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Injury to the chest and its contents occurs in nearly a quarter of all trauma patients.1 Thoracic trauma constitutes a diverse spectrum of disease that can be rapidly progressive and that can have both immediate life-threatening consequences and the potential for long-term sequelae. This chapter addresses management of specific injuries to the thoracic contents and chest wall, many of which require intervention immediately or within the first few hours of hospitalization.


Due to the size of the chest, it is susceptible to injuries from both blunt and penetrating mechanisms. While lethal injuries can occur anywhere within the chest, the most concerning site of injury is classically described as “the box.” The box is an area circumscribed by vertical lines drawn down from the mid-clavicle at the level of the sternal notch to the costal margin and then across. This external landmark overlies the cardiac silhouette and the great vessels of the thorax including the pulmonary hila bilaterally. However, this anatomic view oversimplifies the problem. The box must be considered as a three-dimensional structure wherein injuries to the posterior and lateral thorax can jeopardize vital structures.

It is important to emphasize that injuries outside the box also can be life threatening, both acutely and in a more chronic setting. Most specifically, tension pneumothorax can present acutely after injury well outside the box. It must not be ignored that injuries to the bony skeleton of the chest may be acutely life threatening but also may lead to long-term sequelae that compromises quality of life.

Initial Evaluation

The initial workup of all trauma patients proceeds in an organized algorithmic fashion in order to maximize early identification of life-threatening injuries and prioritize their management while minimizing missed injuries of less morbid consequence. At the time of presentation, injuries to the thorax often cause a significant amount of stress to the prehospital provider and emergency department staff. It is incumbent that providers do not develop tunnel vision and lose sight of the basic strategies of trauma management. In patients presenting with cardiovascular compromise, early definitive management of the airway should be undertaken regardless of suspected injuries. In the acute setting, with minimal history, airway management should occur with standard rapid sequence intubation practices.

Once the airway has been secured, prompt evaluation of breath sounds may simultaneously confirm proper placement of the endotracheal tube, as well as indicate life-threatening causes of cardiovascular collapse. Chest x-ray (CXR) may be ordered at this time but not performed until breath sounds have been evaluated, intravenous access secured, and resuscitation initiated. Interventions on the airway, breathing, and circulation should preclude all imaging.

Pleural Complications

Two imminently life-threatening pleural complications that require immediate intervention are tension pneumothorax and massive hemothorax. Non-life-threatening pneumothoraces and hemothoraces also are commonly encountered in the ...

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