Chest injuries cause one of every four trauma deaths in North America. Multiple life-threatening injuries can result from thoracic trauma and therefore should be sought during the primary trauma survey.

Motor vehicle crashes, falls, and penetrating wounds are the principal causes.

A. Tension pneumothorax. Air enters the pleural space but does not leave because of a flap valve effect in the injured lung or from an open (sucking) chest wound. As a result, positive intrapleural pressure occurs, the ipsilateral lung collapses, and the mediastinum is pushed toward the contralateral lung. This results in hypotension and tachycardia due to impaired venous return.

B. Massive hemothorax. This represents rapid accumulation of >1,500 mL of blood within the pleural space and manifests as hemorrhagic hypovolemia in addition to respiratory compromise.

C. Flail chest. This indicates that a segment of chest wall has lost bony continuity with the remainder of the chest due to fracture of three or more adjacent ribs in more than one location unilaterally or bilaterally. This results in paradoxical movement of the flail segment during respiration. The morbidity of this condition is primarily due to the pain and associated severe pulmonary contusion.

D. Cardiac tamponade. This may result from either blunt or penetrating trauma. Acute accumulation of relatively small amounts of blood can result in tamponade pathophysiology. Clinical findings include hypotension, tachycardia, muffled heart sounds, distended neck veins, and pulsus paradoxus. Detection is by trauma ultrasound exam (“extended FAST exam”).

E. Major airway injury. This injury is characterized by stridor and subcutaneous emphysema. Endotracheal intubation can be very difficult, and failed attempts at intubation can further compromise airway function. It is recommended that an emergency tracheostomy rather than cricothyroidotomy be performed. Urgent operative repair is needed.

F. Penetrating chest injury. Penetrating injuries in addition to the stated problems may also result in bronchovenous fistula, whereby air flows from the injured bronchus into one of the pulmonary veins, resulting in massive
air embolism. This condition can have a delayed presentation and appear when positive pressure ventilation is initiated. The condition is rapidly fatal and requires immediate thoracotomy.

A. Endotracheal intubation. Intubation is indicated when the airway is compromised by direct trauma, aspiration of blood/gastric contents, or a depressed level of consciousness. Orotracheal intubation is the preferred method.

B. Cricothyroidotomy. Dividing the cricothyroid membrane provides a much quicker surgical access to the airway compared to tracheostomy. Tracheostomy is usually not performed in a lifesaving situation.

C. Needle decompression or tube thoracostomy. Immediately on identification of a tension pneumothorax, a needle thoracostomy should be performed. This should be followed by a tube thoracostomy as quickly as possible.

D. Thoracotomy.

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