed MVC and range from minor asymptomatic injury to myocardial rupture and death. [2]

Possible injuries

Clinical features

Consider BCI if tachycardia persists despite fluid resuscitation and hemorrhage has been ruled out.

Diagnostics [17][18]

See “Approach to blunt chest trauma” for initial measures.

Management

Commotio cordis [20][21]

  • Definition: ventricular fibrillation and sudden cardiac death caused by a relatively mild nonpenetrating blunt force trauma to the precordial area
  • Etiology: blow to the precordial area at a perpendicular angle, most commonly by a hard, spherical object (e.g., baseball, golf ball), during a brief electrically vulnerable period of T-wave upstroke
  • Pathophysiology: blunt trauma leads to myocardial stretch → activation of ion channels because of mechano-electric coupling → augmentation of repolarization and premature ventricular depolarizationventricular fibrillation [22]
  • Diagnosis is clinical and based on the following criteria:
  • Management
  • Prevention
    • Avoidance of sports that involve chest wall impact (e.g., baseball, hockey, football)
    • Use of chest protectors and/or safety balls may reduce risk.
    • Treat any underlying cardiac disease.
    • No underlying cardiac disease: no ICD necessary

Blunt thoracic aortic injury [23][24][25]

Pulmonary injurytoggle arrow icon

Pulmonary contusion [1][2][26]

Tracheobronchial injury [1][2]

Suspect tension pneumothorax in patients with tracheobronchial injury and midline shift or distended neck veins.

Blunt abdominopelvic traumatoggle arrow icon

Approach to blunt abdominal trauma [1][2]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

If there are obvious indications for immediate exploratory laparotomy (e.g., hypotension and peritoneal signs), do not delay transfer to the OR for diagnostic studies. [1][2]

Clinical features [1]

General features

The absence of abdominal pain or tenderness does not exclude intraabdominal injuries. [2]

Specific injuries

Suspect herniation of abdominal organs into the chest if there are bowel sounds in the thorax after abdominal or thoracic trauma.

Diagnostics [1][8][28]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Pancreatic, diaphragmatic, small bowel, and mesenteric injuries may be missed on initial CT imaging. [2]

Management [2]

Nonoperative management [29][30][31]

Nonoperative management should take place in a center with facilities for urgent laparotomy.

Operative and interventional management [32]

Hemodynamically unstable patients typically require surgical or interventional management, which may include:

Injury-specific management

Management depends on the type and extent of injuries and is determined in consultation with specialists (e.g., trauma surgery, interventional radiology).

Blunt neck traumatoggle arrow icon

Approach to blunt neck trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

Associated injuries [2]

Clinical features [1]

Diagnostics [1]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Treatment [1][2]

Airway management [38]

Cricothyroidotomy may be impossible if anatomical landmarks are invisible or deformed, e.g., due to a laryngeal fracture. Emergency tracheostomy may be required if intubation has failed. [1]

Surgical management

Consult surgical subspecialties based on clinical and diagnostic findings.

Cerebrovascular injurytoggle arrow icon

Blunt cerebrovascular injury (BCVI) involves the carotid and/or vertebral artery and can cause a stroke as a result of thrombi formation, wall hematomas, and/or vascular occlusion.

Expanded Denver screening criteria [39][40][41]

The expanded Denver screening criteria is a tool used to identify patients at risk for BCVI and the need for advanced imaging. A positive screen is any clinical or diagnostic feature of BCVI or the combination of a high-speed mechanism and any risk factor for BCVI.

Diagnostics [39]

Treatment [39]

Treatment varies based on injury severity and anatomical location and may include:

Blunt extremity traumatoggle arrow icon

Approach to blunt extremity trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

Clinical features

Clinical features depend on the type and extent of associated injuries, and on any complications (e.g., compartment syndrome).

Diagnostics [1][8]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Management

Referencestoggle arrow icon

  1. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  2. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  3. Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 2nd edition. https://www.acep.org/globalassets/new-pdfs/sexual-assault-e-book.pdf. Updated: January 1, 2013. Accessed: November 3, 2021.
  4. Mayglothling J, Duane TM, Gibbs M, et al. Emergency tracheal intubation immediately following traumatic injury. J Trauma Acute Care Surg. 2012; 73 (5): p.S333-S340.doi: 10.1097/ta.0b013e31827018a5 . | Open in Read by QxMD
  5. Chung JH, Cox CW, Mohammed TLH, et al. ACR Appropriateness Criteria Blunt Chest Trauma. J Am Coll Radiol. 2014; 11 (4): p.345-351.doi: 10.1016/j.jacr.2013.12.019 . | Open in Read by QxMD
  6. Shyu JY, Khurana B, Soto JA, et al. ACR Appropriateness Criteria® Major Blunt Trauma. J Am Coll Radiol. 2020; 17 (5): p.S160-S174.doi: 10.1016/j.jacr.2020.01.024 . | Open in Read by QxMD
  7. Rodriguez RM, Hendey GW, Mower W, et al. Derivation of a Decision Instrument for Selective Chest Radiography in Blunt Trauma. J Trauma. 2011; 71 (3): p.549-553.doi: 10.1097/ta.0b013e3181f2ac9d . | Open in Read by QxMD
  8. Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS Chest. JAMA Surg. 2013; 148 (10): p.940.doi: 10.1001/jamasurg.2013.2757 . | Open in Read by QxMD
  9. Rodriguez RM, Langdorf MI, Nishijima D, et al. Derivation and Validation of Two Decision Instruments for Selective Chest CT in Blunt Trauma: A Multicenter Prospective Observational Study (NEXUS Chest CT). PLoS Med. 2015; 12 (10): p.e1001883.doi: 10.1371/journal.pmed.1001883 . | Open in Read by QxMD
  10. ACS TQP Best Practices Guidelines in Imaging. https://www.facs.org/media/oxdjw5zj/imaging_guidelines.pdf. Updated: October 1, 2018. Accessed: October 24, 2023.
  11. Cimbanassi S, Chiara O, Leppaniemi A, et al. Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: Results from an International Consensus Conference. J Trauma Acute Care Surg. 2018; 84 (3): p.517-531.doi: 10.1097/ta.0000000000001774 . | Open in Read by QxMD
  12. Stassen NA, Bhullar I, Cheng JD, et al. Selective nonoperative management of blunt splenic injury. J Trauma Acute Care Surg. 2012; 73 (5): p.S294-S300.doi: 10.1097/ta.0b013e3182702afc . | Open in Read by QxMD
  13. Stassen NA, Bhullar I, Cheng JD, et al. Nonoperative management of blunt hepatic injury. J Trauma Acute Care Surg. 2012; 73 (5): p.S288-S293.doi: 10.1097/ta.0b013e318270160d . | Open in Read by QxMD
  14. Johnsen NV, Betzold RD, Guillamondegui OD, et al. Surgical Management of Solid Organ Injuries. Surg Clin North Am. 2017; 97 (5): p.1077-1105.doi: 10.1016/j.suc.2017.06.013 . | Open in Read by QxMD
  15. Biffl WL, Moore EE, Croce M, et al. Western Trauma Association Critical Decisions in Trauma: Management of pancreatic injuries. J Trauma Acute Care Surg. 2013; 75 (6): p.941-946.doi: 10.1097/ta.0b013e3182a96572 . | Open in Read by QxMD
  16. Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPB (Oxford). 2018; 20 (12): p.1099-1108.doi: 10.1016/j.hpb.2018.05.009 . | Open in Read by QxMD
  17. Tran TLN, Brasel KJ, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability — 2016 updates. J Trauma Acute Care Surg. 2016; 81 (6): p.1171-1174.doi: 10.1097/ta.0000000000001230 . | Open in Read by QxMD
  18. Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients – Challenges and current updates. J Clin Orthop Trauma. 2021; 12 (1): p.101-112.doi: 10.1016/j.jcot.2020.09.035 . | Open in Read by QxMD
  19. Moore EE, V. Feliciano D, Mattox KL. Trauma, Eighth Edition. McGraw Hill Professional ; 2017
  20. Lin MR, Kraus JF. A review of risk factors and patterns of motorcycle injuries. Accid Anal Prev. 2009; 41 (4): p.710-722.doi: 10.1016/j.aap.2009.03.010 . | Open in Read by QxMD
  21. Thompson MJ, Rivara FP. Bicycle-related injuries.. Am Fam Physician. 2001; 63 (10): p.2007-14.
  22. Moreland B, Kakara R, Henry A. Trends in Nonfatal Falls and Fall-Related Injuries Among Adults Aged ≥65 Years — United States, 2012–2018. MMWR Morb Mortal Wkly Rep. 2020; 69 (27): p.875-881.doi: 10.15585/mmwr.mm6927a5 . | Open in Read by QxMD
  23. Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury. J Trauma Acute Care Surg. 2012; 73 (5): p.S301-S306.doi: 10.1097/ta.0b013e318270193a . | Open in Read by QxMD
  24. Kyriazidis IP, Jakob DA, Vargas JAH, et al. Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis. World J Emerg Surg. 2023; 18 (1).doi: 10.1186/s13017-023-00504-9 . | Open in Read by QxMD
  25. Stojanovska J, Hurwitz Koweek LM, Chung JH, et al. ACR Appropriateness Criteria® Blunt Chest Trauma-Suspected Cardiac Injury. J Am Coll Radiol. 2020; 17 (11): p.S380-S390.doi: 10.1016/j.jacr.2020.09.012 . | Open in Read by QxMD
  26. Link MS, Mark Estes NA, Maron BJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 13: Commotio Cordis. Circulation. 2015; 132 (22).doi: 10.1161/cir.0000000000000249 . | Open in Read by QxMD
  27. Peng T, Derry LT, Yogeswaran V, Goldschlager NF. Commotio Cordis in 2023. Sports Med. 2023; 53 (8): p.1527-1536.doi: 10.1007/s40279-023-01873-6 . | Open in Read by QxMD
  28. Spitaler P, Stühlinger M, Adukauskaite A, Bauer A, Dichtl W. A Soccer Shot with Lengthy Consequences-Case Report & Current Literature Review of Commotio Cordis. J Clin Med. 2023; 12 (6).doi: 10.3390/jcm12062323 . | Open in Read by QxMD
  29. Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury. J Trauma Acute Care Surg. 2015; 78 (1): p.136-146.doi: 10.1097/ta.0000000000000470 . | Open in Read by QxMD
  30. Mouawad NJ, Paulisin J, Hofmeister S, et al. Blunt thoracic aortic injury – concepts and management. J Cardiothorac Surg. 2020; 15 (1).doi: 10.1186/s13019-020-01101-6 . | Open in Read by QxMD
  31. Akhmerov A, DuBose J, Azizzadeh A. Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges. Ann Vasc Dis. 2019; 12 (1): p.1-5.doi: 10.3400/avd.ra.18-00139 . | Open in Read by QxMD
  32. Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest. J Trauma Acute Care Surg. 2012; 73 (5): p.S351-S361.doi: 10.1097/ta.0b013e31827019fd . | Open in Read by QxMD
  33. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  34. Kim M, Moore JE. Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Curr Anesthesiol Rep. 2020; 10 (1): p.61-68.doi: 10.1007/s40140-020-00374-w . | Open in Read by QxMD
  35. Henry TS, Donnelly EF, Boiselle PM, et al. ACR Appropriateness Criteria® Rib Fractures. J Am Coll Radiol. 2019; 16 (5): p.S227-S234.doi: 10.1016/j.jacr.2019.02.019 . | Open in Read by QxMD
  36. Shuaib W, Vijayasarathi A, Tiwana MH, Johnson JO, Maddu KK, Khosa F. The diagnostic utility of rib series in assessing rib fractures. Emerg Radiol. 2013; 21 (2): p.159-164.doi: 10.1007/s10140-013-1177-x . | Open in Read by QxMD
  37. Mukherjee K, Schubl SD, Tominaga G, et al. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society. J Trauma Acute Care Surg. 2022; 94 (3): p.398-407.doi: 10.1097/ta.0000000000003830 . | Open in Read by QxMD
  38. Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. J Trauma Acute Care Surg. 2017; 82 (1): p.200-203.doi: 10.1097/ta.0000000000001301 . | Open in Read by QxMD
  39. Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020; 88 (6): p.875-887.doi: 10.1097/ta.0000000000002668 . | Open in Read by QxMD
  40. Brommeland T, Helseth E, Aarhus M, et al. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med. 2018; 26 (1): p.90.doi: 10.1186/s13049-018-0559-1 . | Open in Read by QxMD
  41. Franz RW, Willette PA, Wood MJ, Wright ML, Hartman JF. A Systematic Review and Meta-Analysis of Diagnostic Screening Criteria for Blunt Cerebrovascular Injuries. J Am Coll Surg. 2012; 214 (3): p.313-327.doi: 10.1016/j.jamcollsurg.2011.11.012 . | Open in Read by QxMD
  42. Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma. J Trauma. 2012; 73 (5): p.S315-S320.doi: 10.1097/ta.0b013e31827018e4 . | Open in Read by QxMD

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