Chapter 106: Thoracic Trauma

Emergent Interventions

Thoracic injuries are common, with up to one of five trauma patients presenting with injuries involving the chest. Thoracic injury and the ensuing complications are responsible for as much as 25% of the blunt trauma mortality.¹ Motor vehicle accidents (MVA) are the most common cause of blunt thoracic injuries, followed by falls, with injury resulting from the transmission of energy to the chest wall and underlying structures. The size and location of the chest make it vulnerable to penetrating mechanisms, such as gunshot and stab wounds. Early identification and intervention can lead to significant impact on mortality in the trauma population.

Many injuries to the thorax require immediate intervention during the primary survey to support cardiopulmonary function. Establishment of a secure airway and ventilatory assistance should occur immediately in patients with respiratory compromise. Evidence of reduced respiratory compliance measured on mechanical ventilation (i.e., elevated peak and plateau airway pressures) and decreased breath sounds may indicate a tension pneumothorax, which requires urgent intervention. External bleeding should be controlled with direct pressure while resuscitation with crystalloid solution and blood products is initiated. Hemodynamic instability may signal injuries that need to be addressed during the primary surgery such as tension pneumothorax requiring decompression, hypovolemia requiring hemorrhage control and resuscitation, or cardiac dysfunction secondary to pericardial tamponade. Evaluation for sources of bleeding should commence after addressing airway and breathing issues. This should include a chest X-ray as well as a bedside ultrasound looking for the presence of a pericardial effusion, especially in the setting of penetrating trauma. Based on these initial interventions, decisions regarding subsequent management such as immediate operation can be determined. In the event of cardiac arrest, especially in the setting of penetrating mechanisms, a resuscitative thoracotomy can be considered but carries with it an extremely high mortality. The chance of a salvageable patient is even less in blunt trauma and resuscitative thoracotomy should be reserved for circumstances where there is a witnessed cardiac arrest.

Evaluation

Most thoracic injuries can be identified with a physical examination and plain chest radiography. Physical examination will reveal superficial injuries, including chest wall defects and penetrating wounds. Deviation of the trachea at the sternal notch may reveal intrathoracic tension on the side opposite the trachea. Distended neck veins indicate heart failure or impaired venous return, which requires further evaluation. Chest radiography is performed on all significantly injured patients at risk for thoracic injuries. This study can be obtained rapidly in the trauma bay, with the results quickly revealed. The chest radiograph identifies the presence of a pneumothorax or hemothorax, as well as rib and sternal fractures. The appearance of a widened mediastinum may suggest a thoracic aortic injury (Fig. 106-1). An ultrasound of the pericardium, which may reveal pericardial blood, is a component of the focused abdominal sonography for trauma (FAST) examination. In recent years, thoracic CT angiography has emerged as a ...