The Follow-Up of Patients with Thoracic Injuries

  • Stefania Ianniello
  • Maria Gabriella Merola
  • Matteo Pignatelli
  • Riccardo Ferrari
  • Margherita Trinci
  • Vittorio Miele


Blunt thoracic trauma commonly causes lung contusions, pneumothorax, and pleural effusions, requiring an intensive treatment, often including mechanical ventilation.

Repeated lung diagnostic evaluations are needed in patients affected by blunt thoracic trauma, in order to follow up the clinical situation and monitoring the results of the therapeutic strategies.

Bedside radiography, clinical evaluation and serial measurements of respiratory variables are considered helpful but not sufficient; a daily chest X-ray is not more recommended, but only based on clinical indications or changing in clinical condition.

Nowadays, lung ultrasound is increasingly being incorporated in many stages, including follow-up, of trauma care, with accurate definition of indications.

computed tomography is actually considered the gold standard technique.


Trauma Trauma imaging Thoracic trauma Lung contusion Hemothorax Pneumothorax Bronchopleural fistula ARDS  Follow-up CT US 


  1. 1.
    Miele V, Di Giampietro I (2014) Diagnostic imaging in emergency. Salute e Società (2EN):127–138. doi: 10.3280/SES2014-002010EN.
  2. 2.
    Miele V, Di Giampietro I, Ianniello S, et al. Diagnostic imaging in pediatric polytrauma management. Radiol Med. 2015;120:33–49. doi: 10.1007/s11547-014-0469-x.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Ianniello S, Di Giacomo V, Cuneo G, et al. Pediatric thoracic trauma. In: Miele V, Trinci M, editors. Imaging trauma and polytrauma in pediatric patients. Cham: Springer International Publishing; 2015. p. 43–64.Google Scholar
  4. 4.
    Ianniello S, Merola MG, Trinci M, et al. Priorità diagnostiche nel management del trauma maggiore: ruolo dell’E-FAST e della TCMD. Il Giornale Italiano di. Radiol Med. 2015;2:715–20. doi: 10.17376/girm_2-4-07082015-19.CrossRefGoogle Scholar
  5. 5.
    Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with Sonography for trauma (EFAST). J Trauma. 2004;57:288–95.CrossRefGoogle Scholar
  6. 6.
    Ianniello S, Di Giacomo V, Sessa B, et al. First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography. Radiol Med. 2014;119:674–80. doi: 10.1007/s11547-014-0384-1.CrossRefPubMedGoogle Scholar
  7. 7.
    Volpicelli G, Elbarbabary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577–91.CrossRefGoogle Scholar
  8. 8.
    Croce MA, Fabian TC, Davis KA, et al. Early and late acute respiratory distress syndrome: two distinct clinical entities. J Trauma. 1999;46:361–8.CrossRefGoogle Scholar
  9. 9.
    Antonelli M, Moro ML, Cappelli O, et al. Risk factors for early onset of pneumonia in trauma patients. Chest. 1994;105:224–8.CrossRefGoogle Scholar
  10. 10.
    Hoff SJ, Shotts DS, Eddy VA, et al. Outcome of isolated pulmonary contusion in blunt trauma patients. Am Surg. 1994;60:138–42.PubMedGoogle Scholar
  11. 11.
    Daurat A, Millet I, Roustan JP, et al. Thoracic trauma severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion. Injury. 2015;47:147–53.CrossRefGoogle Scholar
  12. 12.
    Strumwasser A, Chu E, Yeung L, et al. A novel CT Volume Index Score correlates with outcomes in polytrauma patients with pulmonary contusion. J Surg Res. 2011;170:280–5.CrossRefGoogle Scholar
  13. 13.
    Ianniello S, Piccolo CL, Buquicchio GL, et al. First line diagnosis of paediatric pneumonia in emergency: lung ultrasound (LUS) in addiction to chest-X-ray (CXR) and its role in follow-up. Br J Radiol. 2016;89:20150998. doi: 10.1259/bjr.20150998.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Miele V, Buquicchio GL, Piccolo CL, et al. Lung injuries. In: Scaglione M, Linsenmaier U, Scheller G, Berger F, Wirth S, editors. Emergency radiology of the chest and cardiovascular system. Heidelberg: Springer; 2017. p. 3–12.Google Scholar
  15. 15.
    ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307:2526–33. doi: 10.1001/jama.2012.5669.CrossRefGoogle Scholar
  16. 16.
    Wyncoll DL, Evans TW. Acute respiratory distress syndrome. Lancet. 1999;354:497–50.CrossRefGoogle Scholar
  17. 17.
    Weinberger SE, Drazen JM. Disturbances of respiratory function. In: Braunwald E, Fauci AS, Kaspar DL, Hauser SL, Longo DL, editors. Harrison’s principles of internal medicine. 15th ed. New York: McGraw-Hill; 2001. p. 1454.Google Scholar
  18. 18.
    Lichtenstein D. Lung ultrasound in the intensive care unit. Recent Res Dev Resp Crit Care Med. 2001;1:83–93.Google Scholar
  19. 19.
    Meade M, Guyatt G, Cook D, et al. Predicting success in weaning from mechanical ventilation. Chest. 2001;120:400S–24S.CrossRefGoogle Scholar
  20. 20.
    Covelli HD, Nessan VJ, Tuttle WK 3rd, et al. Oxygen derived in acute respiratory, failure. Crit Care Med. 1983;11:646–9.CrossRefGoogle Scholar
  21. 21.
    Nieszkowska A, Lu Q, Vieira S, et al. Incidence and regional distribution of lung overinflation during mechanical ventilation with positive end-expiratory pressure. Crit Care Med. 2004;32:1496–503.CrossRefGoogle Scholar
  22. 22.
    Scialpi M, Cappabianca S, Rotondo A, et al. Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management. Radiol Med. 2010;115:539–50. doi: 10.1007/s11547-010-0467-6.CrossRefPubMedGoogle Scholar
  23. 23.
    Gattinoni L, Presenti A, Torresin A, et al. Adult respiratory distress syndrome profiles by computed tomography. J Thorac Imaging. 1986;1:25–30.CrossRefGoogle Scholar
  24. 24.
    Desai SR, Wells AU, Rubens MB, et al. Acute respiratory distress syndrome: computed tomography abnormalities at long-term follow-up. Radiology. 1999;210:29–35.CrossRefGoogle Scholar
  25. 25.
    MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British thoracic society pleural disease guide-line. Thorax. 2010;65:ii18–31. doi: 10.1136/thx.2010.136986.CrossRefPubMedGoogle Scholar
  26. 26.
    Lomoschitz FM, Eisenhuber E, Linnau KF, et al. Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms. Eur J Radiol. 2003;48:61–70.CrossRefGoogle Scholar
  27. 27.
    Weissberg D, Refaely Y. Pneumothorax: experience with 1,199 patients. Chest. 2000;117:1279–85.CrossRefGoogle Scholar
  28. 28.
    Miele V, Buquicchio GL, Piccolo CL, et al. Injuries of the pleural spaces. In: Scaglione M, Linsenmaier U, Scheller G, Berger F, Wirth S, editors. Emergency radiology of the chest and cardiovascular system. Heidelberg: Springer; 2017. p. 13–23.Google Scholar
  29. 29.
    Chaturvedi A, Lee S, Klionsky N, et al. Demystifying the persistent pneumothorax: role of imaging. Insights Imaging. 2016;7:411–29.CrossRefGoogle Scholar
  30. 30.
    Rhea JT, van Sonnenberg E, McLoud TC. Basilar pneumothorax in the supine adult. Radiology. 1979;133:593–5.CrossRefGoogle Scholar
  31. 31.
    Tocino IM, Miller MH, Fairfax WR. Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR Am J Roentgenol. 1985;144:901–5.CrossRefGoogle Scholar
  32. 32.
    Collins JA, Samra GS. Failure of chest X-rays to diagnose pneumothoraces after blunt trauma. Anaesthesia. 1998;53:74–8.CrossRefGoogle Scholar
  33. 33.
    Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin N Am. 2006;44:213–24.CrossRefGoogle Scholar
  34. 34.
    Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12:844–9.CrossRefGoogle Scholar
  35. 35.
    Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133:204–11.CrossRefGoogle Scholar
  36. 36.
    Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33:1231–8.CrossRefGoogle Scholar
  37. 37.
    Toombs BD, Sandler CM, Lester RG. Computed tomography of chest trauma. Radiology. 1981;140:733–8.CrossRefGoogle Scholar
  38. 38.
    Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. 1997;43:405–11.CrossRefGoogle Scholar
  39. 39.
    Paspatis GA, Dumonceau JM, Barthet M, et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) position statement. Endoscopy. 2014;46:693–711.CrossRefGoogle Scholar
  40. 40.
    Gayer G, Rozenman J, Hoffmann C, et al. CT diagnosis of malpositioned chest tubes. Br J Radiol. 2000;73:786–90.CrossRefGoogle Scholar
  41. 41.
    Peters S, Wolter D, Schultz JH. Dangers and risks of thoracic drainage at the accident site. Unfallchirurg. 1996;99:953–7.CrossRefGoogle Scholar
  42. 42.
    Laws D, Neville E, Duffy J. Pleural Diseases Group, Standards of Care Committee, British Thoracic Society BTS guidelines for the insertion of a chest drain. Thorax. 2003;58:ii53–9.CrossRefGoogle Scholar
  43. 43.
    Tomlinson MA, Treasure T. Insertion of a chest drain: how to do it. Br J Hosp Med. 1997;58:248–52.PubMedGoogle Scholar
  44. 44.
    Harris A, O’Driscoll BR, Turkington PM. Survey of major complications of intercostal chest drain insertion in the UK. Postgrad Med J. 2010;86:68–72.CrossRefGoogle Scholar
  45. 45.
    Heim P, Maas R, Tesch C, et al. Pleural drainage in acute thoracic trauma. Comparison of the radiologic image and computer tomography. Aktuelle Radiol. 1998;8:163–8.PubMedGoogle Scholar
  46. 46.
    Stern EJ, Sun H, Haramati LB. Peripheral bronchopleural fistulas: CT imaging features. AJR Am J Roentgenol. 1996;167:117–20.CrossRefGoogle Scholar
  47. 47.
    Seo H, Kim TJ, Jin KN, et al. Multi-detector row computed tomography evaluation of bronchopleural fistula: correlation with clinical, bronchoscopic, and surgical findings. J Comput Assist Tomogr. 2010;34:13–8.CrossRefGoogle Scholar
  48. 48.
    Ricci ZJ, Haramati LB, Rosenbaum AT, et al. Role of computed tomography in guiding the management of peripheral bronchopleural fistula. J Thorac Imaging. 2002;17:214–8.CrossRefGoogle Scholar
  49. 49.
    Sarkar P, Chandak T, Shah R, et al. Diagnosis and management bronchopleural stula. Indian J Chest Dis Allied Sci. 2010;52:97–104.PubMedGoogle Scholar
  50. 50.
    Takanami I. Closure of a bronchopleural fistula using a fibrin-glue coated collagen patch. Interact Cardiovasc Thorac Surg. 2003;2(3):2387–8.CrossRefGoogle Scholar
  51. 51.
    Uchida S, Igaki H, Izumo T, et al. Effective treatment of empyema with bronchopleural fistula after esophagectomy by endobronchial embolization using endobronchial Watanabe Spigots. Int J Surg Case Rep. 2017;33:1–3.CrossRefGoogle Scholar
  52. 52.
    Giddings O, Kuhn J, Akulian J. Endobronchial valve placement for the treatment of bronchopleural fistula: a review of the current literature. Curr Opin Pulm Med. 2014;20:347–51.CrossRefGoogle Scholar
  53. 53.
    Díaz-Agero Álvarez PJ, Bellido-Reyes YA, Sánchez-Girón JG, et al. Novel bronchoscopic treatment for bronchopleural fistula using adipose-derived stromal cells. Cytotherapy. 2016;18:36–40.CrossRefGoogle Scholar
  54. 54.
    Villa MT, Chang DW. Muscle and omental flaps for chest wall reconstruction. Thorac Surg Clin. 2010;20:543–50.CrossRefGoogle Scholar
  55. 55.
    Sangster GP, Gonzalez-Beicos A, Carbo AI, et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol. 2007;14:297–310.CrossRefGoogle Scholar
  56. 56.
    Mirvis SE. Imaging of acute thoracic injury: the advent of MDCT screening. Semin Ultrasound CT MRI. 2005;26:305–31.CrossRefGoogle Scholar
  57. 57.
    Shanmuganathan K, Mirvis SE. Imaging diagnosis of nonaortic thoracic injury. Radiol Clin N Am. 1999;37:533–51.CrossRefGoogle Scholar
  58. 58.
    Mayberry JC. Imaging in thoracic trauma: the trauma surgeon’s perspective. J Thorac Imaging. 2000;15:76–86.CrossRefGoogle Scholar
  59. 59.
    Meyer DM. Hemothorax related to trauma. Thorac Surg Clin. 2007;17:47–55.CrossRefGoogle Scholar
  60. 60.
    Kaewlai R, Avery LL, Asrani AV, et al. Multidetector CT of blunt thoracic trauma. Radiographics. 2008;28:1555–70. doi: 10.1148/rg.286085510.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Broderick SR. Hemothorax etiology, diagnosis, and management. Thorac Surg Clin. 2013;23:89–96. doi: 10.1016/j.thorsurg.2012.10.003.CrossRefPubMedGoogle Scholar
  62. 62.
    Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. AJR Am J Roentgenol. 2009;192:599–612. doi: 10.2214/AJR.07.3324.CrossRefGoogle Scholar
  63. 63.
    Thoongsuwan N, Kanne JP, Stern EJ (2004) Imaging of blunt chest trauma. RSNA Syllabus 71–79.Google Scholar
  64. 64.
    Brooks A, Davies B, Sethhurst M, et al. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J. 2004;21:44–6.CrossRefGoogle Scholar
  65. 65.
    Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med. 1997;29:312–5.CrossRefGoogle Scholar
  66. 66.
    Villegas MI, Hennessey RA, Morales CH, et al. Risk factors associated with the development of post-traumatic retained hemothorax. Eur J Trauma Emerg Surg. 2011;37:583–9. doi: 10.1007/s00068-010-0064-3.CrossRefPubMedGoogle Scholar
  67. 67.
    DuBose J, Inaba K, Demetriades D, et al. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg. 2012;72:11–22.CrossRefGoogle Scholar
  68. 68.
    American College of Surgeons. Committee on trauma. ATLS: advanced trauma life support for doctors. 8th ed. Chicago: American College of Surgeons; 2008.Google Scholar
  69. 69.
    Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma. 2012;72:422–7.CrossRefGoogle Scholar
  70. 70.
    Gonzalez RP, Holevar MR. Role of prophylactic antibiotics for tube thoracostomy in chest trauma. Am Surg. 1998;64:617–20.PubMedGoogle Scholar
  71. 71.
    Wilson RF, Nichols RL. The EAST practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: a commentary. J Trauma. 2000;48:758–9.CrossRefGoogle Scholar
  72. 72.
    Luchette FA, Barrie PS, Oswanski MF, et al. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: the EAST practice management guidelines work group. J Trauma. 2000;48:753–7.CrossRefGoogle Scholar
  73. 73.
    Kimbrell BJ, Yamzon J, Petrone P, et al. Intrapleural thrombolysis for the management of undrained traumatic hemothorax: a prospective observational study. J Trauma. 2007;62:1175–8.CrossRefGoogle Scholar
  74. 74.
    Skeete DA, Rutherford EJ, Schlidt SA, et al. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma. 2004;57:1178–83.CrossRefGoogle Scholar
  75. 75.
    Ciraulo DL, Elliott D, Mitchell KA, et al. Flail chest as a marker for significant injuries. J Am Coll Surg. 1994;178:466–70.PubMedGoogle Scholar
  76. 76.
    Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20:71–81.CrossRefGoogle Scholar
  77. 77.
    Collins J. Chest wall trauma. J Thorac Imaging. 2000;15:112–9.CrossRefGoogle Scholar
  78. 78.
    Besson A, Segesser F. Blunt trauma of the chest wall. A colour atlas of chest trauma and associated injuries, vol. 1. Weert, Netherlands: Wolfe Medical Publications Ltd; 1982. p. 153–98.Google Scholar
  79. 79.
    Majercik S, Pieracci FM. Chest wall trauma. Thorac Surg Clin. 2017;27:113–21.CrossRefGoogle Scholar
  80. 80.
    Zink KA, Mayberry JC, Peck EG, et al. Lidocaine patches reduce pain in patients with rib fractures. Am Surg. 2011;77:438–42.PubMedPubMedCentralGoogle Scholar
  81. 81.
    Britt T, Sturm R, Ricardi R, et al. Comparative evaluation of continuous intercostal nerve block or epidural analgesia on the rate of respiratory complications, intensive care unit, and hospital stay following traumatic rib fractures: a retrospective review. Local Reg Anesth. 2015;8:79–84.PubMedPubMedCentralGoogle Scholar
  82. 82.
    Schweiger JW, Downs JB, Smith RA. Chest wall disruption with and without acute lung injury: effects of continuous positive airway pressure therapy on ventilation and perfusion relationships. Crit Care Med. 2003;31:2364–70.CrossRefGoogle Scholar
  83. 83.
    Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:s351–61. doi: 10.1097/TA.0b013e31827019fd.CrossRefPubMedGoogle Scholar
  84. 84.
    Fowler TT, Taylor BC, Bellino MJ, et al. Surgical treatment of flail chest and rib fractures. J Am Acad Orthop Surg. 2014;22:751–60. doi: 10.5435/JAAOS-22-12-751.CrossRefPubMedGoogle Scholar
  85. 85.
    Slobogean GP, MacPherson CA, Sun T, et al. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013;216:302–11.e1.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Stefania Ianniello
    • 1
  • Maria Gabriella Merola
    • 1
  • Matteo Pignatelli
    • 1
  • Riccardo Ferrari
    • 1
  • Margherita Trinci
    • 1
  • Vittorio Miele
    • 2
  1. 1.Department of Emergency RadiologyS. Camillo HospitalRomeItaly
  2. 2.Department of RadiologyCareggi University HospitalFlorenceItaly

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