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Blunt thoracic injuries account for up to one fourth of all injury deaths.1 This chapter focuses on the recognition, evaluation, and management of pulmonary, esophageal, and chest wall injuries resulting from thoracic trauma.


In most cases of thoracic trauma, the mechanism of injury predicts the clinical course and outcome. Simple lacerations or punctures that do not violate the pleura can usually be managed with conservative measures, such as simple wound management or observation. Penetrating injuries that violate the pleura typically result in pneumothorax, with accompanying hemothorax in 75% of such cases. A trajectory of injury that appears to traverse the diaphragm should raise concerns for an intra-abdominal injury and may indicate need for laparotomy or laparoscopy.


Blunt trauma produces damage by direct trauma, compression, and forces of acceleration or deceleration. The severity of the tissue damage predicts clinical course and outcome.2 Patients with significant blunt injury may require intubation and mechanical ventilation, and procedures such as thoracostomy to drain a hemopneumothorax. These patients are at risk for secondary sequelae such as pneumonia, persistent air leak, or iatrogenic complications. In general, victims of penetrating injuries who survive to reach the hospital often have better outcomes than those who have sustained blunt injuries.


Initial resuscitation and airway management should be performed according to established principles (see Chapter 250, Trauma in Adults). If the patient is making little or no respiratory efforts, central nervous system dysfunction due to head trauma, intoxication, or spinal cord injury should be considered. In patients with respiratory efforts but with little or no air movement, upper airway obstruction should be suspected.


Absent or abnormal breath sounds may indicate flail chest, hemopneumothorax, diaphragmatic injury, or parenchymal lung damage. Although each of these has specific therapies, respiratory distress that is not immediately relieved by specific intervention should prompt the provider to secure the airway by tracheal intubation or surgical airway and mechanically ventilate the patient with 100% oxygen.


Although emergent rapid sequence intubation of trauma patients is safe, cardiac decompensation and arrest may occur after endotracheal intubation for reasons related to the initial injury or the procedure (Table 258-1). If the patient has poor venous return due to hypovolemia, hyperventilation may increase intrathoracic pressure and further decrease venous return to the heart. In the hypovolemic patient, the resultant reduction in cardiac output can lead to cardiac arrest.3 In the presence of pulmonary injury or preexisting bullous disease, vigorous positive pressure ventilation can lead to tension pneumothorax, further reducing venous return.

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Table 258-1 Potential Causes of Cardiac Arrest after Endotracheal Intubation 

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