Abstract
This article summarizes major life-threatening injuries in thoracic trauma. It explores the immediate approach to a patient presenting with thoracic trauma including diagnostics and pertinent invasive procedures. This is followed by an overview of the clinical features, investigation and management of specific life-threatening injuries that can occur in blunt and penetrating trauma. Airway injuries, chest wall and lung parenchyma injuries, cardiac and aortic injuries and diaphragmatic injuries are covered.
After reading this article, you should be able to
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list the common mechanisms of thoracic trauma
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discuss the immediate resuscitative approach to patients who sustain thoracic trauma
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describe the clinical features, investigation and immediate management of patients with life-threatening thoracic injuries
Aetiology and pathophysiology
Thoracic trauma is the second most common cause of death in polytrauma patients after head injuries. It can be divided into penetrating or blunt. Blunt traumas are commonly secondary to motor vehicle accidents (MVAs), falls and crush or blast injuries. They are the most common type of thoracic trauma, accounting for over 90%, and are often associated with rib fractures, haemothorax, pneumothorax and pulmonary contusions. Penetrating traumas are commonly secondary to gunshot or stabbing injuries. They are less common than blunt injuries but carry higher mortality and often present with direct lung or thoracic organ injury. They are more likely than blunt thoracic trauma to require an operative intervention.
The morbidity and mortality from thoracic trauma is due to a disruption in respiration or circulation or both. Respiratory compromise may result from disruption to the thoracic cage in the case of rib fractures, altering respiratory mechanics or from direct injury to the lung in the case of lung contusions. This leads to hypoxia from a resultant ventilation–perfusion mismatch. Circulatory compromise may occur from obstruction related to pericardial tamponade or a tension pneumothorax, haemorrhage causing haemothorax or injury to the great vessels, or cardiac contusion with myocardial or valvular dysfunction.
Management of patients with thoracic trauma
The approach to the management of patients with chest trauma follows the generalized principles of trauma resuscitation as described in the Advanced Trauma Life Support (ATLS) protocol. The primary survey and correction of immediate life-threatening injuries includes a systematic, team approach to assessment and correction of respiratory, cardiovascular and neurological injuries.
This involves:
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controlling major external haemorrhage
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securing or maintaining a patent airway. High flow oxygen with a reservoir mask should be commenced with target saturations of 94–98%
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protecting the patient from further spinal cord injury
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optimizing ventilation and oxygenation
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establishing large-bore intravenous access
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blood sampling for cross-match, blood counts, biochemistry, blood gas analysis
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assessing neurological deficits full exposure of the patient
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immediate access to chest and pelvic X-ray, and focused assessment with sonography for trauma (FAST)
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establishing early effective analgesia.
There are five life threatening conditions that should be addressed immediately. They are:
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tension pneumothorax
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open pneumothorax
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massive haemothorax
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flail chest
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cardiac tamponade.
In the UK, the Trauma Audit Research Network (TARN) reported that flail chest was the most common type of life-threatening injury (1 in 50 incidence) and an open pneumothorax was the least common (1 in 10,000 incidence). Common presenting signs of these conditions are discussed and compared in Table 1 .
| RR | BP | HR | O 2 sats | JVP | Tracheal deviation | Chest examination/auscultation | Other signs | |
|---|---|---|---|---|---|---|---|---|
| Tension pneumothorax | ↑ | ↓ | ↑ | ↓ | ↑ | Contralateral | Quieter, hyper-expanded, hyper-resonant | |
| Open pneumothorax | ↑ | ↓/– | ↑ | ↓ | ↑/– | Contralateral or midline | Quieter, hyper-expanded, hyper-resonant | Sucking wound |
| Massive haemothorax | ↑ | ↓ | ↑ | ↓/– | ↓/– | Contralateral or midline | Quieter, dull percussion. Reduced expansion | |
| Pericardial tamponade | ↑ | ↓ | ↑ | ↓/– | ↑↑ | Midline | Muffled heart sounds | Pericardial fluid on FAST scan. Pulses paradoxus (10%) |
| Flail chest | ↑ | – | ↑ | ↓/– | – | Midline | Paradoxical chest wall movement during spontaneous ventilation | Signs may disappear after intubation |
| Lung collapse (e.g. after right main bronchus intubation) | ↑ | – | – | ↓ | – | Ipsilateral | Quieter and reduced expansion over collapse |
Invasive procedures
Further invasive procedures are sometimes immediately necessary in the resuscitation of patients with chest trauma. Indications will be discussed later in the article. These invasive procedures are:
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Tube thoracostomy (or finger thoracostomy) ( Figure 1 ): an intercostal catheter (ICC) is placed in the mid-axillary line at the fourth or fifth intercostal space. Emergency department thoracotomy is indicated in blunt and penetrating thoracic trauma, where arrest is witnessed or within 10 minutes of arrest if suitably skilled staff are present. This allows for internal cardiac compressions. Closed chest compression is rarely successful in the trauma setting.
