Management of Thoracic
Trau m a
Morgan Schellenberg, MD, MPH, Kenji Inaba, MD, FRCSC*
KEYWORDS
Thoracic trauma Resuscitation Resuscitative thoracotomy POCUS EFAST
KEY POINTS
Every trauma patient should undergo a rapid clinical examination to screen for traumatic
injuries to the thorax.
There are several imaging modalities that should be considered in the emergency depart-
ment, which include ultrasound, plain radiographs, and computed tomography scan. It is
important to be aware of the indications and pitfalls of each.
Many thoracic injuries can be managed nonoperatively. Invasive bedside procedures,
such as chest tube placement, are critical skills for all emergency medicine physicians
who treat trauma patients.
Resuscitative thoracotomy is a procedure that should be familiar to the emergency med-
icine physician and is indicated for select patients following penetrating and blunt trauma.
INTRODUCTION
The initial assessment of any injured patient must proceed expeditiously and in a sys-
tematic fashion. Injuries to the thorax are common after both blunt and penetrating
trauma and, therefore, all patients who present to the emergency department (ED) af-
ter trauma should be screened for thoracic injury according to the Advanced Trauma
Life Support (ATLS) protocol.1 Because chest injury can impact each of the ABCs
(Airway, Breathing, and Circulation), a rapid evaluation of the chest is performed early
in the evaluation of the injured patient to look for any life-threatening injuries. Non–life-
threatening injuries to the thorax are detected as part of the detailed secondary
survey.
Although shock in the trauma patient is hemorrhagic until proven otherwise, consider-
ation of a tension pneumothorax should occur with any hypotensive trauma patient.
The practical clinical findings associated with tension pneumothoraces include hypo-
tension and tachycardia with poor oxygenation. The classically described absent ipsi-
lateral breath sounds can be difficult to detect in the noisy, chaotic trauma bay, and
tracheal deviation may be missed if a cervical collar is in place. Therefore, clinical sus-
picion should remain high even when breath sounds are equivocal.
If a tension pneumothorax is suspected, the chest should be rapidly decompressed.
A chest radiograph (CXR) is unnecessary and potentially harmful if it delays interven-
tion. An ultrasound probe, if readily available in the trauma bay, can be placed on the
chest to assess lung sliding, the absence of which is suggestive of pneumothorax.
However, tension pneumothorax is a clinical diagnosis, and the clinician should not
wait for radiographic confirmation before intervening.
In the classic description of needle decompression, a large-bore angiocatheter is
placed into the pleural space at the second intercostal space in the midclavicular
line (2IC/MCL). More contemporarily, the fifth intercostal space at the anterior axillary
line has been found to yield greater success rates because of decreased chest wall
thickness at that site.2,3 Needle decompression may fail in up to 58% of cases
when performed at the 2IC/MCL position.4 Because of this, needle decompression
as a means to treat tension pneumothorax should be limited to settings in which finger
thoracostomy or chest tube placement is not feasible.
The first portion of tube thoracostomy, in which decompression of the pleural space
is achieved by opening the parietal pleura and confirming entry by inserting a finger
into the pleural space (referred to by some as a finger thoracostomy), is a better
and more reliable means for decompressing the thorax. A scalpel is used to make a
2-cm to 3-cm skin incision in the fourth or fifth intercostal space in the anterior axillary
line and then is used to cut through the subcutaneous fat and intercostal muscle. A
small cut is made in the pleura and the physician’s finger is then used to widen the
opening into the pleural space, thereby decompressing the chest. This should take
mere seconds to perform and should be followed up with the insertion of a chest
tube through the aperture as soon as time and the patient’s condition permit. The clini-
cian will know the pleural space has been entered with the evacuation of a gush of air
or blood, and the patient’s hemodynamics should normalize accordingly. If they do
not, another etiology for the patient’s altered physiology must immediately be consid-
ered. Entering the pleural space under direct visualization with digital confirmation
provides visual and tactile feedback that the pleural space has been decompressed.
This is not true for needle decompression, in which the absence of air return may sim-
ply be a result of the catheter becoming kinked, blocked, or malpositioned.
Which Patients Require Tube Thoracostomy?
Pneumothoraces and hemothoraces causing respiratory or circulatory compromise
require drainage by way of chest tube connected to a closed suction system and un-
derwater seal. A large hemothorax can present with absent breath sounds, poor
oxygenation, or hypotension, but is more typically detected on supine CXR by
Critical Decisions in Thoracic Trauma 137
toward the placement of smaller chest tubes. One study compared the use of 28 to 32-
Fr with 36 to 40-Fr chest tubes in trauma and found no difference in the successful evac-
uation of hemothoraces or pneumothoraces with smaller-bore chest tubes.10 One
article argued that chest tubes as small as 14 Fr can successfully drain hemothoraces
among stable trauma patients,11 but further confirmation of these findings is required
before chest tubes this small are adopted into widespread practice. At our institution,
28-Fr chest tubes are used in most trauma patients requiring tube thoracostomy.
Both the EAST and the Western Trauma Association (WTA) have published guide-
lines about the indications for RT. The EAST guidelines are centered around signs
of life, defined by the American College of Surgeons Committee on Trauma as any
of the following: pupillary response, respiratory effort, palpable carotid pulse, measur-
able or palpable blood pressure, extremity movement, or cardiac electrical activ-
ity.16,17 EAST strongly endorses RT for patients with penetrating thoracic trauma
who arrive pulseless to the ED but show signs of life.16 For patients with penetrating
thoracic trauma who present without signs of life, patients with penetrating extrathora-
cic trauma with or without signs of life, and patients with blunt trauma and signs of life,
EAST conditionally recommends RT. RT is not recommended for patients who present
pulseless after blunt injury, without signs of life.16 WTA, on the other hand, stratifies
patients first according to duration of cardiac arrest. For blunt traumatic arrests with
less than 10 minutes of cardiopulmonary resuscitation (CPR) and penetrating trau-
matic arrests with less than 15 minutes of CPR, RT is considered beneficial.18 WTA
also supports RT for longer durations of arrest if signs of life (respiratory or motor
effort, electrical activity, or pupillary activity) are present.18
In summary, deciding which patients are candidates for RT requires integrating in-
formation on the mechanism and anatomic location of injury, duration of cardiac ar-
rest, presence or absence of signs of life, findings on bedside ultrasound, and the
available resources and personnel. At our institution, we are liberal with the indications
for RT and perform it on all patients with traumatic cardiac arrest after penetrating
trauma, as well as most patients who arrest after blunt trauma. We do not use ultra-
sound routinely to select candidates for the procedure, but use it selectively in
arrested patients with blunt trauma if they have had a prolonged down time to identify
patients who are unlikely to survive.
Intracardiac medication delivery, such as 1 mg of epinephrine into the left ventricle, and
defibrillation are initiated as warranted. Evacuation of blood from the right chest tube
should prompt extension into a clamshell thoracotomy. Additionally, if a cardiac injury
is discovered and visualization is poor through the left anterolateral thoracotomy, the
physician should not hesitate to extend the incision across the midline and into the right
chest as a clamshell thoracotomy to facilitate repair. A complete description of the pro-
cedural approach to RT can be found elsewhere.19,20
Finding Yourself Face to Face with an Opened Chest: What to Do Once You’re In
Open the pericardium and deliver the heart. Check for and repair any cardiac injuries.
Stop any major intrathoracic bleeding.
Cross-clamp the aorta just above the diaphragm.
Begin open cardiac massage and resuscitation.
Inject intracardiac epinephrine into the left ventricle.
Extend into a clamshell thoracotomy if there is blood in the right chest.
The CXR is considered by most to be the standard initial imaging investigation for all
trauma patients, whether stable or unstable. The traditional single-view AP CXR is
typically obtained as a portable radiograph and therefore has the benefits of being
fast and inexpensive with a low radiation burden, and screens the entire thorax for
injury without having to remove the patient from the trauma bay. Although an upright
CXR is typically advocated for in textbooks, in practice these radiographs are most
Critical Decisions in Thoracic Trauma 141
frequently taken supine. The CXR allows for the assessment not only of the lungs and
pleural space but also of the mediastinum, aorta, diaphragm, and bony structures,
including ribs, thoracic vertebrae, clavicles, sternum, and scapulae. Indeed, ATLS
states that “the chest radiograph [is] a necessary part of any evaluation after traumatic
injury”1 and is one screening factor in the decision to obtain a CT scan.
Although it is somewhat contentious, for these reasons the authors recommend that
all patients undergo a CXR in the trauma bay to screen for thoracic injury. Some pa-
tients can safely have a CXR omitted, but these are the minority. For example, patients
with penetrating trauma remote from the thorax do not require CXR, but the clinician
must maintain a high degree of suspicion for unusual bullet trajectories. All blunt multi-
system trauma patients should have a supine CXR performed in the trauma bay.
Stable patients with an abnormal CXR should proceed next to CT scan. The appro-
priate management of patients after a normal CXR is more controversial and is
explored further in the section on CT thorax, later in this article.
EFAST is excellent in the assessment for pneumothorax, it does not provide any
assessment of the bony elements of the thorax, the mediastinum (apart from the eval-
uation for pericardial effusion), or the diaphragm, all of which are assessed on CXR.
Ultrasound is also a user-dependent test whose validity is constrained by the experi-
ence of the clinician, which is true to a much lesser extent with CXR. Therefore, EFAST
and CXR should be considered complementary rather than competing diagnostic
tests. Given the ease of performing a CXR and the low cost and radiation burden asso-
ciated with it, the authors propose that instead of omitting a CXR from the diagnostic
workup, a better question may be whether or not the CT chest can be forgone in the
context of a normal CXR and EFAST. This has not yet been clearly studied.
CT scan of the chest is the gold standard imaging modality in thoracic trauma for sta-
ble patients, with sensitivity of 74% to 82% and specificity of 99% to 100%.31,32
Despite its excellent diagnostic capability, CT scan has important limitations. It is
costly,33,34 exposes the patient to an effective radiation dose of roughly 9 mSv,35
and perhaps most importantly, necessitates the transport of the patient out of the
trauma bay at a critical time in the clinical course.36 Therefore, it is important to care-
fully select patients who will derive benefit from this diagnostic intervention.
Stable patients with an abnormal physical examination, EFAST, or CXR require CT
chest for further assessment of their injuries. One study of 141 patients with major
blunt trauma found that an abnormal physical examination (chest wall tenderness,
decreased air entry, and/or abnormal respiratory effort) increased the diagnostic yield
of CT chest by odds ratios of 4.1 to 6.7 depending on the specific physical examina-
tion findings.36 Rodriguez and colleagues37 developed the NEXUS Chest Rule, in
which stable patients with blunt trauma who lack all 7 criteria (age >60, rapid deceler-
ation mechanism, chest pain, intoxication, distracting injury, tenderness to chest wall
palpation, and abnormal mental status) do not require either CXR or CT chest.38–40 If
one or more feature is present, the NEXUS Chest Rule recommends CXR as the next
investigation, with the subsequent decision about the need for CT chest based on the
mechanism of injury, the findings on CXR, and the physical examination.
Patients with a normal primary survey and CXR or EFAST present more of a diag-
nostic challenge. A large study of 3639 patients with blunt trauma showed that of
the patients with a normal CXR who went on to receive a CT chest, only 2.7% had
a clinically significant injury.33 Put differently, if none of the 3383 patients in this study
with a normal CXR went on to receive a CT chest, 90 would have had a clinically sig-
nificant missed injury, including 12 patients with a major missed injury, such as an
aortic or other great vessel injury. This rate of missed injuries must be balanced
against the cost and radiation exposure necessitated by a CT chest, as well as the
risks associated with transporting the patient out of the ED. Limiting a CT chest to pa-
tients with a high-risk mechanism or abnormal physical examination, EFAST, or CXR is
a reasonable approach. However, there is no clear definition of what specifically con-
stitutes a high-risk mechanism at this time, and clinical judgment must be used.
underlying lung parenchyma as the flail segment of ribs moves paradoxically against
the remainder of the chest wall on inspiration and expiration. The resultant pulmonary
contusion can contribute to respiratory decompensation. Surgical options for flail
chest (open reduction and internal fixation with rib plating) are current being
explored.41 For now, the cornerstones of management include aggressive pain con-
trol,42 alveolar recruitment, and judicious use of intravenous fluids, especially in the
first few days after injury. Because respiratory failure resulting from inadequate anal-
gesia, poor secretion clearance, evolving pulmonary contusions, and volume overload
can occur precipitously, these patients are typically best monitored in the intensive
care unit for the period immediately after injury.
Blunt cardiac injury (BCI) is an injury pattern that warrants special consideration.
Clinically significant BCI is infrequent and can manifest as either mechanical or elec-
trical cardiac dysfunction. Mechanical BCI, such as injury to the papillary muscles or,
at its extreme, septal or cardiac wall rupture, is exceedingly rare among patients who
arrive alive to hospital. In a large case series of 811,531 patients with blunt trauma who
arrived alive to the ED, the rate of cardiac rupture was 0.045%.12 On autopsy study,
however, blunt cardiac rupture is common (20%).43 Mechanical BCI is therefore
frequently fatal, and most patients who sustain this type of injury die at the scene or
en route to hospital.
Electrical BCI, which manifests as arrhythmia, is far more common and is usually
self-limited. Most cases occur after high-speed motor vehicle collisions, as a result
of rapid deceleration or direct blows to the chest (for example, from the steering
wheel).44 The optimal workup of these patients is unclear. One early study showed
that a normal electrocardiogram (ECG) and troponin at admission ruled out clinically
significant BCI.45 The same institution then repeated this prospective study with a
larger sample (n 5 333) of patients who had sustained significant blunt thoracic
trauma, and found that a normal ECG and troponin were required both at admission
and 8 hours later to exclude clinically significant BCI.46 The EAST guidelines recom-
mend that BCI can be safely ruled out if both the ECG and serial troponins are
normal.47 Our approach to BCI screening is to admit patients with significant blunt
thoracic trauma for 24 hours of continuous cardiac monitoring, and obtain an ECG
and 3 sets of troponins. Echocardiography should be reserved for patients who
have hypotension, an abnormal ECG, or up-trending troponin levels.
Endovascular Therapies
The emerging role for endovascular management of thoracic vascular injuries, in which
the injured vascular segment is excluded from the circulation,48 has garnered much
attention in recent literature. Endovascular management of blunt thoracic aortic injury,
for example, has been shown to result in less blood loss, paraplegia, and mortality, with
a similar risk of stroke, as compared with open repair of these injuries. Although most
patients with free aortic rupture die on scene, patients with traumatic aortic dissections,
intimal flaps, or contained ruptures are typically stable when they present to hospital
and are candidates for endovascular repair, the approach now endorsed by major
trauma societies, such as EAST.49 The use of endovascular therapies is increasing,
with one study using the National Trauma Data Bank showing a significant increase
in the use of endovascular techniques for both penetrating and blunt trauma, as well
as a significant decrease in mortality of these patients over the same period.50
output greater than 1.5 L in 24 hours, were indications for operative interven-
tion.1,6,51,52 Most surgeons now rely primarily on the patient’s physiology, that is, clin-
ical evidence of shock, to guide intervention.6 However, many surgeons would still
consider operative intervention with evidence of ongoing bleeding or chest tube
output greater than 1 L, regardless of the patient’s hemodynamic status. Early involve-
ment of the surgical team is most prudent, although with increased acceptance of
nonoperative management and a rise in the use of catheter-based interventions,
few patients now require urgent or emergent thoracotomy apart from patients
suffering traumatic cardiac arrest.
SUMMARY
Thoracic injury is common after both blunt and penetrating trauma, and can range
from a relatively benign occult pneumothorax to a cardiac injury causing rapid exsan-
guination and clinical death. Expedient assessment of the injury burden is critical, and
familiarity with the imaging options (CXR, EFAST, and CT chest) for further workup of
thoracic trauma is important. The emergency medicine physician must be adept at
decompressing tension pneumothoraces, quickly placing chest tubes, and performing
RT when indicated. Swift management of life-threatening thoracic injuries and appro-
priate workup of others will allow the ED physician to successfully manage patients
from the moment they arrive in the ED to the time at which they are brought to the
OR, interventional radiology suite, intensive care unit, ward, or discharged home.
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Critical Decisions in Thoracic Trauma 147