Blunt and Penetrating Trauma - Medscape

BLUNT
Overview
Chest trauma is a significant source of morbidity and mortality in the United States. This article focuses on
chest trauma caused by blunt mechanisms. Penetrating thoracic injuries are addressed in Penetrating Chest
Trauma.
Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. These
components include the bony skeleton (ribs, clavicles, scapulae, and sternum), the lungs and pleurae, the
tracheobronchial tree, the esophagus, the heart, the great vessels of the chest, and the diaphragm. In the
subsequent sections, each particular injury and injury pattern resulting from blunt mechanisms is discussed.
The pathophysiology of these injuries is elucidated, and diagnostic and treatment measures are outlined.

Morbidity and mortality
Trauma is the leading cause of death, morbidity, hospitalization, and disability in Americans aged 1 year to the
middle of the fifth decade of life. As such, it constitutes a major health care problem. According to the Centers
for Disease Control and Prevention, 126,438 deaths occurred from unintentional injury in 2011. [1]

Frequency
Trauma is responsible for more than 100,000 deaths annually in the United States. [1] Estimates of thoracic
trauma frequency indicate that injuries occur in 12 persons per 1 million population per day. Approximately 33%
of these injuries necessitate hospital admission. Overall, blunt thoracic injuries are directly responsible for 2025% of all deaths, and chest trauma is a major contributor in another 50% of deaths.

Etiology
By far the most important cause of significant blunt chest trauma is motor vehicle accidents (MVAs). MVAs
account for 70-80% of such injuries. As a result, preventive strategies to reduce MVAs have been instituted in
the form of speed limit restriction and the use of restraints. Pedestrians struck by vehicles, falls, and acts of
violence are other causative mechanisms. Blast injuries can also result in significant blunt thoracic trauma.

Pathophysiology
The major pathophysiologies encountered in blunt chest trauma involve derangements in the flow of air, blood,
or both in combination. Sepsis due to leakage of alimentary tract contents, as in esophageal perforations, also
must be considered.
Blunt trauma commonly results in chest wall injuries (eg, rib fractures). The pain associated with these injuries
can make breathing difficult, and this may compromise ventilation. Direct lung injuries, such as pulmonary
contusions (see the image below), are frequently associated with major chest trauma and may impair
ventilation by a similar mechanism. Shunting and dead space ventilation produced by these injuries can also
impair oxygenation.

Left pulmonary contusion following a motor vehicle accident involving a pedestrian.

Space-occupying lesions (eg, pneumothorax, hemothorax, and hemopneumothorax) interfere with oxygenation
and ventilation by compressing otherwise healthy lung parenchyma. A special concern is tension pneumothorax
in which pressure continues to build in the affected hemithorax as air leaks from the pulmonary parenchyma

into the pleural space. This can push mediastinal contents toward the opposite hemithorax. Distortion of the
superior vena cava by this mediastinal shift can result in decreased blood return to the heart, circulatory
compromise, and shock.
At the molecular level, animal experimentation supports a mediator-driven inflammatory process further leading
to respiratory insult after chest trauma. After blunt chest trauma, several blood-borne mediators are released,
including interleukin-6, tumor necrosis factor, and prostanoids. These mediators are thought to induce
secondary cardiopulmonary changes.
Blunt trauma that causes significant cardiac injuries (eg, chamber rupture) or severe great vessel injuries (eg,
thoracic aortic disruption) frequently results in death before adequate treatment can be instituted. This is due to
immediate and devastating exsanguination or loss of cardiac pump function. This causes hypovolemic or
cardiogenic shock and death.
Sternal fractures are rarely of any consequence, except when they result in blunt cardiac injuries.

Clinical
The clinical presentation of patients with blunt chest trauma varies widely and ranges from minor reports of pain
to florid shock. The presentation depends on the mechanism of injury and the organ systems injured.
Obtaining as detailed a clinical history as possible is extremely important in the assessment of a patient who
has sustained blunt thoracic trauma. The time of injury, mechanism of injury, estimates of MVA velocity and
deceleration, and evidence of associated injury to other systems (eg, loss of consciousness) are all salient
features of an adequate clinical history. Information should be obtained directly from the patient whenever
possible and from other witnesses to the accident if available.
For the purposes of this discussion, blunt thoracic injuries may be divided into the following three broad
categories:




Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries)
Blunt injuries of the pleurae, lungs, and aerodigestive tracts
Blunt injuries of the heart, great arteries, veins, and lymphatics
A concise exegesis of the clinical features of each condition in these categories is presented. This classification
is used in subsequent sections to outline indications for medical and surgical therapy for each condition.

Relevant Anatomy
The thorax is bordered superiorly by the thoracic inlet, just cephalad to the clavicles. The major arterial blood
supply to and venous drainage from the head and neck pass through the thoracic inlet.
The thoracic outlets form the superolateral borders of the thorax and transmit branches of the thoracic great
vessels that supply blood to the upper extremities. The nerves that make up the brachial plexus also access
the upper extremities via the thoracic outlet. The veins that drain the arm (of which the most important is the
axillary vein) empty into the subclavian vein, which returns to the chest via the thoracic outlet.
Inferiorly, the pleural cavities are separated from the peritoneal cavity by the hemidiaphragms. Communication
routes between the thorax and abdomen are supplied by the diaphragmatic hiatuses, which allow egress of the
aorta, esophagus, and vagal nerves into the abdomen and ingress of the vena cava and thoracic duct into the
chest.
The chest wall is composed of layers of muscle, bony ribs, costal cartilages, sternum, clavicles, and scapulae.
In addition, important neurovascular bundles course along each rib, containing an intercostal nerve, artery, and
vein. The inner lining of the chest wall is the parietal pleura. The visceral pleura invests the lungs. Between the
visceral and parietal pleurae is a potential space, which, under normal conditions, contains a small amount of
fluid that serves mainly as a lubricant.
The lungs occupy most of the volume of each hemithorax. Each is divided into lobes. The right lung has three
lobes, and the left lung has two lobes. Each lobe is further divided into segments.

The trachea enters through the thoracic inlet and descends to the carina at thoracic vertebral level 4, where it
divides into the right and left mainstem bronchi. Each mainstem bronchus divides into lobar bronchi. The
bronchi continue to arborize to supply the pulmonary segments and subsegments.
The heart is a mediastinal structure contained within the pericardium. The right atrium receives blood from the
superior vena cava and the inferior vena cava. Right atrial blood passes through the tricuspid valve into the
right ventricle. Right ventricular contraction forces blood through the pulmonary valve and into the pulmonary
arteries. Blood circulates through the lungs, where it acquires oxygen and releases carbon dioxide.
Oxygenated blood courses through the pulmonary veins to the left atrium. The left heart receives small
amounts of nonoxygenated blood via the thebesian veins, which drain the heart, and the bronchial veins. Left
atrial blood proceeds through the mitral valve into the left ventricle.
Left ventricular contraction propels blood through the aortic valve into the coronary circulation and the thoracic
aorta, which exits the chest through the diaphragmatic hiatus into the abdomen. A ligamentous attachment (a
remnant of the ductus arteriosus) exists between the descending thoracic aorta and pulmonary artery just
beyond the takeoff of the left subclavian artery.
The esophagus exits the neck to enter the posterior mediastinum. Through much of its course, it lies posterior
to the trachea. In the upper thorax, it lies slightly to the right with the aortic arch and descending thoracic aorta
to its left. Inferiorly, the esophagus turns leftward and enters the abdomen through the esophageal
diaphragmatic hiatus.
The thoracic duct arises primarily from the cisterna chyli in the abdomen. It traverses the diaphragm and runs
cephalad through the posterior mediastinum in proximity to the spinal column. It enters the neck and veers to
the left to empty into the left subclavian vein.

Workup
Initial emergency workup of a patient with multiple injuries should begin with the ABCs (airway, breathing, and
circulation), with appropriate intervention taken for each step.

Laboratory studies
A complete blood count (CBC) is a routine laboratory test for most trauma patients. The CBC helps gauge
blood loss, though the accuracy of findings to help determine acute blood loss is not entirely reliable. Other
important information provided includes platelet and white blood cell counts, with or without differential.
Arterial blood gas (ABG) analysis, though not as important in the initial assessment of trauma victims, is
important in their subsequent management. ABG determinations are an objective measure of ventilation,
oxygenation, and acid-base status, and their results help guide therapeutic decisions such as the need for
endotracheal intubation and subsequent extubation.
Patients who are seriously injured and require fluid resuscitation should have periodic monitoring of their
electrolyte status. This can help to avoid problems such as hyponatremia or hypernatremia. The etiology of
certain acid-base abnormalities can also be identified, eg, a chloride-responsive metabolic alkalosis or
hyperchloremic metabolic acidosis.
The coagulation profile, including prothrombin time (PT)/activated partial thromboplastin time (aPTT),
fibrinogen, fibrin degradation product, and D-dimer analyses, can be helpful in the management of patients who
receive massive transfusions (eg, >10 units of packed red blood cells [RBCs]). Patients who manifest
hemorrhage that cannot be explained by surgical causes should also have their profile monitored.
Whereas elevated serum troponin I levels correlate with the presence of echocardiographic or
electrocardiographic abnormalities in patients with significant blunt cardiac injuries, these levels have low
sensitivity and predictive values in diagnosing myocardial contusion in those without. Accordingly, troponin I
level determination does not, by itself, help predict the occurrence of complications that may require admission
to the hospital. Accordingly, its routine use in this clinical situation is not well supported. [2, 3]
Measurement of serum myocardial muscle creatine kinase isoenzyme (creatine kinase-MB) levels is frequently
performed in patients with possible blunt myocardial injuries. The test is rapid and inexpensive. This diagnostic

modality has been criticized because of poor sensitivity, specificity, and positive predictive value in relation to
clinically significant blunt myocardial injuries.
Lactate is an end product of anaerobic glycolysis and, as such, can be used as a measure of tissue perfusion.
Well-perfused tissues mainly use aerobic glycolytic pathways. Persistently elevated lactate levels have been
associated with poorer outcomes. Patients whose initial lactate levels are high but are rapidly cleared to normal
have been resuscitated well and have better outcomes.
Type and crossmatch are among the most important blood tests in the evaluation and management of a
seriously injured trauma patient, especially one who is predicted to require major operative intervention.

Chest radiography
The chest x-ray (CXR) is the initial radiographic study of choice in patients with thoracic blunt trauma. A chest
radiograph is an important adjunct in the diagnosis of many conditions, including chest wall fractures,
pneumothorax, hemothorax, and injuries to the heart and great vessels (eg, enlarged cardiac silhouette,
widened mediastinum).
In contrast, certain cases arise in which physicians should not wait for a chest radiograph to confirm clinical
suspicion. The classic example is a patient presenting with decreased breath sounds, hyperresonant
hemithorax, and signs of hemodynamic compromise (ie, tension pneumothorax). This scenario warrants
immediate decompression before a chest radiograph is obtained. [4]
A 2012 study by Paydar et al indicated that routine chest radiography in stable blunt trauma patients may be of
low clinical value. The authors propose that careful physical examination and history taking can accurately
identify those patients at low risk for chest injury, thus making routine radiographs unnecessary. [5]

Computed tomography
Because of the lack of sensitivity of chest radiography in identifying significant injuries, computed tomography
(CT) of the chest is frequently performed in the trauma bay in the hemodynamically stable patient. In one study,
50% of patients with normal chest radiographs were found to have multiple injuries on chest CT. As a result,
obtaining a chest CT scan in a supposedly stable patient with significant mechanism of injury is becoming
routine practice.
Helical CT and CT angiography (CTA) are being used more commonly in the diagnosis of patients with possible
blunt aortic injuries. Most authors advocate that positive findings or findings suggestive of an aortic injury (eg,
mediastinal hematoma) be augmented by aortography to more precisely define the location and extent of the
injury.[6, 7, 8]
Abdominal CT alone or combined with cervical spinal CT detected almost all occult small pneumothoraces in
one study of patients with blunt trauma, whereas cervical spinal CT alone detected only one third of cases. [9]

Aortography
Aortography has been the criterion standard for diagnosing traumatic thoracic aortic injuries. However, its
limited availability and the logistics of moving a relatively critical patient to a remote location make it less
desirable. In addition, the introduction of spiral CT scanners, which have 100% sensitivity and greater than 99%
specificity, has caused the role of aortography in the evaluation of trauma patients to decline.
However, where spiral CT is equivocal, aortography can provide a more exact delineation of the location and
extent of aortic injuries. Aortography is much better at demonstrating injuries of the ascending aorta. In
addition, it is superior at imaging injuries of the thoracic great vessels. [10, 11]

Thoracic ultrasonography
Ultrasound examinations of the pericardium, heart, and thoracic cavities can be expeditiously performed by
surgeons and emergency department (ED) physicians within the ED. Pericardial effusions or tamponade can
be reliably recognized, as can hemothoraces associated with trauma. The sensitivity, specificity, and overall
accuracy of ultrasonography in these settings are all greater than 90%.

Contrast esophagography

Contrast esophagograms are indicated for patients with possible esophageal injuries in whom esophagoscopy
results are negative. The esophagogram is first performed with water-soluble contrast media. If this provides a
negative result, a barium esophagogram is completed. If these results are also negative, esophageal injury is
reliably excluded.
Esophagoscopy and esophagography are each approximately 80-90% sensitive for esophageal injuries. These
studies are complementary and, when performed in sequence, identify nearly 100% of esophageal injuries.

Focused assessment for sonographic examination of trauma patient
The focused assessment for the sonographic examination of the trauma patient (FAST) is routinely conducted
in many trauma centers. Although mainly dealing with abdominal trauma, the first step in the examination is to
obtain an image of the heart and pericardium to assess for evidence of intrapericardial bleeding.

Electrocardiography
The 12-lead electrocardiogram (ECG) is a standard test performed on all thoracic trauma victims. ECG findings
can help identify new cardiac abnormalities and help discover underlying problems that may impact treatment
decisions. Furthermore, it is the most important discriminator to help identify patients with clinically significant
blunt cardiac injuries.
Patients with possible blunt cardiac injuries and normal ECG findings require no further treatment or
investigation for this injury. The most common ECG abnormalities found in patients with blunt cardiac injuries
are tachyarrhythmias and conduction disturbances, such as first-degree heart block and bundle-branch blocks.
However, according to a 2012 practice management guideline from the Eastern Association for the Surgery of
Trauma, ECG alone should not be considered sufficient for ruling out blunt cardiac injury. The guideline
recommends obtaining an admission ECG and troponin I from all patients in whom blunt cardiac injury is
suspected and states that such injury can be ruled out only if both the ECG and the troponin I level are normal.
[12]

Echocardiography
Transesophageal echocardiography (TEE) has been extensively studied for use in the workup of possible blunt
rupture of the thoracic aorta. Its sensitivity, specificity, and accuracy in the diagnosis of this injury are each
approximately 93-96%.
The advantages of TEE include the easy portability, no requisite contrast, minimal invasiveness, and short time
required to perform. TEE can also be used intraoperatively to help identify cardiac abnormalities and monitor
cardiac function.[13, 14, 15] The disadvantages include operator expertise, long learning curve, and the fact that it is
relatively weak at helping identify injuries of the descending aorta.
Transthoracic echocardiography (TTE) can help identify pericardial effusions and tamponade, valvular
abnormalities, and disturbances in cardiac wall motion. TTEs are also performed in cases of patients with
possible blunt myocardial injuries and abnormal ECG findings.

Esophagoscopy
Esophagoscopy is the initial diagnostic procedure of choice in patients with possible esophageal injuries. Either
flexible or rigid esophagoscopy is appropriate, and the choice depends on the experience of the clinician. Some
authors prefer rigid esophagoscopy to evaluate the cervical esophagus and flexible esophagoscopy for
possible injuries of the thoracic and abdominal esophagus. If esophagoscopy findings are negative,
esophagography should be performed as outlined above.

Bronchoscopy
Fiberoptic or rigid bronchoscopy is performed in patients with possible tracheobronchial injuries. Both
techniques are extremely sensitive for the diagnosis of these injuries. Fiberoptic bronchoscopy offers the
advantage of allowing an endotracheal tube to be loaded onto the scope and the endotracheal intubation to be
performed under direct visualization if necessary.

Indications and Contraindications

Indications
Operative intervention is rarely necessary in blunt thoracic injuries. In one report, only 8% of cases with blunt
thoracic injuries required an operation. Most such injuries can be treated with supportive measures and simple
interventional procedures such as tube thoracostomy.
The following section reviews indications for surgical intervention in blunt traumatic injuries according to the
previously presented classification system. Surgical indications are further stratified into conditions
necessitating an immediate operation and those in which surgery is needed for delayed manifestations or
complications of trauma.
Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries)
Indications for immediate surgery include (1) traumatic disruption with loss of chest wall integrity and (2) blunt
diaphragmatic injuries.
Relatively immediate and long-term indications for surgery include (1) delayed recognition of blunt
diaphragmatic injury and (2) the development of a traumatic diaphragmatic hernia.
Blunt injuries of pleurae, lungs, and aerodigestive tracts
Indications for immediate surgery include (1) a massive air leak following chest tube insertion; (2) a massive
hemothorax or continued high rate of blood loss via the chest tube (ie, 1500 mL of blood upon chest tube
insertion or continued loss of 250 mL/hr for 3 consecutive hours); (3) radiographically or endoscopically
confirmed tracheal, major bronchial, or esophageal injury; and (3) the recovery of gastrointestinal tract contents
via the chest tube.
Relatively immediate and long-term indications for surgery include (1) a chronic clotted hemothorax or
fibrothorax, especially when associated with a trapped or nonexpanding lung; (2) empyema; (3) traumatic lung
abscess; (4) delayed recognition of tracheobronchial or esophageal injury; (5) tracheoesophageal fistula; and
(6) a persistent thoracic duct fistula/chylothorax.
Blunt injuries of heart, great arteries, veins, and lymphatics
Indications for immediate surgery include (1) cardiac tamponade, (2) radiographic confirmation of a great
vessel injury, and (3) an embolism into the pulmonary artery or heart.
Relatively immediate and long-term indications for surgery include the late recognition of a great vessel injury
(eg, development of traumatic pseudoaneurysm).

Contraindications
No distinct, absolute contraindications exist for surgery in blunt thoracic trauma. Rather, guidelines have been
instituted to define which patients have clear indications for surgery (eg, massive hemothorax, continued high
rates of blood loss via chest tube).
A controversial area has been the use of ED thoracotomy in patients with blunt trauma presenting without vital
signs. The results of this approach in this particular patient population have been dismal and have led many
authors to condemn it.

Treatment & Management
Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries)
Rib fractures
Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are the ones most frequently involved.
Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings
include local tenderness and crepitus over the site of the fracture. If a pneumothorax is present, breath sounds
may be decreased and resonance to percussion may be increased.
Rib fractures may also be a marker for other associated significant injury, both intrathoracic and extrathoracic.
In one report, 50% of patients with blunt cardiac injury have rib fractures. Fractures of ribs 8-12 should raise the

suggestion of associated abdominal injuries. Lee and colleagues reported a 1.4- and 1.7-fold increase in the
incidence of splenic and hepatic injury, respectively, in those with rib fractures.
Elderly patients with three or more rib fractures have been shown to have a fivefold increase in mortality and a
fourfold increase in the incidence of pneumonia.
Effective pain control is the cornerstone of medical therapy for patients with rib fractures. For most patients, this
consists of oral or parenteral analgesic agents. Intercostal nerve blocks may be feasible for those with severe
pain who do not have numerous rib fractures. A local anesthetic with a relatively long duration of action (eg,
bupivacaine) can be used. Patients with multiple rib fractures whose pain is difficult to control can be treated
with epidural analgesia.
Adjunctive measures in the care of these patients include early mobilization and aggressive pulmonary toilet.
Rib fractures do not require surgery. Pain relief and the establishment of adequate ventilation are the
therapeutic goals for this injury. Rarely, a fractured rib lacerates an intercostal artery or other vessel, resulting in
the need for surgical control to achieve hemostasis acutely. In the chronic phase, nonunion and persistent pain
may also necessitate an operation.
Flail chest
A flail chest, by definition, involves three or more consecutive rib fractures in two or more places, which
produce a free-floating, unstable segment of chest wall. Separation of the bony ribs from their cartilaginous
attachments, termed costochondral separation, can also cause flail chest.
Patients report pain at the fracture sites, pain upon inspiration, and, frequently, dyspnea. Physical examination
reveals paradoxical motion of the flail segment. The chest wall moves inward with inspiration and outward with
expiration. Tenderness at the fracture sites is the rule. Dyspnea, tachypnea, and tachycardia may be present.
The patient may overtly exhibit labored respiration due to the increased work of breathing induced by the
paradoxical motion of the flail segment.
A significant amount of force is required to produce a flail segment. Therefore, associated injuries are common
and should be aggressively sought. The clinician should specifically be aware of the high incidence of
associated thoracic injuries such as pulmonary contusions and closed head injuries, which, in combination,
significantly increase the mortality associated with flail chest.
All of the treatments mentioned above for rib fractures are suitable for flail chest. Respiratory distress or
insufficiency can ensue in some patients with flail chest because of severe pain secondary to the multiple rib
fractures, the increased work of breathing, and the associated pulmonary contusion. This may necessitate
endotracheal intubation and positive-pressure mechanical ventilation. Intravenous fluids are administered
judiciously; fluid overloading can precipitate respiratory failure, especially in those with significant pulmonary
contusions.
To stabilize the chest wall and avoid endotracheal intubation and mechanical ventilation, various operations
have been devised for correcting flail chest (eg, pericostal sutures, application of external fixation devices, and
placement of plates or pins for internal fixation). With improved understanding of pulmonary mechanics and
better mechanical ventilatory support, surgical therapy has not proved superior to supportive and medical
measures. Most authors, however, would agree that stabilization is warranted if thoracotomy is indicated for
another reason.
First and second rib fractures
First and second rib fractures are considered a separate entity from other rib fractures because of the
excessive energy transfer required to injure these sturdy and well-protected structures. First and second rib
fractures are harbingers of associated cranial, major vascular, thoracic, and abdominal injuries. The clinician
should aggressively seek to exclude the presence of these other injuries.
Pain control and pulmonary toilet are the specific treatment measures for rib fractures. First and second rib
fractures do not require surgical therapy. An exception to this would be the need to excise a greatly displaced
bone fragment.
Clavicular fractures

Clavicular fractures are among the most common injuries to the shoulder girdle area. Common mechanisms
include a direct blow to the shaft of the bone, a fall on an outstretched hand, and a direct lateral fall against the
shoulder. Approximately 75-80% of clavicular fractures occur in the middle third of the bone. Patients report
tenderness over the fracture site and pain with movement of the ipsilateral shoulder or arm.
Physical findings include anteroinferior positioning of the ipsilateral arm as compared with the contralateral arm.
The proximal segment of the clavicle is displaced superiorly because of the action of the sternocleidomastoid.
Nearly all clavicular fractures can be managed without surgery. Primary treatment consists of immobilization
with a figure-eight dressing, clavicle strap, or similar dressing or sling. Oral analgesics can be used to control
pain. Surgery is rarely indicated. Surgical intervention is occasionally indicated for the reduction of a badly
displaced fracture.
Sternoclavicular joint dislocations
Strong lateral compressive forces against the shoulder can cause sternoclavicular joint dislocation. Anterior
dislocation is more common than posterior dislocation. Patients report pain with arm motion or when a
compressive force is applied against the affected shoulder. The ipsilateral arm and shoulder may be
anteroinferiorly displaced. With anterior dislocations, the medial end of the clavicle can become more
prominent. With posterior dislocations, a depression may be discernible adjacent to the sternum. Associated
injuries to the trachea, subclavian vessels, or brachial plexus can occur with posterior dislocations.
Closed or open reduction is generally advised. Treatment strategies depend on whether the patient has an
anterior or posterior dislocation.
For anterior dislocations, local anesthesia and sedative medications are administered, and lateral traction is
applied to the affected arm that is placed in abduction and extension. This maneuver, combined with direct
pressure over the medial clavicle, can occasionally reduce an anterior dislocation. For posterior dislocations, a
penetrating towel clip can be used to grasp the medial clavicle to provide the necessary purchase for anterior
manual traction to reduce the joint. Proper levels of pain control, up to and including general anesthesia, are
provided. If closed reduction fails, open reduction is performed.
Sternal fractures
Most sternal fractures are caused by MVAs. The upper and middle thirds of the bone are most commonly
affected in a transverse fashion. Patients report pain around the injured area. Inspiratory pain or a sense of
dyspnea may be present. Physical examination reveals local tenderness and swelling. Ecchymosis is noted in
the area around the fracture. A palpable defect or fracture-related crepitus may be present.
Associated injuries occur in 55-70% of patients with sternal fractures. The most common associated injuries
are rib fractures, long bone fractures, and closed head injuries. The association of blunt cardiac injuries with
sternal fractures has been a source of great debate. Blunt cardiac injuries are diagnosed in fewer than 20% of
patients with sternal fractures. Caution should be exercised before myocardial injury is completely excluded.
The workup should begin with electrocardiography (ECG).
Most sternal fractures require no therapy specifically directed at correcting the injury. Patients are treated with
analgesics and are advised to minimize activities that involve the use of pectoral and shoulder girdle muscles.
The most important aspect of the care for these patients is to exclude blunt myocardial and other associated
injuries.
Patients who are experiencing severe pain related to the fracture and those with a badly displaced fracture are
candidates for open reduction and internal fixation. Various techniques have been described, including wire
suturing and the placement of plates and screws. The latter technique is associated with better outcomes.
Scapular fractures
Scapular fractures are uncommon. Their main clinical importance is the high-energy forces required to produce
them and the attendant high incidence of associated injuries. The rate of associated injuries is 75-100%, most
commonly involving the head, chest, or abdomen.

Patients with scapular fractures report pain around the scapula. Tenderness, swelling, ecchymosis, and
fracture-related crepitus can all be present. The fracture is most frequently located in the body or neck of the
scapula. More than 30% of scapular fractures are missed during the initial patient evaluation. The discovery of
a scapular fracture should prompt a concerted effort to exclude major vascular injuries and injuries of the
thorax, abdomen, and neurovascular bundle of the ipsilateral arm.
Shoulder immobilization is the standard initial treatment. This can be accomplished by placing the arm in a
sling or shoulder harness. Range-of-motion exercises are started as soon as possible to help prevent loss of
shoulder mobility. Surgery is infrequently indicated. Involvement of the glenoid, acromion, or coracoid may
require open reduction and internal fixation with the goal of maintaining proper shoulder mobility.
Scapulothoracic dissociation
Sometimes called flail shoulder, this rare injury occurs when very strong traction forces pull the scapula and
other elements of the shoulder girdle away from the thorax. The muscular, vascular, and nervous components
of the shoulder and arm are severely compromised. Physical findings include significant hematoma formation
and edema in the shoulder area. Neurologic deficits include loss of sensation and motor function distal to the
shoulder. Pulses in the arm are typically decreased or lost due to axillary artery thrombosis.
No specific medical therapy has been developed for this devastating injury. Surgery is rarely indicated early in
the course of this injury. If the affected limb retains sufficient neurovascular integrity and function, operative
fixation may be indicated to restore shoulder stability. Many scapulothoracic dissociations result in a flail limb
that is insensate or is associated with severe pain due to proximal brachial plexus injury. An above-the-elbow
amputation may be the best approach for these patients.
Chest wall defects
The management of large, open chest wall defects initially requires irrigation and debridement of devitalized
tissue to avoid progression into a necrotizing wound infection. Once the infection is under control, subsequent
treatment depends on the severity and level of defect. Reconstructive options range from skin grafting to well
vascularized flaps to a variety of meshes with or without methylmethacrylate. The choice of reconstruction
depends upon the depth of the defect.
Traumatic asphyxia
The curious clinical constellation known as traumatic asphyxia is the result of thoracic injury due to a strong
crushing mechanism, such as might occur when an individual is pinned under a very heavy object. Some
effects of the injury are compounded if the glottis is closed during application of the crushing force.
Patients present with cyanosis of the head and neck, subconjunctival hemorrhage, periorbital ecchymosis, and
petechiae of the head and neck. The face frequently appears very edematous or moonlike. Epistaxis and
hemotympanum may be present. A history of loss of consciousness, seizures, or blindness may be elicited.
Neurologic sequelae are usually transient. Recognition of this syndrome should prompt a search for associated
thoracic and abdominal injuries.
The head of the patient's bed should be elevated to approximately 30° to decrease transmission of pressure to
the head. Adequate airway and ventilatory status must be assured, and the patient is given supplemental
oxygen. Serial neurologic examinations are performed while the patient is monitored in an intensive care
setting. No specific surgical therapy is indicated for traumatic asphyxia. Associated injuries to the torso and
head frequently require surgical intervention.
Blunt diaphragmatic injuries
Diaphragmatic injuries are relatively uncommon. Blunt mechanisms, usually a result of high-speed MVAs,
cause approximately 33% of diaphragmatic injuries. Most diaphragmatic injuries recognized clinically involve
the left side, though autopsy and computed tomography (CT)-based investigations suggest a roughly equal
incidence for both sides.
This injury should be considered in patients who sustain a blow to the abdomen and present with dyspnea or
respiratory distress. Because of the very high incidence of associated injuries, eg, major splenic or hepatic
trauma, it is not unusual for these patients to present with hypovolemic shock.

Most diaphragmatic injuries are diagnosed incidentally at the time of laparotomy or thoracotomy for associated
intra-abdominal or intrathoracic injuries. Initial chest radiographs are normal. Findings suggestive of
diaphragmatic disruption on chest radiographs may include abnormal location of the nasogastric tube in the
chest, ipsilateral hemidiaphragm elevation, or abdominal visceral herniation into the chest.
In a patient with multiple injuries, CT is not very accurate, and magnetic resonance imaging (MRI) is not very
realistic. Bedside emergency ultrasonography is gaining popularity, and case reports in the literature have
supported its use in the evaluation of diaphragm. Diagnostic laparoscopy and thoracoscopy have also been
reported to be successful in the identification of diaphragmatic injury.
A confirmed diagnosis or the suggestion of blunt diaphragmatic injury is an indication for surgery. Blunt
diaphragmatic injuries typically produce large tears measuring 5-10 cm or longer. Most injuries are best
approached via laparotomy. An abdominal approach facilitates exposure of the injury and allows exploration for
associated abdominal organ injuries. The exception to this rule is a posterolateral injury of the right
hemidiaphragm. This injury is best approached through the chest because the liver obscures the abdominal
approach.
Most injuries can be repaired primarily with a continuous or interrupted braided suture (1-0 or larger). Centrally
located injuries are most easily repaired. Lateral injuries near the chest wall may require reattachment of the
diaphragm to the chest wall by encirclement of the ribs with suture during the repair. Synthetic mesh made of
polypropylene or Dacron is occasionally needed to repair large defects. [16, 17]

Blunt injuries of pleurae, lungs, and aerodigestive tracts
Pneumothorax
Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib penetrates the lung
parenchyma. However, this is not an absolute rule. Pneumothoraces can result from deceleration or
barotrauma to the lung without associated rib fractures.
Patients report inspiratory pain or dyspnea and pain at the sites of the rib fractures. Physical examination
demonstrates decreased breath sounds and hyperresonance to percussion over the affected hemithorax. In
practice, many patients with traumatic pneumothoraces also have some element of hemorrhage, producing a
hemopneumothorax.
Patients with pneumothoraces require pain control and pulmonary toilet. All patients with pneumothoraces due
to trauma need a tube thoracostomy. The chest tube is connected to a collection system (eg, Pleur-evac) that is
entrained to suction at a pressure of approximately – 20 cm H 2 O. Suction continues until no air leak is
detected. The tube is then disconnected from suction and placed to water seal. If the lung remains fully
expanded, the tube may be removed and another chest radiograph obtained to ensure continued complete
lung expansion.
A prospective, observational, multicenter study sought to determine which factors predicted failed observation
in blunt trauma patients.[18] Using data from 569 blunt trauma patients, the study identified 588 with an occult
pneumothorax (OPTX); one group underwent immediate tube thoracostomy and the second group was
observed.
Patients in whom observation failed spent more days on ventilators and had longer hospital and intensive care
unit lengths of stay; 15% developed complications. [18]No patient in this group developed a tension
pneumothorax or experienced adverse events by delaying tube thoracostomy. The investigators concluded that
whereas most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy, OPTX
progression and respiratory distress were significant predictors of failed observation.
Hemothorax
Accumulation of blood within the pleural space can be due to bleeding from the chest wall (eg, lacerations of
the intercostal or internal mammary vessels attributable to fractures of chest wall elements) or to hemorrhage
from the lung parenchyma or major thoracic vessels.
Patients report pain and dyspnea. Physical examination findings vary with the extent of the hemothorax. Most
hemothoraces are associated with a decrease in breath sounds and dullness to percussion over the affected

area. Massive hemothoraces due to major vascular injuries manifest with the aforementioned physical findings
and varying degrees of hemodynamic instability.
Hemothoraces are evacuated by means of tube thoracostomy. Multiple chest tubes may be required. Pain
control and aggressive pulmonary toilet are provided. Tube output is monitored closely. Indications for surgery
can be based on the initial and cumulative hourly chest tube drainage, in that massive initial output and
continued high hourly output are frequently associated with thoracic vascular injuries that require surgical
intervention. Guidelines are provided elsewhere (see Indications).
Large, clotted hemothoraces may necessitate an operation for evacuation to allow full expansion of the lung
and to avoid the development of other complications such as fibrothorax and empyema. Thoracoscopic
approaches have been used successfully in the management of this problem. [19]
Open pneumothorax
Open pneumothorax is more commonly caused by penetrating mechanisms but may rarely occur with blunt
thoracic trauma.
Patients are typically in respiratory distress due to collapse of the lung on the affected side. Physical
examination should reveal a chest wall defect that is larger than the cross-sectional area of the larynx. The
affected hemithorax demonstrates a significant-to-complete loss of breath sounds. The increased intrathoracic
pressure can shift the contents of the mediastinum to the opposite side, decreasing the return of blood to the
heart, potentially leading to hemodynamic instability.
Treatment for an open pneumothorax consists of placing a three-way occlusive dressing over the wound to
preclude the continued ingress of air into the hemithorax and to allow egress of air from the chest cavity. A tube
thoracostomy is then performed. Pain control and pulmonary toilet measures are applied.
After initial stabilization, most patients with open pneumothoraces and loss of chest wall integrity undergo
operative wound debridement and closure. Those with loss of large chest wall segments may need
reconstruction and closure with prosthetic devices (eg, polytetrafluoroethylene patches). Patch placement can
serve as definitive therapy or as a bridge to formal closure with rotational or free tissue flaps.
With low chest wall injuries, some authors describe detaching the diaphragm, with operative reattachment at a
higher intrathoracic level. This converts the open chest wound into an open abdominal wound, which is easier
to manage.
Traumatic pulmonary herniation through the ribs, though uncommon, may occur following chest trauma. Unless
incarceration or infarction is evident, immediate repair is not indicated.
Tension pneumothorax
The mechanisms that produce tension pneumothoraces are the same as those that produce simple
pneumothoraces. However, with a tension pneumothorax, air continues to leak from an underlying pulmonary
parenchymal injury, increasing pressure within the affected hemithorax.
Patients are typically in respiratory distress. Breath sounds are severely diminished to absent, and the
hemithorax is hyperresonant to percussion. The trachea is deviated away from the side of the injury. The
mediastinal contents are shifted away from the affected side. This results in decreased venous return of blood
to the heart. The patient exhibits signs of hemodynamic instability, such as hypotension, which can rapidly
progress to complete cardiovascular collapse.
Immediate therapy for this life-threatening condition includes decompression of the affected hemithorax by
needle thoracostomy. A large-bore (ie, 14- to 16-gauge) needle is inserted through the second intercostal space
in the midclavicular line. A tube thoracostomy is then performed. Pain control and pulmonary toilet are
instituted.
Pulmonary contusion and other parenchymal injuries

The forces associated with blunt thoracic trauma can be transmitted to the lung parenchyma. This results in
pulmonary contusion, characterized by development of pulmonary infiltrates with hemorrhage into the lung
tissue.
Clinical findings in pulmonary contusion depend on the extent of the injury. Patients present with varying
degrees of respiratory difficulty. Physical examination demonstrates decreased breath sounds over the affected
area. Other parenchymal injuries (eg, lacerations) can be produced by fractured ribs and, rarely, by
deceleration mechanisms.
Pain control, pulmonary toilet, and supplemental oxygen are the primary therapies for pulmonary contusions
and other parenchymal injuries. If the injury involves a large amount of parenchyma, significant pulmonary
shunting and dead space ventilation may develop, necessitating endotracheal intubation and mechanical
ventilation.
Laceration or avulsion injuries that cause massive hemothoraces or prolonged high rates of bloody chest tube
output may require thoracotomy for surgical control of bleeding vessels. If central bleeding is identified during
thoracotomy, hilar control is gained first. Once the extent of injury is confirmed, it may become necessary to
perform a pneumonectomy, keeping in mind that trauma pneumonectomy is generally associated with a high
mortality rate (>50%).[20]
In 2012, the Eastern Association for the Surgery of Trauma released an updated practice management
guideline on the management of pulmonary contusion and flail chest. [21]
Blunt tracheal injuries
Although the incidence of blunt tracheobronchial injuries is low (1-3%), most patients with such injuries die
before reaching the hospital. These injuries include fractures, lacerations, and disruptions. Blunt trauma most
often produces fractures. These injuries are devastating and are frequently caused by severe rapid
deceleration or compressive forces applied directly to the trachea between the sternum and vertebrae.
Patients are in respiratory distress. They typically cannot phonate and frequently present with stridor. Other
physical signs include an associated pneumothorax and massive subcutaneous emphysema.
Blunt tracheal injuries are immediately life-threatening and require surgical repair. Bronchoscopy is required to
make the definitive diagnosis. The first therapeutic maneuver is the establishment of an adequate airway. If
airway compromise is present or probable, a definitive airway is established.
Endotracheal intubation remains the preferred route if feasible. This can be facilitated by arming a flexible
bronchoscope with an endotracheal tube and performing the intubation under direct bronchoscopic guidance.
The tube must be placed distal to the site of injury. Always be prepared to perform an emergency tracheotomy
or cricothyroidotomy to establish an airway if this fails. These maneuvers are best performed in the controlled
environment of an operating room.
The operative approach to repair of a blunt tracheal injury includes debridement of the fracture site and
restoration of airway continuity with a primary end-to-end anastomosis. Defects of 3 cm or larger frequently
require proximal and distal mobilization of the trachea to reduce tension on the anastomosis. The type of
incision made for repairing the tracheal injury is determined by the level and extent of injury and the
involvement of other thoracic organs.
Blunt bronchial injuries
Rapid deceleration is the most common mechanism causing major blunt bronchial injuries. Many of these
patients die of inadequate ventilation or severe associated injuries before definitive therapy can be provided.
Patients are in respiratory distress and present with physical signs consistent with a massive pneumothorax.
Ipsilateral breath sounds are severely diminished to absent, and the hemithorax is hyperresonant to
percussion. Subcutaneous emphysema may be present and may be massive. Hemodynamic instability may be
present and is caused by tension pneumothorax or massive blood loss from associated injuries.
Laceration, tear, or disruption of a major bronchus is life-threatening. These injuries require surgical repair. As
with tracheal injuries, establishment of a secure and adequate airway is of primary importance.

Patients with major bronchial lacerations or avulsions have massive air leaks. The approach to repair of these
injuries is ipsilateral thoracotomy on the affected side after single-lung ventilation is established on the
uninjured side. Some patients cannot tolerate this and require jet-insufflation techniques. Operative repair
consists of debridement of the injury and construction of a primary end-to-end anastomosis.
Blunt esophageal injuries
Because of the relatively protected location of the esophagus in the posterior mediastinum, blunt injuries of this
organ are rare. Blunt esophageal injuries are usually caused by a sudden increase in esophageal luminal
pressure resulting from a forceful blow. Injury occurs predominantly in the cervical region; rarely, intrathoracic
and subdiaphragmatic ruptures are also encountered.
Associated injuries to other organs are common. Physical clues to the diagnosis may include subcutaneous
emphysema, pneumomediastinum, pneumothorax, or intra-abdominal free air. Patients who present a
significant time after the injury may manifest signs and symptoms of systemic sepsis.
General medical supportive measures are appropriate. Fluid resuscitation and broad-spectrum intravenous
antibiotics with activity against gram-positive organisms and anaerobic oral flora are administered. Surgery is
required.
Injuries identified within 24 hours of their occurrence are treated by debridement and primary closure. Some
surgeons choose to reinforce these repairs with autologous tissue. Wide mediastinal drainage is established
with multiple chest tubes.
If more than 24 hours has passed since injury, primary repair buttressed by well-vascularized autologous tissue
is still the best option if technically feasible. Examples of tissues used to reinforce esophageal repairs include
parietal pleura and intercostal muscle. Very distal esophageal injuries can be covered with a tongue of gastric
fundus. This is called a Thal patch.
For patients in poor general condition and those with advanced mediastinitis or severe associated injuries,
esophageal exclusion and diversion is the most prudent choice. A cervical esophagostomy is made, the distal
esophagus is stapled, the stomach is decompressed via gastrostomy, and a feeding jejunostomy tube is
placed. Wide mediastinal drainage is established with multiple chest tubes.

Blunt injuries of heart, great arteries, veins, and lymphatics
Blunt pericardial injuries
Isolated blunt pericardial injuries are rare. Blunt mechanisms produce pericardial tears that can result in
herniation of the heart and associated decrements in cardiac output. Physical examination may elicit a
pericardial rub.
Most blunt pericardial injuries can be closed by simple pericardiorrhaphy. Large defects that cannot be closed
primarily without tension can usually be left open or be patch-repaired.
Blunt cardiac injuries
MVAs are the most common cause of blunt cardiac injuries. Falls, crush injuries, acts of violence, and sporting
injuries are other causes. Blunt cardiac injuries range from mild trauma associated only with transient
arrhythmias to rupture of the valve mechanisms, interventricular septum, or myocardium (cardiac chamber
rupture).
Therefore, patients can be asymptomatic or can manifest signs and symptoms ranging from chest pain to
cardiac tamponade (eg, muffled heart tones, jugular venous distension, hypotension) to complete
cardiovascular collapse and shock due to rapid exsanguination.
Many patients with blunt cardiac injuries do not require specific therapy. Those who develop an arrhythmia are
treated with the appropriate antiarrhythmic drug. Elaboration on these drugs and their administration is beyond
the scope of this article.
Patients with severe blunt cardiac injuries who survive to reach the hospital require surgery. Most patients in
this group have cardiac chamber rupture due to a high-speed MVA. The right side involvement is most

common, involving the right atrium and right ventricle. They present with signs and symptoms of cardiac
tamponade or exsanguinating hemorrhage. A few may be stable initially, resulting in delayed diagnosis.
Those with tamponade benefit from rapid pericardiocentesis or surgical creation of a subxiphoid window. The
next step is to repair the cardiac chamber by cardiorrhaphy. Cardiopulmonary bypass techniques can facilitate
this procedure. Unstable patients may benefit from insertion of an intra-aortic counterpulsation balloon pump.
Commotio cordis or sudden cardiac death in an otherwise healthy individual generally results from participation
in a sporting event or some form of recreational activity. It is a direct result of blow to the heart just before the Twave, resulting in ventricular fibrillation. Survival is not unheard of, if resuscitation and defibrillation are started
within minutes. Preventive strategies include chest protective gear during sporting activities. [22, 23, 24]
Blunt injuries of thoracic aorta and major thoracic arteries
High-speed MVAs are the most common cause of blunt injuries to the thoracic aortic injuries and the major
thoracic arteries. Falls from heights and MVAs involving a pedestrian are other recognized causes. Injury
mechanisms include rapid deceleration, production of shearing forces, and direct luminal compression against
points of fixation (especially at the ligamentum arteriosum). Many of these patients die of vessel rupture and
rapid exsanguination at the scene or before reaching definitive care. Blunt aortic injuries follow closely behind
head injury as a cause of death after blunt trauma.
Important historical details include the exact mechanism of injury and estimates of the amount of energy
transferred to the patient (eg, magnitude of deceleration). Other important details include whether the victim
was ejected from a vehicle or thrown if struck by a vehicle, height of the fall, and whether other fatalities
occurred at the scene.
Physical clues include signs of significant chest wall trauma (eg, scapular fractures, first or second rib fractures,
sternal fractures, steering wheel imprint), hypotension, upper-extremity blood pressure differential, loss of
upper or lower extremity pulses, and thoracic spine fractures. Signs of cardiac tamponade may be present.
Decreased breath sounds and dullness to percussion due to massive hemothorax can also be found.
As many as 50% of patients with these devastating, life-threatening injuries have no overt external signs of
injury. Therefore, a high index of suspicion is warranted for earlier intervention.
The management of these injuries, especially those of the thoracic aorta, is evolving. Many patients undergo
delayed repair of contained descending thoracic aortic ruptures. This approach is most frequently used when
severe associated injuries are present that require urgent correction.
Temporizing medical therapy includes the administration of short-acting beta-blockers (eg, labetalol, esmolol) to
control the heart rate and to decrease the mean arterial pressure to approximately 60 mm Hg.
Because repair of thoracic aortic injuries using cardiopulmonary bypass is associated with fewer major
neurologic complications, some authors advocate stabilization of the victim plus beta-blocker administration
until transfer is feasible to a facility where the injury can be repaired using cardiopulmonary bypass or
centrifugal pump techniques. These techniques maintain distal aortic perfusion. Results have been excellent,
and postoperative paraplegia rates have been significantly reduced. [25]
Endovascular stent grafts are being developed to repair thoracic aortic injuries. Although several authors have
reported success in treating such injuries with endovascular stents, the long-term durability of the stents is yet
unknown. Further experience with this technique will allow more victims with concomitant severe injuries to
become operative candidates.
Techniques for repair of the innominate artery and subclavian vessels vary, depending on the type of injury.
Many require only lateral arteriorrhaphy. Large injuries of the innominate artery are managed first by placement
of a bypass graft from the ascending aorta to the distal innominate artery. The injury is then approached directly
and is oversewn or patched.[26, 27, 28]
Proximal pulmonary arterial injuries are relatively easy to repair when in an anterior location. Posterior injuries
frequently require cardiopulmonary bypass. Pulmonary hilar injuries present the possibility of rapid
exsanguination and are best treated with pneumonectomy. Peripheral pulmonary arterial injuries are

approached easily by thoracotomy on the affected side. They may be repaired or the corresponding pulmonary
lobe or segment may be resected.
Blunt injuries of the superior vena cava and major thoracic veins
Injuries limited to the major veins of the thorax are rare. These patients usually present with associated injuries
to other major thoracic vascular structures. The clinical history, including mechanisms of injury, and physical
examination are similar to those described for blunt injuries of the thoracic aorta and major thoracic arteries.
Major thoracic venous injuries are amenable to lateral venorrhaphy. If repair proves to be difficult or impossible,
injured subclavian or azygous veins can be ligated. Injuries of the thoracic inferior or superior vena cava may
require shunt placement or cardiopulmonary bypass to facilitate repair.
Blunt injuries of thoracic duct
Thoracic ductal injuries due to blunt mechanisms are rare. They are sometimes found in association with
thoracic vertebral trauma. No signs or symptoms are specific for this injury at presentation. The diagnosis is
usually delayed and is confirmed when a chest tube is inserted for a pleural effusion and returns chyle. This is
termed a chylothorax.
Conservative management with chest tube drainage is successful in most cases, effecting closure of the ductal
injury without surgery. Chyle production can be decreased by maintaining the patient on total parenteral
nutrition or by providing enteral nutrition with medium-chain triglycerides as the fat source.
If a fistula persists after an attempt at nonoperative management, thoracotomy is performed to identify and
ligate the fistula. This is usually advisable after 2-3 weeks of persistent drainage or if the total lymphocyte count
dwindles. Provision of a meal high in fat content (or ice cream) the night before the operation increases the
volume of chyle and facilitates identification of the fistula.

General surgical approach
Preoperative
Patients with immediately life-threatening injuries that necessitate surgery cannot afford a protracted workup. At
minimum, the ABCs must be established. Frequently, resuscitation efforts in these patients must continue in
transit to and in the operating room.
Those with indications for surgery but who are not in extremis should also have their ABCs established. On the
basis of the mechanism of injury, clinical history, and physical findings, a search is conducted to exclude
associated injuries. Diagnostic procedures are completed if time and the patient's condition permit (eg, cervical
spine radiography, head CT, chest and abdominal CT, FAST examination). Blood is drawn and sent for typing,
crossmatching, and other tests (eg, complete blood count and arterial blood gas analysis).
Intraoperative
An adequate, secured airway is necessary, as is intravenous access. Monitoring devices such as a Foley
urinary catheter, central venous pressure monitor, or pulmonary artery catheter should be considered based on
the severity of injury, preoperative functional status, and anticipated length of the operation. Some injuries may
require the use of single-lung ventilation techniques. This should be discussed with the anesthesiologist as
early as possible.
Cardiopulmonary bypass or a centrifugal pump is used when necessary. Patient positioning and choice of
incision are very important. Median sternotomy is used to access the heart, intrapericardial portion of the
pulmonary vessels, ascending aorta and aortic arch, venae cavae, and the innominate artery. Branches of the
innominate artery are exposed by extending the median sternotomy into the neck.
A posterolateral left thoracotomy in the fourth intercostal space is used to approach the descending thoracic
aorta. The right subclavian artery is exposed via a median sternotomy that is extended into the neck. Proximal
control for the left subclavian artery is achieved through an anterolateral left thoracotomy in the third intercostal
space. Distal control for this vessel is obtained through a supraclavicular incision.

The distal esophagus can be approached via a left posterolateral thoracotomy; more proximal injuries require a
right thoracotomy. The thoracic duct is approached through a right thoracotomy.
Injuries to the lung or more peripheral pulmonary vessels are accessed through a posterolateral thoracotomy.
Injuries to the proximal two thirds of the trachea are best approached through a collar incision and extension
via a T-incision through the manubrium, which allows exposure to the middle and distal trachea. Injuries of the
distal trachea, carina, or right main stem bronchus are best approached through right fourth intercostals
posterolateral thoracotomy. Injuries of the left mainstem bronchus are best approached through a left
posterolateral thoracotomy.
Postoperative
Patients are extubated as soon as feasible in the postoperative period. Monitoring devices are kept in place
while needed but are removed as soon as possible.
Intravenous fluids are provided until the patient has had a return of gastrointestinal function, at which time the
patient can be fed. Patients with severe associated injuries, especially those in a coma, may require prolonged
enteral tube feedings.
Pain control is important in these patients because it facilitates breathing and helps to prevent pulmonary
complications such as atelectasis and pneumonia. Chest physiotherapy and nebulizer treatments are used as
necessary, and the use of an incentive spirometer is encouraged.
Chest tubes are placed for suction until fluid drainage has fallen sufficiently and the lung is completely
expanded without evidence of air leak. Tubes may then be placed to water seal and may be removed if a chest
radiograph demonstrates continued lung expansion.
Follow-up
After discharge, patients are monitored to ensure that adequate wound healing has occurred and to assess for
the development of complications. Patients with vascular injuries and grafts may be monitored to ensure that
complications such as pseudoaneurysms do not develop.
For patient education resources, see the Skin Conditions and Beauty Center, as well
as Bruises and Bronchoscopy.

Complications
Patients with blunt thoracic trauma are subject to myriad complications during the course of their care.
Wound complications include the following:



Wound infection
Wound dehiscence (particularly problematic in sternal wounds)
Cardiac complications include the following:








Myocardial infarction
Arrhythmias
Pericarditis
Ventricular aneurysm formation
Septal defects
Valvular insufficiency
Pulmonary and bronchial complications include the following:








Atelectasis
Pneumonia
Pulmonary abscess
Empyema
Pneumatocele, lung cyst
Clotted hemothorax





Fibrothorax
Bronchial repair disruption
Bronchopleural fistula
Vascular complications include the following:







Graft infection
Pseudoaneurysm
Graft thrombosis
Deep venous thrombosis
Pulmonary embolism
Neurologic complications include the following:





Causalgia (injuries that involve the brachial plexus)
Paraplegia (the spinal cord is at risk during repair of a ruptured thoracic aorta)
Stroke
Esophageal complications include the following:






Leakage of repair
Mediastinitis
Esophageal fistula
Esophageal stricture, late (click here to complete a Medscape CME activity on treating esophageal
strictures)
Complications involving the bony skeleton include the following:





Skeletal deformity
Chronic pain
Impaired pulmonary mechanics

Outcome and Prognosis
For the great majority of patients with blunt chest trauma, outcome and prognosis are excellent. Most (>80%)
require either no invasive therapy or, at most, a tube thoracostomy to effect resolution of their injuries. The
most important determinant of outcome is the presence or absence of significant associated injuries of the
central nervous system, abdomen, and pelvis.
Some injuries, such as cardiac chamber rupture, thoracic aortic rupture, injuries of the intrathoracic inferior and
superior vena cava, and delayed recognition of esophageal rupture, are associated with high morbidity and
mortality.

Future and Controversies
Future directions for improving the diagnosis and management of blunt thoracic trauma involve diagnostic
testing, endovascular techniques, and patient selection.
The use of thoracoscopy for the diagnosis and management of thoracic injuries will increase. Also, the use of
ultrasonography for the diagnosis of conditions such as hemothorax and cardiac tamponade will become more
widespread. Finally, spiral CT scanning techniques will be used more frequently for definitive diagnosis of major
vascular lesions (eg, injuries to the thoracic aorta and its branches).
Endovascular techniques for the repair of great vessel injuries will be developed further and applied more
frequently. Also, patient selection and nonsurgical therapies for delayed operative management of thoracic
aortic rupture will be refined.

PENETRATING

Background
Thoracic injuries account for 20-25% of deaths due to trauma and contribute to 25-50% of the remaining
deaths. Approximately 16,000 deaths per year in the United States alone are attributable to chest trauma.
[1]
Therefore, thoracic injuries are a contributing factor in up to 75% of all trauma-related deaths. The increased
prevalence of penetrating chest injury (associated with the "drug war" in the United States) and improved
prehospital and perioperative care have resulted in an increasing number of critically injured but potentially
salvageable patients presenting to trauma centers. Recently, the classic "trimodal" temporal distribution of
trauma deaths has been questioned, even though it has been widely taught in the design of trauma systems. [2]
For more information, visit Medscape’s Trauma Resource Center.

History of the Procedure
One of the earliest writings of thoracic injury was noted in the Edwin Smith Surgical Papyrus, written in 3000
BCE. Galen reported attempts to treat gladiators with chest injuries with open packing. In 1635, Labeza de
Vaca first described operative removal of an arrowhead from the chest wall of a Native American. In 1814,
Larrey (Napoleon's military surgeon) reported various injuries to the subclavian vessels. Rehn performed the
first successful human cardiorrhaphy in Germany in 1896. Hill performed the first cardiorrhaphy in the United
States in 1902 and initiated the modern treatment of the wounded heart.
Penetrating trauma to the thoracic vessels was not extensively reported until the 20 th century because of the
absence of survivors. In 1934, Alfred Blalock was the first American surgeon to successfully repair an aortic
injury. Guidelines for treating thoracic trauma were not established until World War II.
Additional experience in the treatment of penetrating trauma to the thorax was gained in later military
experiences, including the conflicts in Korea and Vietnam, and, to a lesser degree, in US actions in Grenada,
Panama, the Balkans, Somalia, and the Persian Gulf. Other large international experiences have derived from
the Falkland Island conflict, various Middle Eastern engagements, and multiple conflicts in the African states.
Significant experience has also been gained from large US metropolitan areas as a result of assaults involving
firearms and handheld weapons and impalements resulting from falls or leaps from elevations. Researchers
from Houston, Tex; Los Angeles, Calif; Atlanta, Ga; Detroit, Mich; and Denver, Colo, have been particularly
productive in their treatments of thoracic penetrating trauma. The number of trauma patients in these large
metropolitan areas rose so rapidly in the 1970s and 1980s that the military sent its medical personnel to train
caregivers at these centers.[3, 4]
With the advancement of wartime medical care and access to The Joint Theater Trauma Registry (JTTR),
thoracic injury patterns have changed dramatically. As a result of advances in body armor and the
establishment of excellent medical care at the battlefield, mortal thoracic wounds seem to have decreased,
allowing patients who would have previously died to live long enough to receive treatment. [5]

Problem
Any entry wound below the nipples (front) and the inferior scapular angles (dorsum) should be considered an
entry point for a course that may have carried the missile into the abdominal cavity. Missiles from gunshot
wounds (GSWs) can penetrate all body regions regardless of the point of entry. Any patient with a gunshot
entry wound for which a corresponding exit wound cannot be identified should be considered to have a retained
projectile, which could embolize to the central or distal vasculature. A patient with combined intrathoracic and
intra-abdominal wounds has a markedly greater chance of dying.
For information on treating penetrating abdominal wounds, see the articleAbdominal Stab Wound Exploration.

Etiology

Mechanism of injury
The mechanism of injury may be categorized as low, medium, or high velocity. Low-velocity injuries include
impalement (eg, knife wounds), which disrupts only the structures penetrated. Medium-velocity injuries include
bullet wounds from most types of handguns and air-powered pellet guns and are characterized by much less
primary tissue destruction than wounds caused by high-velocity forces. High-velocity injuries include bullet
wounds caused by rifles and wounds resulting from military weapons.
Shotgun injuries, despite being caused by medium-velocity projectiles, are sometimes included within
management discussions for high-velocity projectile injuries. This inclusion is reasonable because of the kinetic
energy transmitted to the surrounding tissue and subsequent cavitation, as described by the following equation
in which KE is kinetic energy, M is mass, and V is velocity:
KE = ½ MV2
The 3 major subcategories of ballistics are internal, external, and terminal. Internal ballistics describe the
characteristics of the projectile within the gun barrel. External ballistics examines the factors that affect the
projectile during its path to the target, including wind resistance and gravity. Terminal ballistics evaluates the
projectile as it strikes its target.
The amount of tissue damage is directly related to the amount of energy exchange between the penetrating
object and the body part. The density of the tissue involved and the frontal area of the penetrating object are
the important factors determining the rate of energy loss.
The energy exchange produces a permanent cavity inside the tissue. Part of this cavity is a result of the
crushing of the tissue as the projectile passes through. The expansion of the tissue particles away from the
pathway of the bullet creates a temporary cavity. Because this cavity is temporary, one must realize that it was
once present in order to understand the full extent of injury.
Penetrations from blast fragments or from fragmentation weapons can be particularly destructive because of
their extremely high velocities. Weapons designed specifically for antipersonnel effects (eg, mines, grenades)
can generate fragments with initial velocities of 4500 ft/s, a far greater speed than even most rifle bullets. The
tremendous energy imparted to tissue from fragments with such velocity causes extensive disruptive and
thermal tissue damage. Weaponry of the 21st century consists mostly of improvised explosive devices (IEDs).
These devices are homemade bombs and they create a deadly triad of penetrating, blast, and burn wounds. Of
the thoracic trauma that is seen in the current Global War on Terror, 40% is penetrating chest trauma.

Pathophysiology
As noted by Inci and colleagues in a 1998 study of 755 patients with thoracic injuries, penetrating chest trauma
(PCT) comprises a broad spectrum of injuries and severity.[6] The injuries and number of patients (some with >1
injury) is listed as follows:[6]








o
o







Hemothorax - 190
Hemopneumothorax - 184
Pneumothorax - 144
Diaphragmatic rupture - 121
Open hemopneumothorax - 95
Pulmonary contusion - 50
Open pneumothorax - 24
Rib fracture
Fewer than 2 fractures - 16
More than 2 fractures - 13
Subcutaneous emphysema - 14
Bilateral pneumothorax - 9
Open bilateral hemopneumothorax - 13
Pneumomediastinum - 6
Thoracic wall lacerations - 4
Bilateral hemopneumothorax - 3





Open bilateral pneumothorax - 3
Sternal fracture - 3
Bilateral diaphragmatic rupture - 2
The clinical consequences depend on the mechanism of the injury, the location of the injury, associated
injuries, and underlying illnesses. Organs at risk, in addition to the intrathoracic contents, include the
intraperitoneal viscera, the retroperitoneal space, and the neck.

Presentation
Initial management
As always in trauma, management begins with establishing ABCs. Indications for emergency endotracheal
intubation include apnea, profound shock, and inadequate ventilation. Chest radiography is not indicated in
patients with clinical signs of a tension pneumothorax, and immediate chest decompression is accomplished
with either a large-bore needle at the second intercostal space or, more definitively, with a tube thoracostomy. A
sucking chest wound must be appropriately covered to permit adequate ventilation and to prevent the
iatrogenic development of a tension pneumothorax.
Damage control operation appears to be the new mantra in the advanced care of penetrating thoracic trauma.
Damage control requires modification of the ABCs of trauma, in that resuscitative and diagnostic techniques
are used simultaneously in the immediate time after the unstable patient's presentation. Quickly and solely
controlling hemorrhage and contamination to expedite reestablishing a survivable physiology is the essence of
thoracic damage control. Additionally, aggressive correction of the acidosis, coagulopathy, and hypothermia
occurs in the ICU.[7]
Volume replenishment is the cornerstone of treating hemorrhagic shock but can also cause significant
compromise of other organ systems. Continuous infusions of even blood or normotonic fluids cause significant
peripheral tissue edema, frank acute respiratory distress syndrome (ARDS) or a tremendous increase in lung
water ("soggy lungs"), and cardiac compromise. Newer approaches, described in both military and civilian
literature, are emphasizing the use of hypertonic solutions in an effort to minimize these complications.
Alternatively, several groups have championed the concept of "scoop and run" when treating injuries in the
field.[8] With the development of modern (civilian) emergency medical services, the field care of injured patients
has improved. Rapid assessment to identify life-threatening injuries along with key interventions, namely
management of the airway and control of hemorrhage, and avoidance of massive volume increases before
rapid transport to the closest appropriate facility is the current standard of care. This is in contrast to the
concept of "stay and play," during which trained personnel make major triage and treatment decisions in the
field.
If the patient has persistently low systemic pressure, a source of ongoing blood loss or some other
mechanisms to explain the hypotension (eg, cardiac tamponade, tension pneumothorax) should be
preferentially sought. Additionally, some data suggest that continued volume resuscitation before surgical
control of bleeding may worsen both the bleeding process and final outcome.
Fluid collections in either hemothorax should be treated with percutaneous thoracostomy tubes. See the image
below and the article Hemothorax.

Upright posteroanterior chest rediograph of patient with right-sided hemothorax.

Indications

Thoracotomy
Thoracotomy may be indicated for acute or chronic conditions. Acute indications include the following:













Cardiac tamponade
Acute hemodynamic deterioration/cardiac arrest in the trauma center
Penetrating truncal trauma (resuscitative thoracotomy)
Vascular injury at the thoracic outlet
Loss of chest wall substance (traumatic thoracotomy)
Massive air leak
Endoscopic or radiographic evidence of significant tracheal or bronchial injury
Endoscopic or radiographic evidence of esophageal injury
Radiographic evidence of great vessel injury
Mediastinal passage of a penetrating object
Significant missile embolism to the heart or pulmonary artery
Transcardiac placement of an inferior vena caval shunt for hepatic vascular wounds
Patients who arrive in cardiac arrest or who arrest shortly after arrival may be candidates for emergency
resuscitative thoracotomy. A right chest tube must be placed simultaneously. The use of emergency
resuscitative thoracotomy has been reported to result in survival rates of 9-57% for patients with penetrating
cardiac injuries and survival rates of 0-66% for patients with noncardiac thoracic injuries, but overall survival
rates are approximately 8%.[9]
The proportion of patients with PCT who can be treated without operation has been reported to vary from 2994%.[9]
Chronic indications for thoracotomy include the following:













Nonevacuated clotted hemothorax
Chronic traumatic diaphragmatic hernia
Traumatic cardiac septal or valvular lesion
Chronic traumatic thoracic aortic pseudoaneurysm
Nonclosing thoracic duct fistula
Chronic (or neglected) posttraumatic empyema
Infected intrapulmonary hematoma (eg, traumatic lung abscess)
Missed tracheal or bronchial injury
Tracheoesophageal fistula
Innominate artery/tracheal fistula
Traumatic arterial/venous fistula
Another indication for acute thoracostomy is often based on chest tube output. Immediate evacuation of 1500
mL of blood is a sufficient indication; however, the trend in output is more important. If bleeding persists with a
steady trend of more than 250 mL/h, thoracotomy is probably indicated.

Thoracoscopy
The role of video-assisted thoracoscopic surgery in the management of penetrating chest trauma is expanding
rapidly. Initially promoted for the management of retained hemothoraces and the diagnosis of diaphragmatic
injury, trauma and thoracic surgeons are now using thoracoscopy for treatment of chest wall bleeding,
diagnosis of transmediastinal injuries, pericardial window, and persistent pneumothoraces. [10] The major
contraindication to video-assisted thoracoscopic surgery is hemodynamic instability.

Relevant Anatomy
The anatomy of the thoracic cage is well-known and encompasses the area beneath the clavicles and superior
to the diaphragm, bound laterally by the rib cage, anteriorly by the sternum and ribs, and posteriorly by the rib
and vertebral bodies. Entry into the thorax may be made by sternotomy; thoracotomy (incising between
selected ribs, most commonly the fourth and fifth) on either the right or left side; or a clamshell incision,
consisting of left and right thoracotomy incisions traversing the sternum to join the two. Additional modifications
of each of these approaches are not discussed in detail here.

Particular care must be exercised laterally near the sternum, where the internal thoracic (mammary) artery lies
2-4 cm on either side. Similarly, remember that immediately inferior to each rib body are the intercostal artery,
vein, and nerve, from which voluminous bleeding can occur. Patients have required reexploration for injuries to
these various vessels and have exsanguinated as a result of missed injuries to these vessels.
Anteriorly, injuries to the heart should be presumed to have occurred if entry points are present anywhere
between the 2 midclavicular lines. On occasion, significant injury to the heart has occurred from entry points
lateral to these margins, as in gunshot or missile injuries.
Exceptionally long penetrating instruments and weapons (eg, arrows, swords, lances) can also directly
penetrate the heart from a distant entry point. Similarly, injuries to any of the intrathoracic structures can be
effected with long penetrating devices; consider the possibility of injuries to the diaphragm, great vessels, or
posterior mediastinal structures in these cases.
The right atrium and right ventricle are the anterior portions of the heart; these areas are the primary sites
involved in penetrating injuries of the heart.

Contraindications
Contraindications to various explorations and techniques are discussed in their respective sections.

Laboratory Studies


Laboratory examinations are rarely required in the acute treatment of patients with penetrating chest
injuries. Hemoglobin or hematocrit values and arterial blood gas determinations offer the most useful
information for treating these patients; however, tests may be temporarily delayed until patients are stabilized.
Blood chemistry results, serum electrolyte values, and WBC and platelet counts add little information for initial
treatment but can establish a baseline by which to follow the course of the patient through his or her therapy.
Underlying medical conditions (eg, diabetes, chronic renal insufficiency), either known or discovered via the
laboratory examinations, should be noted and treated when appropriate.

Imaging Studies


With improvements in modern imaging, a number of different diagnostic modalities are available to aid
in precisely defining the extent of trauma. Various groups have championed their own protocols as preeminent.
In reality, any number of acceptable algorithms can help in the treatment of a patient with PCT.

Admission history and physical examination are usually brief and are oriented to the injury.
Evaluations of vital signs, consciousness, airway competency, vascular integrity, and pump (cardiac) function
are rapidly performed before devoting attention to the point of injury.

If the patient is stable and no significant injury is found that requires immediate surgery, a full
diagnostic evaluation can be performed.

Chest radiography remains the basis for initiating other investigations.

CT scanning is rapidly evolving into a primary diagnostic tool because of its ability to image various
intrathoracic structures and to differentiate substances of different densities (eg, solid vs air-containing fluid
collections). With the advent of multidetector CT in clinical practice, the speed of data acquisition and image
reconstruction has improved dramatically, and many reports emphasizing this change in imaging approach
have been published.[11] Delayed radiographs have been the standard of care for stable patients with
penetrating chest trauma. Initial chest CT scan obviates the need for repeat chest radiograph after penetrating
thoracic trauma.[12]

Aortography, once considered the criterion standard for determining vascular injuries, has gradually
fallen out of favor for faster, less invasive, and better-tolerated imaging techniques. The revival of aortography
with endovascular intervention for trauma to the thoracic aorta or branches of the aortic arch (innominate,
carotid, and subclavian arteries) is largely a product of modern technology. Endovascular stent graft arterial
repair has altered the approach to vascular trauma.[13]

Penetrating injuries traversing the mediastinum or in proximity to posterior mediastinal structures
dictate esophageal and tracheal evaluation, preferably by direct visualization (eg, esophagoscopy,
bronchoscopy).






Specialized windows for ultrasonography have been developed to allow imaging of some intrathoracic
structures despite the presence of lung air. Using the Focused Assessment with Sonography for Trauma
protocols, evaluation of the thorax and the abdomen can be completed within minutes.
Readily available in most centers, echocardiography has been developed to a point at which it is now
indispensable in helping evaluate injuries to the heart and the ascending and descending aortas. More recent
work has demonstrated that ultrasonography can also be used to detect hemothoraces and pneumothoraces
with accuracy.[14]
In appropriate settings, close observation (without thoracotomy) may be considered. However, the
limitations of each of the above-noted diagnostic modalities must be remembered, and these modalities must
not be extended beyond their functional limits, especially if patient safety is compromised.

Other Tests


Because most trauma patients are young, extensive cardiac evaluations are often unnecessary.
Admission ECGs can be deferred until the patient is stable unless cardiac injury is considered likely.
Frequently, however, immediacy of resuscitation and definitive treatment preclude obtaining ECGs. In elderly
patients, ECG evidence of prior myocardial infarctions may assist in the management of dysrhythmias or
potential cardiac failure.

Diagnostic Procedures


See Imaging Studies.

Surgical Therapy
Any organ within the chest is potentially susceptible to penetrating trauma, and each should be considered
when evaluating a patient with thoracic injury. These organs include the chest wall; the lung and pleura; the
tracheobronchial system, including the esophagus, diaphragm, thoracic blood vessels, and thoracic duct; and
the heart and mediastinal structures.
There has been an incremental increase in the utilization of cardiothoracic surgeons over the last 10 years for
thoracic trauma operative intervention and with little data available, it does appear to have resulted in improved
patient outcomes. This was recently reported in the Annals of Thoracic Surgery.[15]

Chest wall injury
The chest serves the important functions of respiration and of protection of the vital intrathoracic and upper
abdominal organs from externally applied force and is composed of the rigid structure of the rib cage, clavicles,
sternum, scapulae, and heavy overlying musculature. Most wounds to these structures can be managed
nonoperatively or by simple techniques such as tube thoracostomy. The treatment of a stable patient with a
normal initial chest radiograph remains controversial.
Ammons and coworkers further defined the role of outpatient observation of selected patients with
nonpenetrating thoracic GSWs and stab wounds. In their study, observation for 6 hours with subsequent repeat
chest radiography revealed a 7% rate of delayed pneumothorax, and hospitalization was avoided in 86% of
patients treated according to this protocol.
Large, open, chest wall defect closure can be a formidable task. When techniques involving closure with
autogenous tissue of myocutaneous flaps based on the trapezius, rectus abdominus, pectoral, or latissimus
dorsi muscles fail, prosthetic material (eg, polypropylene mesh, expanded polytetrafluoroethylene,
cyanoacrylate) may be used.
Rarely, chest wall hemorrhage from the muscular, intercostal, and internal mammary arteries can result in
exsanguination and may require operative control.
First and second rib fractures are often accompanied by serious associated injuries, particularly if multiple rib
fractures are evident. Treatment of any associated injuries must be expeditious.

Severe thoracic injury that causes paradoxical motion of segments of the chest wall has been termed flail
chest, which may be categorized by size or location. In adults, pulmonary contusion accompanies flail chest
injuries in approximately half the patients.
The primary treatment of chest wall injuries is a combination of pain control, aggressive pulmonary and
physical therapy, selective use of intubation and ventilation, and close observation for respiratory
decompensation. Sufficient evidence now supports the notion that the pathophysiologic findings associated
with severe chest wall trauma are related to the underlying injuries, chiefly pulmonary contusion and
parenchymal injuries, and have little to do with the movement of the chest wall.
Indications for operative fixation of the chest wall or sternum include the following:

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


Need for thoracotomy for other reasons
Large flail segments in patients with borderline premorbid pulmonary status
Severe instability and pain and failure to wean from the ventilator after an adequate trial
Secondary infections

Lung injuries
Injuries related to the pleural space can generally be divided into pneumothorax or hemothorax. Most patients
with such injuries can be cared for with a simple tube thoracostomy. A massive hemothorax is defined as more
than 1500 mL of blood in the pleural space. Usually, 200-300 mL of blood must collect in the pleural space
before a hemothorax can be detected on a chest radiograph.
Although tube thoracostomy is often a lifesaving procedure and is relatively straightforward, it should not be
taken too lightly. A review of almost 600 tube thoracostomies revealed a complication rate of 21%. [16]
Pulmonary parenchymal lacerations result in bleeding and air leaks, and the vast majority of these lacerations
can be treated with tube thoracostomy. These lacerations extend from the surface of the lung toward the hilum
or the trajectory of the penetrating object. They can vary from minor lacerations to lobar bisection. Of
penetrating injuries that require thoracostomy, 80-90% can be managed using simple measures (eg, stapling,
tractotomy, oversewing).
Less than 3% of all patients who require thoracotomy require a pneumonectomy, and this procedure is
reserved for patients with severe hilar vascular injuries. Postoperatively, aggressive diuresis and selective lung
ventilation may reduce the prevalence of pulmonary edema and stump dehiscence.

Tracheobronchial injuries
Up to 75-80% of penetrating injuries involve the cervical trachea, while 75-80% of blunt injuries occur within 2.5
cm of the carina. These injuries always occur with other injuries, especially to the great vessels; without early
recognition and prompt intervention, they frequently are fatal.
Respiratory distress, subcutaneous emphysema, pneumothorax, hemoptysis, and mediastinal emphysema are
the most common manifestations. Occasionally, complete or near-complete transection results in the "fallen
lung" sign on chest radiographs. If possible, perform bronchoscopy on any patient in whom tracheobronchial
injury is suggested. Patients with small injuries without appreciable leaks who do not require positive-pressure
ventilation can be treated nonoperatively; however, most patients require urgent repair. The principles of
operative repair include debridement with tension-free, end-to-end anastomosis while preserving the blood
supply. The preferred suture technique is debatable but usually requires a monofilament suture with knots tied
on the outside.
Delay or lack of recognition is common, and subsequent complications of stenosis and obstruction are the rule
in missed tracheobronchial injuries.

Esophageal injuries
The exact prevalence of injury to the esophagus due to external trauma is unknown but is less than 1% of
patients with injuries admitted to hospitals. The majority of esophageal injuries are due to penetrating trauma
from a variety of instruments (ie, iatrogenic trauma).

Recognizing injury to the esophagus following trauma is difficult because of the rarity of injuries to this organ,
the paucity of clinical signs in the initial 24 hours, and/or the presence of multiple other injuries. Delayed
treatment results in the rapid development of sepsis and an associated high risk of death; therefore, any
possibility of injury must prompt aggressive investigation, including radiography, endoscopy, and thoracoscopy
(when warranted). The combined use of these techniques has a sensitivity of almost 100%.
Operative management is dictated by the site of primary injury, associated injuries, condition of the patient,
degree of local suppuration, condition of the esophageal tissues, and delay since injury.
Primary repair with adequate tissue buttressing and drainage is the preferred method. Exclusion-diversion
procedures have been advocated when primary repair is thought to be contraindicated. Esophageal
replacement, when required, is, at best, a poor substitute for the original organ.
Complications after esophageal repair include esophageal leaks and fistulae, wound infections, mediastinitis,
empyema, sepsis, and pneumonia. Long-term complications, such as esophageal stricture, are also possible.

Diaphragmatic injury
The diaphragm is frequently injured in penetrating thoracoabdominal trauma. Such injury occurs in 15% of stab
wounds and in 46% of GSWs. Only 15% of the injuries are more than 2 cm long; therefore, herniation of
abdominal contents is rarely immediate. Blunt injuries tend to result in larger lacerations.
Importantly, no distinctive signs and symptoms are associated with penetrating diaphragmatic injuries. A high
index of suspicion is usually required for diagnosis.
Penetrating diaphragmatic injuries are frequently difficult to diagnose without laparoscopy or laparotomy.
Diagnostic peritoneal lavage appears to be the best-studied procedure, although no consensus has been
reached regarding the best RBC count to use. Newer diagnostic modalities, such as laparoscopy and
thoracoscopy, can be useful in both diagnosing and treating penetrating diaphragmatic injuries.
In general, acute injuries are approached with laparoscopy or laparotomy because of associated injuries and
chronic injuries are approached with thoracoscopy because of dense adhesions that arise between the
abdominal contents and the lung. Most injuries require repair with heavy, nonabsorbable sutures; some large
tears may require mesh closure. Lateral tears may require resuspension from the chest wall.
Up to 13% of injuries are missed in emergent settings, and the patient may present years later when visceral
herniation occurs (85% within 3 y), manifesting as decreased cardiopulmonary reserve, obstruction, or frank
sepsis. Bowel strangulation and gangrene are associated with a high mortality rate.

Thoracic great vessel injury
The great vessels of the chest include the aorta, its major branches at the arch (eg, innominate, carotid,
subclavian), and the major pulmonary arteries. The primary venous conduits include the superior and inferior
vena cavae and their main tributaries, as well as the pulmonary veins. Damage to vascular structures depends
on the specific location and degree of vessel disruption; arterial injuries are more rapidly fatal. The prevalence
of great vessel injuries ranges from 0.3-10%.
More than 90% of thoracic great vessel injuries are caused by penetrating trauma (ie, gunshot, shrapnel, stab
wounds, therapeutic misadventures). Historically, thoracic injuries are associated with a high morbidity rate;
however, Pate and coworkers reported a 71% survival rate in patients who reach the hospital alive after
penetrating chest injuries. The trauma surgeon must resuscitate, diagnose, and treat the patient within minutes
following admission to the trauma emergency unit.
A patient's hemodynamic stability dictates the next phase of managing a penetrating great vessel injury.
Patients who are stable after initial resuscitation are best served by a further diagnostic workup. Helical CT
scanning, CT angiography, and transesophageal echocardiography offer several advantages over other
diagnostic studies.
Helical CT scanning is a noninvasive, sensitive test to assess mediastinal hematomas and to assess aortic wall
and intraluminal abnormalities. The development of multidetector-row CT scanning allows for significantly
shorter acquisition times (< 2 min for whole body CT scan), the ability to retrospectively reconstruct thinner
sections, and improvements in 3-dimensional reconstructions. CT angiography is rapidly developing into a

primary method of determining vascular injuries, obviating the much more invasive and operator-dependent
conventional angiographic techniques, long held to be the criterion standard for assessment of vascular
trauma. The role of transesophageal echocardiography is evolving.
While the usefulness of transesophageal echocardiography to characterize and confirm traumatic aortic
dissections is undisputed, it has only recently begun to be used directly in trauma evaluation. The lack of
experienced operators in the emergency department setting is apparently being overcome, and continued
exposure of the technique will undoubtedly increase its use in the evaluation of trauma patients. If required,
conventional angiography or digital subtraction techniques are performed with a surgeon in attendance. The
role of intravascular ultrasound in the evaluation of the trauma patient has yet to be clarified.
Patients who remain in extremis or show continued rapid hemodynamic deterioration are best served by an
emergency thoracotomy for rapid descending aortic cross-clamping and manual control of bleeding. Patients
who are successfully resuscitated but remain hemodynamically unstable or who demonstrate continued
massive blood loss are unable to undergo a further diagnostic workup and are immediately taken to the
operating room.
A choice of proper incision in order to gain adequate exposure for control and repair of the injury is of prime
importance. The median sternotomy with supraclavicular extensions for access to the subclavian vessels is the
most useful incision. The posterolateral thoracotomy is the incision of choice for access to the descending
thoracic aorta. The trapdoor, or book, incision has historic significance only.
Operative repair of thoracic aortic injuries is virtually always possible by lateral aortorrhaphy with extremely
short cross-clamp times. Rarely, if ever, is an interposition graft required. Adjunctive measures of
cardiopulmonary bypass, temporary bypass shunts, or active aortic shunts (eg, a centrifugal pump) are usually
not described for use in patients with penetrating trauma but are almost exclusively used for blunt injury.
Paraplegia has only rarely been reported following successful repair of penetrating thoracic aortic injury, even
after prolonged aortic cross-clamping following emergency thoracotomy.
Because of the proximity of other organs to the thoracic great vessels, an additional diagnostic workup
including bronchoscopy, esophagoscopy, and echocardiography may be necessary. The timing of these
interventions continues to be debated. Patients with great vessel injuries have a higher prevalence of
associated venous, esophageal, and bronchial plexus injuries compared with patients without great vessel
injuries. Trauma patients with severe concomitant injuries who are unlikely to tolerate operative repair may be
treated more frequently with endovascular stenting in the future. Mitchell's series of stent graft repair of thoracic
aortic lesions includes 7 posttraumatic cases.
The Society for Vascular Surgery published data regarding the use of endovascular grafts in the treatment of
acute aortic transections; 97% were due to a motor vehicle accident. Sixty symptomatic patients were treated
with an aortic endograft, with a mean operative time of 125 minutes and an all-cause mortality rate of 9.1% at
30 days.[17]
Nonoperative treatment predominantly applies to patients with blunt aortic injuries who are unlikely to benefit
from immediate repair (eg, minor intimal defects, small pseudoaneurysms). The long-term natural history of
these minor vascular injuries remains uncertain; therefore, careful follow-up monitoring, including serial imaging
studies, is a critical component of nonoperative treatment.

Cardiac injuries
Traumatic cardiac penetration is highly lethal, with case fatality rates of 70-80%. The degree of anatomic injury
and occurrence of cardiac standstill, both related to the mechanism of injury, determine survival probability.
Patients who reach the hospital before cardiac arrest occurs usually survive. Those patients surviving
penetrating injury to the heart without coronary or valvular injury can be expected to regain normal cardiac
function on long-term follow up.[18]
Ventricular injuries are more common than atrial injuries, and the right side is involved more often than the left
side. In 1997, Brown and Grover noted the following distribution of penetrating cardiac injuries: [19]



Right ventricle - 43%
Left ventricle - 34%




Right atrium - 16%
Left atrium - 7%
The Beck triad (ie, high venous pressure, low arterial pressure, muffled heart sounds) is documented in only
10-30% of patients who have proven tamponade. [20]
Pericardiocentesis can be both diagnostic and therapeutic, although some centers report a false-negative rate
of 80% and a false-positive rate of 33%. This procedure is reserved for patients with significant hemodynamic
compromise without another likely etiology.
Echocardiography is a rapid, noninvasive, and accurate test for pericardial fluid. It has a sensitivity of at least
95% and is now incorporated into the Focused Assessment with Sonography for Trauma protocol. Once again,
the management algorithm is based on the patient's hemodynamic status, with patients who are in extremis or
who are profoundly unstable benefiting from emergency thoracotomy with ongoing aggressive resuscitation. In
patients with GSWs from high-caliber missiles, the absence of an organized cardiac rhythm portends a grave
prognosis. For patients with stab wounds or GSWs from low-caliber missiles who are apparently lifeless upon
arrival, resuscitative thoracotomy is justified.
Stable patients with cardiac wounds may be diagnosed using a subxiphoid pericardial window. Bleeding must
be rapidly controlled using finger occlusion, sutures, or staples. Inflow occlusion and cardiopulmonary bypass
are rarely necessary. Distal coronary injuries are usually ligated, whereas proximal injuries may require bypass
grafts. Intracardiac shunts or valvular injuries in patients who survive are usually minor and do not require
emergent repair. Foreign bodies in the left cardiac chambers must be removed.
Postoperative deterioration may be due to bleeding or postischemic cardiac myocardial dysfunction. Residual
and delayed sequelae include postpericardiotomy syndrome, intracardiac shunts, valvular dysfunction,
ventricular aneurysms, and pseudoaneurysms. Wall et al, in a classic 1997 paper, described in detail the
management of 60 complex cardiac injuries.[21]

Follow-up
For patient education resources, see the Procedures Center and Skin, Hair, and Nails Center, as well
as Bronchoscopy and Puncture Wound.

Complications
Retained pulmonary parenchymal foreign bodies
The decision to remove a retained foreign body depends on its size, its location, and any specific problems
associated with it. Objects larger than 1.5 cm in diameter, centrally located missiles, irregularly shaped objects,
and missiles associated with evidence of contamination may be prophylactically removed. Typically, such
removal is best performed 2-3 weeks following the acute injury.

Chest wall hernia
A chest wall hernia is usually a complication of thoracotomy. A patient with a chest wall hernia presents with
pain and an obvious defect, but occasionally a lung may be entrapped and become necrotic. Management
includes resection of nonviable tissue and closure with tissue flaps or artificial material

Posttraumatic lung cyst
Pseudocyst of the lung is a rare development and usually manifests as a well-circumscribed, rounded, central
air cavity identified on chest radiographs or CT scans. Most do not require specific treatment and resolve
spontaneously within a few weeks. Patients with secondary infection present with a lung abscess and should
be treated using standard therapy, including antibiotics and drainage.

Pulmonary hematoma
Hematomas form in 4-11% of patients with pulmonary contusions and are observed more frequently in patients
with blunt trauma. Symptoms of fever and hemoptysis usually abate in 1 week, although chest radiograph
findings usually demonstrate resolution within 4 weeks. Hematomas are associated with an increased
prevalence of abscess formation.

Systemic air embolism
Systemic air embolism is usually described following central penetrating lung injury and is a special risk
following primary blast injuries to the lungs. Air can enter the left side of the heart through bronchial and
pulmonary venous fistulae and embolize to the coronary and systemic circulations. A precipitating factor is often
the institution of positive-pressure ventilation with resulting air being forced into the low-pressure pulmonary
venules. Embolism can also occur with any thoracic great vessel injury. Manifestations include seizures,
arrhythmias, and cardiac arrest. Resuscitation requires thoracotomy, clamping of the pulmonary hilum, and
aspiration of air from the left ventricle and ascending aorta. Experience with hyperbaric oxygen therapy has
generally been good but is usually reserved for those centers with access to larger chambers (ie, to support
associated medical personnel).

Bronchial stricture
Missed tracheobronchial laceration may result in significant strictures. Patients present with variable degrees of
dyspnea. Evaluation with bronchoscopy and CT scanning is followed by treatment with open operative repair or
stenting.

Tracheoesophageal fistula
Delayed tracheoesophageal fistula is rare, generally manifesting approximately 10 days following injury,
possibly from delayed necrosis following a blast injury. Usually, the airway at or just above the carina is
involved. The timing of surgery or intervention is unclear and depends on the degree of ventilatory leak and the
overall condition of the patient.

Persistent air leak and bronchopleural fistula
Traumatic air leaks that last longer than 7 days are unlikely to resolve spontaneously, and judicious
manipulation of the chest tube to increase or decrease the suction may be appropriate in order to facilitate
healing. Bronchopleural fistulae imply a direct communication between the major airways and the pleural space
and usually require some form of intervention for closure.

Empyema
Empyema occurs in 2-6% of patients with PCT. Traumatic empyema differs from nontraumatic forms because it
is more often loculated and requires operative debridement. Initial treatment is tube drainage. Thoracoscopy,
particularly if performed within 7-10 days, is effective for draining the infection.

Ventilator-associated pneumonia
Ventilator-associated pneumonia occurs in 9-44% of ventilated patients. It increases the mortality rate in
patients who do not have ARDS from 26% to 48% and in patients with ARDS from 28% to 67%. Management
consists of ventilator support and appropriate systemic antibiotic therapy.

Missile embolization
Embolization to the pulmonary arteries is usually treated with surgical removal or interventional techniques. A
chest radiograph taken immediately preceding incision or intraoperative fluoroscopy is mandatory in order to
detect more distal embolization that may occur during positioning. Asymptomatic patients with small distal
fragments may be treated expectantly. Occasionally, missile emboli may migrate through a patent foramen
ovale or from central parenchymal or vascular injuries to gain access to the left side of the heart and then to the
systemic circulation.

Cardiovascular fistulae
Most cardiovascular arterial-to-venous fistulae occur following stab wounds. Virtually all manifest as a
machinery murmur after approximately 1 week. Innominate artery-to-vein fistulae are the most common.
Patients with coronary artery fistulae, usually to the right ventricle, present with ischemia, cardiomyopathy,
pulmonary hypertension, or bacterial endocarditis. Aortocardiac, aortopulmonary, and aortoesophageal fistula
are quite rare because the probability of survival from the acute injury is slim. While requiring open repair in the
past, interventional techniques may be used in a large number of these patients.

Thoracic duct injury and chylothorax

Injuries to the thoracic great vessels may be complicated by concomitant thoracic duct injury, which, if
unrecognized, may produce devastating morbidity due to severe nutritional depletion. Initial management of a
delayed chylothorax is always aggressive but nonoperative. Hyperalimentation with total enteral foodstuff
restriction (ie, parenteral hyperalimentation) may result in a significant number of spontaneously sealing
thoracic duct injuries. Failure to spontaneously seal after 5-7 days indicates the need for surgical intervention,
which should be individualized because the optimal approach is controversial. The number of proponents for
direct suture control is equal to the number of those preferring a right thoracotomy to ligate the vessel as it
traverses the diaphragm. Experienced personnel can approach the duct thoracoscopically or with video
assistance, thus minimizing additional discomfort to the patient.

Outcome and Prognosis
The outcomes of treating patients with PCT are directly related to the extents of patients' injuries and the
timeliness of initiation of treatments. Patients arriving in a stable condition may expect full recovery, but patients
presenting with lesser levels of stability have diminishing probabilities of survival. Do not attempt to resuscitate,
let alone definitively treat, patients presenting with no vital signs or with obviously nonsurvivable injuries (eg,
massive cardiac destruction).
Guidelines for initiation of emergency department thoracotomy were published in 2003. [22]
Reporting from a single center in 2010, patients who died had a significantly lower systolic blood pressure (42
+/- 36 mmHg) compared with those who survived (83 +/- 27 mmHg, p< 0.001). [23]

Future and Controversies
The current management of penetrating thoracic injury is a hurried, brute-force approach necessitated by the
life-threatening nature of many of these injuries. As surgical experience with less invasive techniques and
minimal incision approaches increases, these methods will likely find their appropriate places in the treatment
of these patients. Already, interventional radiologic techniques can safely treat many patients with intrathoracic
vascular injuries and have been successfully used to retrieve intracardiac missiles. Traumatically disrupted
aortae have been treated with stenting; in stable patients with penetrating injuries to the thoracic vessels, use
of this modality should be considered. Currently, however, traditional approaches and techniques have little
competition in the treatment of critically injured and frequently unstable patients.
The mechanism of thoracic injury in modern battles is shifting more from penetrating wounds to combination
blast injuries. The mortality of those injured has increased (12% vs 3% in Vietnam) and may represent the
devastation caused by IEDs and the subsequent multisystem injuries they cause. The overall killed-in-action
rate has decreased, whereas the died-of-wounds rate has increased. Half of all thoracic injuries reported from
the battle front on the Global War on Terror occurred in the civilian population. [5]