Thoracic Trauma
John Bailitz and Tarlan Hedayati
KEY POINTS
Emergency life-threatening conditions that need to be
detected during the primary survey include airway
obstruction, tension pneumothorax, open
pneumothorax, massive hemothorax, flail chest, and
pericardial tamponade (Table 78.1).
Urgent life-threatening conditions to detect during the
secondary survey include simple pneumothorax,
hemothorax, pulmonary contusion, tracheobronchial
injury, blunt cardiac injury, traumatic aortic injury,
diaphragmatic injury, and esophageal injury.
Common thoracic cage injuries are not always
associated with serious injury, but some individuals,
especially pediatric and elderly patients, may require
admission for associated injuries and respiratory
therapy.
EPIDEMIOLOGY
Head and thoracic injuries from moving vehicle collisions
(MVCs) and firearms account for the majority of the more
than 160,000 injury-related deaths in the United States each
year. Most fatalities occur immediately as a result of massive
cardiac or vascular injury. Rib fractures are the most common
thoracic cage injury following blunt thoracic trauma. Isolated
first and second rib, sternum, and scapula fractures are no
longer considered markers of traumatic aortic injury.1
However, rib fractures must still be considered markers of
significant injury. Most patients seen in trauma centers with
rib fractures will have hemothorax, pneumothorax, or a pul-
monary contusion. Three or more rib fractures at any ana-
tomic site dramatically increases the risk for spleen and liver
injury. Likewise, scapula fractures are uncommon yet signify
a high-energy mechanism of injury, almost always with
important associated injuries.
Seat belts have increased the incidence of sternum fractures
while reducing the number of lives lost in MVCs. Isolated
nondisplaced sternum fractures are no longer considered
markers of blunt cardiac injury.2 More complicated fracture
patterns predict associated injuries. Fractures of the manu-
brium, manubrium-sternum synchondrosis, and proximal part
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78
of the sternum and severely displaced sternum fractures are
associated with an increased incidence of spinal fractures.
Displaced fractures of the body of the sternum are associated
with a higher incidence of intrapulmonary and cardiac
injuries.3
PATHOPHYSIOLOGY
The most common mechanism of blunt thoracic trauma is an
MVC, followed by falls, assaults, and crush injuries. Com-
pressive forces directly injure the thoracic cage and underly-
ing viscera and result in rib fractures and pulmonary contusion.
Deceleration produces traction on fixed structures such as the
isthmus of the aorta and the carina and results in traumatic
aortic and tracheobronchial injuries. Blunt thoracic trauma
causes penetrating thoracic trauma when rib or clavicle frac-
tures impale thoracic or abdominal viscera.
Gunshot wounds and stab wounds are the most common
mechanisms of penetrating thoracic trauma. Low-velocity
stab wounds disrupt only the structures penetrated. Medium-
velocity handguns and high-velocity military assault rifles
produce temporary and permanent cavities of tissue damage.
Missile injuries to the thorax often involve multiple anatomic
regions, including the neck, diaphragm, abdomen, and
retroperitoneum.
THORACIC CAGE INJURIES: RIB,
STERNUM, AND SCAPULA FRACTURES
MVCs are the most common cause of rib and sternum frac-
tures. Other mechanisms include pedestrian injury by a
moving vehicle, falls, contact sports, and altercations. Frac-
tures occur at the site of direct blows or at their posterior weak
point as a result of compressive forces. Ribs 4 to 9 are the
most commonly fractured.
All thoracic cage injuries result in significant pain, splint-
ing, atelectasis, and increased risk for pneumonia. Multiple
rib fractures interfere directly with the mechanics of ventila-
tion. Fracture fragments may penetrate the pleura and lungs
and result in pneumothorax and hemothorax. Traditionally,
fractures of the 6th to 12th rib on the right suggest liver injury
and on the left suggest splenic injury. However, any fracture,
especially multiple fractures, increases the risk for liver and
splenic injuries.4
681
SECTION VIII TRAUMATIC DISORDERS

Table 78.1 Life-Threatening Emergencies in the Primary Survey

EMERGENCY CLASSIC FINDINGS INITIAL TESTING FURTHER MANAGEMENT

Airway obstruction as Deformity over the clavicle and Clinical Dx Immediate reduction if unable to
a result of stridor; depressed medial intubate
retrosternal clavicle on a chest radiograph
clavicular dislocation

Tension pneumothorax JVD, tracheal deviation, and Clinical Dx Needle decompression followed
unilaterally absent breath sounds immediately by tube
thoracostomy

Open pneumothorax Respiratory distress as a result of Clinical Dx Three-sided tape over the wound
a sucking chest wound and tube thoracostomy

Flail chest Respiratory distress, tenderness, Three or more ribs fractured Early CPAP and close attention to
crepitus, and paradoxic in two or more places on a pain control and fluid status
movement chest radiograph

Cardiac tamponade Hypotension and tachycardia, JVD, Ultrasound confirms the Intravenous fluids,
and the Beck triad late diagnosis; chest radiograph; pericardiocentesis, and
ECG insensitive thoracotomy

Massive hemothorax Respiratory distress, chest wall Ultrasound confirms the Initial chest tube output of 1.5-2L
injury, diminished breath sounds, diagnosis; chest radiograph is an indication for surgical
and dullness to percussion with fluid collection intervention

CPAP, Continuous positive airway pressure; Dx, diagnostic testing; ECG, electrocardiogram; JVD, jugular venous distention.

Because children have more elastic chest walls, more energy
is transmitted to the underlying lung, and greater force is
required for fractures. Excluding other major trauma, 71% of rib
fractures in children younger than 2 years result from abuse.5
PRESENTING SIGNS AND SYMPTOMS
Classically, rib fractures are accompanied by localized tender-
ness and pleuritic chest pain, as well as splinting, crepitus,
and ecchymosis. Patients with a classic sternum fracture have
localized pain and tenderness along with ventral compression,
ecchymosis, and deformity. Pain at the site of thoracic cage
injuries increases with cough and deep inspiration. Patients
with scapular fractures typically have rib and extremity frac-
tures that often mask the diagnosis of scapula fracture.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
The initial portable anteroposterior (AP) chest radiograph
should be inspected to confirm the diagnosis of rib fracture
and underlying pleura or lung injury. Upright posteroanterior
(PA) and lateral radiographs should be obtained if a high clini-
cal index of suspicion remains for fracture or underlying
injury. The presence of an occult clinical rib fracture with
tenderness over the rib should be assumed even in the absence
of radiographic findings. Rib radiographs seldom add to the
clinical evaluation and are not routinely indicated.
Sternum fractures are best detected on the lateral chest
radiograph. Associated rib fractures and mediastinal abnor-
malities may be evident on the PA view. In experienced hands,
bedside ultrasound may be more sensitive than radiographs
for detection of both rib and sternum fractures, as well as
associated hemothorax or pneumothorax.6,7 The electrocardio-
gram (ECG) should be examined for evidence of cardiac
injury. Scapula fractures are often missed on the initial chest
radiograph unless the scapular outline is specifically inspected.
Shoulder radiographs can confirm suspected fractures
(Fig. 78.1).
Helical computed tomographic (CT) angiography should
be performed on hemodynamically stable patients when clini-
cally significant underlying injury is suspected. An abdominal
CT scan can rule out intraabdominal injury in patients with
tenderness or fracture of the sixth rib or below, three or more
rib fractures, hypotension noted in the field or emergency
department (ED), abdominal or flank tenderness, pelvic or
femoral fractures, or gross hematuria.8
TREATMENT
Adequate pain control should be provided to prevent atelec-
tasis in patients with simple acute rib fractures. Patients
should be instructed to perform incentive spirometry or take
10 deep breaths every hour. Binders and belts are not recom-
mended because such devices promote hypoventilation, which
results in atelectasis and pneumonia. Shoulder slings and
pendular exercise should be prescribed for most scapular
fractures. Displaced fractures, especially those involving the
scapular spine and neck, often require consultation with an
orthopedic surgeon for repair.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Otherwise healthy patients with isolated rib fractures or
sternum or scapula fractures may be discharged home. Elderly

682
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A
B
Fig. 78.1 A, Chest radiograph showing fractures of the clavicle
(white arrow)) and scapula (black arrow). B, Lateral scapula
fractures (arrows) visible on a computed tomography scan. (From
Westra SJ, Wallace EC. Imaging of pediatric chest trauma. Radiol
Clin North Am 2005;43:267-81.)
patients and those with multiple comorbid conditions may
require admission for pain control and pulmonary therapy. An
intercostal nerve block can be of marked benefit. Discharged
patients should be informed that the pain will diminish after
2 weeks but may persist for up to 6 weeks. Follow-up with a
trauma surgeon should be scheduled if pain persists beyond 4
weeks to detect delayed rib fracture complications.
FLAIL CHEST
Flail chest occurs when three or more ribs are fractured in two
or more places and a discontinuous segment of the thoracic
wall is produced and moves paradoxically with respiration.
Flail chest is diagnosed in approximately 5% of thoracic
trauma patients seen in level I trauma centers, typically in the
setting of multisystem trauma. Mechanisms include MVCs,
crush injuries, assault, falls, and even minimal trauma in
elderly patients. Respiratory insufficiency results primarily
from the underlying pulmonary contusion. Pneumothorax
occurs in 50% of cases and pulmonary contusion in 75%.9
PRESENTING SIGNS AND SYMPTOMS
Patients may have the classic signs and symptoms of respira-
tory distress, tenderness, crepitus, deformity, and paradoxic
motion of the affected thoracic wall. Affected segments will
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CHAPTER 78 Thoracic Trauma
move inward during inspiration and outward during expira-
tion. More commonly, splinting secondary to severe pain or
mechanical ventilation masks the diagnosis. Forced expiration
and coughing accent the paradox.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
A chest radiograph can confirm the diagnosis and detect com-
plications such as pneumothorax and hemothorax. A chest CT
scan can further evaluate the underlying pulmonary contusion
and assess for other underlying injuries such as traumatic
aortic injury.
TREATMENT
Immediate chest tube placement is required for assessment
and management of other injuries, including pneumothorax
and hemothorax. Continuous positive airway pressure is
the first-line treatment in awake and cooperative patients
with worsening oxygenation or ventilation.10 Criteria for
intubation include airway obstruction, respiratory distress,
shock, closed head injury, and need for surgery. Endotracheal
intubation should be performed only when necessary to
avoid the increased mortality associated with nosocomial
pneumonia.
Fluid replacement should be managed carefully to avoid
overhydration and worsening of lung injury. Analgesia is
titrated so that patients are more willing to make sufficient
inspiratory effort, but excessive sedation should be avoided.
Intercostal nerve blocks, epidural anesthesia, or even surgical
fixation of the flail segment may be beneficial.11 Stabilization
of the flail segment in the ED or prehospital setting has not
been shown to be helpful, and aggressive stabilizing efforts
impede overall thoracic mechanics.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Consultation and admission for trauma or cardiothoracic
surgery is advised when flail chest is suspected. Overall mor-
tality from flail chest, though dependent on other injuries,
ranges up to 35%. All patients with flail chest should be
admitted to the intensive care unit, preferably at a level I
trauma center for close observation of respiratory mechanics
and worsening of pulmonary contusion.
PNEUMOTHORAX AND
HEMOTHORAX
A simple pneumothorax occurs when air accumulates in the
pleural space without shifting the mediastinum or communi-
cating with the atmosphere. Mechanisms include laceration
of the pleura or lung by a fractured rib, alveolar rupture from
compression of the chest against a closed glottis, or a penetrat-
ing wound in the thorax.
Tension pneumothorax occurs when injury to the chest wall
acts as a one-way valve. Outside air enters the pleural space
683
SECTION VIII TRAUMATIC DISORDERS
during inspiration but cannot exit during expiration. Accumu-
lating air increases intrapleural pressure, which eventually
shifts the mediastinum, compresses the vena cava, reduces
venous return, and ultimately decreases cardiac output. Open
or communicating pneumothorax occurs when a significant
thoracic wall defect causes the lung to collapse on inspiration
and expand on expiration, with air being sucked into and
out of the chest and thus preventing effective ventilation.
Mechanisms include high-velocity assault rifle injuries and
shotgun wounds.
Hemothorax occurs when blood accumulates in the pleural
space, typically from minor lacerations in the lung paren-
chyma. Massive hemothorax is defined as greater than 1.5L
of blood in the initial chest tube drainage and is an indication
for immediate surgery. Hemopneumothorax occurs when both
air and blood fill the pleural space and commonly results from
rib fractures or penetrating trauma.
PRESENTING SIGNS AND SYMPTOMS
Patients with a simple pneumothorax classically have chest
pain, diminished breath sounds, crepitus, hyperresonance, and
mild to moderate respiratory distress. Patients with tension
pneumothorax are classically seen in extremis and exhibit
jugular venous distention, tracheal deviation, unilaterally
absent breath sounds, or tachycardia followed by hypotension
immediately before death (or any combination thereof).12
Patients with open pneumothorax have chest wall wounds that
produce sonorous sounds and are in severe respiratory dis-
tress. Typical symptoms of hemothorax are respiratory dis-
tress, chest pain, and diminished breath sounds with dullness
to percussion.
Atypical manifestations are more common than classic
ones. Respiratory distress may occur as a result of multiple
other causes. Patients can have severe pain from distracting
injuries. Breath sounds may be difficult to hear in a noisy
environment. Physical examination in patients with penetrat-
ing thoracic trauma is unreliable for the detection of pneumo-
thorax or hemothorax.13 Patients with simple pneumothorax
may be minimally symptomatic or may be cyanotic and in
severe respiratory distress. Tension pneumothorax most com-
monly occurs in intubated patients as a result of positive
pressure ventilation, sometimes after overzealous bagging.
Clinical reassessment of ventilated patients with decreasing
oxygen saturation and hypotension may allow faster detection
and treatment, even before chest radiographic diagnosis. Open
pneumothorax may be missed if the patient is not completely
exposed and rolled during the primary survey.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
The differential diagnosis for tension pneumothorax includes
cardiac tamponade, massive hemothorax, and right mainstem
intubation with left lung collapse. All will produce respiratory
distress, hypotension, and tachycardia. Cardiac tamponade
results in diminished heart sounds with normal breath sounds
and a midline trachea. Massive hemothorax produces
decreased or absent unilateral breath sounds and dullness to
percussion. Chest tube insertion confirms the diagnosis. Right
684
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Fig. 78.2 Chest radiograph showing obvious left-sided
tension pneumothorax with mediastinal shift. (From Ullman EA,
Donley LP, Brady WJ. Pulmonary trauma emergency department
evaluation and management. Emerg Med Clin North Am 2003;
21:291-313.)
mainstem intubation results in jugular venous distention, tra-
cheal deviation to the left, normal resonance, and diminished
breath sounds on the left versus the right. In an intubated
patient, the endotracheal tube should be checked and pulled
back. In the field or resuscitation bay, bilateral needle thora-
costomy should be performed when the patient is in distress,
even if the diagnosis is uncertain. A rush of air confirms the
diagnosis of tension pneumothorax. Chest tubes must be
placed after needle decompression.
A chest radiograph can confirm the diagnosis of simple
pneumothorax and hemothorax. A distance of 1cm or one
fingerbreadth between the chest wall and visceral pleural line
correlates with a small, 10% to 15% pneumothorax. Anything
larger requires immediate chest tube insertion. On a supine
portable AP chest radiograph, a deep sulcus sign suggests
pneumothorax. The affected costophrenic angle appears
clearer and deep with depression of the hemidiaphragm as a
result of localized air collection in a supine patient. In patients
with a high index of clinical suspicion based on symptoms or
penetrating injuries, some authorities advocate expiratory
upright PA and lateral chest radiographs to make the lung
volume smaller and the pneumothorax volume relatively
larger and easier to visualize. Clinically significant pneumo-
thorax should be evident on standard chest radiographs. The
chest CT scan is more sensitive in visualizing pneumothorax;
it often detects small occult pneumothoraces, which require
close monitoring.
In an upright patient, a hemothorax appears as a fluid layer
in the affected hemithorax. Early collections are noted to blunt
the costophrenic angles on the AP and lateral radiographic
views. Hemothorax often appears as only a diffuse hazy infil-
trate in a supine trauma patient. Hemopneumothorax has a
fluid layer with a flat superior border, in contrast to the round
meniscus of an isolated hemothorax (Figs. 78.2 and 78.3).
Decubitus views better demonstrate a small hemothorax.

Fig. 78.3 Chest radiograph showing right hemopneumothorax
along with a bullet. (Image courtesy Dave Andreski, MD.)
An extended focused assessment with sonography for
trauma (FAST) scan can diagnose pneumothorax and hemo-
thorax with higher sensitivity than portable chest radiography
can in experienced hands. An extended FAST scan is espe-
cially helpful when chest radiography is not immediately
available and in mass casualty situations.14
TREATMENT
Tension pneumothorax and open pneumothorax are both clini-
cal diagnoses that require immediate treatment with needle
thoracostomy followed by tube thoracostomy, even when
based on clinical evaluation, before radiographic confirma-
tion. All suspicious open chest wounds should be covered with
petrolatum gauze secured on three sides to prevent the entry
of air during inspiration and allow the exit of air during expi-
ration. Postprocedure radiographs should be obtained to
confirm placement, drainage of air and blood, and reexpansion
of lung. Prophylactic antibiotics with chest tube insertion do
not reduce the risk for empyema or pneumonia.15
Operating room thoracotomy is indicated for patients with
massive hemothorax (initial drainage of 1.5 to 2L of blood),
persistent bleeding of more than 200mL/hr for 4 hours, and
persistent hypotension or instability despite blood replace-
ment. Autotransfusion should be performed in patients with
massive hemothorax or persistent significant bleeding. It is
prudent to prepare for autotransfusion early because most
blood loss occurs at the time of initial chest tube insertion.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Traumatic pneumothorax and hemothorax generally require
tube thoracostomy. The exception is a small stable pneumo-
thorax in an otherwise healthy and symptom-free patient,
which may be managed with observation.
Occult traumatic pneumothorax detected on a CT scan
requires only close observation for respiratory distress, pro-
gression, and the development of complications. Tube thora-
costomy must be immediately available but is not required
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CHAPTER 78 Thoracic Trauma
even with positive pressure ventilation.16 Any prolonged
surgery, diagnostic testing, or transport preventing immediate
tube thoracostomy requires prophylactic placement.
In patients with penetrating injuries and a negative initial
chest radiograph, upright PA and lateral chest radiographs
should be repeated in 3 to 4 hours.17 Patients with normal
findings on repeated radiographs and no significant associated
injuries are discharged with wound care and follow-up instruc-
tions. Patients with asymptomatic blunt chest trauma and
normal findings on the initial chest radiographs do not require
repeated films before discharge. All patients with chest tubes
are admitted to the trauma, cardiothoracic, or general surgery
service in the care of personnel experienced in managing
chest tube equipment.
PULMONARY CONTUSION
Pulmonary contusion is the most common parenchymal lung
injury in victims of blunt chest trauma. Though typically
described in the setting of flail chest, pulmonary contusion
can occur with less significant chest wall fractures and occa-
sionally even in the absence of overlying injury.
Pulmonary contusion occurs with blunt, blast, or
high-energy penetrating injuries. MVCs and falls are the
most commonly reported mechanisms. Injury to the lung-
parenchyma causes hemorrhage and edema of the alveoli and
interstitium, which results in ventilation-perfusion mismatch-
ing and ultimately hypoxia and hypercapnia. Hemorrhage
worsens over the first 24 to 48 hours and then typically
resolves over the next 7 days. Acute respiratory distress syn-
drome and pneumonia are the most frequent complications,
both with significant morbidity and mortality.
PRESENTING SIGNS AND SYMPTOMS
Patients with pulmonary contusion typically have significant
chest wall injury accompanied by dyspnea and tachypnea and
progressing to hemoptysis, cyanosis, and hypotension. Inspec-
tion often reveals an obvious flail chest or ecchymosis overly-
ing rib fractures. Auscultation reveals rhonchi, wheezes, rales,
or minimal breath sounds. Blast injuries may result in signifi-
cant pulmonary contusion with minimal chest wall injury.
Delayed manifestations of pulmonary contusion can occur in
initially well-appearing patients. Because the hemorrhage and
edema will worsen, patients with even mild initial symptoms
must be observed closely with continuous monitoring. The
clinical findings usually progress over the initial hours through
the first 2 days.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
The differential diagnosis in a trauma patient with respiratory
distress and infiltrates on initial chest radiographs includes
pulmonary contusion, congestive heart failure, aspiration
pneumonia, and acute respiratory distress syndrome. Symp-
tomatic congestive heart failure may predispose patients to
blunt trauma, result from blunt myocardial injury, or develop
during fluid resuscitation. Aspiration pneumonia leads to
685
SECTION VIII TRAUMATIC DISORDERS
Fig. 78.4 Chest radiograph showing right pulmonary
contusion with pneumomediastinum and pneumopericardium.
(From Marx J, Hockberger R, Walls R, editors. Rosens emergency
medicine: concepts and clinical practice. 6th ed. St. Louis: Mosby;
2006.)
lobar opacification. Acute respiratory distress syndrome typi-
cally occurs 24 to 48 hours after the injury, often with diffuse
bilateral infiltrates and a normal heart size.
The patchy or diffuse air space opacification above the site
of injury with pulmonary contusion is often present on the
initial chest radiograph and typically progresses over the first
6 hours (Fig. 78.4). Initial CT scanning is more sensitive than
chest radiography but seldom changes the initial management
of pulmonary contusion. Pulse oximetry is essential to detect
early clinical deterioration.
TREATMENT
Prophylactic intubation is not recommended for patients with
minimal symptoms. Indications for intubation in adult patients
with pulmonary contusion include airway compromise, mod-
erate to severe respiratory distress, hypoxia, hypercapnia, and
the need for general anesthesia, as well as to facilitate the care
of other injuries.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Patients with pulmonary contusion require admission to the
intensive care unit for oxygen administration, chest physical
therapy, incentive spirometry, suctioning, analgesia, and close
monitoring. Overhydration must be avoided to prevent iatro-
genic worsening of capillary leak and lung function. Prophy-
lactic steroids and antibiotics are not recommended.18 Isolated
pulmonary contusions typically resolve within 14 days without
long-term complications. Disability and mortality rates are
686
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higher in patients with larger areas of contusion, flail chest,
acute respiratory distress syndrome, and pneumonia.
TRACHEOBRONCHIAL INJURY
Tracheobronchial injuries are infrequent but present unique
challenges to the emergency physician (EP). Emergency
airway management is often both required and complicated
by these devastating injuries.
Penetrating tracheobronchial injuries are more common
than blunt injuries. Penetrating injuries to the relatively
exposed cervical trachea occur more frequently than injuries
to the protected thoracic trachea. Gunshot wounds involving
the thoracic trachea occur more often than stab wounds. Blunt
injuries to the cervical trachea occur with rapid deceleration
and result in shear stress at the junction of the larynx and
trachea; examples of these types of injury include hyperexten-
sion injury, direct dashboard strikes, and clothesline injuries
in snowmobile and motorcycle accidents.
Blunt injuries to the thoracic trachea are typically caused
by high-energy MVCs, crush injuries, and falls. Rapid decel-
eration produces a shearing force with injury typically within
2cm of the fixed carina. Injuries to the esophagus and spine
are the most common associated injuries. Head, vascular,
nerve, and intrathoracic injuries also occur frequently with
both blunt and penetrating tracheobronchial injuries (Box
78.1).
PRESENTING SIGNS AND SYMPTOMS
Patients with tracheobronchial injuries typically have dra-
matic but nonspecific symptoms, including hoarseness, dys-
phagia, hemoptysis, and dyspnea. Careful inspection for
penetrating wounds should be made, and the trajectory and
proximity of the injury to the trachea should be estimated.
Findings on physical examination include escape of air
from wounds, subcutaneous emphysema in the neck and
supraclavicular region, hypoxia, stridor, pneumothorax, and
pneumomediastinum. Patients with blunt trauma often have
few signs of external injury. Persistent air leaks despite a
functioning chest tube suggest tracheobronchial injury.
Rarely, patients with tracheobronchial injuries without com-
munication with the pleural space maintain respiration with
minimal symptoms until granulation tissue obstructs the
airway and results in delayed lobar atelectasis.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
Chest radiographs may have subtle evidence of tracheobron-
chial injuries such as high rib fractures, the fallen lung sign,
pneumomediastinum, deep cervical emphysema, peribron-
chial air, abnormal location of the endotracheal tube, and a
spherical shape of the normally oval endotracheal tube
balloon. The fallen lung sign occurs when the apical segments
of the lung have collapsed and fallen to the level of the hilum.
Flexible fiberoptic bronchoscopy usually confirms the injury.
Helical CT angiography is particularly effective in diagnosing
blunt laryngeal injury and often provides additional informa-

BOX 78.1 Approach to Thoracic Trauma*
Blunt Trauma
High-energy mechanisms: Falls greater than 3m or motor
vehicle collisions at more than 30mph
All injuries: CXR and pulse oximetry. If pneumothorax or
hemothorax, insert a chest tube
Traumatic aortic injury: A mechanism with chest wall tender-
ness or abnormal CXR evidence requires helical CT angi-
ography; if negative, evaluate for traumatic aortic injury; if
findings indeterminate, obtain an aortogram; if positive,
transfer the patient to the operating room
Blunt cardiac injury: With abnormal ECG, hypotension, or
dysrhythmia, cardiac monitoring and hospitalization multiple tubes to drain the resulting pneumothorax and reex-
for 24 hours with repeated ECGs every 8 hours; pand the affected lung.
with hypotension or symptomatic dysrhythmia, formal
echocardiography
Penetrating Injuries
All injuries: Continuous pulse oximetry and PA and lateral
CXR at 0 and 6 hours
Anterior cardiac box: FAST examination to evaluate for peri-
cardial fluid
Posterior box and transmediastinal gunshot wounds: Angi-
ography for great-vessel injury; with signs and symptoms
of injury, esophagography or esophagoscopy and
bronchoscopy
Posterior box stab wounds: If abnormal mediastinum on
CXR, angiography for great-vessel injury; with signs and
symptoms of injury, esophagography or esophagoscopy
and bronchoscopy
Thoracoabdominal: DPL with a red blood cell count of 10,000
cells/L, laparoscopy/thoracoscopy or laparotomy to
evaluate for diaphragmatic injury
CT, Computed tomography; CXR, chest radiograph; DPL, diagnostic peri-
toneal lavage; ECG, electrocardiogram; FAST, focused assessment with
sonography for trauma; PA, posteroanterior.
*Protocols and approach may vary depending on institutional experience
and availability.
tion in the evaluation of penetrating thoracic and tracheobron-
chial injuries.
TREATMENT
Patients with tracheobronchial injuries who are in respiratory
distress require immediate intubation and mechanical ventila-
tion. Fiberoptic bronchoscopy is the best diagnostic and man-
agement option for patients with cervical and intrathoracic
tracheal injuries. When not available and immediate airway
intervention is required, some authorities recommend orotra-
cheal intubation without paralysis to prevent loss of paratra-
cheal muscle support of the injured trachea. The benefits must
be weighed against the suboptimal intubating conditions in a
nonparalyzed patient. If paralysis is required, prior prepara-
tion for a surgical airway and right-sided thoracotomy is
necessary.
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CHAPTER 78 Thoracic Trauma
During orotracheal intubation, a smaller-size endotracheal
tube should be inserted and placed past the injury if possible.
To prevent worsening of the injury, force should be avoided
during placement of the endotracheal tube. When orotracheal
intubation is not possible, the endotracheal tube should be
placed through the anterior neck wound into the trachea. The
EP must be careful to avoid pushing a transected trachea
deeper into the thorax. In patients with complete transection
and retraction of the trachea, major intervention is required.
A right-sided thoracotomy should be performed (to avoid the
aortic arch on the left), and the EP should attempt to visualize
the injured trachea, support it, and establish an airway. Exten-
sion to a left-sided thoracotomy may be needed for complex
distal injuries.19 Tube thoracostomy is required, often with
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Stable patients with tracheobronchial injuries and a main-
tained airway are best transported to the operating room
immediately for fiberoptic bronchoscopy, intubation, and pos-
sible thoracotomy. Definitive surgical repair is necessary to
prevent acute and late complications. Acute complications
include persistent air leak, pneumothorax, empyema, and
mediastinitis. Delayed complications include granulation of
partial injuries with resultant atelectasis and significant loss
of pulmonary function. Penetrating and blunt injuries are
typically managed early by exploration and repair.
BLUNT CARDIAC INJURY
The pathologic spectrum of blunt cardiac injury begins with
cardiac concussion; includes myocardial contusion, coronary
artery injury, and valve and septal injury; and ends with myo-
cardial rupture. Myocardial contusion remains the most
common clinical challenge to the EP. A definitive diagnosis
can be made only at autopsy, and complications are rare but
life-threatening.
Blunt cardiac injury typically results from MVCs but may
occur after falls, crush injuries, blast injuries, direct blows,
and chest compression. Low-speed deceleration injuries occa-
sionally result in significant injury. Proposed mechanisms
include compression of the heart between the sternum and
vertebral bodies and sudden striking of the heart against the
sternum in deceleration injuries.
Cardiac concussion, or commotio cordis, occurs when
a blow to the chest briefly stuns the heart; it results in
dysrhythmia, hypotension, syncope, and often sudden death
but without permanent cellular damage. Commotio cordis
may result from an anterior chest wall impact at a moment
when the myocardium is refractory to depolarization and
can result in fatal arrhythmia, also known as the R-on-T
phenomenon.20
Myocardial contusion occurs when injury to the anterior
wall, formed by the right ventricle, results in well-defined
areas of red blood cell extravasation and eventually in
subendocardial and transmural necrosis. Infrequent delayed
complications include mural thrombus, pericardial effusions,
687
SECTION VIII TRAUMATIC DISORDERS
constrictive pericarditis, and ventricular aneurysms. Direct
injury to already atherosclerotic coronary arteries or
severely contused myocardium can result in myocardial
infarction. The rare blunt cardiac rupture is typically
immediately fatal except when limited to the low-pressure
right side of the heart or to small, self-sealing ventricular
injuries.
PRESENTING SIGNS AND SYMPTOMS
Blunt cardiac injury typically occurs in patients with multiple
blunt trauma injuries. Patients with commotio cordis generally
experience immediate dysrhythmia and loss of consciousness.
Though usually fatal, the survival rate is increasing as a result
of increased public awareness, immediate cardiopulmonary
resuscitation, and increased availability of automatic external
defibrillators.21
Patients with myocardial contusion typically complain of
angina-type chest pain unrelieved by nitroglycerin, pleuritic
pain, or pain from associated injuries. Evidence of external
trauma is usually but not always present. Information about
the scene of the injury often provides the only evidence of
blunt cardiac injury.
Initial and vital sign trends should be carefully noted,
including mental status, color, jugular venous distention, and
the presence of chest wall ecchymosis or tenderness, gallop
rhythms, and friction rubs. Persistent unexplained tachycar-
dia, hypotension, or dysrhythmia suggests blunt cardiac injury.
Patients with valve dysfunction typically have a loud murmur,
acute heart failure, and jugular venous distention. The rare
patient with cardiac rupture who survives to arrive at the ED
generally exhibits signs of cardiac tamponade or overt cardio-
genic shock.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
An ECG should be recorded in all patients with suspected
blunt cardiac injury. Traditionally, stable patients with
normal results on the initial ECG were considered to be
at low risk for complications and safe for discharge. However,
more recent literature suggests that patents may still be
at risk for complications of blunt cardiac injury, inclu
ding lethal dysrhythmias up to 12 hours after trauma and
nonlife-threatening dysrhythmias up to 72 hours later.22 New
findings on the ECG suggestive of myocardial contusion
include unexplained tachycardia, ST- and T-wave changes,
conduction abnormalities, and dysrhythmias.
Evaluation of cardiac markers is not routinely indicated in
patients with blunt cardiac injury. The exception is serial tro-
ponin I measurement in patients with an ischemic pattern on
the initial ECG and in patients in whom cardiac ischemia may
have precipitated the trauma. However, a recent metaanalysis
supports the use of troponin I as a sensitive test for myocardial
contusion when determined at admission and 4 to 6 hours
later.23
Emergency bedside echocardiography is recommended for
unstable patients with suspected blunt cardiac injury or with
evidence of myocardial infarction on the ECG. Pericardial
effusions are easily identified on the initial subxiphoid view
688
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of the FAST scan. Formal echocardiography with parasternal
and apical views will better identify small effusions, valve
dysfunction, and wall motion abnormalities. Transesophageal
echocardiography is more sensitive than transthoracic echo-
cardiography and provides additional imaging of the aorta in
unstable patients. Routine echocardiography does not predict
complications in stable patients with suspected blunt cardiac
injury.
TREATMENT
Unstable patients with blunt cardiac injury require definitive
airway control to ensure optimal oxygenation and ventilation.
A large-bore internal jugular catheter should be inserted for
fluid resuscitation, monitoring of central venous pressure, and
placement of a Swan-Ganz catheter. Cardiogenic shock sec-
ondary to myocardial contusion or cardiac rupture typically
requires careful fluid replacement and inotropic support.
Refractory cases may require temporary stabilization with an
aortic balloon pump after an aortic injury has been ruled out.
Cardiac catheterization is necessary in patients with myocar-
dial infarction because antithrombotic therapy is contraindi-
cated after trauma.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Stable patients with a normal initial ECG and without signifi-
cant associated injuries can be safely discharged from the ED.
Stable patients with changes on the ECG suggestive of myo-
cardial contusion require observation with continuous moni-
toring for 24 hours and electrocardiography repeated every
8 hours for 24 hours. Brief dysrhythmias seldom require
treatment, and prophylactic antidysrhythmic therapy is not
indicated.
Unstable patients with ventricular dysrhythmias, atrial
fibrillation, sinus bradycardia, and bundle branch block
require intensive care unit admission. In patients with abnor-
mal findings on the initial ECG, the complication rate is low,
with complications predominantly occurring in older patients
with multiple injuries. Wall motion abnormalities and rhythm
disturbances typically resolve within hours. Most patients
with myocardial contusion require only supportive care and
aggressive management of complicating injuries. Morbidity
and mortality are directly related to the presence of other
injuries.
PENETRATING CARDIAC INJURY,
CARDIAC TAMPONADE, AND
EMERGENCY DEPARTMENT
THORACOTOMY
Penetrating cardiac injuries most commonly result from
gunshot wounds, followed by stab wounds. Any gunshot
wound involving the torso can result in penetrating cardiac
injury. Survival is better in patients with stab wounds, single-
chamber involvement, and low-pressure right heart injuries.

Cardiac tamponade most commonly results from stab wounds
to the chest or upper part of the abdomen, followed by gunshot
wounds and infrequently by blunt chest trauma.
Penetrating injuries to the heart result in either death at
the scene or tamponade, which allows transport to the ED.
Tamponade is more likely to occur with smaller injuries from
stab wounds. The tough fibrous sac surrounding the heart
prevents immediate exsanguination. As blood accumulates,
cardiac filling and eventually output are impaired, which
often results in rapid decompensation after arrival at the ED.
Acutely accumulated pericardial blood may be difficult to
visualize on cardiac ultrasonography. The right ventricle is
the most commonly injured structure, followed by the left
ventricle. Approximately three of four patients will die of
the injury.
PRESENTING SIGNS AND SYMPTOMS
Patients with pericardial tamponade classically but uncom-
monly exhibit the Beck triad of hypotension, jugular venous
distention, and muffled heart sounds. Most patients will have
at least one of these signs, with all three appearing only briefly
before cardiac arrest. More frequently, patients either appear
relatively stable or are in extremis. Stable-appearing patients
have small wounds in the pericardium that allow intermittent
decompression of the accumulated blood. Patients with more
rapid accumulation are panic-stricken, appear to be in severe
respiratory distress, and often have needle thoracostomy per-
formed for presumed tension pneumothorax. In these patients,
agitation, tachycardia, and hypotension predominate before
progressing to obtundation, bradycardia, and pulseless electri-
cal activity.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
An ultrasonographic subxiphoid view (Fig. 78.5) may detect
pericardial fluid in patients with suspected cardiac injury.
Pericardial fluid with diastolic collapse of the right atrium and
ventricle is diagnostic of pericardial tamponade. Any pericar-
dial effusion in unstable trauma patients with equal bilateral
breath sounds signals tamponade requiring immediate opera-
tive intervention. Although the sensitivity of FAST scans
approaches 100% for hemopericardium, false-negative results
may occur when blood drains rapidly into the thorax. The
possibility should be considered in patients with small ante-
rior stab wounds and persistent left hemothorax despite tube
thoracostomy.24
An initial ECG should be obtained to evaluate for findings
suggestive of pericardial tamponade and other cardiac injury.
Electrical alternans, low voltage, and PR-segment depression
are specific but not sensitive for the diagnosis of pericardial
effusion. A chronic pericardial effusion is more likely to
reveal such findings. Acute traumatic pericardial effusion
resulting in tamponade does not change the size of the heart
on the chest radiograph. However, a chest radiograph can be
useful in identifying other injuries and the presence of retained
foreign bodies. It is important to remember that normal find-
ings on the ECG and chest radiograph do not rule out trau-
matic pericardial effusion or tamponade.
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CHAPTER 78 Thoracic Trauma
LV
Fig. 78.5 Subxiphoid view of a focused assessment with
sonography for trauma scan showing traumatic hemoperi
cardium (arrows). LV, Left ventricle. (From Mandavia DP, Joseph
A. Bedside echo in chest trauma. Emerg Med Clin North Am
2004;22:601-19.)
TREATMENT
A central venous line should be placed for volume infusion
and monitoring of central venous pressure. The injured hemi-
thorax is preferred for central line placement to avoid iatro-
genic complications in the uninjured side. The exception is
a patient with obvious injury to the clavicle and suspected
injury to the subclavian vein.
Aggressive fluid resuscitation is mandatory for patients
with suspected pericardial tamponade to maximize cardiac
filling pressure and cardiac output. Elevated central venous
pressure in persistently hypotensive and tachycardic trauma
patients suggests impending tamponade. Pericardiocentesis
with catheter placement should be performed in patients with
deteriorating vital signs. Pericardiocentesis may serve as a
diagnostic and temporizing measure but is never a replace-
ment for thoracotomy and definitive repair of the injury. Ultra-
sonography or ECG-guided pericardiocentesis is preferred, if
available. Nonclotting blood traditionally signifies pericardial
blood, but aspiration may be unsuccessful because of needle
placement, continuous brisk pericardial bleeding, or other
reasons. However, removal of even a small amount of pericar-
dial blood can restore vital signs and aid survival until surgical
intervention is available.
Thoracotomy is reserved for patients with cardiac tampon-
ade who are in cardiac arrest or impending arrest. The likeli-
hood of functional survival after ED thoracotomy is greatest
for victims of stab wounds with isolated cardiac injury who
have signs of life on ED arrival. At the trauma center, thora-
cotomy is performed on victims of penetrating trauma who
experienced cardiac arrest in the ED or within 10 minutes of
arrival at the ED and on blunt trauma patients who experi-
enced cardiac arrest in the ED. In the ED without surgical
support, thoracotomy is best performed by a skilled EP only
on patients with thoracic stab wounds or isolated gunshot
689
SECTION VIII TRAUMATIC DISORDERS

Table 78.2 Indications for ED Thoracotomy

PRESENTING SIGNS AND SYMPTOMS
PENETRATING
SETTING INJURIES BLUNT TRAUMA Signs and symptoms of traumatic aortic injury are often not
present or are masked by other injuries. Up to one half of all
Trauma Cardiac arrest in the Cardiac arrest in the patients have no signs of chest wall injury. Common signs and
center ED or within 10min ED
of ED arrival
symptoms include interscapular or retrosternal pain, decreased
blood pressure in the left arm, upper extremity hypertension
Community Patients with thoracic All other ED with absent femoral pulses, bruit, and a harsh systolic murmur
ED without stab wounds or thoracotomies heard over the precordium or interscapular area. Uncommon
emergency isolated gunshot should be findings include extremity pain from distal ischemia, dyspha-
surgical wounds who lose performed only
backup signs of life in the when a surgeon is gia from concomitant esophageal injury, and hoarseness as a
ED or within 10min available within result of compression of the laryngeal nerve.
of ED arrival 10min Evidence of penetrating injury to the great vessels depends
on the mechanism and location of the injury. High-energy
ED, Emergency department.
proximal arterial injury typically results in immediate exsan-
guination or hemorrhagic shock with massive hemothorax.
wounds who lost signs of life in the ED or within 10 minutes Contained mediastinal hematoma can occasionally impair
of arrival in the ED. In all other cases, ED thoracotomy should superior vena cava return and produce engorgement of the soft
be performed only if a qualified surgeon is present or imme- tissues of the neck, face, and airway. Distal injuries may result
diately available (Table 78.2).25-28 in diminished pulses, expanding hematomas, and limb isch-
emia. Careful palpation for pulse symmetry and measurement
of blood pressure in both arms are advisable.
FOLLOW-UP, NEXT STEPS IN CARE, Stab wounds should be inspected carefully to help deter-
AND PATIENT EDUCATION mine the general trajectory. Deep probing of wounds should
be avoided to prevent iatrogenic worsening of the initial
Immediate operative repair is indicated for all penetrating injury, dislodgment of clot and massive hemorrhage, and
injuries of the heart to relieve tamponade and repair the initial infection. Chest tube output should be closely monitored. The
injury. Identification and initial management of all associated chest tube should be clamped when the patient is being trans-
injuries ensure optimal outcomes, but operative intervention ported to the operating room; when massive hemothorax and
must not be delayed. Diagnostic peritoneal lavage should be heavy, continuous bleeding are present, temporary tamponade
performed in the operating room to identify intraperitoneal within the pleural cavity may be required for this short time.
bleeding and assess the need for laparotomy.

DIFFERENTIAL DIAGNOSIS AND MEDICAL

GREAT VESSEL INJURY
Great vessel injury is a significant cause of morbidity and
mortality with both blunt and penetrating thoracic trauma.
Traumatic aortic injury is the second most common cause of
blunt traumatic death. Eighty percent of victims of traumatic
aortic injury die immediately. The majority of survivors can
be saved with prompt ED diagnosis, blood pressure control,
and operative repair. Five percent of patients will be unstable
on arrival and have a mortality rate of up to 98%. The remain-
ing 15% will be hemodynamically stable, which often con-
tributes to a delay in diagnosis and a mortality rate as high
as 25%.29
The descending aorta is fixed within the thorax by the liga-
mentum arteriosum and the intercostal arteries. Sudden decel-
eration causes the aortic arch to swing forward and produces
a shearing force with resultant injury just distal to the takeoff
of the left subclavian artery. Traditionally, traumatic aortic
injuries have been considered only in patients with major
mechanisms of injury, including high-speed MVCs with
frontal or side impact and motorcycle crashes. However, the
injury has been reported with less impressive mechanisms
such as pedestrian-versus-auto collisions, falls, and crush
injuries. Use of restraint systems does not protect persons
from traumatic aortic injuries.30,31 Penetrating injuries to the
great vessels typically result from both gunshot penetration
and stabbing.
DECISION MAKING
The initial chest radiograph should show evidence of trau-
matic aortic injury (Fig. 78.6, A). The most sensitive criterion
is mediastinal widening, usually larger than 8cm on an AP
view; however, a subjective interpretation of mediastinal wid-
ening is more reliable. Other mediastinal abnormalities sug-
gesting mediastinal hematoma secondary to traumatic aortic
injury are an obscured aortic knob, loss of the AP window, a
displaced nasogastric tube, widened paratracheal stripe,
widened paraspinal interface, depression of the left mainstem
bronchus, left hemothorax, left apical pleural cap, deviation of
the trachea to the right, and multiple rib fractures. The more
abnormalities seen on the chest radiograph, the higher the sen-
sitivity in identifying an aortic injury. A normal chest radio-
graph, however, does not rule out a traumatic aortic injury.
With sensitivity near 100%, a normal CT scan rules out
traumatic aortic injury.32 If the results are indeterminate,
aortography should be performed. Rarely, a positive helical
CT angiogram in a stable patient is followed by aortography
for further localization of the injury and identification of
other injuries, such as a pseudoaneurysm (see Fig. 78.6, B).
Advantages of helical CT angiography over aortography are
that it is faster, is noninvasive, requires a smaller volume of
contrast agent, and provides information about other thoracic
injuries. A high index of suspicion and low threshold for
performing screening helical CT angiography are required

690
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A C
B Radiol Clin North Am 2005;43:267-81; C, image courtesy Scott
to save patients with traumatic aortic injury who survive
to arrive at the ED.
Transesophageal echocardiography should be performed in
unstable patients with suspected traumatic aortic injury but
is contraindicated in patients with esophageal injuries. Very
high sensitivity and specificity approaching 100% have
been reported, but it varies widely depending on operator
experience.
Aortography remains the gold standard for the diagnosis
of traumatic aortic injury. False-positive and false-negative
results are rare but do occur. Better sensitivity with helical CT
angiography has been reported. Aortography offers improved
localization of injury before surgical repair. Newer techniques
such as intravenous digital subtraction angiography have
improved the speed while reducing the cost of aortography
(see Fig. 78.6, C).
A chest radiograph should be obtained in all patients with
suspected penetrating great vessel injury, and all wounds
should be noted and marked. The examination should be
focused specifically on evidence of mediastinal hematoma,
hemothorax, foreign bodies near vessels or in the trajectory of
a missile, fuzzy missiles created by arterial pulsations, and
the absence of a missile in patients with a gunshot wound to
the chest, which suggests distal embolization. An angiogram
should be obtained to further assess the injuries and plan an
operative approach in the rare stable patient. With the added
benefit of evaluating nearby structures, helical CT angiogra-
phy will probably replace aortography in the evaluation of
stable patients with transmediastinal penetrating injury.33
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CHAPTER 78 Thoracic Trauma
Fig. 78.6 Chest radiographs showing traumatic aortic
injury. A, Widened mediastinum, loss of mediastinal contours,
depression of the left mainstem bronchus (black arrow), and
deviation of the nasogastric tube (white arrow). B, Traumatic
pseudoaneurysm in the proximal descending aorta (arrow).
C, Traumatic pseudoaneurysm seen on an aortogram. (B, From
Westra SJ, Wallace EC. Imaging of pediatric chest trauma.
Sherman, MD.)
TREATMENT
Early orotracheal intubation is required because hematoma
expansion can make both orotracheal intubation and creation
of a surgical airway impossible. Tracheostomy is contraindi-
cated in patients with great vessel injury involving the upper
mediastinum or zone I of the neck because major bleeding
can result.
Patients with penetrating great vessel injuries often require
ED thoracotomy or immediate thoracotomy in the operating
room. In patients with penetrating wounds involving the sub-
clavian vessels, traditional left lateral thoracotomy will often
not provide adequate exposure.
Before operative repair of traumatic aortic injury, blood
pressure must be controlled, with systolic pressure maintained
at 100 to 120mmHg to decrease shear stress and progression
of the injury. Patients with isolated aortic injuries may be
hypertensive and will require short-acting titratable agents
such as nitroprusside and esmolol.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Surgical repair of traumatic aortic injury is performed after
stabilization of other life-threatening intracranial or intraab-
dominal injuries. Delayed surgical repair is frequently
indicated in elderly patients with multiple comorbid condi-
tions. The mortality rate during surgery is approximately 10%,
691
SECTION VIII TRAUMATIC DISORDERS
and such mortality is primarily related to the extent of the
injury and condition of the patient.
ESOPHAGEAL INJURY
Esophageal injuries occur infrequently with both blunt and
penetrating trauma. More immediate life-threatening inju-
ries often mask the clinical findings, and esophageal leakage
can progress to fatal mediastinitis. Esophageal evaluation is
indicated in patients with a significant penetrating injury
to the neck. The majority of esophageal perforations result
from medical endoscopic procedures, not from traumatic
injuries.
Penetrating esophageal injury must be considered in any
patient with injury near or trajectory through the esophagus.
Common mechanisms of penetrating injury include lacera-
tion, missile penetration, iatrogenic perforation, and ingested
foreign body. Stab wounds to the neck often directly injure
the esophagus. High-velocity gunshots result in direct esopha-
geal perforation, as well as delayed necrosis. The majority of
penetrating injuries occur at the proximal or distal end of the
esophagus during routine endoscopy.
Blunt esophageal injuries are much less common than
penetrating injuries. Common mechanisms include crush
injuries to the cervical esophagus and barotrauma. Blunt
laryngotracheal trauma and cervical spine fractures are asso-
ciated with injuries to the upper part of the esophagus. Blunt
injuries to the lower third of the esophagus occur with
sudden increases in intraabdominal pressure against a closed
upper esophageal sphincter, analogous to Boerhaave syn-
drome. The initial rupture typically originates from an inher-
ent weakness in the left posterior aspect of the distal end of
the esophagus.
Both cardiopulmonary resuscitation and the Heimlich
maneuver have been associated with perforation of the tho-
racic esophagus. Blast injury can result in primary esophageal
injury as a result of the pressure wave, in secondary injury
from impact of the patient against fixed structures, and in
tertiary injury from blast projectiles.
PRESENTING SIGNS AND SYMPTOMS
Typical symptoms of esophageal injury include pleuritic chest
pain anywhere along the course of the esophagus, dyspnea,
odynophagia, dysphagia, hoarseness, and pain with flexion or
extension of the neck. The physical examination should include
palpation for subcutaneous emphysema and auscultation for a
systolic Hamman crunch produced by mediastinal air.
Commonly, patients have emergency life-threatening inju-
ries that obscure the clinical findings, which can lead to
delayed recognition and management. Fever, tachycardia,
hypotension, and progressive dyspnea are noted as mediasti-
nitis develops.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
AP or PA chest radiographs should be examined for evidence
of mediastinal air, subcutaneous emphysema, left-sided
692
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pleural effusion, pneumothorax, and a widened mediastinum.
A lateral neck radiograph may reveal prevertebral air displac-
ing the tracheal air column forward. Early in the course of a
perforation, radiographic evidence is often minimal. Later CT
scans of the chest may demonstrate collections of air or fluid
as infection develops, but CT scans are not usually performed
for esophageal injury.
Esophagography and esophagoscopy should be performed
in all patients with suspected esophageal injury, although
neither modality alone is sensitive enough to rule out
esophageal injury. The initial esophagography is done with
Gastrografin to avoid mediastinal irritation from leakage
of barium. Incidentally, a CT scan after barium ingestion
may detect small esophageal perforations and small metallic
foreign bodies better than plain radiographs can. Negative
findings on an esophagogram with Gastrografin enhancement
should be followed by the more sensitive barium-
enhanced esophagography. Neither contrast agent prevents
the use of endoscopy. If findings on both esophagograms
are negative, flexible endoscopy can be used to exclude subtle
injuries.
TREATMENT
Chest tube drainage is often necessary for associated pneu-
mothorax. Persistent air leak is suggestive of esophageal
injury. Food particles in the chest tube confirm major injury.
Patients should be kept on nothing-by-mouth status. Fluid
resuscitation is mandatory. Broad-spectrum antibiotics that
cover oral anaerobes should be administered. Placement of a
nasogastric tube is controversial because of the risk for medi-
astinitis and should be done in consultation with trauma or
general surgery services.
FOLLOW-UP, NEXT STEPS IN CARE,
AND PATIENT EDUCATION
Management can be operative or nonoperative. Small, mini-
mally symptomatic or chronic perforations, particularly those
involving the cervical esophagus secondary to instrumenta-
tion, are most amenable to a nonsurgical approach.34 Consul-
tation with trauma or general surgery specialists for primary
surgical repair dramatically improves outcomes.
DIAPHRAGMATIC INJURIES
Diaphragmatic injuries are a diagnostic challenge and are
associated with significant delayed complications. Complica-
tions often develop weeks to years after the initial trauma
and consist of symptoms of visceral herniation. Both blunt
and penetrating trauma can cause diaphragmatic injuries, but
with very different injury patterns. The most common mecha-
nisms for blunt diaphragmatic injuries are MVCs and falls,
followed by pedestrian-versus-vehicle collisions, motorcycle
accidents, and crush injuries. Penetrating injuries result
from gunshot or stab wounds. When detected initially, dia-
phragmatic injury signals that other severe injuries are
probably present.
 CHAPTER 78 Thoracic Trauma

Gunshot and stab wounds result in injuries to the diaphragm

with nearly equal incidence. Stab wounds with a trajectory
reaching the 4th intercostal space superiorly or the 12th inter-
costal space inferiorly must be considered to have perforated
the diaphragm and require prudent evaluation. Stab wounds
outside this area may also penetrate the diaphragm, depending
on the length and angle of the blade. Gunshot wounds any-
where in the neck, chest, abdomen, or pelvis can penetrate the
diaphragm. Blunt force to the chest or abdomen often results
in large tears in the diaphragm. Left-sided injuries are more
common in survivors, whereas an equal incidence of right-
and left-sided injuries is noted at autopsy. The negative pres-
sure of inspiration prevents closure and promotes herniation
through the wound into the chest cavity. If not detected
initially, diaphragm injuries frequently result in visceral her-
niation months to years later.

PRESENTING SIGNS AND SYMPTOMS

Three phases of injury have been described. The acute phase
begins with the injury and ends with the initial recovery. A
patient with acute diaphragmatic rupture will typically com-
plain of chest pain, abdominal pain, and dyspnea. Findings on
physical examination include diminished breath sounds in
the lung bases, respiratory distress, bowel sounds in the chest,
peritoneal signs, and palpation of viscera during chest tube
placement. Large left-sided blunt injuries are more obvious
than smaller penetrating and right-sided injuries. Acute dia-
phragmatic injuries are often overshadowed by other injuries.
Frequently, no abdominal tenderness is noted.
In the second, or latent, phase, intermittent herniation of
abdominal viscera results in mild and vague symptoms sug-
gesting biliary, gastric, coronary artery, or pulmonary disease.
Patients with latent manifestations often appear to have other
gastrointestinal or cardiovascular diseases and complain of
vague abdominal pain relieved when upright or cough and
vague chest pain.
In the last, or obstructive, phase, incarceration, strangula-
tion, and ischemia develop.35 Additionally, the compressive
effects of the intrathoracic bowel on the heart and lung can
result in tension enterothorax or viscerothorax.36 In this phase,
symptoms of visceral obstruction, ischemia, and ultimately
visceral infarction develop. Rarely, tension viscerothorax also
develops. Herniation should be considered in any patient with
vague complaints of chest or abdominal pain and a history of
thoracoabdominal trauma.
DIFFERENTIAL DIAGNOSIS AND MEDICAL
DECISION MAKING
The initial chest radiograph should be inspected for the classic
diagnostic finding, which is a nasogastric tube or viscera in
the left hemithorax. Other important but more subtle signs
include an indistinct or elevated left hemidiaphragm and left
lower lobe atelectasis. Hemopneumothorax is present in 50%
of patients with penetrating injury. Up to 25% of patients with
penetrating diaphragmatic injuries have normal chest radio-
graphic findings and no abdominal tenderness. CT scanning
Fig. 78.7 Chest radiograph showing obvious left-sided
viscerothorax secondary to a stab wound in the diaphragm
3 years earlier. (Image courtesy Dave Andreski, MD.)
is 100% specific but only 66% sensitive for the diagnosis of
blunt diaphragmatic injury.37
In the latent phase of injury, the chest radiograph is typi-
cally abnormal. Findings can be subtle, such as a unilaterally
elevated hemidiaphragm, unilateral pleural thickening, or
basilar atelectasis, or can be significant, such as a shift of the
mediastinum or viscera evident above the diaphragm. In cases
of delayed herniation, upper or lower gastrointestinal contrast-
enhanced studies may be needed to demonstrate herniation
(Fig. 78.7).
FAST can also be used in the diagnosis of diaphragmatic
rupture. The sonographic features of a ruptured diaphragm
include nonvisualization of the spleen or heart, poor dia-
phragmatic movement, elevated diaphragm, liver sliding
sign, pleural effusion, subphrenic effusion, or viscera visu-
alized in the thorax.38,39 Traditionally, a diagnostic peritoneal
lavage count of less than 10,000 red blood cells/L is used
to rule out a diaphragmatic injury in patients with penetrat-
ing thoracoabdominal trauma. Lavage fluid draining from
the chest tube is diagnostic. However, diagnostic peritoneal
lavage misses up to 25% of diaphragmatic injuries because
of bleeding into the chest. Laparoscopy or thoracoscopy is
the diagnostic study of choice in patients with high clinical
suspicion for diaphragmatic injury not otherwise needing
surgery.
TREATMENT
A nasogastric tube should be placed carefully in obstructed
patients to avoid further trauma to a herniated gastroesophageal

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SECTION VIII TRAUMATIC DISORDERS

junction. In cases of tension viscerothorax, a chest tube should

be placed into the thoracic cavity while taking care to avoid DOCUMENTATION
the viscera. The EP should palpate for viscera and diaphrag-
matic injuries before insertion of a chest tube.
Careful documentation helps ensure identification and evalu-
ation of all significant injuries. The documentation chart
should reflect the following thought processes and
FOLLOW-UP, NEXT STEPS IN CARE, actions:
AND PATIENT EDUCATION Primary survey assessment and management
Secondary survey findings: Use a figure or drawing of
Consultation and admission to trauma or general surgery
the patient to describe the injuries
services is recommended for early surgical repair to prevent
Ample history
delayed complications. Patients with suspected diaphragmatic
Initial laboratory and imaging findings
injuries typically have multiple injuries requiring treatment
Definitive testing
and hospitalization. An asymptomatic patient with a mecha-
Results of consultations
nism for diaphragmatic injury but a negative work-up should
Main assessment and plan: Patient, mechanism, and
be instructed about the need for immediate evaluation if signs
list of injuries with a plan for each.
of delayed herniation and obstruction develop, such as abdom-
Tertiary survey or reassessment before discharge:
inal discomfort, chest discomfort, shortness of breath, or
Follow-up provided
vomiting.
Patient education provided

RED FLAGS

Subtle Life-Threatening Emergencies in the Diaphragmatic Injury

Secondary Survey
Traumatic Aortic Injury
Patients may have no external sign of trauma. Never say She
looks too good to have a traumatic aortic injury, It was only
a lateral impact, or He was wearing a belt and the airbag
went off. The patient will look good until the aorta ruptures;
with lateral impact in a moving vehicle collision, there may
be increased risk for traumatic aortic injury, and restraints
alone do not reduce the risk for traumatic aortic injury.
Esophageal Injury
For any injury near the esophagus, esophagography and esoph-
agoscopy should be performed. Injuries are often subtle until
fatal mediastinitis develops.
Penetrating injury anywhere near the diaphragm requires chest
radiography, computed tomography, and in some cases,
diagnostic peritoneal lavage.
Tracheobronchial Injury
Persistent air leaks despite a functioning chest tube indicate a
tracheobronchial injury until proved otherwise. Bronchos-
copy must be performed to prevent delayed infection, atel-
ectasis, and loss of lung function.
Liver and Splenic Injuries
Three or more rib fractures or any fracture or tenderness of the
sixth rib or below is an indication for abdominal computed
tomography to rule out liver and splenic injury.

Soreide E, Deakin CD. Prehospital fluid therapy in the critically injured patienta
SUGGESTED READINGS clinical update. Injury 2005;36:1001-10.

EAST management of pulmonary contusion and flail chest practice guidelines 2006.
Available at http://www.east.org/.
Eroglu A, Turkyilmaz A, Aydin Y, et al. Current management of esophageal REFERENCES
perforation: 20 years experience. Dis Esophagus 2009;22:374-80.
Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin References can be found on Expert Consult @
injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med www.expertconsult.com.
2005;46:232-6.
Practice management guidelines for emergency department thoracotomy: Working
Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons
Committee on Trauma. J Am Coll Surg 2001;193:303-9.

694
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For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

REFERENCES
1. Lee J, Harris Jr JH, Duke Jr JH, et al. Noncorrelation between thoracic skeletal
injuries and acute traumatic aortic tear. J Trauma 1997;43:400-4.
2. Gouldman JW, Miller RS. Sternal fracture: a benign entity? Am Surg 1997;63:
17-9.
3. von Garrel T, Ince A, Junge A, et al. The sternal fracture: radiographic analysis of
200 fractures with special reference to concomitant injuries. J Trauma 2004;57:
837-44.
4. Shweiki E, Klena J, Wood GC, et al. Assessing the true risk of abdominal solid
organ injury in hospitalized rib fracture patients. J Trauma 2001;50:684-8.
5. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child
abuse: systematic review. BMJ 2008;337:a1518.
6. Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical
acumen, and radiography in patients with minor chest injury. J Trauma 2004;
56:1211-3.
7. Jin W, Yang DM, Kim HC, et al. Diagnostic values of sonography for assessment
of sternal fractures compared with conventional radiography and bone scans. J
Ultrasound Med 2006;25:1263-1268; quiz 1269-70.
8. Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin
injuries require radiographic evaluation for intraabdominal injury? Ann Emerg
Med 2005;46:232-6.
9. Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department
evaluation and management. Emerg Med Clin North Am 2003;21:291-313.
10. Gunduz M, Unlugenc H, Ozalevli M, et al. A comparative study of continuous
positive airway pressure (CPAP) and intermittent positive pressure ventilation
(IPPV) in patients with flail chest. Emerg Med J 2005;22:325-9.
11. EAST management of pulmonary contusion and flail chest practice guidelines
2006. Available at http://www.east.org/.
12. Barton ED. Tension pneumothorax. Curr Opin Pulm Med 1999;5:269-74.
13. Bokhari F, Brakenridge S, Nagy K, et al. Prospective evaluation of the sensitivity
of physical examination in chest trauma. J Trauma 2002;53:1135-8.
14. Kirkpatrick AW, Sirois M, Laupland KB, et al. Handheld thoracic sonography
for detecting posttraumatic pneumothoraces: the extended focused assessment
with sonography for trauma (EFAST). J Trauma 2004;57:288-95.
15. Maxwell RA, Campbell DJ, Fabian TC, et al. Use of presumptive antibiotics
following tube thoracostomy for traumatic hemopneumothorax in the prevention
of empyema and pneumoniaa multicenter trial. J Trauma 2004;57:742-8.
16. Brasel KJ, Stafford RE, Weigelt JA, et al. Treatment of occult pneumothoraces
from blunt trauma. J Trauma 1999;46:987-90.
17. Seamon MJ, Medina CR, Pieri PG, et al. Followup after asymptomatic
penetrating thoracic injury: 3 hours is enough. J Trauma 2008;65:549-53.
18. Wanek S, Mayberry JC: Blunt thoracic trauma: flail chest, pulmonary contusion,
and blast injury. Crit Care Clin 2004;20:71-81.
19. Huh J, Milliken JC, Chen JC. Management of tracheobronchial injuries following
blunt and penetrating trauma. Am Surg 1997;63:896-9.
20. Maron BJ, Estes NAM. Commotio cordis. N Engl J Med 2010;362:917-27.
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
21. EAST trauma practice guidelines, EAST blunt cardiac injury guidelines. Available
at http://www.east.org/tpg/archive/html/chap2body.html.
22. Ismailov RM, Ness RB, Redmond CK, et al. Trauma associated with cardiac
dysrhythmias: results from a large matched casecontrol study. J Trauma 2007;
62:1186-91.
23. Jackson L, Stewart A. Best evidence topic report. Use of troponin for the
diagnosis of myocardial contusion after blunt chest trauma. Emerg Med J 2005;
22:193-5.
24. Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to the performance of
pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma
2009;67:1123-4.
25. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department
thoracotomy: review of published data from the past 25 years. J Am Coll Surg
2000;190:288-98.
26. Branney SW, Moore EE, Feldhaus KM, et al. Critical analysis of two decades of
experience with postinjury emergency department thoracotomy in a regional
trauma center. J Trauma 1998;45:87-94.
27. Practice management guidelines for emergency department thoracotomy: Working
Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons
Committee on Trauma. J Am Coll Surg 2001;193:303-9.
28. Wise D, Davies G, Coats T, et al. Emergency thoracotomy: how to do it. Emerg
Med J 2005;22:22-4.
29. Cook CC, Gleason TG. Great vessel and cardiac trauma. Surg Clin North Am
2009;89:797-820, viii.
30. Horton TG, Cohn SM, Heid MP, et al. Identification of trauma patients at risk of
thoracic aortic tear by mechanism of injury. J Trauma 2000;48:1008-13.
31. Nagy K, Fabian T, Rodman G, et al. Guidelines for the diagnosis and
management of blunt aortic injury: an EAST Practice Management Guidelines
Work Group. J Trauma 2000;48:1128-43.
32. Dyer DS, Moore EE, Ilke DN, et al. Thoracic aortic injury: how predictive is
mechanism and is chest computed tomography a reliable screening tool? A
prospective study of 1,561 patients. J Trauma 2000;48:673-82.
33. Stassen NA, Lukan JK, Spain D, et al. Reevaluation of diagnostic procedures for
transmediastinal gunshot wounds. J Trauma 2002;53:635-8.
34. Eroglu A, Turkyilmaz A, Aydin Y, et al. Current management of esophageal
perforation: 20 years experience. Dis Esophagus 2009;22:374-80.
35. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their
longterm sequelae. J Trauma 1998;44:183-8.
36. Wong P, Vendargon SJ. Tension enterothorax. Asian Cardiovasc Thorac Ann 2003;
11:375.
37. Allen TL, Cummins BF, Bonk RT, et al. Computed tomography without oral
contrast solution for blunt diaphragmatic injuries in abdominal trauma. Am J
Emerg Med 2005;23:253-8.
38. Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture.
Am J Emerg Med 2010;28:387.e1-387.e3.
39. Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic
diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med
2004;22:601-4.
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