Kaplan Surgery

Current Problems in
Surgery °
Volume 35 Number 8 August 1998
Cardiothoracic Trauma
.11
A. Thomas Pezzella, MD
Associate Professor of Surgery
Division Cardiothoracic Surgery
Department of Surgery
University of Massachusetts Medical Center
Worcester, Massachusetts
Wayne E. Silva, MD
Professor of Surgery
Vice Chairman, Department of Surgery
Robert A. Lancey, MD
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
Department of Surgery
[~v~ Mosby
A Times Mirror
Company
Current Problems in
Surgery °
Volume 35 Number 8 August 1998
Foreword 651
In Brief 652
Biographical Information 655
Introduction 656
General Characteristics of Cardiothoracic Trauma 656
Epidemiologic Characteristics 656
Historical Aspects 660
Causes/Classification 664
Mechanism of Injury 668
Pathophysiotogic Features of the Host Response 674
Injury Severity 678
Management Algorithms 682
Initial Resuscitation 683
Critical Care Phase 688
Diagnostic Modalities 693
Treatment 699
Complications of Chest Trauma 719
Specific Injuries 719
Chest Wall Injuries 719
Pleural Injury 730
Lung Injury 736
Injuries of the Larynx, Trachea, and Bronchus 741
Injuries of the Diaphragm 746
Mediastinal Injuries 749
Esophageal Injuries 753
Cardiac Injuries 757
Injuries of the Tht~racic Aorta and Great Vessels 762
Curr Probl Surg, August 1998 649

Special Problems 771
Inhalation Injury 771
Foreign Bodies 772
latrogenic Injury 775
Military Cardiothoracic Trauma 776
Pediatric Cardiothoracic Trauma 777
Cardiothoracic Trauma in the Elderly 778
References 779
650 Curr Probl Surg, August 1998

[]
Foreword
This issue of Current Problems in Surgery is devoted to the
topic of "Cardiothoracic Trauma," written by Drs Thomas
Pezzella, Wayne Silva, and Robert Lancey of the University of
Massachusetts. The monograph is divided into three parts that
address general aspects of cardiothoracic trauma, specific
injuries of the thorax and its contained organs, and special
problems of cardiothoracic injury. The monograph is particu-
larly well illustrated with abundant tables and figures; the ref-
erences are complete and current. This treatise represents a
thorough review of the topic and will provide an excellent
resource for those who deal with the critically injured patient.
It will be especially valuable for house officers in all disci-
plines who are learning to manage the conditions of victims of
vehicular trauma and criminal assault, which are common
causes of death in a vibrant sector of our population.
Samuel A. Wells, Jr, MD
Editor-in-Chief

In Brief
Trauma remains the fourth leading cause of death in the United States
after heart disease, cancer, and cerebrovascular disease, t More than
145,000 trauma-related deaths occurred in 1993. Trauma accounts for an
increasing proportion of the total health care expenditures for hospitaliza-
tion and disability. Because trauma affects a relatively large number of oth-
erwise healthy young individuals, the loss in terms of potential and actual
employment hours and variable disability is difficult to assess completely,
but is likely significant.
Cardiothoracic trauma is responsible for more than 25% of trauma
deaths and contributes to death in an additional 50%. 2 In-hospital mortality
rates for isolated chest trauma are 4% to 8% and increase to 13% to 15%
when one other organ system is involved and to 30% to 35% when more
than one other system is involved. Blunt trauma accounts for 70% of chest
injuries, and more than 70% of these injuries result from motor vehicle
accidents. For penetrating injuries, 60% to 70% are due to stab wounds.
The 2% to 3% mortality rate in this group rises to 14% to 20% in those
individuals with gunshot wounds.
Chest wall and soft tissue are the most common locations for both blunt
and penetrating injuries. The least commonly injured structures (the aorta
and great vessels), however, carry the highest mortality rate, ranging from
27% for penetrating injuries to 50% for blunt injuries.
The documentation of chest injuries extends from 3000 BC, in the
Edwin Smith papyrus papers, to the Vietnam experience. Over this time
span, many anecdotal and retrospective cardiothoracic experiences have
been documented. Homer, in 950 BC, vividly described cardiac wounds.
Galen, in 200 AD, described packing open chest wounds. Rehn success-
fully repaired a penetrating cardiac wound in 1896. Over the past 100
years, advances in cardiothoracic trauma have paralleled the growth of
surgery in general. Endotracheal intubation, blood transfusion, antibi-
otics, evolving surgical procedures, and sophisticated diagnostic tech-
niques have all contributed to that growth.
An understanding of the pathophysiologic features of cardiothoracic
trauma and the contribution of associated injuries is crucial to proper eval-
uation and treatment. Blunt chest trauma involves deceleration, accelera-
tion, crush, compression, and stretch/shearing components. Penetrating
trauma involves a knowledge of ballistics and the resulting permanent and
temporary cavitation effects. Blast injury historically has been peculiar to
652 Curr Probt Surg, August 1998
the military and combat environment, but a substantial number of these
victims have associated blunt and penetrating injuries resulting from the
secondary and tertiary effects.
Severity scoring has helped the clinician to better understand and eval-
uate the trauma victim. Proper International Classification of Diseases
(ICD) coding (ICD-9) along with trauma registries may facilitate better
follow-up and documentation.
The comerstone of care for the cardiothoracic trauma victim is provided
in the first 2 to 4 hours after the injury. There is a trimodal pattern of death
(ie, early, hospital, and delayed), but the greatest number of deaths occur
early. The Advanced Trauma Life Support (ATLS) approach has con-
tributed to a more organized and systematic management scheme for the
trauma victim.3 The six life-threatening injuries (ie, airway obstruction,
tension pneumothorax, cardiac tamponade, open pneumothorax, flail
chest, and massive hemothorax) and the six potentially lethal injuries (ie,
pulmonary contusion, myocardial contusion, aortic disruption, diaphrag-
matic hernia, tracheobronchial disruption, and esophageal disruption)
demand early recognition and an aggressive approach to ensure improved
survival.
In addition to a knowledge of the accident circumstances or mechanism of
injury, a detailed history and physical examination are vital. Missed injuries
are increasing in frequency. Sophisticated and newer diagnostic techniques
including computed tomography (CT) scanning, traditional and digital
angiography, thoracoscopy, and transesophageal echocardiography (TEE)
have aided the clinician in establishing or documenting concealed or subtle
injuries.
Less than 15% of all chest trauma victims require an operation beyond
tube thoracostomy. Subxiphoid pericardiaI window, median sternotomy,
and thoracotomy remain the traditional operative procedures. Video-
assisted thoracoscopic surgery will find an increasing role. The role of
cardiopulmonary bypass with heparin-coated circuits is an exciting new
area both in trauma resuscitation and for specific intrathoracic injuries.
Supportive therapeutic adjuncts are important. Prophylactic antibiotics
are recommended in penetrating and operative wounds. Volume resuscita-
tion with crystalloid, colloid, or hypertonic saline solution remains contro-
versial. Pain control has vastly reduced the morbidity associated with chest
wall trauma. Double-lumen or bronchial-blocker endotracheal intubation
greatly facilitates approaches to the hilum, heart, aorta, and esophagus.
An increasing volume of literature is emerging regarding the delayed and
chronic problems'after injury. 4 Pleural space and lung parenchymal prob-
lems, particularly atelectasis and collapse, demand aggressive approaches
in the intensive care or ward setting. Chronic problems, such as chest wall
pain and disability, challenge the clinician.
Specific cardiothoracic injuries have received increased attention.
Management of the flail chest focuses on renewed approaches to chest
wall stabilization along with a better understanding of the contribution of
the underlying lung contusion. Sophisticated mechanical ventilation
schemes have emerged. The role of CT scanning in better identifying
intrathoracic pleural collections and lung injury makes drainage proce-
dures more accurate and focused. TEE has improved our diagnostic capa-
bility. Pericardial fluid collections, myocardial wall motion, valve func-
tion, intracardiac shunts or fistulas, and aortic injuries can be assessed with
increasing sensitivity and specificity with TEE. Contrast aortography
remains the gold standard for aortic injury, yet CT scanning and magnetic
resonance imaging (MRI) have gained increased applicability. The timing
of surgery for blunt aortic tears has been challenged. Better anatomic doc-
umentation of the degree of injury with better control of associated injuries
will certainly improve survival rates in this most lethal of all cardio-
thoracic injuries. The dreaded complication of spinal cord injury has been
addressed exhaustively. The accepted incidence of 5% to 8% paraplegia
after operative repair of blunt thoracic aortic tears has not improved statis-
tically. However, for repairs requiring more than 30 minutes of aortic
crossclamping, most groups favor a shunt or bypass technique. Left heart
(ie, left atrial to femoral artery) centrifugal pump bypass techniques are
presently the most common method of spinal cord protection and lower
body perfusion.
Special areas in cardiothoracic trauma include the elderly and pediatric
populations. The military and combat scenarios demand an appreciation
of mass causality, triage, and the change of treatment focus from the most
injured to the least injured to preserve the fighting strength and the need
to conserve vital medical resources to benefit the most salvageable vic-
tims. Foreign bodies and inhalation injury remain a challenge. Innovative
removal techniques are used for the former, and a better understanding of
the underlying inhalation injury pathophysiologic condition now assists
in the care of the latter.
There is no question that rapid and sophisticated evaluation at the scene
and subsequent transfer to level I trauma centers has dramatically
changed the profile of the patient with cardiothoracic trauma. The rising
injury severity score with multisystem involvement demands even more
complicated diagnostic and therapeutic strategies. The rewards are grati-
fying, with a progressive decrease in deaths from cardiothoracic trauma.
The fiscal cost, however, continues to rise.
~ . ~ ~
~ A. Thomas Pezzella, MD, has been
Associate Professor of Surgery at the
University of Massachusetts Medical
Center in Worcester, Massachusetts
since 1986. A graduate of Holy Cross
College and St. Louis University School of Medicine, he obtained his general
and cardiothoracic surgery training at the University of Kentucky. A Colonel in
the United states Army Reserve, Dr Pezzella has a special interest in both civil-
ian and military trauma.
~ ) ~ Wayne E. Silva, MD, is Professor

~_~~ of Surgery at the University of
Massachusetts Medical Center. Dr
Silva received a bachelor of sci-
ence degree from Tufts College
and an medical degree from Tufts University Medical School. His surgical
residency training at the St. Vincent Hospital, Worcester, Massachusetts,
was interrupted briefly for 2 years of service with the United States Army
Special Forces. Presently Vice Chairman of the Department of Surgery at
the University of Massachusetts Medical School, Dr. Silva has served as
Level I Trauma Center Director and Chief of General Surgery and is
presently Residency Program Director. A member of the Army Reserve, he
served as Chief of Surgery of an evacuation hospital during the Gulf War.
His principal clinical and research interests have been in trauma, teach-
ing of surgical techniques, and abdominal wall reconstruction.
,o er., a ce, .a,ra, a.e

of the University of Massachusetts
Medical School and completed his
general surgical residency and his
cardiothoracic surgical training at the University of Massachusetts Medical
Center. He is presently Assistant Professor of Surgery at the University of
Massachusetts Medical Center, and his primary research interests include
thoracic trauma, aortic valve replacement and its effects on left ventricular
hypertrophy, and cardiopulmonary bypass.
Curr Probl Surg,August 1998 655

T his monograph highlights the broad spectrum of cardiothoracic
trauma, with the use of the range of experience in the literature.
Our institutional bias or approach will be stated. Whereas in
1991 Symbas 5 focused on the Grady Hospital experience in Atlanta,
Georgia, we will attempt to glean information from a variety of sources.
Given the incidence of trauma in American society and the tremendous fis-
cal cost, with the associated mortality, morbidity, and disability rates, it is not
surprising that a large volume of the surgical literature is devoted to the under-
standing and advancement of newer and more efficient methods of trauma
evaluation and more appropriate and coordinated strategies for patient man-
agement. This monograph collates the recent advances and approaches to
the care of the victim of cardiothoracic trauma. Newer technology has
broadened our depth of understanding. Exciting new potential treatment
options may further enable us to salvage some of these desperately trauma-
tized individuals. The future will focus on prevention, access, resuscitation,
cost, documentation, analysis of complications, and long-term results.
Trauma can be defined as an external harmful force, stress, or act
inflicted on or sustained by the human host. It exacts a host response pro-
portional to the extent of the traumatic stimulus and modified by the envi-
ronmental milieu in which it occurs. It is a global disease, transcending
age, sex, race, religion, culture, or economic status. It is random and spo-
radic in occurrence and location and without host predisposition. It is
largely preventable and predictable. The extent and consequences range
from the benign and self-limited to the disabling, mortal, and catastroph-
ic. Scientifically, the degree of injury sustained is proportional to the
amount of energy transferred, speed of transfer, and host-area involved.
General Characteristics of Cardiothoracic Trauma

Epiderniologic Characteristics
The population of the United States is over 250 million people. There
are more than 2.2 million deaths per year. Tragically, in 1993 of these
total deaths, 90,523 accidental deaths, 31,102 suicides, and 26,009 homi-
cides (totaling 147,634 deaths) made trauma the fourth leading cause of
death (Table 1). Trauma is the leading cause of death in individuals
younger than 34 years of age. Most of these deaths are due to motor vehi-

TABLE 1. Ten leading causes of death, United States, 1993
Cause No. of deaths
Heart disease 743,460
Cancer 529,904
Cerebrovascular diseases 150,108
Chronic obstructive pulmonary disease 101,077
Accidents 90,523*
Pneumonia & influenza 82,820
Diabetes mellitus 53,894
H1V infection 37,267
Suicide 31,102 ¢
Homicide 26,009'
All causes 2,268,553
*Male, 60,117.
tMale, 25,007.
*Male, 20,290.
*Adapted from CA A Cancer Journal for Clinicians 1997;47:5-27.
TABLE 2. Mortality rates after blunt chest trauma

Overall Direct Contributory
mortality mortality mortality
Study Country rate (%) rate(%) rate (%)
Kemmerer et al, 1961 ~s United States 50 -- --
Slatis, 1 9 6 2 Finland 49 -- --
Schulz, 1 9 6 9 Germany 51 -- --
Hoffman, 1 9 7 6 England 50 -- --
Shorr et al, 198714 United States -- 15.5
Kulshrestha et al, 198813 India 33 19 14
Glinz, 199012 Switzerland 28 10 18
UMMC, 1996 United States -- 11 --
Adapted from Glinz W. Causes of early death in thoracic trauma. In: Webb WR, Besson A, editors.
Thoracic surgery: surgical management of chest injuries, St. Louis, MO: Mosby-Year Book; 1991, p, 26-9.
cle accidents (MVA). Accidents account for the fourth leading death rate,
at 31.5 per 100,000 individuals.
Trauma affects more than 60 million people per year in the United
States, resulting in more than 3 million annual hospital admissions. 6
Twelve percent of all hospital beds and more than 7% of all health costs
annually are related to trauma. 7 In 1989 the cost of accidents was $148.5
billion. This figure included medical expenses, insurance, lost wages,
vehicle or fire loss, and indirect work lost.
More than 9 million trauma injuries involve the thorax and account for
more than 250,000 hospital admissions annually. 8"9 It is estimated that
25% of all trauma,deaths (ie, MVA, suicide, homicide) are due to chest
injuries, with chest trauma contributing to death in an additional 50%. It
is estimated that there are 180 severe chest injuries per 1 million individuals
TABLE 3. Location of blunt chest trauma
Total no. Chest Flail Pneumothorax
Study of patients wall (%) chest (%) (%)
Kemmerer et al, 196115 585 39 -- --
Beeson & Saegesser, 1983 s 1500 54 13 20
Beg et al, 198616 553 68 23 17
NAMTOS*, 19879 (70% blunt) 15,047 45 5 20
Glinz, 199012 675 -- -- 18
Campbell (PTOS t) 17, 1992 15,136 57.7 4.4 22.8
UMMC, 1996 ~ 1372 -- 3.7 38
*North America Trauma Outcome Study.
tPennsylvaniaTrauma Outcome Study.
tUniversity of Massachusetts Medical Center data (from authors)
TABLE 4. Chest trauma, 1990 (MIEMS) is

Blunt trauma* Penetrating trauma t
No. of Mortality No. of Mortality
patients rate (%) patients rate (%)
Chest wall 772 9 151 15
Diaphragm 16 38 40 28
Heart 125 12 15 60
Hemothorax 97 44 62 26
Pneumothorax 161 25 45 18
Lungs 129 26 28 25
Great vessels, including aorta 15 50 15 27
"1150 patients.
t195 patients.
From Tarantino DP, Bernhard WN. Anesthesia considerations in thoracic trauma. Semin Thorac
Cardiovasc Surg 1992;4:187-94.
per year. Hospital mortality rates for isolated injuries are 4% to 8% but
increase to 13% to 15% if one additional system is involved and to 30%
to 35% if two or more other systems are involved. 2
In Europe it is estimated there are four chest injury hospital admissions
per day per 1 million population. In the United States, the estimate is 2.5
per day, with a greater incidence of MVA. 1°
The World Health Organization estimates that there are 200,000 motor
vehicle deaths per year and that more than 6 million individuals are
injured, ]] with a 50% chest or chest-related mortality rate. Despite these
findings, several recent reports show a decrease in thoracic (caused or
contributed) mortality rates. Glinz, ~2 in a study of 460 deaths occurring
within the first week after injury, reported that 58% of those individuals
who died had chest injuries, with 10% of deaths directly and 18% of
deaths indirectly related to the chest injury. Kulshrestha and colleagues ~3
noted a similar 19% mortality rate directly related to chest injuries in
Hemothorax Pulmonary Heart Diaphragm Aorta/great Esophagus
(%) (%) (%) (%) vessels (%) (%)
28 16 6 5 10 0.2
21 21 . . . .
20 10 2.85 4,3 -- 0.57
25 25 9 7 4 0.5
51 21 16 4 2.9 0.15
13.6 28.8 . . . .
65.6 40.7 1.1 3.1 1.4 0.01
blunt trauma. Shorr and colleagues 14 at The Maryland Institute for

Emergency Medical Services Systems (MIEMSS) showed that, of 515
patients with blunt chest trauma from 1982 to 1984 (70.9% in MVA),
15.5% died. In our own experience of 1450 chest injuries (95% blunt)
from 1991 to 1996, the mortality rate was 11% (Table 2).
A breakdown of mortality rates related to the location of chest injury is
illustrated in Table 3. Our own experience at the University of Massachu-
setts Medical Center (UMMC) shows a distinct increase in hemothorax,
pneumothorax, and lung contusion. This is consistent with the predomi-
nance of MVA victims in our population. An updated series from MIEMS
(Table 4) compares both blunt and penetrating injuries. 18In blunt injuries,
the more common injuries (ie, chest wall and soft tissue) have the lowest
associated mortality rates (9% and 5%, respectively) whereas the least
common injuries (ie, vessels and diaphragm) have the highest mortality
rates (50% and 38%, respectively).
More detailed reports now give us additional data regarding the location
of chest injuries, location-related mortality rates, and the incidence and
mortality with relation to associated body regions. One example is the
Pennsylvania Trauma Outcome Study, which noted that the association of
head and neck injury with hemothorax carried a 53.7% mortality rate and
that the association of tracheobronchial and hemothorax injury carried a
75.9% mortality rate (Table 5). ~7
Penetrating chest trauma is less common and carries a lower overall mor-
tality rate than blunt trauma. However, the rate varies according to the mech-
anism of injury and the structures involved. The mortality rate for stab
wounds ranges from 1% to 8% and for gunshot wounds ranges from 14% to
20%. These figure..#, however, relate to hospital summaries (Table 6).
Involvement of the heart carries the highest mortality rate (60% in the
MIEMS series). When the diaphragm, lung, or great vessels are involved, the
TABLE 5. Pennsylvania Trauma Outcome Study: associated injuries by ISS body region17
Head/Neck Face T-spine
No. of Mortality No. of Mortality No. of Mortality
injury patients rate (%) patients rate (%) patients rate (%)
Chest trauma 6540 21.6 2776 16.9 985 19.6
Pneumothorax 1510 16.4 693 13.4 183 9.8
Hemothorax 827 53.7 315 45.1 213 44.6
Combined: 597 23.6 229 16.2 128 12.5
pneumo/hemothorax
Flail chest 338 34.6 172 26.7 53 50.9
Rib fracture 3935 19.5 1659 15.7 671 19.1
Pulmonary contusion 2442 26.9 1023 21.5 312 20.2
Tracheobronchial 29 75.9 7 42.9 6 100.0
From Campbell DB. Traumato the chest wall, tung and major airways. Semin Thorac Cardiovasc Surg
1992;4:234-40.
TABLE 6. Mortality rates after penetrating chest trauma

Series No, of patients Mortality rate (%)
Baillot et al, 1987 t9 ' 76 10.5
Robison et al, 1988 2o 1168 2.4
Mandal & Oparah, 1989 21 1109 2.4
Tarantino & Bernhard (MIEMS), 1990 18 195 13
mortality rate ranges from 25% to 28%. Most nonsurvivors do not reach the
hospital and usually die of cardiac or ~eat vessel injury (the result of tam-
ponade or exsanguinating hemorrhage). Future analyses must stress the
agent, mechanism of injury, clinical state, severit3, score, structures involved,
associated injuries, complications, and both short- and long-term outcome.
A discussion regarding the cost-effectiveness and prevention of traumatic
disease is beyond the scope of this monograph.22 There is still controversy
regarding the criteria for admission to level I trauma centers, given the
hospital costs, because 75% to 96% of the patients are uninsured.
Regarding prevention in blunt trauma from MVA, shoulder and seat belts,
airbags, lower speed limits, and improved vehicle design features (especially
side impact) have contributed to less morbidity and lower mortality rates.
With regard to penetrating trauma, flak jackets and handgun control each
have proponents. As an example, lowering the speed limit in 1973 to 55
MPH saw a 19% decrease in highway fatalities in the subsequent year. 23
Historical Aspects
Edwin Smith, an American Egyptologist, discovered a papyrus at Luxor
in 1862. 24 A roll 15 feet in length contained 3 of 58 cases that referred to
660 Curr Probl Surg, August 1 9 9 8
Abdomen Extremities External None
No. of Mortality No. of Mortality No. of Mortality No. of Mortality
patients rate (%) patients rate (%) patients rate (%) patients rate (%)
4479 28.6 7164 17.2 11,354 17.4 1404 14.3
957 16.7 1644 12.7 2518 10.9 409 3.7
977 58.1 934 47.1 1472 52.0 242 37.2
534 23.6 698 17.5 997 17.4 207 8.2
234 42.7 414 29.0 522 31.4 25 36.0

2604 27.7 4724 15.7 6824 15.6 547 9.0
1678 33.2 2536 20.8 3538 21.7 193 7.8
21 81.0 20 65.0 36 69.4 6 50.0
chest traumaY .26 Dated around 3000 BC, chest wall abscess, fractured
ribs, heart trauma, perforated esophagus, and empyema were described.
Interestingly, once a diagnosis was made only three therapeutic decisions
were made in 42 of the 58 cases: (1) an ailment that I will treat; (2) an ailment
with which I will contend; or (3) an ailment not to be treated. Certainly
the traditional triage system and the recently applied damage-control concept
took their roots over 5,000 years ago.
Other significant historical events in the evolution of chest trauma are
summarized in Table 7. A considerable amount of insight has been
demonstrated. As an example:
Ad Jesus autem corn venissent (milites), ut viderunt cure jam mortuum, non
frequrent, ejus crura, sed unus militum inncer intus, ejus aperuit, et continue,
exirit sanguis et agun (John XIX, 33, 34). But after they (the soldiers) were
come to Jesus, when they saw that He was already dead, they did not break
His legs. But one of the soldiers with a spear opened His side, and immediate-
ly there came out blood and water. The Bible, (New Catholic Edition, 1953)
Barbet 27 clearly presents this case as that of a postmortem hydrohe-

mothorax involving postmortem pulmonary effusion and penetration of
the pericardium and right side of the heart with subsequent hemothorax.
The early history was clearly anecdotal but reflective in that basic con-
cepts regarding diagnosis and treatment were being used despite a lack of
understanding of the underlying pathophysiologic condition involved.
In 1346 firearms were first used in the Battle of Crecy. The morbid lega-
cy of gunshot wourlds continues to grow. Despite this trend, however, the
mortality rate has recently decreased. Larrey, Napoleon's surgeon, intro-
duced the ambulance which decreased the recovery time from the battle-
TABLE 7. Historical highlights in cardiothoracic trauma
3000 BC Smith Papyrus Treatment of chest injuries by Egyptian
physician Imotep
950 BC Homer Vivid account of penetrating chest wounds
400 BC Hippocrates Rest, bloodletting for fractured ribs
Chest binding
352 BC Epaminondas Vivid description of penetrating chest wound
300 BC Aristotle Heart alone of all the viscera cannot with-
stand injury
200 AD Galen Packing open chest wounds suffered by
gladiators
13th Century Theodoric Described chest wounds
17th Century Riolanus Treatment of cardiac injuries in animals
17th Century Scultetes Empyema as a complication of chest injury
Chest drainage/irrigation
18th Century Hunter Do not explore every penetrating wound
1829 Larrey Successful drainage of hemopericardium
from stab wound
1840 Par~ Cardiac tamponade described
1889 Cohnheim Oil in pericardium causes increased venous
and decreased arterial pressures
1896 Rehn First successful repair of penetrating cardiac
wounds
1896 Paget First text on surgery of the chest
field. Letterman, during the Civil War, also advocated the concept of rapid
evacuation of the wounded. The helicopter dramatically changed the early
evacuation scheme during the Korean and Vietnam conflicts.
In 1885 Theodore Billroth stated that "the surgeon who should attempt
to suture a wound of the heart would loose the respect of his colleagues."
Despite this and failed prior attempts, Rehn in 1896 successfully repaired
a penetrating cardiac wound.
One exception to the anecdotal approach is the reflective observation of
John Hunter, the father of modem trauma surgery. His observation that all
penetrating wounds need not be explored was based on the simple fact
that they healed better if not explored:
"It has been hereto recommended in universal practice by almost every surgeon
to open immediately upon it being received as soon as possible the external ori-
fice of all gunshot wounds made by musket balls; so much has this practice been
recommended that they have made no discrimination between one gunshot
wound and another. "28
In the 20th century major advances in cardiothoracic trauma occurred in
the military or combat setting. The major advances involved the approach
to empyema by the Graham Commission after World War I. The high
TABLE 8. Mortality rates for combat penetrating chest trauma
Incidence (%) Mortality rate (%)
Crimean War 6-8 79*
American Civil War 8 63
Italian War, 1859 -- 61
Franco Prussian War -- 56
World War I 2-5 25
World War II 8 12
Vietnam 7
*French, 91.6%; British, 79.2%.
TABLE 9. Cause of chest trauma

Nonpenetrating
Blunt Motor vehicle
Driver
Occupant
Pedestrian
Motocycle
Falls
Sports injury
Assault
Crush
Blast Primary, secondary, tertiary
Penetrating Gunshot
Low velocity (<1000 f t / s or 305 m/s)
High velocity (>3000 f t / s or 914 m/s)
Shotgun
Stab wound
Impalement
Other latrogenic
Foreign bodies
Inhalation (burns/toxins)
Barotrauma (diving)
Drowning (fresh/salt)
Altitude
Accidental hypothermia (with/without immersion)
Combinations of nonpenetrating,
penetrating, and other
mortality rate associated with empyema was related to an open pneu-

mothorax in the presence of persistent pneumonia. The concept of closed
drainage improved the results remarkably. The establishment of focused
thoracic surgery units in World War II led to improved management of
thoracic foreign bodies, immediate closure of chest wounds, early
decortication, and an appreciation of rapid, efficient evacuation. 29,3° The
wet lung syndrome or adult respiratory distress syndrome (ARDS) and
the need for aggressive management of vascular injuries were appreciat-
FIG. 1. Prehistoricarrow wound to sternum with penetration and exsanguinating heart laceration.
(Courtesy Guido Majno, MD, Department of Pathology, University of Massachusetts Medical Center,
Worcester, Mass,)
ed during the Vietnam conflict. The mortality rates for combat-related

thoracic injuries parallels the civilian experience figure (Table 8).
The insulting victor with disdain best rode the prostrate prince, and on his
bosom trode.
He withdrew the weapon from his panting heart,
The reeking fibers clinging to the dart;
From this wide wound gushed out a stream of blood,
And the soul issued in the purple flood.
Iliad, Homer
Certainly the history of cardiothoracic trauma continues (Fig. 1).

Modem day contributions include sophisticated anesthesia techniques,
antibiotics, blood banks, and better diagnostic modalities, along with
sophisticated trauma registries and coding systems.
Causes/Classification
Chest injuries are classified conveniently as penetrating or nonpenetrating.
A more comprehensive classification is summarized in Table 9. Nonpene-
trating trauma accounts for more than 70% of injuries, with more than
50% of these the result of MVA. Crush injuries are usually fatal and occur
primarily in disasters such as earthquakes and major transportation disas-
ters. An increasing number of penetrating injuries are seen with urban
violence and military combat scenarios. Blast injuries occur with explo-
sions. A component of thermal, blunt, and penetrating injury can occur
with these injuries as well.
It is important to stress the associated injuries in the patient with multi-
trauma (polytrauma). The interaction of blunt and penetrating forces must
PHYSIOLOGICAPPROACHmFIRSTMETHODOF ATTACK
Defects affecting outer reRion
Defects affecting inner region
Defects affecting innermost region
ETIOLOGICAPPROACHmSECONDMETHODOF ATTACK
~)~_~/ ~ Nonpenetratingwounds
~'~ ~ Penetratingwounds
Perforating wounds
/"-2
ANATOMICAPPROACH~THIRDMETHODOF ATTACK
J ~__~L.~." Injuries of upper thorax
-\\ Injuriesof midthorax
/ ~ ~ ~ " ~ii Injuriesoflowerthorax
FIG.2. NaderioClassificationsystemForcardlothoracictrauma.(FromNaclerioEA.Chestinjuries,physi-
ologicalprinciplesandemergencymanagement.NewYork:GruneandSlratton;1971.)
Curr Probl Surg,August 1998 665
TABLE 10. A simple breakdown of the principal pathologic processes associated with
chest injuries
Chest region Area involved Pathologic processes
Outer Chest wall (soft tissues and Subcutaneous emphysema
thoracic cage)
Flail chest
Open pneumothorax
Inner Pleura and lung Closed pneumothorax
Hemothorax
Secretional obstruction of lower airways
(wet lung, contused lung, aspiration
pneumonitis)
Innermost Mediastinum (trachea, Mediastinal emphysema
bronchi, esophagus), heart,
and diaphragm
Cardiac tamponade
Compression atelectasis (diaphragmatic
hernia)
From NaclerioEA. Chest injuries, physiologicalprinciplesand emergencymanagement.New York: Grune
and Stratton; 1971.
also be emphasized. This unique combination is highlighted with high

muzzle velocity (>3000 ft/sec) bullet wounds. In addition to obvious pen-
etration injury, the shock wave creates an element of blunt trauma and
temporary cavitation to neighboring anatomic structures. Shotgun blasts
produce varying degrees of injury from the local injury, pellets, and
degree of wad penetration. 31
Inhalation of toxins, especially in fires, iatrogenic injury, and foreign
bodies (ingested, aspiration, or inflicted) are also forms of chest trauma.
Military or combat injuries have a higher incidence of high velocity
missiles, shrapnel, and blast wounds. Impalement injuries, although
uncommon, are difficult to manage. Innovative operative techniques have
been described to treat these rare injuries. 32
The etiologic classification of chest trauma does not provide the clini-
cian with a complete system to organize an approach to the patient with
chest trauma. Two broad-based classifications have been proposed.
Historically, Naclerio devised the physiologic, etiologic, anatomic
approach (Fig. 2). 33 The physiologic or pathologic approach accents the
type of problem to expect as each region is violated (Table 10). Flail
chest, tension pneumothorax, and open pneumothorax of the outer region
along with hemothorax from a torn aorta in the inner region, and cardiac
tamponade of the innermost region are lethal or potentially lethal injuries.
Trunkey34devised a holistic or torso approach to trauma. The body or torso
is a cylinder divided into three coronal primary zones 0~ig. 3) and three
FIG. 3. Trunkeytorso classificationof trauma (coronal).(FromTrunkeyDD. Torsiontrauma.Curr Probl
Surg 1987;24:209-65,)
sagittal zones (Fig. 4). Both approaches share the focus of proceeding from
superficial to deep structures with the degree of pathophysiologic insult pro-
portionate to the structures contained within the zone (Tables 11 and 12).
In the lateral zone (zone 1) areas, the injuries are less morbid and lethal.
Zone 2 injuries are ,predominantly abdominal. Zone 3 injuries are all
extrathoracic. An institutional approach that uses the Trunkey concept is
summarized by Geer and colleagues35 from Vanderbilt University.
2
FIG. 4. Trunkey torso classificationof trauma (sagittal).[FromTrunkeyDD. Torsiontrauma.Curr Probl

Surg 1987;24:209-65.)
Mechanism of Injury
Trauma was defined earlier as a force, act, or stress inflicted on the
human host. 8,36-38 The absorption or transfer of kinetic energy into the
human torso results in tissue damage, deformation, or distortion produced
by this energy exchange. The severity of injury is proportional to the force
or kinetic energy (KE) defined by:
KE = M(V12 - V22)/2g,
where m is the mass (pounds); V1 is the striking velocity (feet/second);
V2 is the exit velocity (feet/second), and g is the gravity (feet/second2).
668 Curr Probl 8urg, August 1998
TABLE 11. Anatomic localization in blunt torso trauma
Zone* Lateral Midline Lateral
1 Lung Great vessels Lung
Chest wall Heart Chest wall
Spinal cord
Most managed High morbidity and Mortality rate range,
nonoperativety mortality rates 15%-40%
2 Diaphragm Liver Diaphragm
Liver Pancreas Spleen
Colon Duodenum Kidney
Kidney Stomach Colon
Gallbladder Colon
Aorta
Cava
Most require operative Almost all require Should have a low
treatment operation mortality rate
3 Colon Small bowel Colon
Small bowel Aorta Small bowel
Pelvis Rectum Pelvis
Bladder
Ureters
Genitalia
Most can be managed Potentially high mortality Mortality rates should
without operation rate be low
*Zones of injuries in the torso with organs susceptible to injury and the probability of an organ injury
requiring surgery.
From Trunkey DD. Torsion trauma. Curr Probl Surg 1987;24:209-65.
In nonpenetrating trauma the concern is related to the effect of the

kinetic energy or pressure wave transference. With penetrating trauma the
velocity of penetration is the primary concern. These principles are sum-
marized in the equation: F = MA, where F is the force; M is the mass, and
A is the acceleration.
Blunt Trauma. The mechanism of injury in blunt trauma is summarized
in (Fig. 5). A stationary host may be either struck or crushed, resulting in
direct trauma to the chest wall or a crushing phenomenon of the chest
wall and the thoracic cavity contents as the result of sudden acceleration
of nonfixed structures.
A moving host may suddenly be stopped, causing forward deceleration
of nonfixed structures, compression, and crushing of fixed structures.
This creates strain and stretching in the fixed areas. The result is varying
degrees of shearing and disruption. The subsequent injury and damage is
proportional to the magnitude of the forces applied.
It is important to emphasize that acceleration/deceleration injury has all
the components of dir¢ct impact, crush, compression, tension, and shearing.
The forces involved especially in MVA can involve frontal, lateral, rear,
rotational, or rollover mechanisms of delivery.
TABLE 12. Anatomic localization in penetrating torso trauma
Zone* Lateral Midline Lateral
1 Lung Great vessels Lung
Heart
Spinal cord
Approx. 15% will require High mortality rate; almost Low mortality rate
operation; most can all will require operation,
be managed with tube if the patient survives to
thoracostomy the emergency department
2 Diaphragm Liver Diaphragm
Uver Pancreas Spleen
Colon Stomach Colon
Kidney Colon Kidney
Gallbladder Duodenum
Aorta
Cava
Almost all require All require operation and Mortality rates should
operation have modest mortality be low
rates
3 Colon Small bowel Colon
Small bowel, Aorta Small bowel
Pelvis Rectum Pelvis
Bladder
Ureters
Genitalia
Most will require Almost all will require Mortality rates should
operation operation and can have be low
modest mortality rates
*Zones of injuries in the torso with organs susceptible to injury and the probability of an organ injury
requiring surgery.
From Trunkey DD. Torsion trauma. Curr Probt Surg 1987;24:209-65,
Most blunt trauma injuries are due to MVA. Soft tissue injury, rib frac-
tures, and lung contusion are the most common injuries. A direct frontal
steering wheel impact at 60 km/hr or a fall of more than five stories can
produce 10 Gs (the force equal to gravity) of force. Direct forces cause
sternal and rib fractures. The heart can strike the anterior chest wall
directly, or be compressed and crushed between the structure and the ver-
tebral column. The fixation of the descending aorta can cause the great
vessels to strain, stress, and stretch with subsequent shearing at the max-
imum point of fixation, in this case the aortic isthmus at the point of
attachment of the ligamentum arteriosum.
Penetrating Injury. Penetrating trauma is either inflicted or project-
ed. 39,4° Inflicted wounds include stab wounds, low-velocity wounds, high-
velocity wounds, shotgun wounds, (GSW) and impalement wounds.
Projected wounds include shrapnel or firchettes from mines, grenades,
bombs, and rockets. The amount of tissue damage is dependent on the
- Compression~
- Crushing - Strain
...)
- Direct Impact f - Stress
- Stretching
Cohesion of
structure is disrupted/sheared
IL
Injury/Damage
FIG. 5. Mechanism of injury in blunt chest trauma.
TEMPORARY
CAVITY F ~, J
.
-. ..
.. "
;,).::.
"~"
.
l
'., / ,,. -
., " .j _
PERMANENT ).::~ .//~ ", - ' . , ~ / ~ . ~ ' l

CAVITY !iJ ....
FIG. 6. Yaw, or the Rotation of the bullet around its center of gravily. (From Weiner SL, Barrel J, editor.
Trauma management for civilian and military physicians. Philadelphia: Saunders; 1986.)
amount of kinetic energy or force imparted to the tissue. A high-velocity

missile (>3000 fVsec) is 36 times more destructive than a low-velocity
missile (<500 fVsec). In general, gunshot wounds (GSW) cause local and
adjacent structural damage by crushing, cavitation, and stretching. Knife
wounds create damage by direct laceration and penetration and produce
little adjacent or collateral damage. Shotgun blasts at close range have
three effects: (1) The scattered pellets cause penetrating injury; (2) the
large central blast site ~causes extensive local injury; and (3) the wad, a
piece of cloth or plastic separating the pellets and powder, can enter the tis-
sues with potential for causing secondary infection unless it is removed.
,TEMPORARY
FIG. 7. Fragmentation: fragments of bullet (tiny black dots) are dispersed radially causing adiacent tissue
damage and necrosis. (From Weiner SL, Barret J, editor. Trauma management for civilian and military
physicians. Philadelphia: Saunders; 1986.)
A basic understanding of wound ballistics is necessary to understand pen-

etrating gunshot wounds. A missile may change its shape from sharp to
blunt (profile modification). This causes greater crush on penetration.
Military bullets have a steel or copper-plated jacket around the head case to
prevent this. Yaw or tumble is the deviation of the bullet from its longitudi-
nal axis about a vertical axis of rotation established by the center of gravi-
ty of the bullet (Fig. 6). Fragmentation occurs when the missile breaks into
pieces, with each piece becoming an individual projectile (Fig. 7).
Once the missile penetrates, a cavity is created along the line of the
missile tract. The size of the cavity varies in size with sharp, blunt, or
tumbling missiles. This will form the permanent cavity. A temporary cavity
is created by the energy size of the missile. High-velocity missiles impart
larger energy loads. This stretched temporary cavity will ultimately
decrease in size. Adjacent structures, such as bone, can fragment and also
cause tissue destruction (Fig. 8). Low-density structures (eg, lung) absorb
less energy from penetrating missiles, whereas high-density structures
(eg, heart, liver) absorb more energy.
Blast Injury. Blast is rapid burning (3000 ft/sec) of a substance that
burns in 0.00001 seconds. 41,42 Blast injuries occur from explosions that
transmit energy (1.4 x 106 lb/inch2) in the form of shock waves. The pri-
mary blast causes disruption of tissue by spalling, where the pressure
wave passes through a transition zone between a dense medium (liquid)
and a less-dense medium (air). The tissue-alveolar air interface may be
damaged, leading to tissue disruption and hemorrhage. Implosion also
occurs as intensely compressed gas forces blood and fluid into the alveoli,
FIG. 8. Secondary fragmentation of bone causing local tissuedamage and increasing exit wound
size.(From Weiner SL, Barret J, editor. Trauma management for civilian and military physicians.
Philadelphia: Saunders; 1986.)
which then rupture from rapid expansion. Subsequent pneumothorax or

lethal air embolization.Flay occur. After this first phase of blast, the second
phase or heat of the blast occurs. The third or final phase refers to the
injuries sustained from scattered debris or displacement of the host, away
i 100
~120'~ 80
~,00. ~>.,¢=
Q
z eo- 40
60-
"IN C.AIIDIACTAM/q0NADEV~IOUS PIIE~dH IIS1=$NK)GIIESSIVEL'
ANO UNF.AIILY/ARTERIALNi~ISUIE MAY lie NOIUV~L OR ELEvArl
ANO IS mAGNOSTtC~LY UI.41~I~IUE
FIG. 9. A, Clinical aspects of cardiac tamponade; arterial pressure changes are unreliable eady. (From
Naclerio EA. Chest Irauma. Ciba Geigy Clinical Symposia, 1971 ).
from the explosion itself. Indirect effects include crush injury from adjacent
structures and toxic inhalation of combustion gases. Explosions in water
are more lethal because water is incompressible and the speed of energy
wave propagation is greater.
PathophysiologicFeaturesof the Host Response

The end result of the mechanism of injury is the pathologic change it
inflicts on the host. The extent of the pathophysiologic response ultimately
! 'I | !
SYSTOLIC -140 ~
m
E 120
~ 10 " m
g
F- -
Z l 5t'CENTRAL ~ /
0 I--- I I , ,,I I
200 400 600 800 1000
III II
B INCREASING PERICARDIAL FLUIDVOLUME (ml)
FIG. 9. cont'd. B, Beyond 100 mL of intrapericardial pericordial fluid, the intrapericardlol pressur,: rises
dramatically. (From Ivatury RR, Cayten CG, editor. The textbook of penetrating trauma. Baltimore:W Iliams
& Wilkins, t996.)
determines the extent of the damage and harm to the patient. The car-
diopulmonary system is responsible for oxygenation, elimination of car-
bon dioxide, and delivery of blood to and from the tissues. Inadequate
oxygen delivery results from hypoxemia, hypovotemia, or cardiac p~lmp
failure. The end result is tissue acidosis, shock, cell death, and ultimately
patient death. When shock and acute respiratory failure complicates chest
trauma, the outcome is poor. Wilson and colleagues43 reported an inci-
dence of chest trauma in 19% of 218 patients, with an overall 36% mor-
tality rate and a 63% morbidity rate.
The major lethal cardiac event is cardiac tamponade (Fig. 9). Open and
tension pneumothorax are the lethal pulmonary events. Exsanguinating
hemorrhage or massive hemothorax is a hypovolemic event from disruption
or injury of an intrathoracic vascular structure. Upper airway obstruction
is one of the major causes of hypoxia.
AIR ENTERS PLEURAt CAVITY. NEGATIVE PRESSURE AIR IS EXPELLED FROM R~.EURAL CAVITY.
IS DIMINISHED OR LOST. COLLAPSING IPSII.ATERAL LUNG MEDIASTtNUM SHIFTS TO AFFECTED SIDE.
AND REDUCING VENOUS RETURN. SHIFT OF MEDIASTINUM SIDE-TO-SIDE SHIFT (FLUTTER) OF
COMPRESSES OPPOSITE LUNG AND IMPAIRS ITS VENIILATH~*)N MEOlAStlNUM FURTHER REDUCES VENOUS
RETURN BY DISTORTING VENAE CAVAE
FIG. 10. Pathophysiologic features of open pneumolhorax.(FromNaclerio EA. Chesttrauma.Ciba Geigy

Clinical Symposia, 197t.)
Cardiac Tamponade. Cardiac function may be impaired either by

direct injury to the heart itself or pericardial tamponade (defined as
fluid or blood in the intact pericardial sac compressing the heart and
causing severe impairment of venous return). Rapid accumulation
within the inelastic pericardial sac beyond 75 to 100 mL causes a rise
in the intrapericardial pressure. Subsequent small increases to 100 to
120 mL may double this pressure. Eventually cardiac chamber filling
is impaired, and there is a decreased systolic volume. Compensatory
sympathetic responses increase heart rate and peripheral vascular
resistance to maintain cardiac output. Eventually the compensatory
mechanisms are exhausted and circulatory collapse and cardiac arrest
occur.
Respiratory Derangements. The normal features of respiratory func-
tion include chest wall mechanics, ventilation, perfusion, ventilation-per-
fusion interaction, and neurohumoral mechanisms (Figs. I0 and 11). All
are involved to some degree in chest trauma. The major insults are sucking
chest wounds or open pneumothorax and tension pneumothorax. With
open pneumothorax, air enters and exits the previous negative-pressure
intrapleural space. The lung collapses and venous return decreases. The
mediastinum shifts to the opposite side and impairs contratateral lung
ventilation. With tension pneumothorax, increased pressure in the closed
pleural space compresses the lung and forces a mediastinal shift to the
contralateral side. Both contralateral lung function and venous return to
~ ^ T ~ O U W l ~ n ~ y OF PROGRESSIVE
)THORAX
AS DIAPHRAGM RISES AND CHEST CONTRACTS,

AIR ENTERS PLEURA[ CAVITY FROM A LUNG INTRAPLEURAL PRESSURERISES AND VALVE-LIKE
PERFORATION {OR RARELY FROM AN EXTERNAL OPENING THROUGH WHICH AIR ENTEREDCLOSES.
CHEST WOUND). LUNG CO~[APSES AND MEDIASTINUM PRESSURE ~S THUS PROGRESSIVELY INCREASEO AND
SHIFTS TO OPPOSITE SIDE COMPRESSING CONTRA- MEOIASTINAI SHIFT AUGMENTED WITH EACH
LATERAL LUNG AND IMPAIRING ITS VENTILATING RESPIRATION, VENOUS RETURN IS IMPAIRED BY
CAPACITY INCREASED INTRATHORAC~CPRESSUREAND BY
OIS[ORTION OF VENAE CAVAE
FIG. 11. Pathophysiologicfeaturesof tensionpneumothorax.(FromNaclerio EA. Chesttrauma. Ciba Geigy

Clinical Symposia, 1971.)
the heart are impaired. Both conditions are lethal unless recognized and
managed appropriately.
Whole Body Response. A cascade of total body responses occurs with
operation or trauma and have been summarized by Wilmore. 44 The host
response to trauma is a reaction to an acute and intense alteration in the
normal physiologic state and metabolism. This response is predictable,
dramatic, and reproducible. Clotting mechanisms become activated.
Extravascular fluid shifts into the intravascular space. Autoregulation of
blood flow preferentially directs blood flow to the vital organs, such as
the heart, brain, and kidneys. Respiratory and renal adaptations occur to
maintain acid/base balance and total fluid osmolality. The ebb or low-flow
phase of the response is characterized by a fall in the metabolic function but
increased stress hormones. With adaptation and time, the flow phase occurs
with recovery of the metabolic activity and a heightened stress hormone or
catecholamine response. From this adrenergic-corticoid phase the anabolic
or corticoid-withdrawal phase begins (usually at 3 to 6 days after injury).
This phase is characterized by a spontaneous sodium and free-water diure-
sis. In its absence, one must consider continued stress, particularly sepsis. In
the patient with cardiothoracic trauma, an intrathoracic process (eg, pneu-
monia, abscess, empyema) should be the concern. Multisystem problems
may also be encountered (ie, intra-abdominal sepsis).
TABLE 13. Trauma score and Glasgow Coma Scale
Points
Trauma score
Respiratory rate
10-24/min 4
24-35/min 3
36/min or greater 2
1-9/min 1
None O
Respiratory expansion
Normal 1
Retractive (use of accessory muscles) 0
Systolic blood pressure
90 mm Hg or greater 4
70-89 mm Hg 3
50-69 mm Hg 2
0-49 mm HE 1
No pulse 0
Capillary refill
Normal 2
Delayed (>2 sec) 1
No capillary refill 0
Add to this the usual Glasgow Coma Scale Trauma Score points
from Glasgow Coma Scale
14-15 5
11-13 4
8-10 3
Injury Severity
For an injury severity grading method to be used effectively it must
have strong predictive value and be widely accepted as accurate because
it will be used to make important and often expensive decisions. 45-49
Injury scoring methods are used to define field triage and transfer criteria,
detemfine the prognosis, compare trauma systems and centers, compare
treatments, justify reimbursements, and allocate resources and their use
for quality assurance purposes. Despite criticisms and shortcomings, the
most widely used and best-verified methods are the Injury Severity Score
(ISS), the Revised Trauma Score (RTS), and the Trauma Injury Severity
Score (TRISS) method.
The ISS is an anatomic injury code based on the Abbreviated Injury
Scale (MS). The AIS, developed by the American Association for Auto-
motive Medicine, provides a common language to describe the severity of
injury sustained in automobile accidents. The AIS defines injury severity
for organs and tissues in each of seven arbitrarily defined body regions.
The severity is described from "minor" to "maximum" and for some
TABLE 13. cont'd.
Points
5-7 2
3-4 1
TOTAL1-16
Glasgow Coma Scale
Eye opening
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible words 2
None 1
Motor responses
Obeys command 6
Localizes pain 5
Withdraws (pain) 4
Abnormal flexion (pain) 3
Abnormal extension (pain) 2
TOTAL 3-15
Trauma Score Survival rate (%)
16 99
13 93
10 60
7 15
4 2
1 0
organs "unsurvivable." A number is assigned to each grade, and the total

scores for each region are calculated. Because the AIS does not relate the
severity of injury within each body region to the whole body, it is not use-
ful for meaningful clinical comparisons and studies. Although it was sug-
gested that there must be a numeric relationship between the defined
regions and the entire body, logic assumed that the relationship was not
likely to be as simple as adding or averaging the numbers.
The ISS used the AIS and observations from a large trauma study to
describe the relationships mathematically between body region scores
and an overall measure of death. Simply stated, the mortality rate increases
in a nonlinear fashion with increasing severity of the most injured region.
Only the second and third highest graded regions affected the mortality
rate after that. The ISS therefore can be described as the "sum of the
squares of the highest AIS scores in each of the three most injured areas"
Curt Probl Surg, August 1998 679
TABLE 14. ISS score and associated mortality rates
ISS score
Age (yrs) No. of patients 15 (%) 25 (%) 35 (%) 45 (%) 55 (%)
~49 1540 3 8 32 61 89
5~69 316 5 21 56 68 100
70+ 109 16 45 82 100 100
TABLE 15. Classification of algorithms

General Approach
Blunt chest trauma
Penetrating chest trauma
Blast injury
Specific Organ/Structure Approach
Cardiac
Esophagus
Lung
Tracheobronchial tree
Aorta/great vessels
The ISS can range from 0 to 75, with 75 representing maximal (nonsur-
vivable) injury.
Because the ISS is based on anatomic injury assessment, coders must
necessarily use everything, from documented physical examinations and
operative notes to radiology reports and even autopsy reports, to determine
the ISS. The ISS is a more useful tool retroprospectively than prospective-
ly. A physiologic scoring system was a natural outgrowth of the usual prac-
tice of grading injury severity and even making decisions based on mea-
surements such as the blood pressure, heart rate, and respiratory
parameters. Although there are several physiologic scoring systems, the
Trauma Score (Table 13) or its successor, the RTS, is the most useful. Its
value lies in its simplicity and the fact that its calculation requires no addi-
tional work on the part of the medical personnel in the field or in the trauma
room. Studies relating trauma scores to predicted mortality rates allow the
Revised Trauma Score to be used for triage and transfer purposes.
The ISS, Revised Trauma Score, and the TRISS methods have been
used to (1) define field triage and transfer criteria, (2) determine prognosis
(morbidity/death; Tables 13 and 14), (3) compare trauma systems and
centers, (4) study aeromedical transport systems, (5) compare treatments,
(6) analyze reimbursements, (7) allocate resources, and (8) provide data
for quality assurance (internal auditing) purposes.
The American Association for the Surgery of Trauma, through its Organ
Penetrating or blunt trauma tothe ches!
1
Depending upon the patkmt's condition
I
t t t Recetd ftesh~entlyand accurately
Secure adequate Establish central venous Treat caKllac tamponaae Signs of hemolhorax
ventilation ~ra lice ~ routes (see algorithm, Fig. 4-1 ) or hemopneumothorax the quality and rate of arterial
pulse, heart ~ u nds, Iocalion of
fo~ ~ ratio(i
administ andofrapid
blood 1 apical pulse, ~ arterial and
~0~umeexpanders C4~tral *verlouspc~;:~ras
Clean al~,'ay of blnod or Administer crystallblds Establish tube Recoi'd i n t ~ of blood fluids Or
secretions azld/or inser! and blood thoraccetomy other blood volume exl0anders,
o ~ airway and/or driftage thoracostomy tube d ralnage.
administer oxygen by mask udrmry outpul, e~-~ldr~cege
and serf-lnflating bag MesSiVeble~liPCJ~...........~ ~ from othersites
andtor lntubate trachea M,onilor drainage first
and adminLstere..~ed every few minutes and
Veotttatton
Immediate anterotateral thoracolomy 10co~r~//then even/15 to 30 minutes Obtain blnod for t,ype arid
croesmatch, EKG, che~
meritgenogram, and other
IS0 ml bloo~ drathed appr~ roemgenographlc
200 to ~ O ml bkx:<l every h~ur aria sludies
progressively
dmiced everf hour decreasing
for 2 Io 3 houP~
Perf0cm rapid and thorough
pl'qsical e~mination, urinalysis.
t0utirle blOOdchemisfdes
FIG. 12. P.N. Symbas/Grady Memorial Hospital, Atlanta, Georgia, algorithm for chest trauma (From
Symbas PN. Cardiothoracic trauma. Philadelphia: Saunders; 1989.)
PENETRATING CHEST INJURY
CHEST WOUNO~ ( TYPE • CR(~;SMATCH IV LINES

I•PENETRATING FOLEY CATHETER
t l ~ C ~ , * x-My ~.A~
rEm4o. ~ e ro~
r,o~co~o., t
le"
CO.Tt.UEOS~S
IIF T ~ A e E
NEGATIVE PNEUMOTt~ILX " ~
RE-EXAMt~TION T~OSTOMY
D RE-EXA,titBtATION
X
BLEEDING STOPS
FIG. 13. J.D. Richardson/LouisvilleGeneral Hospital, Louisville,Kentucky, algorithm for penetrating chest
injury.(From RichardsonJD, MavroudisC. Management of thoracic injuries.In: RichardsonJD, Polk HC,
Flint LM, editors. Trauma: clinical care and pathophysiology. Chicago: Year-Book; 198Z p.291-352.1
Injury Scaling committee, has refined the ISS for individual organs to
facilitate clinical research. In addition to other organs, injuries to the chest
wall, thoracic vascular, lung, cardiac, and diaphragm structures are defined
and graded, and an AIS score is assigned. The AIS scores are linked to
International Classification of Diseases (ICD) codes; the ICD-9 is used in
all hospitals at the time of discharge to codify diagnoses and the levels of
severity.
Champion, 45 Rutledge and colleagues,47 and others have used the codes
Thorncotomy - open massage
J (penetrating) - control bleeding
- crossdamp aorta
Unstable
- Hi~ory/Physieal Wide mediaslinum ~ Aortogram - Repair Aortic Tear

- ABC • ~ Heart , ,~. Obsesve
- 1"/2+ Survey Conturaon..~ Lung p V~tilalor

Flail C h ~ ~. V~tilstortOparatlve Rep~dr
l (2 large bore) = Stable~

BI Rupture diaphragm , Repair
Massive All"Leak....,, Broncho~copy ~ Repair Traebea/Bronehus
Massive Hcmotborax ~ Thoraeotomy
Cbe~ Injury
(13unl/~enetraling]
I Chest tube
(#38 or 40)
\ Op¢~ Wound '~ Closure
5th or 6th Penelratlng ~,~Vaseular Injut't---'~" Repair
intercostal space Esophagus ~ Contrast Study -'-* Repair
mid-axillary line ~
- Hct
Perieardiat
Tamponade ~
' Perienrdlocentesi
LeR anterior thoracotomy
Subx3'phoid Window
then median sternotomy
Median sternotomy
- Type and Crossmatch
- CXR
- C-spine fl[m
- ECG
- Blood gases
FIG. 14. Modified algorithm for cardiothoracic trauma. ABC,Airway, breathing, circulation; Hct, hemato
ocrit; ECG,electrocardiogram.(From Norton LW, Steele G, Eiseman B, editors• Surgical decision making.
3rd ed. Philadelphia: Saunders; 1993.)
(ICD-8 and 9) devised by the World Health Organization to classify

injury severity. ICD-9 diagnosis codes fulfill many of the criteria of an
ideal stratification tool, including ease of use and relatively low cost. It is
used in all US hospitals and many other hospitals worldwide for reim-
bursement and data collection purposes, and it has been continually
revised and standardized. This system also codes for the mechanism of
injury (E-codes) and for any procedures performed. Rutledge and colleagues
and others have evaluated the predictive value of ICD-9 codes and conclude
that there is reason to believe that ICD-9 codes can be used effectively and
may be superior to ISS in predicting trauma outcomes.
ManagementAlgorithms
Several monographs and most trauma texts have published broad-based
and specific management schemes and decision trees for cardiothoracic
trauma. 5°,5| Their major goal is to approach cardiothoracic problems sys-
tematically. On the basis of established principles and retrospective clin-
ical experiences, most major civilian and military systems follow gener-
a l established protocols for patients with cardiothoracic trauma. We
should caution, however, that individualized management is necessary
when the clinical situation or management environment dictates. A classi-
fication of algorithms is summarized in Table 15.
Several algorithms for blunt and penetrating trauma have been developed
TABLE 16. Life-threatening cardiothoracic injuries
Problem Resuscitation Approach
Airway obstruction Auscultation Oral airway
Retraction Endotracheal tube
$ Air movement Cricothyroidotomy
Foreign body Tracheostomy
Tension pneumothorax Cyanosis Needle aspiration
Distended neck veins Chest tube thoracostomy
Unilateral absent breath sounds
Deviation of trachea
Subcutaneous emphysema
Cardiac tamponade Distended neck veins Pericardiocentesis
Muffled heart sounds Operation
Narrowed pulse pressure
Paradoxical pulse
Open pneumothorax $ Breath sounds Seal defect
Penetration of thoracic wall Chest tube thoracostomy
Flail chest Loose segment Chest tube thoracostomy
Multiple palpable fractured ribs Mechanical ventilation
Decreased or moist breath sounds
Hemoptysis
Massive hemothorax Shock Restore volume
Persistent bleeding Operation
(Figs. 12 through 14). 52,53Unfortunately, few scientific data are available

to evaluate their overall efficacy. A study by Bishop and colleagues54 in
1991, at Kings Drew Medical Center in Los Angeles, evaluated a com-
prehensive algorithm. A total of 434 patients were evaluated over 4
months. The overall mortality rate was 17%. Improved survival was
found in 108 patients with ISS scores between 20 and 50. The mortality
rate was 55% when deviation from the algorithm occurred, but only 5%
if there was no deviation. Trauma injuries with an ISS of more than 50
were usually fatal. The outcome in patients with an ISS of less than 20
were not affected by deviation from the algorithm.
Initial Resuscitation
In urban trauma, characterized by short distances to major trauma
facilities, the "scoop and run" philosophy prevails. This approach allows
aggressive resuscitation in a controlled, coordinated setting and avoids
delay from attempted resuscitation in the field. Injuries in rural, suburban,
or remote settings require increasing responsibility at the scene, especially
regarding airway control, fluid resuscitation, and control of hemorrhage.
In either scenario, the recognition and management of trauma begins at
the scene of injury.
TABLE 17. Potentially lethal cardiothoracic injuries
Problem Recognition Approach
Pulmonary contusion Hypoxia Increased oxygenation
Agitation Pain control
History Mechanical ventilation
Multiple trauma
Myocardial contusion Sternal fracture Serial electrocardiogram,
enzymes
Pain Monitor arrhythmias,
infarction
Trauma
Electrocardiographic changes
Echocardiography
Aortic disruption Widened mediastinum Aortogram
History of deceleration Operation
Severe associated injuries
Diaphragmatic hernia Elevated diaphragm Nasogastric tube; contrast
study
SBreath sounds Operation
SRespiratory dysfunction
Tracheobronchial disruption Hoarseness; subcutaneous air Control of airway
Respiratory distress Operation
Persistent pneumothorax
Large air leak
Esophageal disruption Fever, tachycardia Contrast study
Pleural fluid Esophagoscopy
Pneumomediastinum Operation
The trimodal distribution of trauma mortality rates reveals that 50% of

trauma deaths are immediate (ie, within a few minutes). Thirty percent occur
within 2 to 3 hours, and 20% occur late (80% of these resulting from sepsis
or multiorgan failure). 55 The American College of Surgery Committee on
Trauma recognized the first hour after insult as the "golden period" of trau-
ma management. The Advanced Trauma Life Support (ATLS) course was
initiated to focus on this critical period of trauma management. More than
135,000 physicians have completed the ATLS course. 56As it expands inter-
nationally, the ATLS approach will become the standard of care for the
resuscitation of multitrauma victims during the first hour of injury.
The initial management of any trauma victim is aimed at restoring both
adequate oxygenation and perfusion of vital tissues. The primary therapy
includes evaluation of the "ABCs" (airway patency, breathing and venti-
lation, and circulation with hemorrhage control). This is followed by the
resuscitation phase or management of shock. The secondary assessment
or complete physical evaluation follows. Finally, in the definitive care
phase, all of the patient's injuries are treated. 57
Respiratory Distress
Injury Scene
Extricate
4• Intubata Trachea"
Bag Mask Assistance
Chest Needle or Tube to
Tension Pneumothorax
4 ~ iILJnetabta--Hypotenalve
3bvious Chest Injury
Evaluate During Transport
I
Establish Airway
chest Injury Ambulance ~--
:tespiratory
Assistance,
PASG
Start I.V. Fluid,
°" Aled Trauma
Team Prior to
Arrival
= ( Emergency I
Secondary Evaluation
Improve Airway
! Stable Patient
Stabilize Fractures
Start LV. Fluids
Start LV. Replacement
Communicate
"Scoop and Run" If: l
<5 Minutes from Hospital
Cardiac Injury, Unrelieved
Respiratory Distress Alert Trauma
Deteriorating B.P, I Team Prior to
Unconscious I Arrival
"If ~ramedic possesses iP,dicatad
training and equipment,
"'Controversial: do not delay to apply.
( Anti-Shock Garment )
FIG. 15. Prehospital protocol. (From Hood RM, Boyd AD, Culliford AT, editors. Thoracic trauma.
Philadelphia: Saunders; 1989.)
PHASE II
FuabetEvakmtion t
Se,~chfo~U~e~
Problems
~E 11
FurOreEva~uMlue I
Chest Tube.Volume
TensionPrmurnolhorl
Se~ehI~ Urgent
Pro~ems
CheslTube
OpenPn~rnolP,omx
Close
SevereRill Chest
IV. Access
tnlubalu
VenMale
Cardl=cTampom~e
CVP
OR. """"1
'
La~aledRing~'s UpperAirway
Ra~dRE. Obstruction
Eva~ation CtK~tlhy/oKlolOIlly
Tmcheoslomy
E,R.Timp0n~Thorl¢otomy I
Conlm~Hemorn~ge
FIG. 16. Initial emergency department protocol (From Hood RM, Boyd AD, Culliford AT, editors. Thoracic
trauma. Philadelphia: Saunders; 1989.)
Less than 15% of thoracic injuries require operative intervention. Much

of the significant care will be provided during the early acute phase. The
establishment and maintenance of a clear airway are essential. Restoration
of chest wall integrity, evacuation of the pericardial sac, and reexpansion
of the lung highlight the goals of restoration of cardiorespiratory function.
Sealing chest wall holes and defects, removal of blood from the pericar-
dial sac with pericardiocentesis, removal of blood and air from the chest
TABLE 18. The lethal lesions of thoracic trauma: an overview
Lesion Symptoms Physical findings
Tension pneumothorax Dyspnea Absent breath sounds; dyspnea;
mediastinal shift; cyanosis;
subcutaneous emphysema (maybe)
Intrathoracic hemorrhage Dyspnea; shock-like Absent breath sounds; dullness to
state; apprehension percussion; hypotension
Cardiac tamponade Dyspnea; apprehension Hypotension; venous distention;
distant heart sounds
Deceleration aortic injury Nonspeciflc Nonspecific
Tracheobronchial rupture Nonspeciflc dyspnea; Nonspeciflc; may have pneumothorax

hemoptysis or tension pneumothorax; mild
subcutaneous emphysema
Rupture of the diaphragm None or progressive None; absent breath sounds;
with gastric herniation respiratory distress mediastinal shift; bowel sounds
heard over chest
Massive flail chest with Dyspnea;shock-like state Destabilized chest wall; dyspnea,
pulmonary contusion rales, cyanosis, hypotension
Esophageal perforation Pain; dysphagia;fever; Swelling of cervical area; auscultate

history of etiologic for mediastinal air
injury
Airway obstruction
Upper Dyspnea; wheezing Stridor; dyspnea; cyanosis
Lower Dyspnea; wet cough; Rales; wheezing; cyanosis; absent

history of aspiration breath sounds
CVP,Centralvenouspressure, ABG,arterial bloodgas.
From HoodRM, BoydAD, CullifordAT, editors. Thoracictrauma. Philadelphia:Saunders;1989.
cavity, and restoration of circulating volume deficits are life-saving

maneuvers that must be performed during the first hour.
Six life-threatening and six potentially lethal chest injuries have been
identified (Tables 16 and 17). The common factors in life-threatening
injury include airway obstruction, obstruction of venous blood return,
obstruction of blood flow through the heart, and hypovolemic shock.
Hood and colleagues58 offer an expanded and simplified overview of
these lethal injuries (Table 18).
It is important to divide the resuscitative phase into the prehospital and
early hospital phases. The early responders include police and fire per-
Portable chest radiograph Diagnostic procedure Surgical management
Pneumothorax; mediastinal shift; Thoracentesis; chest Chest tube insertion
interstitial air in tissues radiograph
Opacification of hemithorax Chest film; Thoracotomy

thoracentesis
Slight enlargement of heart shadow; CVP measurement Thoracotomy
bottle-shaped cardiac silhouette over 15 cm
Widened mediastinum; narrowed Aortogram Thoracotomy; prosthetic
trachea; left main bronchus; pleural graft
fluid; fracture of ribs 1 and 2
Not consistent: tension, pneumorathorax, Bronchoscopy Thoracotomy; primary
rib fracture; air bronchogram absent repair
Gastric air bubble above diaphragm; Nasogastric tube; Nasogastric tube; early
lower rib fractures; mediastinal shift fluoroscopy; contrast thoracotomy or
studies of stomach; laparotomy
look for paralysis of
diaphragm
Rib fractures evident; pulmonary Serial ABG plus Chest tube; intercostal
contusion; pneumothrax observation block; stabilize chest
wall; intubate; venti-
late; restrict fluids;
control secretions
Mediastinal air; widened retrotracheal Contrast study of Immediate operative
space; widened mediastinum; pleural esophagus repair
fluid; pneumothorax
Nonspeciflc Observation only (1)Oral or nasal airway

(2)endotracheal tube
(3) cricothyroidotomy
(4)tracheostomy
Absent air bronchogram; pulmonary Auscultate; ABC; chest Bronchoscopy; intubate;
infiltrate; atelectasis radiograph ventilate if necessary
sonnel, citizens, emergency medical technicians, and paramedics, all with

varying levels of ability. At the UMMC, an accident is reported to the
emergency medical system (EMS). Either helicopter or ambulance evac-
uation is recommended depending on the severity of the injuries, number
of casualties, and weather conditions. As always, cervical-spine stabiliza-
tion is highlighted. Fig. 15 summarizes a reasonable approach to the pre-
hospital thoracic injury victim .58 On arrival at the hospital, the first 5 to
10 minutes are crucial (Fig. 16). Expansion of the prehospital care
includes paramedics performing cricothyroidotomy. Jacobson and col-
leagues 59 reported on 50 cricothyroidotomies among 509 patients that
TABLE 19. American College of Surgeons categorization of injuries
Category 1 Patients with combined system injury, bleeding, open fractures,
uncontrolled hemorrhage, severe maxillofacial injuries, severe head and
neck and upper respiratory tract injuries, unstable chest injuries, pelvic
fractures, blunt abdominal trauma with hypotension and/or penetrating
abdominal wounds, and neurologic injuries producing prolonged loss of
consciousness, abnormal posturing, lateralizing signs, or paralysis
Category 2 Patients with open or closed fractures, soft tissue injuries with stabilized
bleeding, multiple rib fractures without flail segments, blunt abdominal
trauma not producing hypotension, and transient loss of consciousness
Category 3 Patients with uncomplicated fractures, no hypovolemia or hypotension, no
neurologic injuries, no abdominal injuries, soft tissue injuries of
moderate degree, and chest injuries not producing respiratory distress
TABLE 20. Military experience with cardiothoracic trauma

Time (hrs) Mortality rate (%)
World War I 12-18 8.5
World War II 6-12 5.8
Korea 2-4 2.4
Vietnam <11.7
required airway control. There were no complications and 19 patients sur-

vived. Richardson 6° reported on 56 (15%) field cricothyroidotomies with
a 28.5% survival rate. Nonetheless, only 3 of 56 patients (5%) had ade-
quate neurologic recovery. This is an exciting area where expansion is
likely to occur. 6~
Once the patient survives the prehospital phase and the initial hospital
resuscitative phase, the next decision is whether to keep the patient at the
initial health care facility or to initiate transfer to a skilled trauma facility.
In general, if the patient care requirements cannot be met in terms of space,
equipment, personnel, and sophisticated diagnostic and therapeutic tech-
niques, then the patient should be transferred. An estimated ISS of more
than 15 indicates the need for transfer to a level I trauma unit. 62 Category
1 or 2 injuries also dictate transfer (Table 19). The decrease in delay from
initial injury care to definitive care translates into a decrease in the overall
mortality rate. This was borne out in the military experience (Table 20).
Critical Care Phase

Once the patient survives the resuscitation phase and transfer, the hospital
phase (including the intensive care unit and ward) commences. A holistic
approach involving the care of both the patient and family is critical.
Medical, personal, and legal problems can be resolved by appropriate con-
TABLE 21. Subsystem approach to cardiothoracic trauma
Problem Consider
Hemodynamics Cardiac tamponade
Arrhythmias
Congestive heart failure
Respiratory Respiratory failure
Mechanical problems: ventilator
Secretions/ atelectasis/collapse
Pleural collections
Pulmonary embolus
Aspiration
Hematologic Surgical bleeding
Coagulopathy
Fluid/electrolytes Hypovolemia
Hypervolemia: third space overload
Na+, K+, Mg+÷, Ca++
Infectious Prophylaxis
Established source: lung, wound, urine, IV sites, deep lines, drugs
Neurologic Head injury
CVA
Air emboli
Acute psychosis
Renal Acute failure
Mechanical obstruction
Miscellaneous
Nutrition Parenteral/enteral
GI UGI bleeding prophylaxis
Endocrine Diabetes, steroids
Vegetative Fever, pain, sedation, agitation
Wound Wound checks, dressing changes, IV sites
IV, Intravenous;CVA, cerebralvascularaccident; GI, gastrointestinal;UGI, uppergastrointestinal.
cern and communication. It is crucial that the team approach be monitored

by a senior physician or surgeon who coordinates the care and who com-
municates information to all members of the trauma team, consultants, and
especially, the family and involved parties (eg, patient representatives, legal
authorities, and risk management personnel as indicated).
The critical care phase of patients with cardiothoracic trauma parallels
that of any critically ill surgical patient. The subsystem approach to critical
care medicine has become standard. Originally conceived and popular-
ized by Civetta63 and Kirklin, 64 this approach has served us well over the
past 25 years. A brief overview of cardiothoracic subsystem problems
must include a high index of suspicion and an organized, logical approach
to their solution or resolution (Table 21).
The most common cardiothoracic problems encountered in the inten-
sive care setting are summarized in Table 22. Each of these problems
TABLE 22. Cardiothoracic problems encountered in the intensive care setting
Respiratory insufficiency
Chest wall instability
Pericardial effusions
Multiloculated effusions/air fluid levels
Evolving lung cyst/abscess
Persistent chest tube air leaks
Atelectasis
Chest wall pain
Retained secretions
Subcutaneous emphysema
TABLE 23. Indications for intubation/ventilation

pO2 < 60 or FlO2 requirement > 50%
pCO2 > 55
pH < 7.25
Comatose or otherwise unable to protect the airway
Uncontrolled airway bleeding or secretions
Apnea
Progressive stridor
requires an individualized approach. Investigative procedures include

chest radiographs (CXRs) with lateral and decubitus views, ultrasono-
graphy, thoracic CT scanning, and transthoracic or transesophageal
echocardiography and video-assisted thoracoscopy surgery (VATS).
Treatment strategies range from observation to therapeutic fiberoptic
bronchoscopy, CT or ultrasound-guided thoracentesis or thoracostomy
tube placement, chest tube thoracostomy, VATS, intercostal nerve blocks,
and occasionally surgery to include intercostal chest wall/rib stabiliza-
tion, decortication, abscess drainage, or definitive procedures to repair
damaged intrathoracic structures (eg, perforated esophagus).
There should be major concerns for the respiratory status. If the patient
does not arrive in the intensive care unit having been intubated and treat-
ed with mechanical ventilation, then basic criteria must be used to deter-
mine the need for these treatments. 65 The indications for tracheal intuba-
tion and establishment of mechanical ventilation are summarized in Table
23. The indications for subsequent mechanical ventilation are summa-
rized in Table 24.
Monitoring. Data are emerging regarding the level of care required for
patients with chest trauma. A patient with an apparently uncomplicated
stab wound to the chest with hemothorax treated by chest tube thora-
costomy and admitted to an unmonitored ward bed may be found dead
TABLE 24. Indications for subsequent mechanical ventilation
Apnea
Respiratory rate > 35
Vital capacity < 15 cc/kg
Maximum inspiratory pressure < - 2 0 cm H20
Minute ventilation > 10 L/min
pCO2 > 5 0
VD/Vt > 0.6
pH < 7.25
pO2 < 50; FIO2 > 50%
A-a gradient > 3 0 0
Qp/Qt > 20%
after exsanguination from unsuspected injury to the thoracic aorta or

heart. A high index of suspicion for severe occult injury should accompany
the care of seemingly uncomplicated isolated chest injuries. There is con-
troversy regarding mandatory hospitalization versus the safety and cost-
effectiveness of selective outpatient management. Ammons and col-
leagues66 at Denver General Hospital admitted 150 consecutive chest
trauma victims to an observation unit. All 21 patients requiring subse-
quent admission to the hospital were identified within 6 hours, whereas
129 patients were discharged and required no later hospitalization.
Once a patient is admitted to the intensive care unit, the extent of mon-
itoring varies; but the minimum should include an arterial pressure
catheter, electrocardiogram telemetry, measurement of urine output, arterial
blood gas determination, and serial CXRs. Pulmonary artery catheters
with determination of pulmonary artery pressures, thermodilution cardiac
indices, and systemic vascular resistance are indicated when the resusci-
tation needs to be guided or when there is persistent hemodynamic
instability. Central venous catheters, nasogastric tubes, temperature control
and monitoring, and suction devices are routine. More sophisticated mon-
itoring includes continuous peripheral oximetry and mixed venous oxygen
saturation. Cardiac emergency carts, temporary pacing pads, and cardiac
defibrillators should be available. 67
A period of monitoring or observation is required for most cardiothoracic
trauma, regardless of the cause. Given the cost constraints of health care,
bold attempts are being made to decrease and contain elaborate and
sophisticated diagnostic and therapeutic modalities. This is especially
true for penetrating stab wounds of the chest and uncomplicated blunt
anterior chest trauma.
Kerr and colleagues68 at Temple University Hospital reported on 105
asymptomatic patients with stab wounds of the chest. Four patients experi-
TABLE 25. Incidence of missed injuries in trauma cases
Albertsen
Chan et ai Hamdan and Thomsen Enderson
(1980) (1989) (1989) et al (1990)
Trauma type Blunt Penetrating Blunt (autopsy) Blunt
Total no. of patients 327 -- 218 399
No. of missed injuries (%) 39 (12) 35 75 (34) 36 (9)
Total no. of missed injuries 49 36 -- 41
Injuries missed
Head/facial 2 -- 35 2
Spine 3 2 -- 5
Chest 6 1 70 5
Abdomen 1 3 28 6
Extremities 33 14 15 - 21
Neurovascular 4 15 -- 2
From Enderson BL, Maull KI. Missed injuries: the trauma surgeons nemesis. Surg Clin North Am
1991;71:399-418.
enced the development of a pneumothorax or hemothorax within 6 hours,

whereas the remaining patients experienced no difficulties at 6 to 24
hours. These investigators concluded that a 6-hour rule was valid for
asymptomatic stable stab wounds of the chest not involving the precordium
or in proximity to the subclavian artery. Ordog and colleagues 69 at King/
Drew Medical Center in Los Angeles studied 4106 patients from 1978 to
1993 with stab wounds to the chest. Eighty-eight percent of these patients
were discharged 6 hours after the injury with no sequelae.
Reif and colleagues 7° at St. Joseph Mercy Hospital in Ann Arbor,
Michigan, evaluated 115 patients with blunt chest trauma and found
echocardiography to be the most sensitive index of cardiac complications.
Seventy-three percent of patients had a normal echocardiogram, with
complications developing in only one of these patients. This would support
mandatory hospital monitoring for 24 to 72 hours (yet not in the intensive
care unit) in this group of patients.
Missed Diagnoses. Delayed, missed, or residual injuries may become
manifest at any point during hospitalization. The term delayed implies a
natural history of the injury process itself. Examples include a lung contu-
sion that develops central necrosis and evolves into a cavity or cyst that
may become infected secondarily. An aortic intimat tear may evolve into a
delayed rupture as the pressure in the contained adventitial layer rises. A
missed injury is an initial injury (eg, diaphragmatic hernia) that is unrec-
ognized for a period of time. An unrecognized new systolic murmur after
a penetrating cardiac wound signaling the presence of a traumatic ventric-
ular septal defect is an example. Residual or chronic injuries usually refer
692 Curr Probl Surg, August 1 9 9 8
TABLE 26, Reasons injuries may be missed
Hemodynamic instability Inexperience/low index of suspicion
Alterations in consciousness Radiologic errors
Head injury Failure to perform study
Ethanol/drug intoxication inadequate films
Intubated Misinterpretation
Paralyzed Technical errors
Spine fracture Admitted to inappropriate service
Medically
From EndersonBL, Maull KI. Missed injuries: the trauma surgeon's nemesis. Surg Clin North Am
1991;71:399-418.
to complications of the wound, operation, repair, or the healing process

itself. These injuries (eg, ruptured bronchus with distal collapsed lung) can
manifest themselves at any time, even years, after the original injury.
The true incidence of all missed injuries in trauma is unknown but has
been estimated to range from 9% to 35% (Table 25). 71-73 Missed chest
injuries are less common, likely because of the serious consequences of
the initial injury. Missed injuries that subsequently contribute to death
were reported to be 5% in one series. 71 Inadequate clinical evaluation,
diagnostic errors, and inexperience all contribute to missed injuries.
It is estimated that 9% of patients with multiple trauma sustain injuries
that are overlooked during the primary and secondary phases of resusci-
tation. Interestingly, in one autopsy series, almost 33% of all missed
injuries were thoracic. 71 The most feared missed chest injury is thoracic
aortic injury because more than 90% of these patients will eventually
experience aortic rupture. Enderson and Maul171 summarized the poten-
tial reasons for missed injuries (Table 26).
Diagnostic Modalities
History~Physical Examination. Significant advances have been made
in the diagnosis of cardiothoracic injuries. Nonetheless, the history and
physical examination remain extremely important in the evaluation of
chest trauma. Although they may initially be incomplete during the
resuscitation, a thorough history and physical examination should be per-
formed during the hospitalization and certainly within the first 24 hours.
Details involving the mechanisms of injury, medical history, and review
of systems should be obtained, using other sources as necessary. A photo-
graph of the accident scene may be helpful.
Details of the mechanism or pattern of injury, including the height of the
fall, speed of the automobile, damage to the vehicle, extrication time, num-
ber of fatalities, damage to the steering wheel, and whether the victim was
TABLE 27. CXR diagnostic checklist for cardiothoracic trauma
Primary findings
Anatomy Pathologic
Chest wall Subcutaneous air/rib, sternum, vertebral, scapula, clavicle
fractures
Pleura Pneumothorax/hemothorax
Mediastinum Shift/widening/pneumomediastinum
Lung Infiltrate/atelactasis/consolidation/edema/cyst/pneumonia
Diaphragm Elevation/herniation
Heart 1"Silhouette/pneumoperic ardium
Foreign body Location/position, endotracheal tube, chest tube,
nasogastric tube, deep lines, balloon-tipped pulmonary
artery catheter
Secondary findings
Pathologic Suspect
1st Rib fracture Heart contusion; traumatic tear of aorta
Scapula fracture Lung contusion; rib fractures
Flail chest Lung, heart contusion
Rib 6 to 12 fractures Liver injury
Right side Diaphragm rupture
Left side Spleen injury; diaphragm rupture
Pelvis fracture Traumatic tear of aorta
thrown from a vehicle, should be documented. The time of injury and time
from injury to arrival at the acute care facility should also be documented.
Deferred or deleted areas of the physical examination (such as the back
and vertebral area) should be noted and then completed as soon as possible.
A delayed complete physical examination should be done within 24 hours.
The location of foreign bodies and entry and exit wounds should be noted
and marked in diagrams in the hospital chart. Respiratory distress in the
absence of airway obstruction suggests rib fractures or abdominal pain.
Increasing ventilatory effort with obvious air hunger suggests flail chest,
pneumothorax, or airway obstruction. Cyanosis of the head and neck should
suggest the possibility of tension pneumothorax or cardiac tamponade.
Chest Radiograph. The CXR remains the single most valuable diagnos-
tic tool in the recognition and continuing assessment of chest trauma. 74,75
The anteroposterior supine CXR (along with the cervical-spine films) is
usually performed first. The CXR helps to define the extent of the injuries
to the chest wall and deeper structures. Findings on the CXR may include
subcutaneous air, fractures (eg, sternum, ribs, vertebrae), mediastinal
widening or shifting, pneumomediastinum, pneumothorax, hemothorax,
lung parenchymal changes (including infiltrates, atelectasis, collapse,
consolidation, abscess, cyst, focal and diffuse pneumonia), elevated
diaphragm, and enlargement of the cardiac silhouette. The presence and
location of foreign bodies are important. Skin markers help to document
TABLE 28. Chest CT checklist for cardiothoracic trauma
Early (emergency department) Rib fractures/flail/sternal fracture
Pneumothorax
Hemothorax
Pneumomediastinum
Diaphragm injury
Vertebral body fractures
Mediastinal hemotoma/fluid
Periaortic hematoma
Chest tube location
Late (intensive care setting) All of the above
Lung parenchyma changes
Loculated pleural collections
Location of chest tubes
entrance and exit sites. The position of the endotracheal tube, nasogastric
tube, central venous and pulmonary artery catheters, and chest tubes may
also be visualized to allow for documentation and repositioning, if neces-
sary. Serial CXRs allow for recognition of delayed pneumothoraces,
missed rib and vertebral fractures, progressive widening of the medi-
astinum, increasing pleural collections, lung parenchymal changes, and
ruptured diaphragm with herniated viscus. It is important to note that the
CXR is an objective documentation of an anatomic event. The presence
of a positive finding should lead to a suspicion of associated abnormalities
or a worsening pathophysiologic situation (eg, pneumothorax caused by
tracheobronchial tear and leading to increasing respiratory dysfunction
and failure; Table 27). It is useful to proceed from the anatomy to the
pathologic features (primary) and then relate the pathologic features to
additional associated or suspected injuries (secondary).
Fluoroscopy is occasionally useful, especially for documenting the
movement of foreign bodies. Inspiration and expiration films help to
demonstrate small pneumothoraces and air trapping on expiration with
aspirated foreign bodies. Pneumothorax on the anteroposterior supine
film may be difficult to identify. In the erect patient, pleural air is best
seen outlining a fine, thin visceral pleural margin superiorly and laterally.
In supine views, it tends to be seen medially, laterally, in the minor fis-
sure, and below the lung bases. Tangential or oblique CXRs and rib detail
films should be discouraged initially.
Computed TomographyScanning. CT scanning (with or without con-
trast) plays a prominent diagnostic role in chest trauma. CT can unmask
subtle or unsuspected injuries and may be used serially to monitor various
pathological processes (Table 28). In patients with blunt trauma, the CT
scan has become an invaluable diagnostic tool. An increasing number of
FIG. 17. Periaortic hematoma of descending aorta (arrow) on abdominal CT scan above diaphragm.
associated thoracic injuries have been identified on abdominal CT scans.

In 65 of 174 multiple trauma patients, Rhea and colleagues76 identified
associated chest injuries on the abdominal CT scan. In 41 patients, the
chest injuries were detected only by abdominal CT scan and not by the
CXR. As a routine part of the initial assessment of blunt chest trauma,
however, the CT scan has limited value. Its principal role is in subtle or
complicated cases, especially in the intensive care unit environment.
The chest CT scans help in the diagnosis of a variety of specific injuries,
including rib fractures, sternal fractures, sternoclavicular dislocations,
retrosternal hematoma, vertebral spine injuries, anteromedial and subpul-
monic pneumothoraces, and posterior fluid or blood collections.
Pulmonary contusion appears as scattered, fluffy parenchymal densities.
The location of chest tubes in relation to drained or undrained pleural col-
lections can be better appreciated than with CXRs. Intraparenchymal
placement can also be evaluated. Pneumomediastinum present on CT
scans is often missed on the CXR. Pericardial effusion or hemopericardium
can often be identified before widening of the cardiac silhouette. Contrast
CT chest scans also help to evaluate the vascular structures and the presence
and location of periaortic hematomas (Fig. 17). In some instances with a
normal CXR, a periaortic hematoma may be the only clue to the presence
of a torn aorta and may indicate the need for a thoracic aortogram.
The chest CT has significant value in the evaluation of infectious
FIG. 18. ChestCT scan with atelectasisof the right lung and multiloculatedpleural collections.
TABLE 29, Wagner classification of lung parenchymal injury

Type 1 Air-filled or air-fluid level in an intraparenchymal cavity
Type 2 Air-containing cavity or intraparenchymal air-fluid level within the paravertebral
lung
Type 3 Peripheral cavity or linear radiolueency close to chest wall fracture
Type 4 Previous pleural adhesions causing lung tear with direct trauma
complications, particularly multiloculated empyema, lung abscess, and

pseudocyst. Precise localization is possible and selective needle or
catheter drainage can be performed with CT guidance (Fig. 18). The chest
CT scan may also be used to localize foreign bodies, especially in the
paravertebral area.
Advancing the Trunkey torso approach to trauma, the CT scan is
invaluable in total body assessment. Several recent series 77-79 attest to its
value in patients with blunt thoracic trauma. CT scanning did have an
advantage over the standard CXR in assessing parenchymal damage. This
premise has led to the Wagner approach (Table 29) to classify lung
parenchymal injury by CT scan. s°
Echocardiography. Echocardiography (both transthoracic and trans-
esophageal) has helped in the evaluation of trauma victims, especially at
the bedside (Fig. 19).8~-83It is particularly useful in the assessment of cardiac
and aortic injuries. Its value in the initial evaluation of acute thoracic aor-
tic dissection has been extended to blunt injury as well. The major draw-
backs include logistics (eg, availability, technical constraints, expertise in
interpretation) and the potential technical difficulties (eg, avoiding neck
FIG. 19. Echocardiographlcdemonstrationof a large pericardial effusion (PE). RV, Right ventricle; LV, left
ventricle; LA, left aorta; R/k, right aorta. (From Plotnick GD, Hamilton S, Lee YC. Noninvasive testing.
SeminThora¢ Cardiovasc Surg 19924:168-76.)
manipulation, agitation, possible esophageal injury, aspiration).

Echocardiography has proved useful in the operating room to monitor the
cardiac status and to assess pericardial collections, wall motion abnor-
malities, valve damage, and the presence of shunts or fistulas.
Electrocardiogram. Although it is important to note that the electrocar-
diogram does not detect significant abnormalities as well as echocardio-
graphy, the electrocardiogram may still be helpful in chest trauma and par-
ticularly in nonpenetrating trauma. Preexisting abnormalities, particularly
in older patients, may suggest underlying cardiac disease. The cause of an
automobile accident, such as a myocardial infarction in the driver, may be
suggested by the electrocardiogram. Other findings include arrhythmias
and conduction abnormalities. Berk84 found 63% of electrocardiograms to
be abnormal in a series of 240 patients with blunt chest trauma.
Knowledg~e Objective
Technical S k i l l /
Problem/Challenge Solution/Resolution
Subjective
FIG. 20. Problem-solutionequation.
Abnormalities of the ST segment and T waves were present in 35% of

patients, and bundle branch block was present in 10% patients.
Other. Of all the nonsurgicat diagnostic techniques, contrast thoracic
angiography performed via the transfemoral route with the Seldinger
technique most accurately defines vascular injury or hemorrhageY
Biplane images and digital subtraction angiography enhance the accuracy
of this technique. Angiography is indicated whenever vascular injury is
suspected but may need to be omitted when the clinical condition requires
emergency operation. For suspected blunt traumatic tears of the thoracic
aorta, aortography is the "gold standard?' Cardiac catheterization may be
required in the evaluation of subtle or delayed complications of cardiac
trauma, particularly when valve injury, shunts, or coronary injuries are
suspected.
Treatment
For the surgeon, problem is a negative term. On the other hand, challenge
is a positive tenn. To reach a solution or resolution, certain requirements are
necessary (Fig. 20). These subjective and objective requirements are crucial
for the successful management of victims with cardiothoracic trauma.
Chest trauma management requires both supportive (nonoperative) and
operative therapy (Fig. 21). Because fewer than 15% of patients with chest
trauma require operative intervention, the focus of care is on supportive
measures that include fluid resuscitation, antibiotics, mechanical ventila-
tion, pain control, and miscellaneous drug regimens. Minor operative pro-
cedures include airway access (eg, cricothyroidotomy, conventional and
percutaneous tracheotomy), rigid and flexible bronchoscopy, esophago-
I CARDIOTHORACIC
,,, TRAUMA
], TREATMENT
i\
lop ! ! N°N-°PI
/ \ /
GENERAL i MAIOR/MINOR
PROCEDURES
/
SPECIFIC [
PROCEDURES
FIG. 21. Management schemefor cardiothoracictrauma,
scopy, thoracentesis, pericardiocentesis, and tube thoracostomy. Major

operative procedures include subxiphoid pericardial window, median ster-
notomy, thoracotomy, and VATS. Adjunctive technical modalities include
autotransfusion (eg, shed blood autotransfusion, cell-saver techniques),
cardiopulmonary bypass (CPB; as part of an operative procedure or sup-
port), and intra-aortic balloon counterpulsation. These procedures are
summarized in Table 30.
Supportive Measures
Volume Resuscitation.--There remains disagreement regarding the type
of sanguineous or intravenous fluid should be used for hypovolemic fluid
resuscitation.86Advocates of colloid fluids argue that the increased oncotic
pressure retains fluid in the intravascular space and that crystalloid dilutes
the oncotic pressure and diffuses into the pulmonary interstitium. Crystal-
loid advocates have shown that during shock, capillary permeability
increases, allowing colloid extravasation and an increase in extravascular
lung water. Crystalloid is more easily mobilized from third space areas
than colloid, which relies on the lymphatic system for mobilization.
In fact, neither of these approaches is ideal and both may be detrimental.
TABLE 30. Procedures in cardiothoracic trauma
Supportive Fluid resuscitation
Antibiotics
Mechanical ventilation
Pain control
Pulmonary emboti prophylaxis
Minor overative Airway access
Endoscopy
Thoracentesis
Pericardiocentesis
Chest tube thoracostomy
Major operative VATS
Subxyphoid pericardial window
Median sternotomy
Thoracotomy
Adjunctive modalities* Autotransfusion
CPB
Intr~aortic balloon (lAB)
*Specific operativeprocedurespeculiarto organs or structures involved.
Our bias is to use crystalloids initially. Blood transfusions are administered

when the hematocrit falls below 30%, and colloids are administered when
there is a poor response to crystalloids and in cases of underlying heart
dysfunction. In focusing on pulmonary contusion, it has been postulated
that hemodilution or crystalloid resuscitation accentuates pulmonary dys-
function. 87,88Recent data, however, support the conclusion that contusions
are not worsened by hemodilution. The mortality rate after contusion more
often relates to associated injuries or complicating pneumonia. 89
Antibiotics.--In general, the moderate approach is to use antibiotics for
penetrating trauma and when a chest tube thoracostomy is performed.
Grover and coUeagues9° in 1977 showed, in a randomized prospective
double-blind study of penetrating chest trauma, that clindamycin (300 mg
every 6 hours for up to 5 days) reduced the incidence of pneumonia,
empyema, fever, operations, hospital days, and positive blood cultures.
Locurto and colleagues9~ in 1986, in another prospective randomized
study, showed that cefoxitin (1.0 g every 6 hours beginning before chest
tube thoracostomy and terminating 12 hours after removal) resulted in
fewer infectious chest complications. Antibiotic usage is generally recom-
mended during and after thoracotomy for esophageal or major bronchial
injuries and when extensive destruction of lung parenchymal or soft tissue
has occurred. In a 1995 meta-analysis of six randomized studies, Evans
and colleagues92 concluded that antibiotics should be used in patients who
were undergoing chest tube thoracostomy for maximum Staphylococcus
aureus infection coverage.
TABLE 31. Pain management protocol at the UMMC
Narcotics orders must be rewritten every Monday and Thursday.
Pain is a frequent companion of our patients in the intensive care setting. There is
rarely a reason for our patients to be in pain. Whether a patient's pain is being
adequately controlled should be evaluated, at a minimum, on a daily basis. Many
studies have demonstrated that nurses and physicians alike, but particularly
physicians, underestimate the extent of patients' pain. Therefore if there is any
question, one should err on the side of giving more pain medication, not less.
Narcotics are the most frequently used and are generally the preferred agents.
Narcotics are potent, and potency is required, given the severity of injury in the
trauma population and those undergoing major surgery.
Narcotics provide some independent element of sedation, which can be helpful in the
patient whose condition requires mechanical ventilation. This effect is at least
additive to that of other sedative agents.
Contrary to popular belief, narcotics do not induce addiction in those patients who
truly have pain and are receiving titrated doses.
Morphine is the preferred agent because it is the least expensive, works as well as
other agents, and has a side-effect profile that is no less favorable. It is best used as
an infusion because it provides for more uniform pain control. Patients should first
receive intravenous morphine with doses ranging from 2 to 20 rag. Bolus doses
should be administered slowly (minutes) to avoid hypotension as the result of
histamine release..
Infusion rates begin at I to 3 mg/h but can exceed 30 mg/h.
An as-needed order for morphine should also be provided for all patients.
In addition to intravenous infusion of narcotics, the following methods may also be
considered in appropriate patients:
Patient-controlled analgesia (PCA)
Epidurat analgesia
Intrapleural catheter
Transcutaneous electrical nerve stimulation (TENS)
Intercostal nerve block
Mechanical Ventilation.--Patients with extensive parenchymal injury,

ARDS, flail chest, or severe multisystem disease with hypovolemic shock
often require mechanical ventilation. This allows needed time for volume
resuscitation, chest wall stabilization, and reversal of lung parenchymal
changes. Wilson and colleagues 43 showed that 11% of patients with chest
trauma require endotracheal intubation. The mortality rate in this group
was 58% and rose to 73% if associated with shock.
Various types of assisted ventilation are available. 18,93 The volume-
cycled pressure-limited ventilator is the principal method of mechanical
ventilation for respiratory failure that complicates chest trauma. High-fre-
quency (jet) ventilation offers promise for some situations, such as bron-
chopleural fistulas and tracheal surgery. With this technique a short high-
pressure jet of air directed into the trachea through a small cannula inflates
the lung at 100 to 200 times per minute. Air is pulled in by the Venturi
effect. The resulting decreased airway pressure reduces barotrauma. With
TABLE 32. Drug dosing guidelines
Agent Adult Pediatric (<10 yrs)
Fentanyl (Sublimaze)* 1-3 I~g/kg 1-3 I~g/kg
Haloperidol (Haldol)* 2.5-10 mg Not recommended
Midazolam 1-5 mg 0.05 rng/kg
Morphine 2.5-10 mg 0.1 mg/kg
Pancuronium (Pavulon)* 0.1 mg/kg 0.1 mg/kg
Succinylcholine (Anectine)* 1-2 mg/kg 1-2 mg/kg
Vecuronium (Norcuron) 0.1 mg/kg 0.1 mg/kg
*Higher doses may be used in patientswho are intubated.
tReduce doseto 0.05 mg/kg if used beforesuccinylcholineto preventfasciculations,
~Pretreatwith atropine0,01 mg/kg.
bronchopleural fistula, there is a decrease in tidal volume loss. The use of

jet ventilation also facilitates open surgery on the tracheobronchial tree.
Simultaneous independent lung ventilation uses two ventilators and a
double-lumen endotracheal tube, allowing independent ventilation of each
lung. Selective exclusion of the severely injured lung with endotracheal
blockers offers promise in patients with severely injured blunt trauma.
Independent lung ventilation with conventional or high-frequency ventila-
tion offers exciting new possibilities. 94,95 Extracorporeal membrane oxy-
genation has gained increased popularity in the neonatal population but
has limited application in the patient with chest trauma or multisystem
injuries.
Pain ControL--Systemic and local pain control is critical in the man-
agement of the chest trauma victim. Tables 31 and 32 summarize our pain
control protocol. Therapies range from intravenous and intramuscular
drug administration to epidural and regional nerve blocks. Chest trauma,
particularly rib fractures and flail chests, causes considerable pain.
Associated injuries accentuate the discomfort and pain. Consequent pul-
monary dysfunction results from decreases in tidal volume, vital capacity,
and functional residual capacity.
Small intravenous doses of narcotics (eg, morphine sulfate 1 to 2 mg
every 15 to 60 minutes) at frequent intervals is preferred to intramuscular
administration. Patient-controlled analgesia has gained popularity, allow-
ing a patient to deliver an intravenous narcotic on demand when a com-
puterized bedside module is activated. Epidural administration relieves
pain effectively but may cause undesirable hypotension, ileus, and respi-
ratory depression. 96 Transcutaneous electric nerve stimulation (TENS)
has been described in patients after thoracotomy with good early results
but equivocal long-term benefit. 97 Intrapleural blocking is helpful but not
as effective as epidural anesthesia. 98
Curr Probl Surg, August1998 703
.- .. + .(~)-... Skin
/ . . 5 = ..,~'-' ~ " Skln "'.. ..... Muscle
.h... "'.
L N; v.
FIG. 22. Intercostal local nerve block technique.(From Hood RM, Boyd AD, Culliford AT, editors. Thoracic
trauma. Philadelphia: Saunders; 1989.)
An intercostal nerve block may control local pain effectively. It relieves

the somatic pain and splinting from rib fractures particularly well. A typical
regimen includes 2 to 4 mL of 0.5% bupivacaine hydrochloride or 5 to 10
mL of 2% lidocaine with a 20- to 22-gauge needle injected under the
lower rib margin approximately three fingerbreaths lateral to the vertebral
spine (Fig. 22). This technique can be repeated two to four times over a
3- to 4-day period. If difficult, complicated, or chronic pain control issues
occur, a service specializing in pain control is frequently consulted.
Pulmonary Embolism. Pulmonary embolism occurs in more than
500,000 patients per year with a 10% to 40% fatality rate. Thirty percent
of patients have no demonstrable deep vein thrombosis. Compression
boots, subcutaneous heparin, and low-dose warfarin have been used as
prophylaxis in surgical patients. Increased age, pelvic fracture, and trun-
cal trauma are associated with an increased incidence of deep vein throm-
bosis. Despite aggressive routine prophylaxis, Winchell and colleagues, 99
in a review of 9721 patients with trauma, reported an overall 0.4% inci-
dence of pulmonary embolism. In a high-risk group of patients, the inci-
dence ranged from 1.5% to 3.8%. Geerts and colleagues t°° at Sunnybrook
in Toronto identified age, blood transfusion surgery, femur or tibia frac-
ture, and spinal cord injury as significant risk factors. A management
scheme for prophylaxis at UMMC is summarized in Table 33.
Adjunctive Modalities
Autotransfusion.--Autotransfusion in trauma and after open heart
surgery is well documented, l°l Several systems are available. Symbas 52
established the safety and efficacy of autotransfusion in traumatic hemo-
thorax. Blood drained from the pleural space, usually defibrinated, is rein-
fused into the patient. A second type of system is the shed-blood system.
TABLE 33. Thromboembolism prophylaxis scheme* at the UMMC
Classification Description Prophylaxis options
Low risk Uncomplicated surgery in patients No specific treatment; early
who are younger than 40 yrs of ambulation
age (no other VTE risk factors)t
Moderate risk Major surgery in patients who are Elastic stockings or heparin
older than 40 yrs of age (no other 5000 units, subcutaneously,
VTE risk factors) twice daily, or IPC boots
High risk Major surgery in patients who are Heparin 5000 units, subcuta-
older than 40 yrs of age and 1 or neously, 3 times daily, or IPC
more of the following: MI, CHF, boots or LMWH
immobility (>3 days), or elective
neurosurgery
Very high risk Major surgery in patients who are LMWH or warfarin and IPC
older than 40 yrs of age and i or boots or elastic stockings
more of the following: pelvic,
femur, tibial fracture, malignancy
(not skin cancer), history of VTE,
spinal cord injury, or paralytic stroke
Orthopedic Total hip arthroplasty LMWH or warfarin*
Total knee arthroplasty LMWH or IPC boots
Medical patients Acute MI or paralytic stroke Heparin 5000 units, subcut-
neously, twice daily
/PC, Intermittent pneumatic compression; MI, myocardial infarction; CHF, congestive heart failure;
LMWH, low-molecular weight heparin.
*Venous thromboembolism (VrE) prophylaxis should be selected according to each patient's level of
risk, be initiated at or near the time of surgery (when applicable), and continued until the patient is fully
ambulatory.
tCommon risk factors for VTE: prior VTE, acute MI, CHF, cancer, trauma, paralytic stroke, immobilization
(>3 days), increasing age (above 40 yrs of age), and hypercoagulable states.
tAdjusted-dose heparin is also effective after total hip arthroplasty.
Adapted from American College of Chest Physicians Consensus. Chest 1995;$312-34.
A collection system is placed in the suction line. The blood is reinfused

with the use of a filter to eliminate aggregates, fat particles, and debris. The
third type of system is the blood concentrator, or cell saver. The blood is
aspirated or suctioned from the field, washed, and concentrated. There can
be a 20- to 30-minute delay to set up the system. In our experience, how-
ever, this time ranged from 5 to 10 minutes. This technique is usually
reserved for selected high-risk patients with increased bleeding potential.
Cardiopulmonary Bypass.--The role of CPB in chest trauma is not well
defined. ~°2 Injuries requiring CPB include coronary artery lacerations,
valve injury, septal perforation, and repair of difficult free wall lacerations
of the heart. Femoral artery to femoral vein bypass, requiring full sys-
temic heparinization, or left atrial to left femoral artery bypass techniques
allow perfusion beyond the distal aortic clamp during repair of descend-
ing thoracic aortic injuries. In those centers with level l trauma care and
open heart facilities, the use of CPB will probably increase in the future.
2. /~ 3.
Pleural
Anterior
Axillaty U ~ ..,
FIG. 23. Technique of chest tube thoracostomy.(From Symbas PN. Cardiothoracic trauma. Philadelphia:
Saunders; 1989.)
Extracorporeal membrane oxygenation (now termed extracorporeal life

support [ECLS]) is an extended support modality for severe respiratory
dysfunction in both the adult and neonatal population. Recent advances in
membrane oxygenators and heparin-bonded circuits give promise to
extended application in the patient with trauma. CPB with deep hypother-
mia and circulatory arrest is used in complex traumatic injuries of the
ascending aorta and aortic arch. An exciting area is the use of CPB as part
of the resuscitative effort for patients with multiple trauma, especially
those with massive intra-abdominal injury (eg, complex liver trau-
ma). 1°3,1°4Restoration of the circulating blood volume, correction of aci-
dosis and tissue perfusion, oxygenation, and improvement of coagulation
parameters are achievable with CPB. More basic research is needed to
justify this aggressive approach, however.
Intra-aortic Balloon.--Intra-aortic balloon counterpulsation is used
widely to support decreased or impaired myocardial function after open
heart surgery. The intra-aortic balloon has been used anecdotally in
trauma.lOs However, given its ready availability and percutaneous femoral
insertion it might prove useful in patients with blunt cardiac contusion
and myocardial dysfunction.
Operative Procedures. The invasive procedures essential to the suc-
Three Bottle~ Sy~em
l l m o w h ~ ~int
I,,l~ To Suction
~ S e ~ ~ s ~ e m
venl
±
T
G ~sttnrl
FIG. 24. Chesttube drainage/collectionsystem.(FromSymbasPN. Cardiothoracictrauma. Philadelphia:

Saunders; 1989.)
cessful assessment and treatment of chest trauma are divided into minor
and major. Minor procedures generally require no anesthesic or only local
anesthesic. Rigid bronchoscopy and esophagoscopy usually are per-
formed with general anesthesic but can be performed with local anes-
thesic. Major procedures are performed with general anesthesic.
Occasionally, a subxiphoid pericardial window must be initiated with
local anesthesic until the tamponade has been relieved.
J \
FIG. 25. Pericardiocentesistechnique. (From RichardsonJD, Mavroudis C. Management of thoracic

injuries. In: RichardsonJD, Polk HC, Flint LM, editors. Trauma: clinical care and pathophysiology. Chicago:
Year-Book; 198Z p. 291-352.)
All operative procedures performed must be documented in the med-

ical record. Before performing any operation, the surgeon must consider
the indication (relative/absolute), any contraindications relative/absolute),
the most appropriate timing (emergency/urgent/delayed), the type of
procedure needed, the details of technique, and potential complications
(intraoperative/postoperative).
Intravenous Access.---~travenous access is usually accomplished with
one or two large-bore peripheral cannulas. The subclavian vein, internal
jugular vein, and femoral vein routes offer access for resuscitation,
measurement of the central venous pressure, access for pulmonary artery
catheter placement, and temporary cardiac pacing. Cutdowns of the
saphenous or femoral veins allow placement of larger cannulas and rapid
volume administrations that may be needed when autotransfusion devices
are used.
Bronchoscopy.--Fiberoptic bronchoscopy plays a major role in chest
Xiphoid
process
Pericardium
Diaphragm
FIG. 26. Subxiphoid pericardial window technique.(From Richardson JD, Mavroudis C. Management of
thoracic injuries. In" Richardson JD, Polk HC, Flint LM, editors. Trauma: clinical care and pathophysiology.
Chicago: Year-Book; 1987. p. 291-352.)
trauma. Indications include the evaluation of airway injury, hemoptysis,

inhalation injury, and particularly evaluation and treatment of parenchymal
atelectasis and collapse. Foreign bodies may be removed with greater care
and safety with a rigid bronchoscope. Large quantities of blood may pre-
clude the use of a flexible bronchoscope and necessitate rigid bron-
choscopy. Hara and Prakash, 1°6 in a review of 50 patients with blunt chest
trauma, found bronchoscopy to be valuable in 28 of these patients, par-
ticularly for identifying tracheobronchial injuries in the acute setting. One
practical point to remember is that flexible bronchoscopy via an endotra-
cheal tube requires a tube of at least 7.5 mm. Thick tenacious secretions
require a bronchoscope with a large (2.6 mm) suction channel.
Chest Tube Thoracostomy.--The most common procedure performed in
cardiothoracic trauma (more than 85% of cases) is insertion of a chest
tube to drain air, fluid, or blood from the thoracic cavity, l°v-~°
Hippocrates first described drainage of the pleural space. The goal of
chest tube thoracostomy is to restore a negative intrathoracic pressure. In
44
i,llf-5
Cardiac Injuries
1. Proximal Aortic Arch
2. Proximal Innominate Artery
3. Right Subclavian Artery
4. Right & Left Common Carotid Arteries
5. SVC
6. IVC
FIG. 27. Standard mediansternotomyapproachto the head, ascendingaorta, and aortic arch. (FromTam
VK, Casale NS, BuchmanTG. Management of penetratingthoracic trauma. In: TurneySF, RodriquezA,
Cowley RA, editors. Management of cardiothoraclc trauma. Baltimore, MD: Williams & Wilkins; 1990.
p. 285-309.)
a trauma situation a large (38F to 40F) chest tube is inserted in the 4th or
5th intercostal space in the anterior or midaxillary line (Fig. 23). The
major complications include unintentional tube placement into the
diaphragm, lung, liver, spleen, esophagus, or heart itself. Bleeding, residual
pneumothorax, hemothorax, and empyema may be related to technique or
the disease process itself. The drainage system used in most centers is the
commercial plastic self-contained unit, which is a modification of the
three-bottle drainage system (Fig. 24). Heimlich valves are one-way flutter
valves that allow egress of air and fluid from pleural tubes and catheters.
They are valuable for ambulatory and transfer situations. In fact there has
been recent enthusiasm for their use for simple traumatic or spontaneous
pneumothorax.
Pericardiocentesis. Pericardiocentesis is usually performed in the
resuscitative phase as a diagnostic or at best temporizing modality. This
II.
FIG. 28. Variationsof mediansternotomyor alternativeincisions in the supine posifion.(FromSymbasPN.

Cardiothoracictrauma.Philadelphia:Saunders;1989.)
procedure is performed with an 18-gauge needle on a 20 or 50 mL syringe

(Fig. 25). Originally performed in 1849 by Larrey, this became the treat-
ment of choice for pericardial tamponade in World War II as popularized
by Blalock and Ravitch in 1943.110a In 1968 Sugg and colleagues 111 advo-
cated pericardiocentesis as a temporizing treatment with aggressive oper-
ation as the treatment of choice for injuries to the heart and pericardial
cavity. Because of high false-positive and false-negative results in the
trauma setting, pericardiocentesis cannot necessarily be relied on to diag-
nose or treat possible cardiac injuries.
Major Procedures.--Major operations are required in only 10% to 15%
of patients with chest trauma. 112
Subxiphoid Pericardial Window. Trinkle and colleagues 1~3 in 1974
popularized the subxiphoid pericardial approach for pericardial window
(Fig. 26). Miller and colleagues I ~4carried this philosophy to Louisville. In
1987 they reported on 104 patients (95 penetrating) who were treated over
a 5-year period. There were one false-positive and one false-negative
result. Brewster and colleagues ~15 in 1988 reported a similar series of 108
Curr Probl Surg, August 3.998 711
Clamp on
Descending Aorta
FIG. 29. Left anterior resuscitative thoracotomy allows access to the heart and descending thoracic
aorta.(From Rodriguez A. Initial patient evaluation and indications for thoracotomy. In: Turney SF,
Rodriquez A, Cowley RA, editors. Management of cardiothoracic trauma. Baltimore, MD: Williams &
Wilkins; 1990. p. 7-18.)
Table 34. Use of VATS for cardiothoracic trauma

Evacuation of clotted blood and Iocutated pleural collections 117
Evaluation and treatment of diaphragmatic injuries 118,119
Decortication of post-traumatic empyemas 12o
Pericardial window 121
Evaluation and management of thoracoabdominal injuries 122.123,124
Investigation and removal of intrathoracic foreign bodies 125
patients with penetrating chest wounds undergoing subxiphoid window

and noted that 10% of asymptomatic patients had a positive exploration.
Both groups of these investigators concluded that the procedure is rapid
and accurate and carries minimal morbidity. Duncan and colleagues 116in
1989 highlighted an occult injury rate of 17.6% in 51 patients with pene-
trating wounds and suspected cardiac injuries. The technique is performed
with light anesthesic, and gastrointestinal contamination is negligible.
Video-Assisted Thorascopic Surge13:--VATS has become an increasingly
popular technique in the armamentarium of the cardiothoracic surgeon. The
attractive feature is less morbidity for the patient. This technique does, how-
1. Emergency Open-Chest Cardiac Mas-
sage; Cardiac Tamponade
2. Clamping of Descending Aorta
3. Left Pulmonary Injury
FIG. 30. Left anterior thoracotomy with access to the heart, hilum, and descending thoracic aorta.(From
Wiles CE. In: Turney SF, Rodriquez A, Cowley RA, editors. Management of cardiothoracic Irauma.
Baltimore, MD: Williams & Wilkins; 1990. p. 107-21.)
ever, require technical skill, patience, increased operative time, and the abil-
ity to work in a tahree-dimensional magnified environment without tactile
sensation. Its applications in cardiothoracic trauma are summarized in
Table 34.
The evacuation of retained or residual hemothoraces can be accom-
plished with VATS, especially if performed early (48 to 72 hours). In
penetrating thoracoabdominal trauma, VATS may be useful to comple-
ment or precede laparoscopy and may be used to identify diaphragmatic
injuries and thereby avoid unnecessary diagnostic laparotomy. Isolated
diaphragmatic tears are easily approached and repaired, if they are small
and do not require more extensive repair.
Median Sternotomy.--Median sternotomy is the standard approach for
open heart procedures. In chest trauma this is the incision of choice for
suspected injury to the heart and great vessels. It is also helpful as an
extension of a midline abdominal incision for access to the inferior vena
cava when hepatic vein injury is encountered (Fig. 27). The sternotomy
Curr Probt Surg, August 1998 713
1. Left Proximal SubclavianArtery
2. Left PulmonaryInjury
3. Lower Third of Esophagus
4. Aortic Injuries
FIG. 31. Left posterolaterallhoracotomy.(FromWiles CE. In: Tumey SF, Rodriquez A, Cowley RA, editors.
Management of cardiothoracic trauma. Baltimore,MD: Williams & Wilkins; 1990. p. 107-21.)
incision can be extended into either neck or an intercostal space for com-
plicated great vessel injuries (Fig. 28). Prepping and draping should
include the groins and thighs for femoral vessel access and potential
greater saphenous vein harvesting.
Thoracotomy.---Oneof the most useful thoracotomy incisions in trauma
is the anterior thoracotomy, usually through the left 4th or 5th interspace
(Fig. 29). This incision offers rapid access to the heart, hilum of the lung,
and descending thoracic aorta (Fig. 30). The incision can be extended
across the sternum, requiring ligation of the internal mammary vessels
(Fig. 28). This is the approach most commonly used for emergency or
resuscitative thoracotomy. The pericardium may be opened anterior to the
phrenic nerve. Clamping of the flaccid descending aorta in shock may be
performed while injury to the adjacent esophagus is avoided.
The posterolateral thoracotomy is the standard approach for intrathoracic
structures. A left thoracotomy in the 4th, 5th, or 6th interspace gains
access to the proximal left subclavian artery and descending aorta, the
hilum of the lung, and the lower esophagus (Fig. 31). A right posterolateral
thoracotomy in the 4th or 5th interspace gains access and control of the
carina, hilum of the lung, and the midportion of the esophagus (Fig. 32).
Thoracotomy may be considered as an emergency, urgent, or delayed
procedure. Emergency or resuscitative thoracotomy is performed in the
3. Carin~
4. RightLung
FIG. 32. Right posterolateral thoracotomy.(From Tam VK, CasateAS, BuchmanTG. Management of pen-
etrafing thoracic trauma. In: Turney SF, Rodriquez A, Cowley RA, editors. Management of cardiothoracic
trauma. Baltimore,MD: Williams & Wilkins; 1990. p. 285-309.)
emergency room or the initial hospital acute care area. This procedure
may be indicated to initiate open cardiac massage, to clamp the distal
thoracic aorta for distal hemorrhage to relieve cardiac tamponade, or to
control local exsanguinating hemorrhage from the heart or great vessels.
These desperate circumstances require immediate action. Open cardiac
massage is a desperate measure, especially in hypovolemic shock,
because there is poor venous return to the heart, and it succeeds only
when there is sufficient circulating volume. Emergency thoracotomy is
more often useful in the setting of penetrating trauma. It is rarely indicated
or successful with blunt chest trauma or in children. A ruptured aorta with
massive hemothorax or a severe tracheobronchial rupture may respond to
aortic crossclamping or clamping of the hilum. Urgent thoracotomy with-
in the first 24 hours is performed in a controlled operating room setting.
Delayed or semielective thoractomy is performed after 24 hours.
Emergency Thoracotomy.--Resuscitative thoracotomy or emergency
thoracotomy can be summarized as being effective in penetrating thoracic
trauma (with or without electromechanical dissociation) but ineffective in
blunt thoracic trauma and penetrating injuries below the diaphragm. Bodai
and colleagues 126 in 1983 summarized the available literature about emer-
gency thoracotomy for penetrating trauma and noted mortality rates rang-
ing from 2% to I6%. In large series (more than 30 cases) of penetrating
cardiac injury, the mortality rate ranged from 45% to 83%. Emergency
TABLE 35. Relative indications for emergency or resuscitative thoracotomy
Penetrating cardiac/thoracic trauma
Acute deterioration, uncontroled hemorrhage, cardiac arrest with heart wounds
Penetrating subclavian/great vessel wounds with threatened exsanguination
Suspected air embolism
Penetrating abdominal trauma
Suspicion of intra-abdominal arterial bleeding and signs of life
Blunt thoracoabdominal trauma
On the spot deterioration in a healthy patient with signs of life
TABLE 36. Thoracotomy within and beyond 24 hours

Urgent thoracotomy
Penetrating trauma Continuing hemothorax
Mediastinal traverse injury
Tamponade
Parasternal wound
Blunt trauma Defect of chest wall/open wound
Heart/great vessels
Trachea/bronchus
Esophagus
Diaphragm
Delayed thoracotomy (>24 hrs) Clotted hemothorax
Delayed tamponade
Massive air leak
Empyema Ioculated
Severe lung damage/sequelae
Heart sequelae
Widened mediastinum
thoracotomy for penetrating abdominal trauma yielded a survival rate of

less than 10% and an even worse survival rate (less than 5%) for blunt trau-
ma. Baxter and colleagues ~27 at Denver General Hospital in 1988 summa-
rized 632 emergency thoracotomies. The overall survival rate was 5%.
However, when vital signs were present (113 cases) the survival rate was
32% for stab wounds, 15% for gunshot wounds, and 5% for blunt trauma.
In children the outcome for emergency thoracotomy is similar to that of
adults. In a meta-analysis by Boyd and colleagues ~28 in 1992 of 24 studies
involving 2294 patients trauma, there was an 11% overall survival rate for
emergency thoracotomy. The survival rate after penetrating trauma was
14%, and the survival rate after blunt trauma was 2%. There was a 100%
mortality rate when there were no signs of life at the scene. A useful strat-
egy for emergency thoracotomy is summarized in Tables 35 and 36.
Specific Operative Approaches.--General guidelines for major opera-
tions must be directed by a sense of which structures might be damaged
and how they are best approached. The right and left thoracotomy
FIG. 33. Median sternotomy approach to liver injury. (From Novick TL, Moylan JA+ Hepatic trauma.
In: Moylan JA, editor. Principlesof trauma surgery. New York: Gower Medical Publishers;1992. p. 7.1-.10.)
approaches are divided into anterolateral and posterolateral. Each

approach has advantages in terms of access and control of the outlined
structures. The median steruotomy provides exposure to the heart, aorta,
proximal great vessels, and retrohepatic veins, with the use of inferior
vena cava occlusion devices (Fig. 33). Intraoperative events are important
to highlight. Technical problems with one-lung anesthesia include
desaturation along with an inability to collapse the lung. Exposure may
be difficult. Bleeding, hypotension, hypothermia, acidosis, and coagulo-
pathies add to the severity and complexity of the operation. The surgeon
and anesthesiologist must always keep air embolization in mind. Hilar
clamping may be crucial. Iatrogenic injury to adjacent structures must be
avoided, especially to the aorta, esophagus, phrenic nerve, recurrent
laryngeal nerve, and thoracic duct. Sudden cardiac tamponade may be
related to inadvertent pericardial entry.
One of the most difficult challenges for the cardiothoracic surgeon is the
decision regarding reoperation. The major early indications include
bleeding and major air leak. Later indications include empyema with or
without fistula formation, an infected graft, or pseudoaneurysm.
The postoperative patient with chest trauma presents a number of man-
agement challenges. Pain and sedation require an appreciation of the fact
that thoracotomy wounds are more painful than median sternotomy
wounds. Epidural and regional rib blocks are helpful. Nasogastric decom-
pression is advised because aerophagia and gastric distension is common.
Hemodynamic difficulties may include arrhythmias and hypertension.
Supraventricular tachycardia is common, especially with associated
myocardial contusion. Digoxin is the preferred initial treatment to control
the heart rate. When supraventricular tachycardia causes hemodynamic
instability, verapamil (intravenously) or cardioversion is used. Hyper-
tension occurs commonly after repair of traumatic tears of the aorta.
Nitroprusside is discouraged in favor of labetolol, which possesses both
alpha and beta antagonist properties. The importance of respiratory toilet,
particularly the control of secretions, cannot be overemphasized after tho-
racotomy. In the patient who has been extubated, a variety of breathing
exercises including incentive spirometry are initiated. Early ambulation,
coughing, nasotracheal suctioning, and minitracheostomy may improve
pulmonary toilet. Atelectasis or persistent parenchymal lung collapse may
require bronchoscopy, especially in patients who are being mechanically
ventilated. Volume overload requires fluid restriction and diuretics.
Postoperative bleeding may be caused by coagulopathies or be due to sur-
gical causes. Autotransfusion, previously discussed, is particularly valu-
able when volume is needed or blood products are in short supply.
Anesthesia.--Anesthesiologists play a pivotal role in the management
of the victim with cardiothoracic trauma. ~8 Difficult intubation, intra-
venous access, sophisticated monitoring techniques, and transesophageal
echocardiography are all within their domain. Double-lumen or bronchial
blocker endotracheal tubes are crucial to facilitate transthoracic operative
techniques. Early indications for selective intubation include massive uni-
lateral hemothorax, massive broncho-pleural fistula, suspected air embo-
lus, and traumatic aortic injury.
Epidural anesthesic is valuable for postoperative pain control.
MacKersie and colleagues96 showed a distinct advantage of epidural over
intravenous fentanyl in pain control for multiple fractures. The maximum
inspiratory pressure and vital capacity were better with the epidural route.
Luckette and colleagues 98 also showed better results for epidural than for
intrapleural administration of bupivacaine.
Intraoperative communication between the surgeon and anesthesiologist
is crucial. Specific examples include the use of specific anesthetic agents
and preinduction prepping and draping in patients with suspected cardiac
tamponade, control of hypertension after thoracic aortic crossclamping,
avoidance of nitroprusside in aortic surgery, cooperation in the removal of
tracheal and esophageal foreign bodies, and blood replacement strategies. A
major challenge for the anesthesiologist is emergency intubation and the
avoidance of aspiration during intubation when the gastrointestinal status
of the patient is unknown.
Complications of Chest Trauma

Patients often pay a high price in terms of pain, disability, and cost for
the delayed complications and sequelae of chest trauma. 4'129'13°From 25 %
to 50% of victims with serious blunt trauma have subjective and objective
complaints 4 to 5 years after injury. 55 Fifty percent of patients with flail
chest injury have significant pulmonary impairment at 5 years. Table 37
summarizes some of the delayed sequelae that may follow chest trauma.
Surprisingly, long-term results are scant. An encouraging report by
Livingston and Richardson TM in 1990 revealed a study of 25 patients with
severe chest trauma. The mean ISS was 34, and the long-term disability
rate was less than 5%.
Specific Injuries
Chest Wall Injuries
Damage to the chest wall is the most common injury in both blunt and
penetrating trauma. 132 The degree of injury ranges from isolated rib frac-
tures to massive chest wall instability or flail chest. With the exception of
children (who have a more compliant and cartilaginous rib cage), the
degree of chest wall trauma is directly proportional to the degree of
intrathoracic damage, particularly lung contusion. Ribs 1 and 2 are the
least injured, and ribs 3 through 9 (posteriorly) are the most commonly
injured. The ribs 11 and 12 are short and less exposed. Lee and col-
leagues 133 in 1990 recommended that patients with three or more rib frac-
tures be transferred to a level I trauma center. The incidence of splenic or
liver injury was increased in this subgroup. As a marker of the severity of
injury, in 1994 Ziegler and Agarwa1134 noted a 10% incidence of rib frac-
tures in 7147 patients with trauma over a 5-year period. There was a 12%
TABLE 37. Delayed sequelae of cardiothoracic trauma
Acute Chronic
Chest wall Rib fracture Chronic pain
Callus
Flail chest Bone cyst
Costochondral separation
Costal osteomyetitis
Sternum Fracture; displacement Malalignment (cosmesis)
Pseudoarticulation
Osteomyelitis
Soft tissue Abrasion; laceration; avulsion Muscle defects, keloid
Galactorrhea
Lung hernia
Lung parenchyma Contusion/laceration/cyst Pseudocyst
Abscess
AV fistula
Trachea/bronchus Varying injuries Avulsion
Stricture
Obstruction
TEF
Diaphragm Rupture; stretch injury Delayed hernia
Paradoxical motion
Paralysis hemidiaphragm
Mediastinum Hematoma Abscess/fibrosis
Thoracic outlet Arterial; venous; brachial plexus Thoracic outlet syndrome
Upper extremity swelling
Pleura Hemothorax; pneumothorax Trapped lung
Fibrothorax
Empyema
Chylothorax
Residual space
Esophagus Blunt; penetrating Fistula (aortic/trachea)
Strictures
Heart Contusion; penetration LV aneurysm
Constrictive pericarditis
VSD
Valvular insufficiency
Residual foreign bodies
Aorta/great vessels Blunt/penetrating injury Aneurysm (true/false); occlusion
Fistula
Compression adjacent structures
(SVC; esophagus; trachea)
AV, Arteriovenous; TEF, tracheoesophagealfistula; LV, left ventricular; VSD, ventricularseptal defect;
SVC, superiorvena cava,
mortality rate in that group of patients, usually from severe associated

injuries. A hemothorax or pneumothorax was present in 32% of the
patients, and overall 35% of the patients had a pulmonary complication,
usually a pulmonary contusion.
The diagnosis is usually established by the clinical history and physical
examination, with pain on inspiration and palpation being the most com-
mon findings. After the acute resuscitation, careful documentation of the
chest wall injury is essential. This process involves a careful physical
examination, particularly of any posterior injuries. The entrance and exit
wounds must be identified. Wound care and debridement serves to pre-
vent both local and deep infections. The aseptic care of chest tube sites
decreases the incidence of pleural contamination and subsequent pleuritis
and empyema.
CXRs with frontal and oblique rib detail films will usually document
the complete thoracic cage profile. Additional radiographs are rarely
needed. Sternal views and apical lordotic views are added if sternal or
first or second rib fractures are suspected.
The treatment for most simple undisplaced rib fractures is analgesic
control. Intercostal nerve blocks may be extremely helpful (Fig. 22). Rib
binders are discouraged because they encourage chest wall splinting and
aggravate atelectasis.
Rib fractures are more common in elderly individuals and less common
in children. Underlying rib conditions, such as metastatic rib tumors, may
predispose the patient to stress rib fractures, particularly after a deep
cough. Fractures not initially identified on the CXR may appear in 3 to 6
weeks with callus formation. It is important to obtain inspiration and
expiration views in patients with rib fractures to evaluate for a subtle
pneumothorax. Rib fractures that occur at thoracotomy for cancer should
be documented in the operative note to avoid later concern for metastatic
rib involvement. Rib fracture pain usually resolves in 1 to 2 weeks.
Healing occurs in 3 to 4 weeks, even with malalignment. Costochondral
separation with nonunion may cause persistent pain and require surgical
resection of the involved cartilage.
Injuries of the Skin and Soft Tissue. Chest wall contusion with local-
ized soft tissue swelling, interstitial hemorrhage, and hematoma forma-
tion occurs commonly. Deeper muscle injury after crushing and lacera-
tion also occurs. This causes pain, discomfort, and occasionally infection.
Such infection may remain localized or spread along the fascial planes.
Occasionally, intrathoracic blood, fluid, or air will dissect into the chest
wall. A pleural empyema may spread into the chest wall, creating an
empyema necessitans. Ultrasound and CT scanning help to document the
extent and content of local masses and any associated rib fractures.
Needle aspiration may confirm a suspected infection. Treatment of super-
ficial infections requires wound care with debridement and rotation of the
patient away from areas of cutaneous pressure. Deeper infections require
incision and drainage. Surgical drainage should be avoided for a localized
mass or phlegmon that has not yet organized into an abscess cavity. In
general, infected skin and soft tissue wounds should only be incised,
drained, and debrided in a sterile setting. Galactorrhea is a rare chronic
complication of soft tissue chest trauma.
Chest Wall Loss. Massive chest wall loss occurring with penetrating or
avulsion injuries requires coverage of the entrance to the thoracic cavity
to maintain ventilatory homeostasis and to avoid further internal contami-
nation. A flap dressing (sealed on three of four sides) allows egress of air
yet prevents aspiration of air into the pleural space. Positive pressure
ventilation, however, permits the initial open treatment of chest wall
defects without the liability of an open pneumothorax. After debridement,
early coverage may be accomplished with temporary prosthetic materials.
Subsequent, definitive chest wall reconstruction with prosthetic meshes,
rotational muscle flaps, or skin grafts is used to restore the stability of the
chest wall. As in military trauma, the concept of delayed primary closure
(4 to 5 days) for contaminated wounds applies as long as the integrity of
the chest has been maintained.
Burns. Bums may compromise normal chest wall motion. Traditional
bum wound care may require supplementation with escharotomy to allow
for improved chest wall expansion. With circumferential bums involving
the lower thorax, bilateral incisions made longitudinally along the anteri-
or axillary line and joined transversely across the breasts and upper
abdomen allow for improved chest wall excursion. J35
Rib Fractures. Rib fracture is the most common blunt thoracic injury.
The number of fractures correlates directly with the degree of intrathoracic
injury and the associated mortality rate. The point of maximum stress
along the posterior axillary line explains the predominance of fractures in
this region. The shoulder girdle protects the first three ribs from injury.
Fractures of these ribs increase the likelihood of more serious internal
injury. Fractures of ribs 10 through 12 suggest possible injuries of the
liver, spleen, and diaphragm. Fractures or separation in the costochondral
area deserve special mention because of propensity for delayed healing
and the potential to serve as a source of long-term pain and discomfort
(sometimes necessitating local resection). Fractures involving three or
more ribs usually require hospitalization, with particular emphasis on the
accompanying underlying lung contusion. This is especially true for
elderly patients and patients with underlying pulmonary disease.
Fractured ribs cause pain on inspiration. Because of splinting and the sub-
sequent decline in local ventilation, alveolar stasis may result in accumu-
lation of secretions with subsequent atelectasis and possible pneumonia.
The physical examination should focus on the point of maximum tender-
ness as the area of the fracture. The initial radiographs may not always
confirm a fracture. Follow-up radiographs at 3 to 6 weeks, however, may
show callus formation at the fracture site.
Pulmonary function studies with vital capacity should be performed.
The normal vital capacity is 60 to 70 cc/kg. A vital capacity of less than
10 to 15 cc/kg necessitates monitoring in the intensive care unit and may
require ventilatory support. In general, simple undisplaced rib fractures
characterized by local pain and tenderness are treated with analgesics,
anfiinflammatory agents, and occasionally, local rib blocks. CXRs should
be obtained after rib blocks to evaluate for pneumothorax, developing
atelectasis, or pneumonia. Injection at the costal areas should be avoided
because of the risk of causing a localized chondrifis. Rib binders should
be avoided.
Upper Rib Fractures. The first five ribs are relatively protected, anteri-
orly by the clavicle, posteriorly by the scapula, and laterally by the arms
and upper thoracic muscles. Injury in this area indicates a higher proba-
bility for deeper injury, especially to the brachiocephalic vessel, and may
require further diagnostic evaluation.
Richardson and colleagues 136in 1975 focused on the first rib fracture as
a hallmark of severe trauma. In 55 patients there was a 36.3% mortality
rate. Thirty-five patients had major chest trauma: 18 patients had major
abdominal injuries, and 8 patients had injuries to the heart. Poole 137 in
1981 reported an 11.9% mortality rate. A collective review of 1393
patients with blunt trauma with first and second rib fractures revealed 86
patients (6.2%) with aortic or great vessel injuries. This was not felt to be
significantly different from an overall incidence of 3% to 8% in victims
with severe blunt chest trauma. The major concern with these injuries in
cardiothoracic trauma is potential injury to the aorta and great vessels,
recognizing that increased mortality rate in this group of patients is related
to such associated injuries and to cranial and maxillofacial injuries.
Sternal Fracture. Isolated sternal fractures are uncommon. Most sternal
injuries are due to blunt trauma. Direct trauma is the most common mech-
anism, but crushing and hyperflexion may also be implicated causes.
Most fractures occur in the body or gladiolus near the manubrial junction.
The fracture is usually transverse with posterior displacement of the
manubrium. The posterior periosteum is usually intact. Pain is the major
symptom and is usually localized and severe. Undisplaced fractures are
treated nonoperatively. With general anesthesic, displaced fractures have
sometimes been reduced by spinal hyperextension with the arms over-
head, forcing the lower sternal segments posteriorly. However, because of
the usual overriding phenomenon, this is rarely successful. Operative
:i
E
FIG. 34. Method of repair: intad posteriorper~osternummustbe fracturedto allow proper reductionand
realignment,(FromHood RM, BoydAD, CullifordAT, editors,Thoracictrauma.Philadelphia:Saunders;
1989.}
approaches are recommended primarily for pain and cosmesis. Operation

is recommended early (less than 1 to 2 weeks) because synostosis makes
delayed repair more tedious (Fig. 34). 138 The main concern with sternal
fractures is the severe associated injuries, especially myocardial contu-
sion. Brookes and colleagues 139 in 1993 reviewed 272 cases and found an
overall mortality rate of 0.7%. Conservative management in isolated
TABLE 38. Patterns of flail chest
Anterior Bilateral anterior fractures with bilateral costochondral separations (15%)
Fracture of sternum with associated costochondral separation (7%)
Lateral Muttiple fractures on the same side with/without costochondral separation (73%)
Fracture of several ribs with 2 or more fracture points on the same side (5%)
Adapted from McMurty RY, McLellan BA, editors. Managementof blunt trauma. Baltimore, MD: Williams
and Wilkins; 1990.
injury is advocated if underlying cardiac injury is excluded on the basis

of the electrocardiogram, cardiac enzymes, and/or echocardiography.
Clavicular Fracture. In some cases the fractured ends of the clavicle
may cause injury to the subclavian vessels or brachial plexus. 14° Callus
formation may compress the subclavian artery and may eventually pro-
duce thoracic outlet syndrome. Most dislocations of the clavicle occur
distally and involve the acromion process. Posterior sternoclavicular dis-
locations, however, may cause serious injury to the trachea or innominate
vessels. CT scanning may be necessary to evaluate complex clavicular
fractures fully.
Scapular Fracture. Isolated fractures a r e r a r e . 141 When this injury is
identified, there are usually associated injuries and an overall mortality
rate of 10%. More than 50% of patients have associated rib fractures and
lung contusion, and I0% to 20% are accompanied by a pneumothorax.
More than 10% of patients have associated brachial plexus and/or arterial
injuries. The presence of a scapular fracture should prompt the search for
ipsilateral torso injuries. The lesions may be subtle and require detailed
evaluation including CT scanning and angiography to define the anatomy.
Occasionally fractures of the neck, acromion process, and spine require
open reduction and internal fixation.
Flail Chest. A flail chest usually results from blunt trauma. An MVA
was the cause of 84% of these injuries in the Sunnybrook series from
Toronto, 62 with falls and industrial injuries responsible for most of the
remainder. A flail chest is defined as multiple rib fractures occurring in
two places along the same rib, producing a segment of chest wall that
moves paradoxically inward with inspiration. Usually the rib fractures are
anterior with two fractures of the same rib. Bilateral costochondral
separation and a sternal fracture can also produce a flail segment. Four
patterns are described (Table 38; Fig. 35). The pathophysiologic features
of this injury are still unresolved. "Pendelluft" or to-and-fro movement of
useless and expired air between the two lungs has never been proved/42
Instead, direct injury or contusion to the underlying lung parenchyma is
the major physiologic insultJ 43 The clinical insult may be delayed 24 to
J
FIG. 35. Anterior, lateral (most common), and posterior flail segments. (From Campbell DB. Trauma to the
chest wall, lung and major airways. Semin Thorac Cardiovasc Surg 1992;4:234-40.)
48 hours, with varying degrees of respiratory dysfunction. This respiratory

insult is due to a decrease in the vital capacity, functional residual cavity,
total lung volume, and lung compliance along with an increase in airway
resistance and work of breathing.
Approximately 50% of patients with flail chests can be managed without
mechanical ventilation, with the use of systemic and regional analgesic and
pulmonary physiotherapy. The remainder, especially elderly patients or
those with underlying chronic obstructive pulmonary disease, require
0 t
FIG. 36. Methods of rib flxafion.(From Rodriguez A. Injuries of the chest wall, the lungs, and the pleura.
In: Turney SF, Rodriquez A, Cowley RA, editors. Management of cardiothoracic trauma. Baltimore, MD:
Williams & Wilkins; 1990. p. 155-77.)
mechanical ventilation because of pain and inadequate ventilatory exchange

characterized by progressive hypoxia, hypercarbia, inefficient coughing, and
subsequent retention of secretions. This maneuver allows time for the rever-
sal of the underlying lung dysfunction and improved pulmonary toilet. Pain
control is mandatory, with systemic and/or local approaches.
Assisted ventilatory support, when required, ranges from 5 to 18 days.
The chest wall stabilizes in 1 to 2 weeks, but there is some degree of chest
wall deformity, depending on the site and extent of injury. Operative
external and internal chest wall fixation techniques have been advocated
in severe cases to avoid or reduce the need for mechanical ventilation
(Fig. 36). Occasionally primary fixation is performed during thoracotomy
TABLE 39. Subcutaneous emphysema: causes
Blunt laryngeal trauma
Penetrating wound of the larynx
Traumatic endotracheal intubation
Perforated cervical esophagus
Tracheobronchial tear
Pneumothorax
Extrapleural extension
Mediastinal extension
Open chest wound
Malfunction/malposition of chest tube
for other associated intrathoracic injuries. A recent study by Ahmed and

Mohyuddin 144 advocates early internal fixation. Among 64 patients, 26
patients were managed by internal fixation, with 80% of these patients
being weaned from mechanical ventilation in an average of 1 to 3 days
versus 15 days for the group not undergoing operation. The mortality rate
was 8% in the operated group and 29% in the conventional group.
Subcutaneous Emphysema. Subcutaneous emphysema occurs when
air is forced into the subcutaneous tissue, usually from a pneumothorax
with associated rib fractures, or from dissection from the mediastinum
caused by injuries of the larynx, tracheobronchial tree, esophagus, or
pulmonary parenchyma extending into the mediastinum. Skin crepitus
should be noted and documented. Its extent and progress should be mon-
itored. Involvement of the neck is common. In the intensive care unit,
malpositioned chest tubes most commonly serve as the source of subcu-
taneous emphysema with air leaks around the hole in the chest wall. A
pressure dressing will usually stop the leak. Advancement of the chest
tubes is discouraged to avoid pleural contamination. Occasionally, place-
ment of a new thoracostomy tube at a different site is necessary. The
presence of nonprogressive subcutaneous emphysema in the absence of
pneumothorax does not warrant a chest tube. A previous lung operation
or pleurai adhesions may make chest tube placement difficult and even
hazardous. If positive pressure ventilation is required for underlying res-
piratory failure or an anesthetic procedure a prophylactic thoracostomy
tube is usually indicated on the same side of the chest trauma.
Subcutaneous emphysema is included in this section on chest wall injuries
because of its manifestation--not because of its cause. Air has been
forced out of the tracheobronchial tree at some level and has dissected out
into the extrapleural space into the face, neck, chest, abdominal wall, and
occasionally scrotal sac. The cornerstone of treatment is identification of
the underlying cause (Table 39). Rarely is treatment necessary except in
worsening cervical subcutaneous emphysema where extrinsic airway
compression may occur. Eyelid closure may occasionally be a problem.
Rarely, cervical mediastinotomy, venting skin incisions, and needle aspi-
ration are used. Subcutaneous emphysema is sometimes encountered in
association with chest tubes. If the tube becomes occluded from blood,
fibrin, or kinking/twisting in the face of a large air leak, subcutaneous
emphysema may develop. In addition, if the air holes in the chest tube are
outside the ribs, subcutaneous air may result. In this situation, a new chest
tube may be therapeutic.
Traumatic Asphyxia. Ollivier 145 in 1837 described "Masque Ecchymo-
tique" in persons crushed to death in mob violence. He outlined a clinical
picture of craniocervical cyanosis, edema, subconjunctival hemorrhage,
and cerebrovascular engorgement. Perfles 145 in 1900 added mental dull-
ness, hyperpyrexia, hemoptysis, tachypnea, and lung contusion to the pre-
sentation. The general syndrome of compressive cyanosis implies a
severe thoracic, abdominal, or thoracoabdominal event. Unfortunately,
children who possess a more compliant chest wall are more susceptible.
Bolt j45 in 1908 highlighted four contributing factors: deep inspiration,
closure of the glottis, thoracoabdominal effect, and prolonged thoracic
abdominal compression.
Fewer than 200 cases of traumatic asphyxia have been reported. Treat-
ment is directed at early recognition and control of any associated
injuries. The overall mortality rate is 10%. Lee and colleagues 145 in 1991
treated 14 cases over a 5-year period with no deaths. Jongewaard and col-
leagues 146 in 1992 reported 14 cases over a 10-year period. Crush injury
was the cause. There were no deaths and no long-term neurologic sequelae.
It should be stressed that early neurologic abnormalities are common
(85% in the literature).
The clinical picture of craniocervical cyanosis, edema, subconjunctival
hemorrhage, and cerebrovascular engorgement may be present after sus-
tained blunt anteroposterior chest wall compression. The prolonged
positive pressure on the chest results in increased venous pressure and
obstructed flow through the valveless veins of the innominate and jugular
system. Closure of the glottis on inspiration may also play a role in the
marked venous hypertension. Associated thoracic injuries including pul-
monary contusion and hemothorax may be present. Treatment is directed
at any associated injuries. Alone, traumatic asphyxia has a good prognosis
without major residual defects.
Lung Herniation. A rare problem after chest wall trauma is herniation
of the pleura and lung through a chest wall defect.147 This problem is
usually benign and asymptomatic, and strangulation is rare. Occasionally
this condition may be uncomfortable to the patient. Elective operations
have been described for repair.
Thoracic Vertebral Body Trauma. The literature on thoracic vertebral
body injury is not v a s t . 148"149 Injuries are due to blunt or closed mecha-
nisms and to penetrating agents, such as gunshot and stab wounds. The
mechanism of injury involves flexion, extension, compression, or rotation
with subsequent involvement of the bone and ligaments. Spinal cord
injury is a disastrous consequence of severe injuries. Blunt thoracic injury
may often be accompanied by a flexion mechanism. Because greater
forces are necessary for thoracic vertebral injuries, the overall conse-
quences are usually more serious. The spinal cord occupies a greater pro-
portion of the spinal canal in the thoracic area. The blood supply in the
upper thoracic spine is more an anastomotic network rather than a direct
radicular arterial supply.
Suspected spinal cord injury should be anticipated during care provided
at the accident site with caution during both the evacuation and the
resuscitative phase. The possibility of associated injuries such as lung
contusion, myocardial contusion and aortic injury should also be consid-
ered. This is especially true for injuries above T6. Below T6, retroperi-
toneal and intra-abdominal injuries should be suspected. Detailed thoracic
spine films and CT scans are necessary to assess vertebral body and com-
pression fractures. Mid-descending thoracic aortic injuries have been
associated with thoracic vertebral fractures.
When neurologic manifestations are present, orthopedic and neuro-
surgical consultation is warranted. Approaches to the thoracic spine are
by posterior laminectomy or anterior thoracotomy. 148
Pleural Injury
A defect in the visceral pleura that communicates with either lung or the
environment allows air into the subatmospheric pleural space, creating a
pneumothorax. The closed pneumothorax causes respiratory dysfunction
proportionate to its size and to the amount of positive pressure in the
pleural space. An increasing pneumothorax may produce subcutaneous air,
pneumomediasfirmm,progressive lung collapse, and eventually with tension
pneumothorax, a shift of the mediastinum that restricts systemic venous
return to the heart. The size of a pneumothorax is usually measured by the
number of ribs above the pneumothorax rather than by a percentage.
Closed Pneumothorax. A closed pneumothorax may occur with either
penetrating or nonpenetrating chest injuries. Penetrating missiles or dis-
placed rib fractures may cause an associated hemothorax. In the absence
of a tension pneumothorax, partial or even total collapse of the lung is
usually well tolerated in normal patients because blood flows preferen-
tially to the normal lung. The collapsed, hypoventilated lung can develop
increased resistance to blood flow.
Decreased breath sounds, hyperresonance to percussion, and a poorly
moving hemithorax should prompt a CXR to confirm the diagnosis. In the
supine anteroposterior film, the diagnosis may be overlooked, and an
expiratory or upright film may be needed to confirm the diagnosis. Chest
tube thoracostomy is the proper treatment. Recent studies demonstrate a
role for needle aspiration or catheter drainage of smaller, isolated,
uncomplicated pneumothoraces.15° Occasionally an occult pneumothorax
is detected on a chest or abdominal CT scan and not on the conventional
CXR. Collins and colleagues 151 reported a series of 27 cases among
which 13 cases without chest tube placement with no adverse sequelae
were followed. Data are lacking regarding the size of traumatic pneu-
mothorax and the risk for progression and possible development of a ten-
sion pneumothorax.
A spectrum of problems may occur with traumatic pneumothorax.
Caution should be exercised with subcutaneous emphysema in the
absence of a pneumothorax. Adhesions may be present, and if so, chest
tube insertion could cause parenchymal lung damage. However,
pneumothorax may appear later if loose adhesions break. A persistent air
leak with an expanded lung can delay chest tube removal and discharge.
Occasionally the chest tube is attached to a one-way flutter valve
(Heimlich tube). If the lung remains expanded, the patient can be dis-
charged from the hospital. In most cases the tube is removed in 1 to 2
weeks. A pneumothorax after chest tube removal is most commonly
related to technical difficulties during removal. Recurrent pneumothorax
reoccurring later may be related to necrosis of the penetrating parenchy-
mal lung injury site. If the patient is to undergo surgery with attendant
positive pressure ventilation, a chest tube should be inserted for either a
pneumothorax or for subcutaneous emphysema without a documented
pneumothorax. The risks of chest tube thoracostomy are small when
compared with the devastating consequences of a tension pneumothorax
developing after the patient has been given a general anesthesic.
Tension Pneumothorax. A tension pneumothorax is immediately life
threatening (Fig. 37) but may, however, have a delayed presentation.
Needle aspiration followed quickly by chest tube thoracostomy may be
both lifesaving and diagnostic. Unexplained deterioration of ventilation,
blood pressure, or cardiac output after a general anesthesic is adminis-
tered must also raise the possibility of tension pneumothorax. Cardio-
pulmonary decompensation after internal jugular or subclavian vein
FIG. 3Z CXRdemonstratesright tension pneumothorax with deviation of mediastinum to left.
cannulation also warns of a possible tension pneumothorax. If the

patient's condition does not improve after release of the tension
pneumothorax, the possibility of pericardial tamponade must be con-
sidered. Closed-tube thoracostomy usually constitutes definitive thera-
py for a tension pneumothorax. If a large air leak persists, a tracheal or
bronchial tear must be considered.
If the lung does not expands completely after tube thoracostomy, the
following causes may be suspected: (1) improper position of the chest
tube, (2) an inadequate number of chest tubes, (3) inadequate suction, (4)
an occluded tube from clotted blood or exudative material, (5) a kinked
or twisted chest tube, or (6) chronic adhesions. A persistent air space in
the absence of an air leak implies a trapped, atelectatic lung or a pneumo-
thorax loculated away from the chest tube. A peripheral traumatic
pneumatocele must also be considered. CT scanning may help differentiate
between these possibilities. Operative removal of pleural clot, aggressive
pulmonary physiotherapy and therapeutic bronchoscopy, or insertion of
another chest tube may be required to achieve full expansion of the lung.
A chest tube placed into a pneumatocele will cause a persistent continuous
air leak.
A delayed pneumothorax after either penetrating fractures or blunt trauma
with rib fractures suggests lung parenchymal injury with cavitation,
necrosis, and pleural rupture. Likewise, a chest tube should remain for at
least 3 to 5 days to prevent this problem from occurring after early chest
tube removal.
Open Pneumothorax. The incidence of open pneumothorax is low,
and the diagnosis is often obvious. Audible air rushes to and fro through
a gaping hole. With free communication between the pleural space and
the atmosphere, a total pneumothorax exists. Immediate application of
an occlusive dressing decreases air exchange through the defect and
may reestablish a negative intrathoracic pressure. Chest tube thoracos-
tomy must then be performed through a separate site to avoid tension
pneumothorax and allow reexpansion of the lung. In a field environ-
ment, a petroleum jelly gauge dressing with one of four sides open to
allow egress of expired air may be used. Definitive operative closure of
the defect, reconstruction of the chest wall defect, and pleural drainage
are necessary.
Hemothorax. The incidence of hemothorax and hemopneumothorax
ranges from 50% to 60% in penetrating chest trauma to 60% to 70% in
blunt chest trauma. 152The major sources of hemothoraces from penetrating
and nonpenetrating trauma include chest wall vessel injury, lung lacera-
tions, and major injuries to the heart and great vessels. Hemothorax pro-
duces hemodynamic compromise through two mechanisms: hypovolemia
and respiratory dysfunction as the result of compressed or restricted lung
parenchyma.
Although decreased breath sounds and dullness to percussion are usually
present, the diagnosis depends on the CXR. The supine film, however, may
show only haziness or increased density of the hemithorax. Rib fractures
are common. Bleeding is classified as: minimal (<350 cc), moderate (350
to 500 cc), and massive (>1500 cc).3 Chest tube thoracostomy and volume
replacement are usually definitive. The goal of tube thoracostomy is
expansion of the lung and obliteration of the pleural space. Thoracotomy
Curr Probl Surg, August t998 733
is necessary in 10% to 15% of cases when the initial blood drainage is
more than 1500 mL or when bleeding persists at a rate of 200 to 300 mL/h
over 3 to 4 hours.
Fibrinolytic enzyme instillation has been used but usually causes pain
and an intense febrile reaction. Moreover, this technique has not reduced
the frequency of the late complications of fibrothorax or posttraumatic
empyema.153 Early evacuation, most recently using VATS techniques, has
gained general acceptance.
Posttraumatic Empyema. Failure to expand the lung completely and
eliminate pleural collections or clotted hemothoraces increases the risk of
empyema. Persistent blood in the pleural space develops angioblasts and
fibroblasts at its periphery within the first week. At 3 to 4 weeks a fibrous
peel develops. If this becomes infected, an empyema develops. This risk
increases further in the presence of an air leak from the lung. Incomplete
lung expansion that creates atelectasis, consolidation, or collapse may
lead to pneumonia, abscess, or pseudocyst formation. The ultrasound and
CT scan have become important for identifying the presence of and docu-
menting the evolution of these processes. Treatment strategies include mul-
tiple chest tubes, guided-needle and catheter aspiration and drainage, VATS,
and thoracotomy with drainage and decortication.154 Early decortication (at
5 to 6 weeks) should be considered for (1) retained or clotted hemothorax,
(2) air/fluid levels in the presence of sepsis, (3) persistent collapse or lung
trapping, and (4) residual uniloculated or multiloculated pleurat collections,
especially if infection is documented or suspected. In most of these semi-
chronic situations, chest tube thoracostomy has usually been met with fail-
ure. Early aggressive chest tube drainage of the traumatic hemothorax and
reexpansion of lung parenchyma cannot be over-emphasized.155:56 In high-
risk or elderly patients, open chest tube drainage or permanent open
drainage (Eloesser flap) may be the most prudent alternative.
Traumatic Chylothorax. Chylothorax rarely complicates chest trau-
ma. 4"52"157 This condition usually manifests 2 to 10 days after injury and
often occurs as a result of hyperextension of the spine, falls, crush
injuries, or surgical procedures performed in the vicinity of the thoracic
duct. More superior injuries usually appear in the left chest, and more
inferior injuries usually appear on the right. With injury or obstruction of
the thoracic duct, chyle or lymph drains into the pleural cavity. The tho-
racic duct arises from a lymphatic confluence at the cisterna chyli, at the
level of the first and second lumbar vertebra. The duct then ascends to the
right and posterior to the aorta, close to the esophagus, and behind the azy-
gos vein. Injuries are more common in children. From 1500 to 2400 mL of
lymph per day or 1.38 mL/kg/h flows through the thoracic duct into the
Azygos Vein '"1~ J I
-,---..-----.r- T 7
Thoracic
FIG. 38. Thoracic duct anatomy. Left thoracotomy provides easier accessto mid thoracic duct. Rightthora-
cotomy allows better accessto lower thoracic duct (From Goins WA, Rodriguez A. Traumaticchylothorax.
venous system. Needle aspiration of milk-like fluid confirms the diagnosis.

It is usually alkaline, without bacteria, has specific gravity greater than
1.012, contains a high triglyceride level, stains for fat with Sudan red dye,
and has a high lymphocyte count. Empyema rarely develops. Pseudochyle
may occur with infection or malignancy. There are no fat globules, and
the specific gravity is less than 1.012. Repeated thoracenteses may be
therapeutic, but tube thoracostomy is preferred. The leak usually stops.
Persistent chylothorax may produce a fibrothorax. Dietary medium-chain
triglycerides compliment chest tube drainage to reduce the volume of
lymph flow, but total intravenous hyperalimentation is far more effective
in reducing the thoracic duct flow. If the drainage is less than 0.25
mL/kg/h, chest tube drainage can be continued for 3 to 4 weeks. If the
drainage persists or if it exceeds 1500 mL per day for 1 week, operation
and ligation of the thoracic duct must be considered. Ingestion of a fatty
meal or instillation of 100 to 200 mL of olive oil through a nasogastfic tube
2 hours before operation may aid in visualization of the leak. An intraop-
erative injection of methylene blue into the esophageal wall may also be
helpful. With extensive mediastinal injury or when the location of a tho-
racic duct tear is in doubt, a fight thoracotomy to ligate the duct at the
diaphragmatic aortic hiatus will stop the leak (Fig. 38). Clips should not
be used because they may become dislodged. Suture ligation is preferred.
Lung Iniun/
It is important to differentiate direct from indirect lung injury. Direct
anatomic lung parenchymal trauma from penetrating and nonpenetrating
injury produces local effects and subsequent physiologic lung dysfunction.
Indirect lung injury associated with multitrauma can result in varying
degrees of diffuse lung dysfunction. These injuries may include aspira-
tion, fat embolism, ARDS, multiple blood product transfusions, and fluid
overload. In the patient with multiple trauma, the direct and indirect
causes may occur in varying combinations to produce the ultimate effect
of acute respiratory failure requiting mechanical ventilation and long-
term intensive care management.
Pulmonary Contusion. Pulmonary contusion occurs in 50% to 60% of
patients with blunt chest trauma. ~58Intrusion of fibs after frontal or lateral
impact can cause direct damage. Injury to the alveolar lining, capillaries,
and lung parenchyma cause hemorrhage and cellular disruption. Grossly,
the involved lung becomes hemorrhagic, edematous, and consolidated in
irregular patches. Intra- and extracellular edema compromises oxygena-
tion by increasing diffusion barriers. There is also a decrease in the vital
capacity, tidal volume, and functional residual capacity associated with
this decrease in arterial oxygenation and compliance. In addition,
increased mucus production obstructs the bronchioles, leading to atelectasis
of both injured and noninjured areas. The resulting hypoxemia usually
occurs within 24 to 36 hours after the injury. Localized contusions usually
736 Curr Probl Surg, August "1998
TABLE 40. Mechanisms of injury in lung contusion
Implosion: overexpansion of intrapulmonary air causing stretching and shearing of alveoli
Shearing of alveolar secondary to differential acceleration of intrathoracic structures
The Spalling effect: concussive wave at liquid/gas interface resulting in disruption of the
interface
resolve spontaneously without major sequelae. In some patients this

process progresses to a diffuse consolidative stage resulting in varying
degrees of ARDS. Three possible mechanisms of injury in lung contusion
are summarized in Table 40.
The CXR may initially be unrevealing, followed by a localized infil-
trate, usually within 4 hours and in most cases within 24 hours. Resolution
of uncomplicated localized contusions occurs within 10 to 14 days. CT scan-
ning detects lung contusion before the appearance of infiltrates on the
C X R . 159
The treatment of lung contusion is contingent on the degree of lung dys-
function. Supplemental oxygen, pulmonary physiotherapy, and a decrease
in fluid administration usually suffice. Steroids are usually not indicated,
but they are advocated by some authorities. Diuretics help eliminate the
fluid that is administered during the initial resuscitation and is later mobi-
lized from third-space sequestration. When localized contusion progress-
es to a diffuse process culminating in ARDS, mechanical ventilation is
usually necessary. In fact, earlier institution of mechanical ventilation
may reduce the severity of ARDS. Relative indications for mechanical
ventilation include (1) elderly patients, (2) multiple large contusions on
the initial CXR, (3) multiple rib fractures or a flail chest, (4) the need for
a general anesthesic required for other associated injuries, (5) anticipated
overhydration, (6) significant hypoxemia, (7) underlying lung disease,
and (8) progressive radiographic deterioration with or without clinical
respiratory decompensation. Objective indications include a respiratory
rate greater than 40/min, pO 2 less than 60 mm Hg on 60% FIO2, and pCO 2
greater than 50 mm Hg (implying increased dead space). One exciting
new area of treatment is continuous oscillation therapy. 16° The mortality
rate is ultimately related to ISS, blood product transfusion, the Glascow
Coma Scale (GCS), and lower PaO2/FiO 2 ratios at 24 to 48 hours after
admissionJ 61
Lung Tear~Laceration. These injuries occur more commonly with pene-
trating trauma. From 50% to 80% of penetrating chest trauma has lung
parenchymal involvement. Injury can occur to the blood vessels, the lung
parenchyma, or the bronchial tree. Associated hemopneumothorax and
hemoptysis are common. Penetrating localized injury with associated
pneumothorax, hemothorax, or hemopneumothorax is treated with tube
thoracostomy. Massive hemothorax requires thoracotomy. More worri-
some is the delayed pneumothorax that may be encountered with central
necrosis of the lung parenchyma and leakage of air into the pleural space.
If pleural communication does not occur, localized hematomas or cystic
cavities may develop. The diagnosis of tears or lacerations at the time of
thoracotomy requires control of bleeding, suture ligation of air leaks, and
local resection with stapling techniques (20% to 25% of cases). Extensive
parenchymal tears with involvement of the hilum may necessitate more
extensive repair, resection, or even pneumonectomy if irreparable major
vessel or airway involvement is encountered. Technical maneuvers that
may be useful should include "en masse" hilar clamping, intrapericardiai
control of the pulmonary artery, and knowledge of lobectomy technique
if needed (less than 1% of cases).
Pulmonary Hematoma. Localized parenchymal hematomas may occur
after either blunt contusions or penetrating tears and may be difficult to
distinguish from a preexisting coin lesion. Uncomplicated hematomas
usually resolve in 3 to 4 weeks. Penetrating hematomas from high-velocity
wounds may require thoracotomy and local resection.
Lung Cysts. Posttraumatic lung cysts, pseudocysts, and pneumatoceles
are cavities within the lung parenchyma that contain blood and air.
Penetrating trauma causes permanent and temporary cavitation along the
path of injury. Blunt trauma creates a cavity from the bursting of the lung
parenchyma. Cavities may appear early on the CXR but more often appear
later after resorption of blood and tissue debris. The chest CT scan is useful
for localizing and defining the size of these cysts or cavities. Most lung
cysts will resolve spontaneously. If infection is suspected clinically or by
air/fluid levels on the CXR or CT scan, then CT-guided aspiration is
indicated. Confirmed infection in a cyst usually necessitates resection.162
Other Lung Injuries. Traumatic pulmonary arteriovenous fistulas can
result from penetrating trauma. 163This diagnosis is made with pulmonary
angiography. Traumatic torsion of the lung is rare, with only five cases
reported. 164The CXR shows opacification of all or part of the hemithorax
with shift of the mediastinum toward the unaffected side. There is a
reversal of the bronchovascular markings, with the major pulmonary
vessels coursing cephalad rather than caudad. Suspicion of the diagnosis
followed by urgent thoracotomy and reduction of the torsion is indicated.
Adult Respiratory Distress Syndrome (ARDS). ARDS occurs in a
variety of settings, but especially after thoracic and nonthoracic trau-
ma. ~65There are approximately 200,000 cases per year, including 15% to
20% after chest trauma. The physiologic dysfunction is thought to occur
TABLE 41. Diagnostic criteria for ARDS*
Diagnostic criteria may include the following:
An underlying disease or injury known as a factor in ARDS development
Hypoxemia
Clinically relevant respiratory distress
Tachypnea
PaO2/FiO 2 < 150 or < 200 with PEEP
Radiographic evidence of multilobar infiltrates
A generalized process is evident on the chest radiograph.
Patchy inhomogeneity may be present on chest CT.
Cardiac filling pressures low enough to ensure a noncardiac cause of the pulmonary
infiltrates.
Associated with ARDS and sometimes included as diagnostic criteria are the following:
Reduced pulmonary compliance (stiffening of lung parenchyma)
Improved oxygenation in response to increased PEEP
Thrombocytopenia
Increased pulmonary artery blood pressures
PEEP, Positive end-expiratory pressure.
*The definition of ARDS can include a variety of criteria, and specific entry criteria often vary between
studies.
From Russell GB, Campbell DB. Thoracic trauma and the adult respiratory distress syndrome. Semin
Thorac Cardiovasc Surg 1992;4:241-6.
as a consequence of increased capillary permeability that is the result of

direct or indirect damage to the alveolar/capillary interface. The alveolar
endothelial pore size increases, resulting in a leaky capillary system.
Interstitial edema increases with compression of the arterial and bronchial
conduits. Subsequently, hyaline membranes develop. 97 This diffuse alve-
olar damage evolves into three phases: exudative (days 1 to 3), prolifera-
tive (days 3 to 7), and fibrotic (after 1 week). The lung has only limited
responses to varied insults, and unfortunately, one of those responses is
ARDS.
Primary traumatic lung contusion can evolve into a generalized ARDS
pattern as a result of shock, sepsis, aspiration, fat embolization, multiple
blood product transfusions, and fluid overload. The mechanisms responsible
for ARDS have not been fully elucidated. Vasoactive substances including
serotonin, histamine, and catecholamines can produce platelet aggrega-
tion, pulmonary vasoconstriction, and bronchoconstriction. In cases of fat
embolism, the alveolar capillary damage is induced by the inflammatory
response to hydrolyzed free fatty acids. Recently neutrophils have been
implicated as mediators of ARDS. 166An inciting event, such as trauma or
sepsis, activates complement that then attracts neutrophils to the pulmonary
vascular bed. Lung injury develops with the release of toxic products from
the neutrophil. The toxic products are lysosomal granules, which cause
tissue injury, and oxygen free radicals, which are known to produce lung
damage in animal models.
The clinical syndrome was recognized by Burford 166a in World War II
and Geiger 166bin the Vietnam conflict. The term ARDS was popularized
by Ashbaugh and Petty ~66~in 1967. The syndrome is characterized by dif-
fuse interstitial edema with resultant intrapulmonary shunting and
decreased compliance. The resultant hypoxemia is refractory to increas-
ing levels of inspired oxygen. The diagnostic criteria have been summa-
rized by Russell and Campbell 167 (Table 41).
Radiographically, diffuse bilateral infiltrates are typical. The treatment
focuses on maintaining adequate tissue oxygenation. Overhydration is
avoided and, if present, is treated with diuretics. Secondary pneumonia is
treated appropriately. Positive end-expiratory pressure has become the
cornerstone of mechanical ventilation to help avoid increased inspired
oxygen levels. The outcome for patients with posttraumatic ARDS is still
poor, with mortality rates ranging from 50% to 80%. When ARDS mani-
fests early (less than 5 days) after trauma, there is a better prognosis than
when it manifests late (more than 5 days).
Hemoptysis. There are two types of bleeding from the tracheo-
bronchial tree: traumatic and effusive.168 Traumatic massive hemoptysis
(>600 mL per 24 hours) is unusual. A tracheoinnominate fistula com-
plicating tracheostomy requires prompt attention and operative care.
Hemoptysis associated with parenchymal lung laceration or tear may be
associated with air embolism.
Effusive hemoptysis consists of bloody bronchorrhea usually caused by
pneumonia. In the patient who is severely traumatized, coagulation dys-
function may aggravate or precipitate hemoptysis. Bronchoscopy may
identify focal mucosal ulceration, tracheobronchial tears, or a diffuse tra-
cheobronchitis.
Air Embolism. Traumatic bronchopulmonary venous fistula can cause
systemic air embolism. 169This complication has been reported in as many
as 14% of all major chest injuries and occurs three times more frequently
with penetrating trauma. Iatrogenic causes include needle biopsy, chest
tube insertion, thoracotomy, and diagnostic studies of empyema cavities,
especially with a coexisting bronchopleural fistula. This complication
occurs because disrupted bronchi leak higher-pressure air into the lower-
pressure pulmonary veins. The left ventricle then ejects the air systemi-
cally. The magnitude of the air embolus depends on the pressure gradient
between the bronchus and pulmonary veins, and the proximity of the two
torn structures. Cerebral vascular and coronary artery air emboli precipi-
tate the clinical picture of neurologic and cardiac collapse. An echo-
cardiogram may reveal air in the cardiac chambers. Once the diagnosis is
suspected or established, immediate thoracotomy must be performed to
control the communication. Trendelenburg position is preferred.
Advancing an endotracheal down the uninvolved bronchus, if known, can
be helpful. Immediate clamping of the lesion or blind clamping of the
hilum may also be performed. Aortic and left ventricular venting may be
used to help remove additional air. Positive pressure ventilation must be
avoided before repair. Use of a hyperbaric oxygen chamber (2 to 6
atmospheres) decreases bubble size by nitrogen diffusion, thereby relieving
the obstruction of coronary and cerebral arteries.
Iniuries of the Larynx, Trachea, and Bronchus

Although the bronchi and trachea are well protected in the medi-
astinum, the trachea is vulnerable to injury in the neckJ 7°A71Overall, this
type of injury occurs infrequently. Anatomically the trachea is 10 to 13 cm
in length with 22 cartilaginous rings and a posterior membranous portion.
Depending on the level of injury, the degree of injury may cause dys-
function varying from subcutaneous emphysema to acute airway obstruction
with stridor. Bronchial injury may cause dysfunction that varies from seg-
mental asymptomatic atelectasis to massive bronchopleural fistula. An
injury may involve total or partial disruption of the airway wall, with
focal swelling and edema. Neglected or undiagnosed tears can heal with
formation of scarring granulation tissue and secondary partial stenosis or
total occlusion of the tracheal lumen. This process can lead to potential
long-term problems and complications, particularly recurrent pneumonia
or irreversible lung destruction. When injured by penetrating trauma, an
associated injury to the esophagus must also be suspected.
Injuries of the Larynx. Blunt trauma to the larynx is usually associated
with anterior neck injuries in MVA. Collisions with fences and cords can
also cause injuries with varying degrees of tracheal severance.
Penetrating injuries and iatrogenic injuries caused by traumatic endo-
tracheal intubation may also be encountered. Local tenderness, ecchy-
moses, swelling, subcutaneous air, and hoarseness are typical clinical fea-
tures. With airway obstruction, inspiratory stridor and air hunger are
noted. Direct laryngoscopy and bronchoscopy must be performed care-
fully to avoid further damage. Urgent endotracheal intubation, cricothy-
roidotomy, or tracheostomy may be required to maintain the airway. With
total severance of the larynx, retrieval and intubation of the distal cervical
trachea through a cervical incision may be lifesaving.
Injuries of the Cervical Trachea. Blunt trauma to the cervical trachea
is rare. This can be an acute injury or be sustained (ie, with foreign body
FIG. 39. Intubationof severedtracheaby the emergencymedical personnelat scene.
aspiration). Penetrating trauma is more common. Cough, dyspnea,

hemoptysis, subcutaneous air, and mediastinal emphysema suggest tracheal
involvement. In blunt trauma the membranous portion is usually involved,
whereas penetrating injuries occur in the direction of the foreign body.
Bronchoscopy is usually diagnostic. Neck exploration is usually per-
formed for penetrating injuries that violate the platysma. Tracheal lacera-
tion from endotracheal intubation is generally approached operatively
although there are anecdotal reports of nonoperative management for
uncomplicated small tears. When the cervical trachea has been partially
or totally severed, the distal end may retract into the mediastinum and
result in airway occlusion. Immediate intubation of the severed distal seg-
ment may be lifesaving (Fig. 39). A subsequent repair should focus on the
extent of injury and the status of the recurrent laryngeal nerve function
(Fig. 40). As with tracheal surgery, a meticulous search for the recurrent
laryngeal nerve is not necessary or advised. The technical aspects of tra-
cheal reconstruction have been described elsewhere. ~70
Injuries of the Distal Trachea and Bronchus. Scannel in 1949 per-
formed the first successful bronchial rupture repair and Beshin in 1957
performed the first successful repair of a tracheal rupture.~7° Injuries of the
distal trachea and mainstem bronchus have a variable presentation depend-
ing on the location and extent of injury. Most of these injuries are due to
blunt trauma with a high incidence of associated injuries. The mainstem
bronchus at the level of the carina is the most frequent site of injury. The
mechanism of tear involves shearing forces with compression of the tra-
FIG. 40. Endotrachealintubationand debridementof severedtrachea.
chea against the vertebral column and lateral movement of the lungs, air-
way distension against a closed glottis (valsalva maneuver), and sudden
vertical stretch of the tracheobronchial tree. Ruptures or tears are com-
monly transverse and involve part or all of the circumference between car-
tilaginous rings, with varying degrees of separation. Right-sided longitu-
dinal spiral tears of the membranous trachea may also be encountered. The
left bronchus is better protected by the adjacent structures.
The clinical manifestations include subcutaneous air, fractured ribs,
pneumomediastinum, and pneumothorax. A large persistent pneumotho-
rax with a significant air leak is suspicious for injury. Bronchoscopy and
immediate operative repair are manditory once the diagnosis is estab-
lished. The bronchoscope should not be advanced through the defect.
Thoracic tracheal, carinal, or right bronchial injuries are approached
through a 4th or 5th fight posterolateral thoracotomy. Left bronchial
injuries are approached through a similar left incision, but proximal left
mainstem injuries may also be approached easier from the right side (Fig.
41). A double-lumen endotracheal tube or bronchial blocker is preferred
in most cases. Primary repair is usually possible. A pleural, muscle, peri-
cardial, or omental flap may be used to bolster the repair. The use of CPB
has been reported for complex injuries in which the ventilation is com-
promised.
Posttraumatic Tracheoesophageal Fistula. An acquired tracheo-
esophageal fistula in the neck may result from prolonged endotracheal or
tracheostomy intubation often in conjunction with nasogastric intubation.
FIG. 41. Typesof tracheobronchialiniuries.(FromHood RM, BoydAD, Cdtiford AT, editors.Thoracictrau-
ma. Philadelphia:Saunders; 1989.)
Blunt injury can cause a midesophageal fistula into the membranous trachea
at the level of the carina. Subcutaneous emphysema of the neck and thorax
is usually present. Increasing amounts of air in the nasogastric suction
suggests this diagnosis, and bronchoscopy and esophagoscopy confirm
the diagnosis in most cases. These fistulas rarely close spontaneously and
require operative repair. Repair may be undertaken early while the patient
R. Common
Carotid A r t e r Y ~ l ._~ ~Trachea
~,l,,i~ l... L Con~mon
R. Internal ~11~lJ~,,,t,,~ ' CarotidArtery
Jugular Vain ~ ' "-~ . ~ ~~j
II1
wo
R. In~ern~nate :' , ~( ~ Manubrium
Aorta ~.: ~[/~ ~'~Retractor

~----------~l~Arf//'/,//'/q//
Tracheoinnominate Innominate Artery Resected
:,:? I
FIG. 42. Repair of tracheoinnominate fistula. {From Leonard DJ, Rodriguez A. Trocheoinnominate artery
fistula. In: Turney SF, Rodriquez A, Cowley RA, editors. Management of cardiothoracic trauma. Baltimore,
MD: Williams & Wilkins; 1990.p.373-8.)
is mechanically ventilated or after the patient is weaned from the ventilator.

For complicated blunt traumatic large distal fistulas, the technique of
esophageal diversion with reverse gastric tube or colon interposition
offers promise.
Posttraumatic Tracheoinnominate Fistula. Acquired tracheoinnominate
fistula is encountered after long-term tracheostomy or tracheal recon-
struction. 172 Massive hemoptysis or hemorrhage from the tracheostomy
stoma is diagnostic but is usually heralded by a lesser sentinel bleed.
Without immediate control of the bleeding and the distal airway with a
cuffed endotracheal tube or bronchoscope placed beyond the fistula site,
these patients will suffocate and die. An exploration should be performed
in the operating room. A lifesaving maneuver involves occlusion of the
-T8
% "~
Xiphoid \
I
I
li
I -kl
I
!
-L3
FIG. 43, Anatomy of the diaphragm: attachments and excursion are important. (From Rodriguez A. Injuries
of the diaphragm. In: Turney SF, Rodriquez A, Cowley RA, editors. Management of cardiothoracic trauma.
Baltimore, MD: Williams & Wilkins; 1990. p. 219-27.)
innominate artery by digital pressure against the sternum. This requires

blunt dissection in the suprastemal notch anterior to the trachea. A medi-
an sternotomy with ligation and division of the innominate artery is the
recommended treatment (Fig. 42). Repair of the innominate artery is not
advised. The incidence of subsequent stroke is negligible. The overall
mortality rate approaches 75% to 80%.
Injuries of the Diaphragm

Diaphragmatic injuries include penetrating wounds of the diaphragm or
blunt rupture with or without secondary displacement of the abdominal
contents into the thoracic cavity.173 The incidence of this injury ranges
from 1% to 3% of all chest trauma cases, with a 3.1% incidence at our
institution from 1991 through 1996. In only 15% to 30% of patients is the
TABLE 42. Classification of traumatic diaphragmatic hernia
Right side
Immediate herniation With injury to liver or other viscera
With obstruction of the colon or small bowel
Asymptomatic
Delayed herniation Uver
Colon or small intestine
Asymptomatic
With obstruction or strangulation
Left side
Immediate herniation With injury to hollow viscus, liver, or spleen
With limited visceral herniation
With extensive herniation of multiple viscera and
respiratory embarrassment
Asymptomatic
Delayed herniation Obstruction of the stomach, with or without perforation
Obstruction or strangulation of small bowel or colon
Asymptomatic
Herniation into the pericardium
Rupture through the esophageal
hiatus
Disruption of surgical wounds of
the diaphragm
From Hood RM. Traumatic diaphragmatic hernia. Reprintedwith permission from the Society of Thoracic
Surgeons (Ann Thorac Surg 1971;12:315).
diagnosis made before operation because 20% to 50% of patients have an

initial negative CXR. The injury to the left side is four times more com-
mon than to the right side. Diaphragmatic injuries are accompanied by
major injuries to the abdomen (60%) and thorax (54%). Recently, atten-
tion has been given to diaphragmatic dysfunction after blunt trauma. ~74
The dysfunction is related to stretch and subsequent paraparesis of the
diaphragm. Iatrogenic injury to the phrenic nerve secondary to topical
cooling during open heart surgery has also been reported. Hood's classi-
fication of these injuries, although detailed, is all-inclusive (Table 42).
Blunt Diaphragmatic Injury. The diaphragm is a muscle attached to the
10th, llth, and 12th ribs, posteriorly and laterally, and to the costal carti-
lages anteriorly (Fig. 43). The diaphragm is innervated bilaterally by the
phrenic nerves. Blunt disruption occurs when a sudden increase in abdom-
inal pressure results in rupture; this injury is encountered predominantly in
MVA. The left diaphragm ruptures more commonly because of the protec-
tion afforded by the liver on the right side; in 95% of patients with left-sided
ruptures, there is accompanying visceral herniation. The degree of respira-
tory compromise is proportional to the amount of displacement of abdom-
inal contents into the thorax and secondary lung restriction. The most
common rupture is a radial tear in the posterolateral aspect of the left
1. ~ - ~ / J r aq~
of Diaphragm __ ' :/j__
FIG. 44. Repair techniques for ruptured diaphragm.(From Rodriguez A. Injuries of the diaphragm.
diaphragm, but avulsion from the anterior chest wall may also occur.
Symptoms vary from none to severe respiratory compromise and even
abdominal pain caused by visceral strangulation. The CXR is the most
valuable diagnostic test for confirming rupture accompanied by intestinal
herniation. Passage of a nasogastric tube or barium swallow confirms the
presence of abdominal contents in the chest or mediastinum. However, with
many diaphragmatic ruptures, it is only later that the intestine migrates into
the chest. Tears rarely heal, given the constant motion of the diaphragm.
Acute diaphragmatic ruptures are usually repaired through the
abdomen, whereas late repairs (more than 1 month after injury) are per-
formed through the chest because this approach facilitates the release of
adhesions between the abdominal viscera and intrathoracic structures.
Primary repair is possible in most instances, but if this causes tension,
prosthetic mesh should be used. Lateral injury with detachment of the
diaphragm from the periphery requires reattachment to the ribs (Fig. 44).
Acute right-sided tears initially approached abdominally can be carried
into the chest with median sternotomy and opening of the right pleura
exposing the diaphragm from above.
Penetrating Injury of the Diaphragm. Penetrating diaphragmatic
injuries occur more commonly than blunt injuries. Entry sites in either the
chest or abdomen must raise the suspicion of a diaphragmatic laceration.
Stab wounds are more common on the left side (because right-handed
assailants are more common), whereas gunshot wounds occur with similar
frequency on either side. Initial herniation of abdominal contents is
unusual, but associated abdominal injury is common. The initial clinical
presentation is one of intra-abdominal bleeding or peritonitis. The possi-
bility of diaphragmatic injury must be evaluated whenever the chest or
abdomen is opened in the treatment of penetrating trauma. CXR findings
are not specific. Hemothorax, pneumothorax, abnormalities of the
diaphragmatic contour, apparent elevation of the hemidiaphragm, and dis-
placement of the mediastinum contralaterally have been reported. Chest
CT scanning has not been reliable. Herniated abdominal contents establish
the diagnosis, but this is an infrequent finding. The treatment is early
operative repair, usually transabdominally. Recent experience with VATS
may change this traditional approach, especially if the possibility of intra-
abdominal injury has been excluded. Primary repair is the correct treat-
ment. Chronic injuries are better approached through the chest because
adhesions between the herniated viscera and intrathoracic structures can
be divided more easily. Again, primary repair with nonabsorbable suture is
preferred. As in the care of blunt diaphragmatic rupture, the use of pros-
thetic mesh may be necessary to avoid repairs under tension.
Diaphragm Dysfunction. An elevated, damaged hemidiaphragm will
not be noticed while the patient is on positive pressure mechanical venti-
lation. If diaphragm dysfunction is encountered after heart surgery, an
injury to the phrenic nerve is usually suspected. Iced slush in the peri-
cardium in an attempt to cool the heart may injure the adjacent phrenic
nerve, more commonly on the left side. Direct injury to the phrenic nerve
from stab wounds, gunshot wounds, and operation may also occur. Stretch
injury to the phrenic nerve has also been reported, more commonly from
blunt trauma. Bilateral involvement can cause severe respiratory insuffi-
ciency. Unilateral injury, particularly the left side, will improve over 6 to
12 months. After 2 years, more than 90% of unilateral left-sided cold-
induced injuries with elevated diaphragms have been resolved.
Mediastinal Injuries
The mediastinum, bounded by the sternum anteriorly, the spine posteri-
orly, and the lungs laterally, contains the heart, great vessels, esophagus,
Ant~
corn
eora -
verle~ol
"sulcus
FIG. 45. Mediasfinal compartments.(From ShieldsTW. Mediastinal surgery. Philadelphia:Lea & Feloiger;
1991.)
tracheobronchial tree, thoracic duct, and the vagus and sympathetic nerve
trunks. The mediastinum has anterior, middle, and posterior compart-
ments (Fig. 45). As such, the mediastinum is not an organ or structure but
a region.
Posttraumatic radiographic mediastinal changes suggest the possibility
of specific organ injury: a widened mediastinum with great vessel or tho-
racic aorta tear; pneumomediastinum with injury to the larynx, trachea,
bronchus, lung, or esophagus; and fractures of the sternum, vertebral
body, or first rib with major mediastinal organ damage.
Pneumomediastinum. Air dissects into the mediastinum from several
sources. It may track along the pulmonary perivascular space from rup-
tured alveoli (the Macklin effect) or down from the neck after tears in the
laryngeal or pharyngeal mucosa from endoscopic or intubation trauma.
Air may even extend down from the site of dental surgery or when high
oral pressure is applied (eg, trumpet players). Air may broach the medi-
astinal pleura, especially in children, when a pneumothorax occurs. It
FIG. 46. Death rectangle bordered by the suprasternal notch, mid clavicles, nipples, and epigastrium.
(From Ivatury RR, Cayten CG, editor.The textbook of penetratingtrauma. Baltimore:Williams & Wilkins,
1996.)
may also exit directly into the mediastinum from rupture of the trachea,
bronchus, or esophagus.
Except in the rare cases of tension pneumomediastinum, the air itself
has no deleterious effect. However, concomitant contamination (eg,
esophageal tears) may lead to mediastinitis and, if untreated, may prove
fatal. There is no convincing evidence to implicate trauma in the devel-
opment of the late sequelae of chronic or sclerosing mediastinitis.
Widened Mediastinum. A widened mediastinum on the anteroposterior
supine or upright posteroanterior CXR after blunt trauma raises the ques-
tion of injury to the thoracic aorta or great vessels and demands urgent
aortography for confirmation. Simple mediastinal hematomas will
resolve. However, the natural history of patients with asymptomatic,
widening of the mediastinum without great vessel injury has not been
reported. Compression of adjacent structures is unusual. Late mediastinal
constriction has not been reported.
Mediastinal Penetrating Wounds (Mediastinal Traverse Injury).
Because of the potential for serious injury to vital organs, wounds that
transgress or traverse the mediastinum require careful evaluation (Fig.
• Procedures
Esophagogram
4, Arteriogram
FIG. 47. Diagnosticapproach to mediosfino]froverse injury. (From Rodriguez A. Initial patient evaluofion
and indicationsfor thorocofomy. In: Turney SF, Rodriquez A, Cowley RA, editors. Manogemenf of cordio-
thoracic trauma. Baltimore,MD: Williams & Wilkins; 1990. p. 7-18.)
46).175-177 This area is appropriately called the death rectangle or zone of

suspicion. Mediastinal penetration must be suspected with direct stab
wounds and in gunshot and shotgun wounds that occur below the mid-
clavicles, medial to the nipples and above the diaphragm, or where there
is indirect evidence that the penetration has crossed through this area.
The indications tbr early exploration via thoracotomy or median ster-
notomy include (1) hemorrhage, (2) cardiac tamponade, (3) parasternal
entrance wounds, and (4) an incompletely evacuated hemothorax.
Marking the entrance and exit wounds with radiopaque markers on
CXRs is helpful in trying to track the trajectory of the missile or foreign
body. Impalement instruments along with other foreign bodies should
not be removed before proper assessment. In the patient whose condition
is stable, traverse injuries require angiography, barium swallow,
esophagoscopy, and bronchoscopy (Fig. 47). Chest CT scanning,
echocardiography, and magnetic resonance imaging are also helpful for
the localization of foreign bodies, fluid, or blood. The median sternoto-
TABLE 43. Esophageal trauma
Blunt, external
Penetrating, external
Foreign body ingestion
Organic
Inorganic
latrogenic perforation
Endoscopy: diagnostic or therapeutic
Pneumatic dilatation
Sclerotherapy
Intraoperative injury (during operation in neck, chest, or abdomen)
Miscellaneous (eg, cardiopulmonary resuscitation, Heimlich maneuver, nasogastric
tube
Ingestion injury
Caustic (lye)
Pharmaceuticals (capsules, tablets, liquids)
Barotrauma
Postemetic rupture (Boerhaave's syndrome)
Blast injury, external
Miscellaneous (eg, mediastinal infection, aortic aneurysm, tracheostomy tube erosion
(tracheoesophageal fistula)
my approach provides access to the heart, ascending aorta, proximal arch

vessels, and retrohepatic veins entering the inferior vena cava. A right
thoracotomy provides access to the upper trachea, carina, hilum, mid-
portion of the esophagus, lower thoracic duct, and superior vena cava,
whereas a left thoracotomy provides access to the distal aortic arch,
descending thoracic aorta, hilum, distal esophagus, and anterior thoracic
vertebral bodies.
Esophageal Injuries
An etiologic classification of esophageal trauma is summarized in Table
43.17818° Blunt and penetrating wounds are rare because of the well-pro-
tected posterior thoracic position of the esophagus. Foreign bodies occa-
sionally erode through the wall or are pushed through the wall during
endoscopy. Foreign bodies can cause perforation or fistula formation.
Iatrogenic injuries are the most common. Alkaline ingestion, particularly
the liquid variety, causes full-thickness damage to the esophagus and the
stomach. Crystals usually burn and often cause the victim to spit out the
material before total ingestion. Perforation leads to contamination, and
contamination leads to sepsis. The degree of injury depends on the amount
of contamination. Infection may dissect along periesophageal planes in the
mediastinum and ultimately perforate into the pleural space. Cervical per-
forations are less lethal than mid or distal esophageal perforations.
, i¸¸.~
FIG. 48. Exposure of cervical esophagus for repair or excision and drainage. (From Wilson RF, Steiger Z.
Oesophageal injuries. In: Champion HR, Robbs JV, Trunkey DD, editors. Rob and Smith's operative
surgery: trauma, part I. 4th ed. London: Butterworths; 1989.)

FIG. 49. Pleural-basedflap buttress (Grillo technique). (From Wilson RF, Steiger Z. Oesophageal injuries.
In: Champion HR, Robbs JV, Trunkey DD, editors. Rob and Smith'soperative surgery: trauma, part I. 4th
ed. London: Butterworths; 1989.)
The clinical suspicion of esophageal perforation is heightened by the

association of fever, pain, and tachycardia (Makler's triad). Cervical sub-
cutaneous air may occur with injury in the neck. A "mediastinal crunch"
may be heard on auscultation. Pneumomediastinum and pleural effusions
on the CXR should suggest esophageal perforation in the differential
diagnosis. Meglumine diatrizoate (Gas~ografin; a water soluble agent) is
used initially and may be followed by barium if no leak is detected.
Thoracentesis and esophagoscopy are useful for establishing a diagnosis.
Esophagoscopy is especially valuable to assess the mucosal integrity if con-
trast studies demonstrate no leak.
Treatment follows early recognition and diagnosis. Hydration and
antibiotic administration should precede surgical intervention. Small cer-
vical perforations without significant contamination may respond to
antibiotics and nonoperative management. Most cervical tears, however,
require debridement, closure, and drainage (Fig. 48). Almost all intratho-
racic perforations require surgical exploration, repair or excision, and
drainage. The midportion of the esophagus is better approached through
a right thoracotomy and the lower one third is better approached through
FIG. 50. Stomach as a buttressfor closure (modification of Woodward procedure).(From Wilson RF,
Steiger Z. Oesophageaf injuries. In: Champion HR, RobbsJV, Trunkey DD, editors. Rob and Smith's oper-
ative surgery: trauma, part I. 4th ed, London: Butterworths; 1989.)
the left side of the chest. The principles of repair are drainage, decom-
pression, and diversion. Enteral access (eg, gastrostomy, jejunostomy)
should also be obtained.
The long-term results depend on the site of injury and the time from
injury to treatment. The mortality rate of 10% to 25% when treated with-
in 12 to 24 hours rises to 25% to 60% if treated after 24 hours.
The concept of staged procedures for delayed recognition (ie, after 12
to 24 hours) has been challenged. The available data support primary
repair of perforation in the face of contamination. The principles of opera-
tion include drainage and debridement followed by meticulous closure
with buttressed pleural or intercostal muscle flap, stomach, or diaphragm
is stressed (Figs. 49 and 50).
Bleeding and obstruction must also be considered in patients with
esophageal trauma. In patients with delayed sepsis and abscess formation
after blunt chest trauma, the possibility of esophageal injury must be con-
sidered. A new pleural effusion or change in the pleural drainage should
TABLE 44. Sequelae of blunt cardiac injury (contusion)
Minor echocardiogram/enzyme abnormality
Complex arrhythmia
Cardiac failure
Coronary artery thrombosis/laceration/dissection
Septal rupture/fistulas
Free wall rupture
Left ventricle aneurysm
Valvular injury
Aortic
Mitral
Tricuspid
Combinations
Miscellaneous
Atrial rupture
Atrial/caval rupture
Prosthetic valve injury
Pulmonary artery aneurysm
Cardiopulmonary resuscitation; Heimlich maneuver
From Mattox KL, Flint LM, Carrico CJ, et aL Blunt cardiac injury (formerlytermed "myocardialcontu-
sion")[Editorial].J Trauma 1992;33:649-50.
prompt studies for amylase and gastric contents. Fistulas are serious and
potentially lethal problems. Foreign bodies, such as chicken bones, can
erode into the aorta causing upper gastrointestinal bleeding.
In difficult cervical esophageal injuries that preclude primary repair, a
diverting proximal esophagostomy can be performed. Distally the
esophagus is stapled closed. If this cannot be accomplished, celiotomy
with transhiatal resection can be undertaken along with gastrostomy and
jejunostomy. A definitive reconstruction with the stomach or colon can
follow at a later setting. If the leak cannot be localized at operation, air or
saline solution may be injected into the field through the nasogastric tube
to highlight the perforation.
When he drinks water, it will choose to come out of the opening of his wound ....
and as a result develops fever...you should say of him: this is a man who has a
wound of his throat that has perforated all the way to his guillett.
Edwin Smithpapyrus (circa 3000 BC)
Cardiac Injuries
Penetrating and nonpenetrating trauma may injure the heart and peri-
cardium in a variety of ways (Tables 44 and 45). tin'm2 Miscellaneous
injuries include electric shock and the local cardiac effects of bums, radi-
ation, and heat.
TABLE 45. Penetrating cardiac injuries
Pericardium Hemorrhage with/without tamponade
Pericarditis
Effusion
Constriction
Delayed tamponade
Myocardium Laceration
Left ventricle aneurysm
Ventricular septal defect
Fistula
Coronary artery Laceration
Fistula
Left to right
Left to left
Cardiac valves Unusual
Both penetrating trauma (commonly) and nonpenetrating trauma (less

commonly) may result in cardiac tamponade. This condition requires
prompt recognition and treatment. Needle aspiration of the pericardial sac
may afford both diagnostic confirmation of blood in the pericardial space
and immediate but transient relief of any hemodynamic compromise.
However, this technique may be misleading with high false-negative and
false-positive rates reported. In acute tamponade the unyielding pericar-
dial sac does not distend as it may with chronic effusions. Blood may be
forced into the pericardium during systole resulting in less space for
diastolic distension of the myocardium, thereby compromising the stroke
volume and cardiac output and narrowing the pulse pressure. Initially an
increased heart rate compensates for the decreased stroke volume to
maintain the cardiac output. Hypotension, increased venous pressure, and
muffled heart tones constitute Beck's triad. These findings suggest the
diagnosis, but all three findings are present in fewer than 40% of trauma
victims with tamponade. Elevation of the central venous pressure is the
most significant diagnostic finding. A pulsus paradoxis (>10 mm Hg
decrease in systolic pressure during' normal inspiration) is difficult to
demonstrate in a noisy trauma environment. An enlarged cardiac silhou-
ette on the CXR and/or a pericardial effusion documented by echocardio-
~aphy help confirm the clinical suspicion and diagnosis. After a positive
pericardiocentesis, all cardiac tamponade victims require operative inter-
vention. Almost all anesthetic agents abolish the compensatory tachycardia
and vasoconstriction on which the patient's blood pressure depends.
These agents should be avoided or used only after the tamponade can be
drained with the use of local anesthesic, if necessary. A subxiphoid win-
dow affords excellent drainage and evaluation of continued bleeding. If
FIG. 51. Technique to control penetrating cardiac injury. (From Hood RM. Thoracic surgery. Philadelphia:
Saunders; 1985.)
serious injury or bleeding is encountered, conversion to a median sterno-

tomy or a left anterolateral 5th interspace submammary thoracotomy can
be performed. CPB may be necessary.
Penetrating Cardiac Injuries. Claude Beck 182ain 1926 summarized the
history of cardiac injuries from the Smith Papyrus through the early
1900s. The first surgical treatment of penetrating cardiac trauma occurred
with the successful repair of a stab wound of the right ventricle by
Rehn 11°a in 1896. Before then, cardiac wounds were uniformly fatal. This
prompted Billroth's H°" famous statement in 1883: "The surgeon who
should attempt to suture a wound of the heart would lose the respect of
his colleagues". Within 10 years of his original case, Rehn compiled 124
patients with a 40% recovery rate. Lister Hill H°~ of Montgomery,
Alabama in 1902 performed the first successful American repair of a stab
wound of the heart in a 13-year-old boy. This was also the first success-
ful repair of a left ventricular wound. Survival rates of 40% to 50% were
subsequently reported.
Civilian stab wounds and gunshot wounds are the most frequent cause
of cardiac injury and are occurring with increasing frequency. Rarely do
displaced rib or sternal fractures penetrate the heart. The injured areas in
decreasing order of frequency are the right ventricle, left ventricle, right
atrium, left atrium, and great vessels. Right ventricular wounds bleed
more than those of the thicker left ventricle, which tends to be self-sealing.
The clinical spectrum ranges from stable and asymptomatic to tamponade
or massive hemothorax. From 30% to 80% of penetrating cardiac victims
die in the field of tamponade or hemorrhage, but the survival rate may be
as high as 50% to 70% if vital signs are present when the patient arrives
in the emergency department. CXRs have limited value except for docu-
menting a foreign body in relation to the entrance wound. Mediastinal
penetration or the trajectory may be highly suspicious for cardiac injury.
Echocardiography should be used liberally for diagnosis because the
cardiac wound may initially seal (resulting in a hemodynamically stable
condition) only to rapture hours to days later with lethal consequences.
Entrance into the "death rectangle" should prompt an aggressive evaluation.
Pericardiocentesis may be diagnostic, and at times lifesaving, but at
best temporizing. Operative exploration is indicated in all cases. A sub-
xiphoid window is performed in most situations initially. Various tech-
niques of operative repair of defects have been advocated when median
sternotomy is required (Fig. 51). The availability of CPB along with auto-
transfusion techniques add greater flexibility and safety in the operative
management. Technical maneuvers include preparing the leg for possible
saphenous vein harvesting; inflow occlusion; temporary fibrillation and
reverse Trendelenburg to decrease cardiac volume; and the use of esmolol
or adenosine to slow the heart temporarily. These maneuvers make tech-
nical placement of sutures more precise and safer. Pericardial rather than
prosthetic bolstered sutures may decrease the potential for infection.
Associated injuries are more common with gunshot wounds, particularly
intra-abdominal injury, and the overall mortality rate is higher with gunshot
wounds. Tamponade is responsible for death in 90% of stab wounds and
67% of gunshot wounds to the heart. The more common residual defects or
complications include intramyocardial fistulas or shunts and complications
of coronary artery injury or laceration. A new murmur, angina, or conges-
tive heart failure is an indication for evaluation with echocardiography, par-
ticularly to evaluate for a fistula or shunt. Formal cardiac catheterization
and coronary angiography is usually indicated to clarify complicated
injuries. Ivatury and Rohman 181 has proposed a cardiac index (Table 46).
Blunt Cardiac Trauma. MVA account for more than 80% of blunt
trauma. 183,184 Bleeding from blunt cardiac trauma can produce cardiac
tamponade or, if there is pleuropericardial communication, exsanguinating
hemorrhage. Contusion is the most common blunt cardiac injury, occurring
in 10% to 30% of cases. The right ventricle, being more anterior, is the
most common area involved. Sixty percent of cases have associated tho-
racic injuries. Clinical suspicion, serial electrocardiography, cardiac
enzymes, echocardiography, and nuclear scanning techniques have all
been used to confirm the diagnosis.
TABLE 46, Penetrating cardiac trauma index
Anatomic:
Organ risk factor: 5
Injury severity estimate:
1. Tangential, involving pericardium or wall up to but not through the endocardium
2. Single right-sided chamber
3. Comminuted tears of a single chamber
4. Multiple chambers; isolated left atrial or ventricular injury
5. Coronary vessel injury; major intracardiac defects
Penetrating cardiac trauma index; 5 x injury severity estimate
Total penetrating thoracic trauma index: sum of indices of all thoracic organs
Penetrating trauma index = thoracic trauma index + abdominal trauma index
Physiologic:
Fatal = 20
Agonal = 15
Profound shock = 10
Stable = 5
From Ivatury RR, Rohman M. The injured heart. Surg Clin North Am 1989;69:93-110.
Hospitalization with observation, electrocardiogram monitoring, and

myocardial infarction precautions are the mainstay of treatment, and a
full unrestricted recovery is often the result. Complications are related to
the severity of the initial injury. In cardiac concussion occasional arrhyth-
mias occur. With contusion, myocardial hemorrhage and fibrillar disruption
occur. Because the blood supply is not compromised, uneventful healing
occurs in most cases.
There has been recent controversy about whether the diagnosis of car-
diac contusion should be sought, given the usual benign course of its
victims, and about the appropriate management algorithm for those who
are suspected to have this injury. One policy is generally to perform
echocardiography in patients with a mechanism of injury highly sugges-
tive of cardiac contusion and/or if the initial electrocardiogram is abnormal.
Patients with positive findings on the echocardiogram or abnormal
electrocardiograms are then monitored for 48 hours on a telemetry ward
(if otherwise appropriately stable) before discharge, because almost all
adverse sequelae of contusions will occur within this time period. Despite
the majority of reports in the literature that document generally benign
courses for those patients with cardiac contusions, several series have
reported serious sequelae that range from arrhythmias to shock to death
in these patients. The concern is heightened in patients undergoing major
operations for accompanying injuries. Rhythm and conduction distur-
bances are the major sequelae of cardiac contusion, with tachycardia
being the most common. The electrocardiogram is not diagnostic, but
transmural infarction patterns may be seen. Serum creatine kinase-MB
enzymes (MB >5%) are helpful for establishing the presence of acute
infarction but fall short of absolute specificity and sensitivity. Circulatory
cardiac troponin-T levels may be more helpful in the future. Radionuclide
imaging has proved to be helpful, but echocardiography offers increased
diagnostic promise. Echocardiography offers better documentation of
abnormal segmental wall motion, thinning of the wall, myocardial hema-
toma, chamber dilatation, filling defects, valve dysfunction, and pericar-
dial effusions. Coronary angiography is indicated if coronary artery
thrombosis, laceration, or fistula is suspected.
The prognosis of contusion is excellent, in particular with superficial
and limited full-thickness injury. Delayed sequelae including the forma-
tion of ventricular aneurysm, ventricular septal defect, and coronary
artery fistulae, which may appear weeks or months later. Left ventricular
aneurysms may occur with or without coronary artery occlusion. Severe
acute myocardial contusion with cardiogenic shock has been treated suc-
cessfully with intra-aortic balloon counterpulsation. Isolated pericardial
injury is rare. Isolated rupture with cardiac herniation has been reported.
Pericarditis with varying degrees of effusion and constriction can occur
weeks or months after injury. 16'144'145 Antiinflammatory agents with
closed or open drainage may be required for these sequelae.
Injuries of the Thoracic Aorta and Great Vessels

Penetrating Injuries. Most aortic and great vessel injuries result from
gunshot and stab wounds. 185These injuries are usually extrapericardial in
contrast to intrapericardial aortic injury with subsequent cardiac tampon-
ade. Subsequent hemorrhage into the mediastinum or thoracic cavity is
usually fatal. Occasionally a false aneurysm, arteriovenous, aortocardiac,
or aortopulmonary fistula develops. Because of systemic pressure, a thin
fistula or false aneurysmal wall, a distensible mediastinum, and delayed
rebleeding, these injuries carry a high mortality rate. More than 50% of
patients have massive bleeding.
Aortic lacerations usually manifest with hemorrhage into the left side of
the chest, requiring an urgent thoracotomy. The condition of these
patients is rarely stable enough for preoperative angiography. Great vessel
injury may manifest with bleeding from the skin entry site, hemothorax,
continuous murmur or bruit, widened mediastinum, expanding apical
chest hematomas, or expanding neck masses. The presence of pulses does
not exclude the possibility of arterial injury, especially if a pseudoa-
neurysm is present. Central nervous system deficits suggest innominate
or carotid artery injury. Additional brachial plexus injury from direct
trauma or compression should be assessed. In the patient whose condition
Innominate a.
Llgarnentum
arledosum
~ / W'"~...~-
Lefl c°mm°n car°lid a"
Left subclavian a,
FIG. 52. Pathophyslologicfeaturesof blunt thoracic aortic injury. (From Symbas PN. Cardlothoracic trau-
ma. Philadelphia: Saunders; 1989.)
is stable, angiography is indicated to assist with operative planning. The

need for proximal and distal arterial control should dictate the operative
approach.
The ascending aorta, aortic arch, and proximal innominate and left
carotid arteries are best approached via a median sternotomy. The sub-
clavian arteries can pose difficult exposure problems. The operative
approaches for injuries to these vessels are summarized and illustrated by
Schaff and Brawley.186
Blunt Injuries. Blunt trauma to the thoracic aorta is a highly lethal
injury that has been implicated in up to 25% of all deaths in patients with
thoracic trauma. The frequently cited autopsy series of Parmley and col-
leagues ~87 in 1958 established the high mortality rate that accompanies
this injury, with death occurring immediately in 80% to 90% of victims
and within 24 hours in 30% of those who survived the initial injury. A
more recent study of motor vehicle fatalities in Erie County, New York,
confirmed the presence of aortic trauma in 20% of patients, with 99% of
these fatalities occurring within the first 24 hours. 188 Most injuries occur
at the isthmus (85% to 95% in survivors), but those which involve the
ascending aorta, although much less common, are more lethal. Injuries in
the mid-descending aorta 189 and multiple tears 19°,191occur rarely.
Traumatic mechanisms that result in injury include bending and shear-
ing stresses at the isthmus and torsion and "water hammer" stresses at the
ascending aorta. Injuries to the descending aorta have been attributed to
A
FIG. 53. Degree of aortic injury from (A) rupture to pleurol cavity, (B) contained by adventitia, to (C)
chronic aneurysm.(From Naclerio EA. Chest injuries, physiological principles and emergency manage-
ment. New York: Grune and Stralton; 1971.)

FIG.54. Anteroposterior portable CXR demonstrates a widened mediastinum.
compression of the aorta between the spine and the thoracic cage and also
may occur in association with hyperextension of the spine with an accom-
panying vertebral fracture (Fig. 52).
Severe blunt trauma to the chest may produce complete transection
involving all layers of the aorta (resulting in immediate exsanguination
and death) or may involve partial disruption with only the intima and
media disrupted (Fig. 53). In this case, the rupture is contained by the
strong but thin adventitial layer. The need for an expedient diagnosis is
therefore important but at times difficult. Less than one half of the
patients with traumatic injury to the aorta have external evidence of chest
trauma, and although abnormal physical findings may be present
(including a supraclavicular bruit, absence of distal pulses, and upper
extremity hypertension), these are more commonly absent than present.
The mechanism of injury is the strongest indicator that this injury is pre-
sent, with the more common mechanisms being MVA (especially for
those ejected from the vehicle or hit by a moving vehicle) and falling
from a significant height. Patients who sustain a severe blow to the chest
and victims of blast or crush injuries are also susceptible to disruption of
the integrity of the aorta.
The findings on the CXR most suggestive of aortic injury include a
widened mediastinum, obscuration of the aortic knob, apical capping, loss
of the aortopulmonary window, and a widened paravertebral strip.
Although the sensitivity of the finding of a widened mediastinum is often
FIG. 55. Thoracicaortogramdemonstratestear/ruptureat aortic isthmus.
90% or better, the specificity is quite low, because most trauma CXRs are
performed with the patient in the supine position (Fig. 54). The predictive
ability of a CXR in this setting may be improved by obtaining an upright
instead of a supine view 192 or by identifying the presence of either devia-
tion of the nasogastric tube and depression of the left main stem bronchus,
which are the most specific indicators of blunt aortic injury. 193,194
TABLE 47. Radiologic findings in aortic rupture
1. Transverse width of the mediastinum at a level just above the aortic knob equal to
8 cm or greater
2. Mediastinal- to chest- width (M-C) ratio greater than 0.25 at the level of the aortic
arch
3. Abnormality of the aortic contour
4. Aortopulmonary window opacification
5. Deviation of an opaque nasogastric tube to the right of the spinous process of T4
6. Deviation of the trachea or endotracheal tube to the right of midline
7. Depression of the left mainstem bronchus greater than 40 degrees below the horizontal
8. Widening of the right paratracheal stripe to 5 mm or greater
9. Widening of the right or left paraspinal line
10. Right or left apical cap
11. The presence of left hemothorax, without associated rib fractures
The gold standard for the diagnosis of blunt injury to the aorta is aor-
tography. Left anterior oblique and right anterior oblique views are used
to identify the signs of injury, which include the presence of a subadventi-
tial hematoma or false aneurysm (Fig. 55). False-negative studies are rare,
but false-positive results may occur at a rate of 1% to 2%, often caused
by the presence of a ductus diverticulum. 195,196Aortography is also an
invasive procedure, and in almost all reports has a low yield (often less
than 10%). The clinical suspicion, mechanism of injury, and classic radio-
graphics findings (Table 47) dictate the need for aortography.
CT of the chest has been used as a screening technique to identity
those patients with aortic injuries in blunt trauma. Raptopoulos and
colleagues 197 from our institution showed a sensitivity of 100% in 131
trauma victims who underwent both chest CT scan and aortography. CT
was identified to be an effective screening tool, potentially decreasing the
need for aortograms by 56% while increasing their yield by 65%. The
helical or spiral CT scan may eventually prove to be an effective tool for
confirming the diagnosis without aortography in selected cases. 198
Magnetic resonance imaging has been identified as a means of surveying
for the development of an expanding pseudoaneurysm for patients in
whom delayed repair is deemed necessary. 199
TEE has also been used as a screening tool for those patients with
suspected aortic injury. 2°°2°~ Besides being a more rapid diagnostic
method than aortography and less expensive, it also allows the severely
injured patient to remain in the emergency department during the procedure
to continue other diagnostic and therapeutic interventions. Complications
and contraindications are rare, and concomitant injuries to the heart may
be identified. Limitations of this diagnostic modality include the need for
skilled personnel to perform and interpret the studies and the possibility
Medical Force 2000 (MF2K)
PATIENT FLOW IN A THEATER OF OPERATIONS
uNrr
SUPPORT"
AR,~.A
CZ
= MEDC
DIVISION
4th E MEDC
.4J
COi~,IUNIC~t1~ON
ZONE
AS: Aid Station

ASF: Aea~orneclteelStaging Facility, USAF
CM: Combat Medic
C~H: Combat .~upport Hospitel
Coml~t Zone
E: Echelon
FH: Field Ht~pital
GH: General Ho~pitel
MASF: Mobile Aeromedical Staging Facility, USAF
MASH: Mobile Army Surgical Hospital
M.EDC: Medical Company
RTD: Remr~ to l~ty
FIG. 56. Combat flow of casualties.(From ZaitchukR, editor. Textbookof military medicine:conventional
warfare: ballistics, blast, and burn injury.Washington, DC: US Government Printing Once; 1990.)
of missing significant great vessel injuries that would otherwise be identi-

fied by aortography. The specificity of TEE ranges from 84% to 98%, and
the sensitivity ranges from 62% to 100%. 202,203
Once the diagnosis is confirmed, emergency operation is mandated
with few exceptions. Invasive monitoring with upper and lower extremity
arterial pressure recordings and large bore venous resuscitation lines are
needed. Single-lung ventilation enhances the exposure, and repair often
requires the use of an interposition graft, although primary repair may
also be appropriate with less extensive injuries. 2°4'2°5
For injuries at the isthmus, control of the aorta proximal and distal to
the injury is necessary and often requires clamping of the left subcla-
vian artery. The surgeon may then choose between several techniques
for protection against paraplegia: full CPB with femoral arterial and
venous cannulation; left heart bypass with cannulation of the left atri-
um and descending aorta or femoral artery; or a heparinized-shunt
bypassing the injured segment. A simple clamp and sew technique may
be an alternative means of repair, but with a theoretically increased risk
of paraplegia. A meta-analysis examining the results from numerous
reports in the literature of repair of traumatic aortic injuries has indi-
cated a significantly higher incidence of paraplegia with the clamp and
sew technique. A clamp time of less than 30 minutes was found to be
relatively safe, but a clamp time of greater than 50 minutes was associ-
ated with an unacceptably high risk of paraplegia. 2°6 A more recent
analysis evaluating data from 50 trauma centers in the United States
demonstrated a significantly higher rate of paraplegia with either the
clamp and sew technique or a crossclamp time longer than 30 min-
utes. 207
Prioritization of treatment often must be considered in patients with
blunt aortic trauma because multiple injuries are often present.
Greendyke2°8 identified an average of 2.9 major visceral injuries and 3.9
major fractures in an autopsy series of patients with blunt aortic injury.
Lee and colleagues2°9 found that 35% of their patients with aortic trauma
required laparotomy, 49% required orthopedic operations, and 25% sus-
tained significant closed head injuries. In our institution, we have found
an average of 2.5 major organ injuries or fractures in patients with blunt
thoracic aortic injury.
In patients with accompanying intracranial injuries, a neurosurgical
procedure often takes precedence over aortic repair. For patients with
intra-abdominal injuries who are hemodynamicatly stable and have no
evidence of ongoing intraperitoneal bleeding, repair of the aortic injury
generally takes precedence. In cases of hemodynamic instability in which
there appears to be another source of bleeding, however, repair of the aortic
injury may need to be delayed until operative control of the hemorrhage
is obtained.
Recent reports have identified several major traumatic injuries that
appear to be associated with aortic trauma. Kram and colleagues21° identi-
fied cardiac contusions in 62% of patients with traumatic aortic injuries,
and these patients were found to have higher rates of cardiac arrest,
ARDS, operative complications, and death. Other c o m m o n associated
injuries include diaphragmatic rupture, 2H thoracic vertebral fractures, 212
and posterior dislocation of the hip. 213
In a small subset of patients with blunt aortic injury and severe con-
comitant injuries, delayed operative repair may be necessary. Akins
and colleagues 214 reported on 14 patients in w h o m repair was delayed
an average of 33 days with only a 14% mortality rate. Griffith and col-
leagues 215 also identified a similar acceptable survival rate (86%) in 10
patients in w h o m operations were delayed or not performed. Other
series have reported on patients who underwent repair at an average of
6 months to 1 year later with no deaths. ~99,216The reasons for delayed
repair may include the presence of a severe head injury, an unstable
cervical spine injury, a severe pulmonary injury or contusion produc-
ing respiratory insufficiency, a significant cardiac injury or infarct,
massive intra-abdominal hemorrhage, extensive pelvic or extremity
fractures, and major burns. During the interim between injury and
repair, antihypertensive therapy and frequent reevaluation for an
expanding pseudoaneurysm are essential. Patient selection is critical,
however, because aortic injuries remain highly lethal early in their
course.
For patients undergoing operation, postoperative complications are unfor-
tunately common and often are due to the myriad of accompanying injuries.
Cowley and colleagues 2~7 at the Maryland Shock Trauma Center noted
more than one major complication in 41% of those who survived repair
procedures. One of the most devastating complications is paraplegia, with
an incidence of 2% to 22%. von Oppell and colleagues 2°6 revealed in a large
meta-analysis a significantly lower rate of paraplegia in those patients
whose injuries were repaired with left heart bypass versus the use of a shunt
and in both of these procedures versus the clamp and sew technique. Other
series 2~8-22° have documented a very low incidence of paraplegia with the
use of left heart bypass, as we have found in our experience. Using left heart
bypass almost exclusively since 1986, we have identified only one case of
postoperative paraplegia in 30 repairs (in a patient who experienced free
rupture and exsanguinated before operation).
The overall mortality rate in most major series ranges from 13% to
42%. 217'220-223 Deaths are often due to preoperative exsanguination (most
commonly in the emergency department), intraoperative instability
caused by either hemorrhage and cardiac decompensation, and postoper-
ative death from associated injuries and multisystem organ failure. In our
experience since 1978, we have treated 72 patients with 73 injuries (one
TABLE 48. Origin of thoracic foreign bodies
Aspiration (inhalation) Organic
Inorganic
Ingestion Solids
Organic
Inorganic
Liquids (eg, caustic lye)
Penetrating Gunshot wound (high velocity, low velocity, shotgun)
Shrapnel
Penetrating missiles (eg, staples, nails, blowgun darts)
patient with both ascending and mid-descending aortic injuries). The

overall mortality rate at our institution is 34.7%; of the 25 deaths, eight
(32.8%) occurred preoperatively, resulting in an operative mortality rate
of 26.7%. All of the preoperative deaths resulted from exsanguination at
the aortic injury site, and all occurred within 6 hours of the injury.
Mattox 224 summarizes the contemporary management of injuries to the
aorta and great vessels.
Special Problems
Inhalation Injury
Inhalation injury is the most significant associated event contributing
to burn deaths, with carbon monoxide and smoke poisoning being the
major cause of early death. 225 The overall incidence is 25% with an
associated mortality rate of 50%, accounting for 6000 of the 12,000
fire-related deaths per year in this country. The incidence of and deaths
from pulmonary burns rise with an increase in the body surface area
burned.
The thermal burn results in direct injury above the trachea. Noxious
sources cause a chemical injury of the lower airway. In addition to bron-
chiolar and alveolar damage, this injury inhibits ciliary movement. Direct
irritation, failure to clear mucus and debris, and subsequent alveolar
edema from changes in capillary permeability combine to cause broncho-
spasm and pulmonary edema, with resultant increasing degrees of
respiratory dysfunction.
The clinical features of facial bums, singed nasal vibrissae, carbona-
ceous sputum, and a burn that occurred in a closed space should raise the
clinical suspicion of inhalation injury. Hypoxemia may be absent initially.
Elevated carbon monoxide levels are significant, and elevated blood
cyanide levels may be even more accurate. Early (less than 48 hours)
abnormal findings on the CXR are signs of a poor prognosis. Fiberoptic
TABLE 49. Overview of foreign body injury
Cause Blunt
Penetrating
latrogenic
Types Organic
Inorganic
Liquid
Gas
Solid
Mechanism of entry Ingestion
Aspiration
Perforation
Penetration
Location Trachea/bronchus
Esophagus
Chest wall
Vertebral body
Pleural cavity
Mediastinum
Lung parenchyma
Pulmonary vascutature
Pericardium
Heart wall
Heart cavity
Great vessels
Distal vascular tree
Problem Free floating
Trajectory
Projectile (size/shape)
Potential for embolism
bronchoscopy confirms suspected airway bums. Subglottic airway

edema, inflammation, mucosal necrosis or ulceration, and the presence of
soot and charring may all be present. The clinical course is one of respi-
ratory failure with pulmonary edema starting within 72 hours and subse-
quent bronchopneumonia within 3 to 10 days. Treatment includes ventila-
tory support, positive end-expiratory pressure, diuretics, and antibiotics
for secondary or nosocomial pneumonia. The use of steroids is contro-
versial. Bronchopulmonary lavage, heparin, and hyperbaric oxygen therapy
have also been advocated.
Foreign Bodies
Foreign bodies are unique because the entire cardiothoracic cavity may
be involved (Table 48). 226,227 For medicolegal purposes it is important to
document the presence, appearance, and location of penetrating foreign
bodies within the thoracic cavity and to be aware that distal embolization
TABLE 49. cont'd.
Complications Penetration
Migration
Embolus: local/distant
Bleeding
Fistula
False aneurysm
Obstruction
Infection
Impaction
Perforation
Migration
Aspiration
Erosion
Compression
Benign
Medical/legal
Insurance
Disability
Cosmetic
through the vascular tree may have occurred. Table 49 summarizes thoracic
foreign body injuries. Organic materials are usually ingested or aspirated
and include meat, bone, teeth, vegetable matter, and various types of seed,
grasses, and peanuts. In the bronchus, the inflammatory reaction to these
foreign bodies may cause distal obstruction.
Most tracheobronchial foreign bodies occur in children between the ages
of 1 and 4 years and lead to 500 deaths per year, with more than 80% of
the deaths from organic material. Cough, unilateral wheezing, and fever
are the most common clinical features. The foreign body lodges most fre-
quently in the right main bronchus because of its direction relative to the
trachea. Obstructive emphysema on the expiratory CXR is diagnostic to
localize the involved side. Extraction should be performed with a general
anesthesic and rigid bronchoscopy. Conservative treatment with bron-
chodilators and percussion is sometimes successful with fragmented or
distal foreign bodies. Morcellation of the organic material may facilitate
expectoration but may also cause peripheral embolization and impaction.
Excessive salivation and dysphagia characterize foreign body obstruc-
tion of the esophagus. Contrast studies and esophagoscopy confirm the
diagnosis. Proteolytic enzyme dissolution of impacted meat may be suc-
cessful. Most foreign bodies should be extracted with the use of rigid
esophagoscopy and a general anesthesic. Perforation remains the most
significant complication.
The two concerns with penetrating foreign bodies of the thoracic cavity are
TABI.I~ 50. latrogenic cardiothoracic trauma
Procedure Prol~lem I)ocumentatlon AI}13roach
Intubation Acquired pneumonia CXR Expectant
Aspiration CT scan Operation
Larynx tear, tracheal Endoscopy
laceration
Pneumomediastinum
Tracheostomy Acquired pneumonia Contrast study Operation
(traditional) Stricture Endoscopy
Tracheoesophageal fistula
Tracheoinnominate fistula
Tracheostomy Bleeding Endoscopy Operation
(percutaneous)
Cardiopulmonary Fractures (sternum, ribs) CXR Pericardiocentesis
resuscitation Myocardial contusion Electrocardiogram,
enzymes
Tamponade Chest tube
Pneumothorax Echocardiogram
Mechanical Pneumothorax CXR Chest tube
ventilation Barotrauma CT scan Operation
Air ,embolism Echocardiogram
Deep lines, venous Infection CXR Chest tube
Pneumothorax Venogram Transvenous
retrieval
Hemothorax
Retained/migrating
catheter
Arterial cannulation
Thrombosis (artery/vein)
Wound hematoma
the intrathoracic location and which structures were pierced or penetrated on

entry. In general, impaling instruments should not be removed before a com-
plete clinical evaluation has been completed. Chest wall palpation, the CXR,
fluoroscopy, CT scanning, echocardiography, and angiography are all help-
ful for localizing the foreign body. In general, asymptomatic foreign bodies
do not need to be removed surgically. Cardiac chamber foreign bodies, how-
ever, should be removed with CPB to prevent systemic embolization. TEE
has proved extremely helpful for localizing foreign bodies in the pericardial
sac, myocardial wall, or cardiac chambers. In addition, pericardial effusion,
wall motion abnormalities, valve dysfunction, and shunts can also be evalu-
ated. Percutaneous transvenous removal of a bullet from the fight ventricle
has been reported. Angiographically confirmed bullet embolization to the
systemic or pulmonary circulation requires surgical removal. The role of
identification and removal of foreign bodies in the pleural cavity with the
VATS approach will be expanded in the future.
TABLE 50. cont'd.
Balloon-tipped Hemothorax CXR Chest tube
pulmonary artery Parenchymalbleeding Angiogram Mechanical ventilation
catheter Hemoptysis Fluoroscopy
Knotting/kinking
Nasogastric tube Perforationesophagus CXR, CT Operation
Reflux Contrast study Expectant
Aspiration Endoscopy
Stricture
Temporary pacing Cardiactamponade CXR, Drainage
echocardiogram
Chest tube Diaphragm injury CXR Expectant
thoracostomy
Lung l a c e r a t i o n UltrasonographyOperation
Liver, spleen injury CT scan (chest/
abdomen)
Empyema
Angiography/ Subclavian
artery Angiography Expectant
catheterization
Laceration/tear/dissection Echocardiogram Drainage
Cardiac tamponade Repair
latrogenic Injury
Complications related to interventions are not uncommon. If not recog-
nized and managed in a logical and expedient fashion, further harm and
fatality may result. Physician-related thoracic complications of trauma
can be divided into noninvasive and invasive categories. Noninvasive
complications caused by drugs, nosocomial infections, and radiotherapy
will not be discussed. Complications related to invasive procedures and
therapy are summarized in Table 50. These complications occur not infre-
quently in the resuscitative and intensive care environment. They require
an increased awareness, both in terms of incidence and quality assurance.
Traumatic intubation can cause laryngeal damage or tears and usually is
accompanied by subcutaneous cervical emphysema and pneumomedi-
astinum. Expectant care is common, but upper airway compromise
requires further evaluation including laryngoscopy and bronchoscopy.
Endotracheal intubation may suffice for small tears. Tracheostomy may
be needed.
Balloon-tipped pulmonary artery catheters may produce fatal injury by
balloon rupture of the pulmonary arteries. Massive hemoptysis necessi-
tates isolation of the unaffected lung by endobronchial intubation.
Resection of the involved lung may be required. We recently treated three
patients with removal of the catheter (2 to 3 cm), inflation of the balloon,
and sedation for 48 hours. All of these patients survived with no sequelae.
Rupture of a pulmonary artery catheter during heparinized CPB can be
devastating. Urschel and Myerowitz 228 summarized a review of 30 cases
with a 41% mortality rate. If bleeding occurs before bypass, the operation
can be canceled, ff operation is urgent or emergent, operation can be
undertaken and the patient's condition can be managed expectantly.
Tracheostomy is not performed as frequently, and long-term endotra-
cheal intubation is more common. Strictures resulting from these tubes
require formal operative repair.
A pneumothorax from closed chest compression, barotrauma from
mechanical ventilation, or errant subclavian or internal jugular punctures
may frequently manifest as a tension pneumothorax and require immedi-
ate decompression. Cardiac tamponade should always be considered
when a foreign body enters the heart (such as central venous catheters,
pulmonary artery catheters, and temporary pacemaker wires).
Military Cardiothoracic Trauma

Military medicine involves a peacetime and deployable or combat mis-
sion. 41 Newer variations include humanitarian assistance, disaster relief,
and peacekeeping scenarios. The peacetime mission is the same as in
civilian medicine. Military trauma or combat medicine involves both
combat-related and noncombat-related injuries occurring in the combat
zone. The overall philosophy of military medicine is to conserve the fight-
ing strength. Military personnel are generally young and healthy who are
"fit to fight" and "worldwide deployable." Unlike the situation for isolat-
ed civilian casualties where all efforts are made to salvage the victim, the
large number of casualties encountered in combat or large disasters must be
approached in a triage manner. The most care is provided for the least
injured victims to salvage more patients and expend less time and
resources for the more severe casualties.
An understanding of triage and evacuation in a combat zone is essential to
adopt the correct management priorities (Fig. 51). Casualties advance from
self care to buddy care to medic care then up echelons of sophisticated care
to the fourth echelon, which provides the level of care in a general medical
facility (approaching level I trauma). The intensity of a conflict ultimately
determines the quantity and severity of injured patients. Low intensity (eg,
Somalia, Haiti, Bosnia) increases to higher intensity (eg, Grenada, Panama)
and to the highest intensity (eg, Desert Storm).
Historically combat cardiothoracic trauma has included more penetrat-
ing than blunt trauma. This will change on the modern battlefield with a
more mechanized force. An increase in associated blunt and blast injuries
TABLE 51. Differences between military and civilian trauma
1. Greater number of high-velocity missile wounds
2. More frequent multiple fragment wounds (artillery, mortar shells, bombs, booby traps,
land mines)
3. Multiple medical personnel involvement as the patient progresses up the echelons of
care from the battalion aid station/clearing station/combat support hospital/evacuate
hospital/field hospital/general hospital
4. High incidence of contaminated wounds with consequent higher incidence of septic
complications: The incidence of post-traumatic empyema decreased from 15% to 20%
in World War II to less than 5% in Vietnam.1~2 The increased attention to obtaining lung
expansion and complete pleural drainage contributed to that decrease. Earlier thoraco-
tomy and decortication also played a role.
will occur with quantitative increases in casualties. The modern era of

cardiothoracic trauma began in World War II. Dalley and Brewer 29,3° out-
lined the basic principles of care in 1942. Buford and Burbank 29,3°
described traumatic wet lung in 1945. Rockey 229 in 1952 summarized
the care of thoracic and thoracoabdominal wounds in Korea. Whelan 23°
in 1966 summarized the Vietnam experience. A detailed analysis of
chest injuries in Vietnam were published by McNamara 231 in 1970 and
Hardaway 232 in 1978.
Approximately 7% of war wounds in World War II, Korea, and Vietnam
involved the chest. In 1970 in Vietnam, 10,300 of 147,000 wounded person-
nel had injuries of the chest. Approximately 90% of chest casualties will sur-
vive evacuation from the battlefield. Similar to the civilian experience 10%
to 15% of victims of combat chest trauma require thoracotomy. An increase
in this rate has been noted. Z a k h a r i a 233 reported in 1985 on the Lebanon War
in which 71% of patients with chest trauma underwent thoracotomy and
16% underwent lung resection. There is a trend towards increased use of
thoracotomy and lung resection for high-velocity missile injuries. This may
have contributed to a decrease in the subsequent morbidity. The major dif-
ferences between military and civilian trauma are summarized in Table 5 I.
Pediatric Cardiothoracic Trauma

There are several unique features about pediatric chest t r a u m a . 234'235
From 75% to 80% of injuries are due to blunt trauma, with MVA (31%)
and falls predominating. Associated extrathoracic injuries are common.
An isolated mortality rate of 5% increases to 20% if the abdomen is
involved and to 35% if there is also head injury. After a child is 13 years
of age, penetrating injury is more frequent and follows the adult pattern.
Ingestion of hydrocarbons, such as kerosene, cleaning fluid, and furniture
polish, can produce lung parenchymal damage.
The cartilaginous and compliant chest wall of the child reduces the inci-
dence of rib fractures to 30% (compared with 70% in adults) yet increases
the incidence of severe pulmonary contusion. This may be related to the
fact that the fractured rib absorbs direct energy that might otherwise be
delivered to the underlying lung. Flail chest is rare. The mediastinum is
more flexible and mobile, resulting in fewer great vessel and airway
injuries. Gastric dilatation caused by aerophagia is common. With smaller
upper airways, obstruction caused by airway edema is more common.
As with adults, operative intervention for blunt chest trauma is required
less frequently than exploratory laparotomy for associated abdominal
injuries. Most patients can be managed safely with expectant observation.
The general rule for hemothorax in children is that 15 mL/kg as an initial
loss or 2 to 3 mL/kg for 3 hours warrants exploratory thoracotomy. Chest
tube thoracostomy is the most commonly performed procedure. Cardiac
injuries are unusual. Indications for urgent or early thoracotomy are the
same as for the adult. Emergency department thoracotomy is rarely per-
formed or recommended.
Most children with documented or suspected rib fractures should be hos-
pitalized and observed for a period of time. In the intensive care environ-
ment, iatrogenic chest trauma is also unique to the pediatric age group.
Pneumothorax from the barotrauma of mechanical ventilation occurs com-
monly with immature lungs. Bronchial perforation from aggressive suc-
tioning may also occur. Esophageal perforation may result from a stiff
nasogastric tube. Central venous catheters or hyperalimentation lines can
perforate a thin right atrial wall and cause hemopericardium or tamponade.
Cardiothoracic Trauma in the Elderly

Chest trauma in the elderly population is increasing. 236 We will experi-
ence an increase of 2.5 times by the year 2050 in the segment of the pop-
ulation that is over 65 years of age. There is also an increase in the num-
ber of injuries to elderly women. The elderly have a decreased ability to
tolerate shock, and the morbidity and mortality rates are higher. Increased
attention to fluid management, hemodynamic monitoring, pulmonary
thromboembolism prophylaxis, and pulmonary toilet are recommended.
Shorr and colleagues 23s at the Maryland Trauma Unit studied 46 of 515
patients over 65 years of age after blunt chest trauma. Eighty-seven per-
cent of these patients had one or more rib fractures, and eight patients had
flail chest. There were 18 patients with hemopneumothoraces and 2
patients with traumatic tears of the aorta. The overall morbidity rate was
46%, and the overall mortality rate was 37%. The comparable morbidity
rate was 35%, and the mortality rate was 13.4% in the nonelderly (less
than 65 years of age) group. Late deaths occurred in 35% of all elderly
deaths, compared with 16% in the nonelderly group. The authors attrib-
uted this difference to more associated injuries. These patients required
longer hospitalization and placed greater demands on the acute care
resources. Recently, Peterson and colleagues236 summarized the age-related
deaths in thoracic trauma. The elderly population was defined as older
than 60 years of age. These individuals were less often the victims of vio-
lent crimes, but the mortality rate was higher probably because of worse
underlying pulmonary function. This finding was also noted by
Livingston TM who found pulmonary function to be 40% to 50% of nor-
mal in elderly patients shortly after severe trauma.
The authors thank the secretarial staff, the Trauma Registry, the Department of
Radiology at the University of Massachusetts Medical Center, and the Cardiothoracic
Surgery Services at Walter Reed Army Medical Center and Brooke Army Medical Center
for their help, support, and contributions.
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Current Problems in

Curr Probl Surg, August 1998 649

650 Curr Probl Surg, August 1998

Curr Probl Surg, August 1998 651

~ ) ~ Wayne E. Silva, MD, is Professor

,o er., a ce, .a,ra, a.e

Curr Probl Surg,August 1998 655

General Characteristics of Cardiothoracic Trauma

656 Curr Probl Surg, August 1998

TABLE 2. Mortality rates after blunt chest trauma

TABLE 4. Chest trauma, 1990 (MIEMS) is

blunt trauma. Shorr and colleagues 14 at The Maryland Institute for

TABLE 6. Mortality rates after penetrating chest trauma

234 42.7 414 29.0 522 31.4 25 36.0

Barbet 27 clearly presents this case as that of a postmortem hydrohe-

TABLE 9. Cause of chest trauma

mortality rate associated with empyema was related to an open pneu-

ed during the Vietnam conflict. The mortality rates for combat-related

Certainly the history of cardiothoracic trauma continues (Fig. 1).

also be emphasized. This unique combination is highlighted with high

FIG. 4. Trunkey torso classificationof trauma (sagittal).[FromTrunkeyDD. Torsiontrauma.Curr Probl

In nonpenetrating trauma the concern is related to the effect of the

PERMANENT ).::~ .//~ ", - ' . , ~ / ~ . ~ ' l

amount of kinetic energy or force imparted to the tissue. A high-velocity

A basic understanding of wound ballistics is necessary to understand pen-

which then rupture from rapid expansion. Subsequent pneumothorax or

PathophysiologicFeaturesof the Host Response

FIG. 10. Pathophysiologic features of open pneumolhorax.(FromNaclerio EA. Chesttrauma.Ciba Geigy

Cardiac Tamponade. Cardiac function may be impaired either by

AS DIAPHRAGM RISES AND CHEST CONTRACTS,

FIG. 11. Pathophysiologicfeaturesof tensionpneumothorax.(FromNaclerio EA. Chesttrauma. Ciba Geigy

organs "unsurvivable." A number is assigned to each grade, and the total

TABLE 15. Classification of algorithms

PENETRATING CHEST INJURY

CHEST WOUNO~ ( TYPE • CR(~;SMATCH IV LINES

NEGATIVE PNEUMOTt~ILX " ~

- Hi~ory/Physieal Wide mediaslinum ~ Aortogram - Repair Aortic Tear

- 1"/2+ Survey Conturaon..~ Lung p V~tilalor

l (2 large bore) = Stable~

(ICD-8 and 9) devised by the World Health Organization to classify

(Figs. 12 through 14). 52,53Unfortunately, few scientific data are available

The trimodal distribution of trauma mortality rates reveals that 50% of

Less than 15% of thoracic injuries require operative intervention. Much

Tracheobronchial rupture Nonspeciflc dyspnea; Nonspeciflc; may have pneumothorax

Esophageal perforation Pain; dysphagia;fever; Swelling of cervical area; auscultate

Lower Dyspnea; wet cough; Rales; wheezing; cyanosis; absent

cavity, and restoration of circulating volume deficits are life-saving

Opacification of hemithorax Chest film; Thoracotomy

Nonspeciflc Observation only (1)Oral or nasal airway

sonnel, citizens, emergency medical technicians, and paramedics, all with

TABLE 20. Military experience with cardiothoracic trauma

required airway control. There were no complications and 19 patients sur-

Critical Care Phase

cern and communication. It is crucial that the team approach be monitored

TABLE 23. Indications for intubation/ventilation

requires an individualized approach. Investigative procedures include

after exsanguination from unsuspected injury to the thoracic aorta or

enced the development of a pneumothorax or hemothorax within 6 hours,

to complications of the wound, operation, repair, or the healing process

associated thoracic injuries have been identified on abdominal CT scans.

TABLE 29, Wagner classification of lung parenchymal injury

complications, particularly multiloculated empyema, lung abscess, and

manipulation, agitation, possible esophageal injury, aspiration).

FIG. 20. Problem-solutionequation.

of Diaphragm ' :/j