Less than 10% of blunt chest injuries and only 15% to 30% of penetrating chest injuries require operative intervention. Most patients who sustain thoracic trauma can be treated by technical procedures within the capabilities of clinicians trained in ATLS.

Most life-threatening thoracic injuries can be treated with airway control or decompression of the chest with a needle, finger, or tube.

The physiologic consequences of thoracic trauma are hypoxia, hypercarbia, and acidosis.

Life-Threatening Thoracic Injuries (Primary Survey)

Airway Problems

• Airway obstruction secondary to swelling, bleeding, or aspiration. Results from multiple injury mechanisms (laryngeal injury, posterior clavicular head dislocation, penetrating injury, etc). Observe the patient for signs of air hunger and respiratory distress, inspect the oropharynx, listen for air movement and stridor, feel for crepitus, feel the SC joint. Treat this issue with suctioning, reduction of a posterior clavicular dislocation, intubation, etc.
• Tracheobronchial tree injury is rare but potentially fatal. These injuries generally occur within 1 inch of the carina. Most patients die in the field. These patients, if alive, present with hemoptysis, cervical subcutaneous emphysema, tension pneumothorax, and hypoxemia/cyanosis. Ongoing air leak after chest tube placement suggests a tracheobronchial injury. The injury is confirmed with bronchoscopy.
  • Intubation is often required but is technically difficult due to airway injury; consider advanced airway support such as fiber-optic intubation past the tear site or selective unilateral intubation.
  • Immediate surgical opinion is warranted for unstable patients
  • Operative treatment can be delayed for stable patients to give time for inflammation and edema to improve.

Breathing Problems

Expose the chest and neck to assess neck veins and breathing. Assess the chest wall expansion during breathing, listen for equal respirations, palpate for crepitus and defects, watch the respiratory rate and pattern.

• Tension pneumothorax causes obstructive shock. The most common cause is positive pressure ventilation in patients with a visceral pleural injury. When awake, patients often show severe air hunger and tachypnea; when ventilated, patients often present as hemodynamic collapse.
  • Requires immediate decompression: needle or finger thoracostomy followed by tube thoracostomy.
• Open pneumothorax is when a chest wall defect allows external air to enter; the respiratory pressures are equalized and ventilation becomes ineffective.
  • Initial management: close the defect with a sterile dressing and secure it on 3 sides to provide a flutter-valve effect to prevent entrainment of external air and allow air to escape from the pleural space
  • Subsequent management: place a chest tube remote from the wound, and then consider definitive surgical closure of the defect.
• Massive hemothorax By definition, it results from the rapid accumulation of more than 1500 mL of blood or more than 1/3 of the blood volume in the chest cavity. It is generally from a penetrating wound to the systemic or hilar vessels but can also result from blunt trauma.
  • Requires chest tube placement (28-32 Fr, 5th ICS, anterior to the mix-axillary line) and emergent surgical consultation for source control
  • The immediate return of 1500 mL or more of blood generally indicates the need for urgent thoracotomy. For patients with less immediate return, the decision for thoracotomy depends on the rate of continuing blood loss (>200 mL/hr for 2-4 hours) and the clinical status/transfusion requirement
  • Penetrating anterior chest wounds medial to the nipples, and posterior wounds medical to the scapula, have a higher risk of significant vascular damage requiring thoracostomy.
  • Restore the blood volume. Consider Massive Transfusion if required. Consider cell-saver device use for autotransfusion.

Circulatory Problems

Inspect the skin for mottling, cyanosis, and pallor. Assess the neck veins for distension although they can be low with hypovolemia. Assess the pulse, capillary refill, temperature, etc. In summary, perform a targeted shock clinical assessment.

• Massive hemothorax as above.
• Cardiac tamponade can result from both penetrating and blunt injury. Consider eFAST use to help rule this out (90-95% accurate for identifying pericardial fluid)
  • In the setting of chest trauma, pericardial fluid or tamponade should be an indication for emergency thoracotomy or sternotomy. Pericardiocentesis can be therapeutic but is not a definitive treatment.
• Traumatic circulatory arrest is defined as when patients are unconscious and have no pulse (including PEA, VF, asystole...).Primary differential: severe hypoxia, tension PTX, profound hypovolemia and hemorrhage, cardiac tamponade, cardiac herniation, severe myocardial contusion, and primary cardiac event).
  • Management
    • Start closed CPR with ABC management as per ACLS protocol. However, differs from medical cardiac arrest in that the priority are the interventions below. > - The European Resuscitation Council (ERC) updated their guidelines in 2015. They state that in cardiac arrest caused by hypovolaemia, cardiac tamponade or tension pneumothorax, c_hest compressions are unlikely to be effective._ Because of this fact, chest compressions take a lower priority than the immediate treatment of reversible causes (e.g. thoracotomy, controlling haemorrhage, etc.). > - https://emottawablog.com/2018/04/management-controversies-in-traumatic-cardiac-arrest/
    • Secure a definitive airway with intubation and proper oxygenation/ventilation.
    • Perform bilateral finger/tube thoracostomies (bilateral chest decompression) to alleviate potential tension pneumothoraces.
    • Address tamponade with pericardiocentesis or thoracotomy
    • Resuscitate using fluids/blood via central/large-bore IV/IO access (above the diaphragm).
    • Epinephrine 1 mg.
    • Shock any shockable rhythms.
    • Resuscitative thoracostomy may be required if there is no ROSC.