Learning Objectives

Understand basic statistics of thoracic

trauma
Recognize potential pitfalls in the acute
management of thoracic injuries
Recognize the types and mechanisms of
life threatening thoracic injuries
Comprehend initial assessment and
management of various thoracic injuries
Understand secondary management of
thoracic injuries and some unique
challenges they can impose
 Key Questions?
What are some of the unique challenges and
pitfalls posed by thoracic injuries?
How can we identify acute life threatening
thoracic injuries early and treat them
appropriately to assure patient
survivorship?
When do thoracic injuries take precedence
over other injuries in the primary survey?
Which thoracic injuries can be treated during
the secondary survey after other issues
have been addressed?
 Statistics
Thoracic trauma accounts for 20-25%
deaths due to injury in US
16,000 deaths per year due to chest injury
Rate of thoracic injuries 12 per million
population per day (~30/day in Miami-
Dade County)
About 50% fatalities of MVA have sustained
some chest injury
Ratio penetrating/non penetrating variable
usually about 75-85% blunt injuries
Management – Primary Survey
Always consider mechanical factors
Airway/spinal stabilization
• Trachea, bronchial disruption
Breathing
• Chest wall integrity, pneumothorax, flail
• Pulmonary contusions, 02 diffusion block
Circulation
• Tamponade, hemothorax, tension
pneumothorax
• Cardiac, great vessel injury
 Immediate Life Threatening
Thoracic Injuries:
Cardiac Tamponade
Pathophysiology – intra-pericardial pressure
exceeds filling pressure of right heart
Impairs venous return and cardiac filling
leading to hypotension, narrow pulse
pressure, PEA
“Beck’s Triad” - hypotension, neck vein
distension, distant/absent heart tones
Signs and symptoms masked by hypovolemia
Treat with immediate volume replacement to
↑ CVP, pericardial decompression
 Immediate Life Threatening
Thoracic Injuries:
Tension Pneumothorax
Suspect with any injury
High intra-thoracic, extra-
pulmonary pressure
Absent breath sounds, shift
of trachea, hypotension
Can be worsened with
intubation and + pressure
Treat symptoms → immediate
decompression
 Crucial 1° Survey Differential Dx:
Cardiac Tamponade vs. Tension
Pneumothorax
Clinical Sign Cardiac Tension
Tamponade Pneumothorax
Blood Pressure Low (PEA) Low
 Cardiac Tones Muffled Normal
 Breath Sounds Normal Absent - collapsed side
 Neck Veins Distended Flat
(flat in hypovolemia)
Respirations ± Normal Tachypnea
Treatment Needle/drain Needle/tube chest
pericardium
Immediate Life Threatening
Thoracic Injuries:
Primary Survey
 Immediate Life Threatening
Thoracic Injuries:
Primary Survey
Cardiac disruption/tamponade
Tracheal disruption
Open pneumothorax
Tension pneumothorax
Massive hemothorax (great
vessels, pulmonary vessels)
Immediate Life Threatening
Thoracic Injuries:
Cardiac Trauma
Immediate Life Threatening
Thoracic Injuries:
Cardiac Tamponade
Distribution of Penetrating
Cardiac Trauma
ED Thoracotomy (EDT)
 Rationale for EDT
Resuscitate agonal patient with penetrating
cardiothoracic injuries
Evacuation of pericardial tamponade
Control intra-thoracic hemorrhage
Perform open CPR
Repair cardiac injuries
Apply x-clamp to thoracic aorta
Apply hilar x-clamp to lung
Aspirate air embolism
Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-
Based Surgery 2003: 1(1) 11-21.
 Indications for ED
Thoracotomy
Indications:
1. Salvageable post-injury cardiac arrest:
 Patients sustaining witnessed penetrating trauma with < 15
minutes of pre-hospital CPR
 Patients sustaining witnessed blunt trauma with < 5 minutes of
pre-hospital CPR
2. Persistent severe post-injury hypotension (SBP<60mmHg) due to:
 Cardiac tamponade
 Hemorrhage – intra-thoracic, intra-abdominal, extremity, cervical
 Air embolism

C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and
outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA World
Journal of Emergency Surgery 2006, 1:4
 Contra-indications for ED
Thoracotomy

Contraindications:
1. Penetrating trauma: CPR >15 minutes and no signs of life
(pupillary response, respiratory effort, motor activity:
2. Blunt trauma: CPR > minutes and no signs of life or asystole

C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and
outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA World
Journal of Emergency Surgery 2006, 1:4
 Emergency Department
Thoracotomy: Outcomes
Review of 42 published series

Survivors/ Survivors/ Survivors/

Total EDT Penetrating Blunt
Trauma Trauma
537/8744 500/8619 35/7945
(6.1%) (5.8%) (0.44%)

Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-
Based Surgery 2003: 1(1) 11-21.
Application of Aortic Cross
Clamp
Esophagus

Aorta

Spine

Diaphragm
Vertical Pericardial Incision
LIM
A
Internal Paddles for Direct
Cardioversion
Laceration Adjacent to
Coronary Artery
Laceration Adjacent to
Coronary Artery
Coronary Artery Laceration
Ventricular Lacerations and
Repairs
Ventricular Lacerations and
Repairs
Ventricular Lacerations and
Repairs
Atrial Lacerations and Repairs
Sub-xyphoid Trans-diaphragmatic
Pericardial Window
Sub-xyphoid Trans-diaphragmatic
Pericardial Window
Blunt Cardiac Injuries
 Blunt Thoracic Trauma: Cardiac
Contusions

Blunt anterior chest trauma

Acute injury pattern (anterior wall: ↑ST’s I, aVL,
V2-V4, ↓II,III, aVF), AF, BBB
W/U & Rx acute myocardial infarction, inotropes
Watch for & treat PVC’s aggressively (K+, temp)
Cardiac echo to assess wall motion, valves
 Immediate Life Threatening
Thoracic Injuries:
Massive Hemothorax
Can be due to blunt
or penetrating
injuries
Immediate volume
replacement,
compression suit
and OR
Caution with CVP
lines
Application of Pulmonary Hilar
Cross Clamp
Pulmonary Tractotomy

Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy,

Partial Lobectomy, and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades,
MD, PhD; Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD

Arch Surg. 1999;134:186-189.

Pulmonary Tractotomy

Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy, Partial

Lobectomy, and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades, MD, PhD;
Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD

Arch Surg. 1999;134:186-189.

 Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
Massive subcutaneous
emphysema in chest
wall – displaced trachea
Cervical, facial sub-
cutaneous emphysema
Hemoptysis
Blunt injuries almost
always within 1” carina
 Blunt Thoracic Trauma:
Tracheobronchial Injury
2° Blunt injury
Persistent
pneumothorax
Huge air leak
Rare injury 2-3% of
survivors MVA
Definitive repairs
with pleural flap
Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
 Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
 Blunt or penetrating trauma (extrinsic compression
from hematoma)
• Intra/extra thoracic location (supraglotic, glotic,
subglotic
 Presentation
• Massive, sometimes uncontrollable air leak
• Stridor, acute respiratory distress, Δ voice
• Neck, upper chest subcutaneous emphysema –
often massive and disfiguring
 Acutely manage with deep intubation (beyond
injury), scope, sometimes tracheostomy
 Immediate Life Threatening
Thoracic Injuries:
Open Pneumothorax
“Sucking” chest wound
Respiratory distress
Preferential path of air
when hole ≥ ⅔
diameter of trachea
Cover 3 sides
Chest tube drainage and
auto-transfusion when
available
 Immediate Life Threatening
Mediastinal Trauma :
Zone 1 Penetrating Injuries
Between mid-clavicular lines
→ sternal notch to xyphoid
and posterior infra-scapular
35% unstable → OR (½ of
unstable patients die in ED)
65% stable on arrival to ED
TEE, CT scan, endoscopy
20% stable patients have
major injury on work up
 Triage and Outcome of Patients with
Mediastinal Penetrating Trauma
The Annals of Thoracic Surgery Burack JH Volume 83, Issue 2, February 2007, Pages 377-382

Stable vs. Unstable Hemodynamic State

1. Traumatic cardiac arrest or near arrest and an EDT

2. Cardiac tamponade
3. Persistent ATLS class III shock despite fluid
resuscitation (blood loss 1500–2000 mL, pulse rate >
120, blood pressure decreased)
4. Chest Tube output > 1500 mL of blood on insertion
5. Chest Tube output > 500 mL/hour for the initial hour
6. Massive hemothorax after chest tube drainage
 Mechanism of Initial Clinical
Presentation

Total Stable (%) Unstable (%) Death (%)

SW 116 89 (77%) 27 (23%) 8 (7%)

GSW 91 46 (51%) 45 (49%) 38 (42%)
Mediastinal Injury Location and
Initial Clinical Presentation
M1= left para-sternal
M2 = right trans-mediastinal
M3 = mid-sternal (anterior and/or posterior)
M4 = lower trans-mediastinal

Total Stable Unstable Death

M1 16 10 (63%) 6 (37%) 2 (13%)

M2 34 26 (76%) 8 (24%) 5 (15%)

M3 137 92 (67%) 45 (33%) 28 (20%)

M4 20 7 (35%) 13 (65%) 12 (60%)

 Management Algorithm for
Penetrating Mediastinal Trauma

(72)
 Occult Injury in Stable Patients
Patient Angiographic Findings Treatment
Injury (thrombosis) to 4th
1 Observation
Intercostal artery
Injury to the vertebral artery at
2 Coil embolization
the thoracic inlet
Injury to the Internal Mammary
3 Coil embolization
artery
Sternotomy/thoracotomy and
Injury to the left Subclavian
4 interposition graft of the
artery
subclavian artery
Inominate artery Endovascular stent graft,
5 pseudoaneurysm and thoracic thoracotomy, and tracheal
tracheal injury resection
Distribution of Arterial Injuries with
Penetrating Mediastinal Trauma
Artery Injuries Patients Deaths
Innominate 23(38%) 18(35%) 1(10%)
Aortic Arch 17(28%) 13(25%) 3(30%)
L Common Carotid 11(18%) 8(15%) 2(20%)
Ascending Aorta 4(7%) 4(8%) 2(20%)
L Subclavian 5(8%) 4(7%) 0
Combined/multiple 8(15%) 2(20%)
Total 60(100%) 52(100%) 10(19%)
K. Buchan and J.V. Robbs, Surgical management of penetrating mediastinal arterial trauma, European
Journal of Cardio-Thoracic Surgery Volume 9, Issue 2, 1995, Pages 90-94. Dept Surgery University of
Natal, South Africa
Traumatic Aortic-Innominate
Vein Fistula
 Immediate Life Threatening
Thoracic Injuries:
Aortic Disruption
Most common at ligamentum
arteriosum but can be
multiple (pendulum effect)
~⅓ fatal on site due to free
rupture (uncontained)
Hypotension, exsanguination
MVA, falls from height
Contained Injuries to the Aorta
Widened mediastinum (53%
sensitivity, 59% specificity and
83% negative predictive value)
Obliteration of aortic knob
Rightward deviation of trachea
(compare NG tube to trachea)
Depression of left main stem
bronchus
Pleural/apical cap
Left hemothorax (can be bilateral)
Fractures of 1st and/or 2nd ribs
Contained Injuries to the Aorta
 Contained Injuries to the Aorta
Not a source of multiple hypotensive episodes
in survivors - look for other injuries
Salvageable tear when hematoma contained
~⅓ die per 24 hours without treatment
Widened mediastinum very unreliable sign on
portable x-ray
TEE, helical contrast CT scan, MRI, aortogram
Consider percutaneous stent placement
Address after life threatening injuries stabilized
 Summary
Life ending thoracic injuries are common
Survival depends on proper and
immediate diagnosis and appropriate
management
ED thoracotomy can save lives but
expected survivorship is <10%
Don’t forget ABC’s of trauma and damage
control principles