Chest Trauma

Pulmonary Contusion
Pulmonary contusion is an injury to lung parenchyma, leading to
oedema and blood collecting in alveolar spaces and loss of normal
lung structure & function. This blunt lung injury develops over the
course of 24 hours, leading to poor gas exchange, increased
pulmonary vascular resistance and decreased lung compliance.
There is also a significant inflammatory reaction to blood
components in the lung, and 50-60% of patients with significant
pulmonary contusions will develop bilateral Acute Respiratory
Distress Syndrome (ARDS).
Pulmonary contusions occur in approximately 20% of blunt trauma
patients with an Injury Severity Score over 15, and it is the most
common chest injury in children. The reported mortality ranges
from 10 to 25%, and 40-60% of patients will require mechanical
ventilation. The complications of pulmonary contusion are ARDS,
as mentioned, and respiratory failure, atelectasis and pneumonia.

Diagnosis
Pulmonary contusions are rarely diagnosed on physical
examination. The mechanism of injury may suggest blunt chest
trauma, and there may be obvious signs of chest wall trauma such
as bruising, rib fractures or flail chest. These suggest the presence
of an underlying pulmonary contusion. Crackles may be heard on
auscultation but are rarely heard in the emergency room and are
non-specific.

CHEST TRAUMA
INITIAL EVALUATION
PNEUMOTHORAX
TENSION PNEUMO
OPEN PNEUMO
HAEMOTHORAX
CONTUSION
RIB FRACTURE / FLAIL
AORTIC INJURY
CHEST DRAINS

PULMONARY
CONTUSION
PRIMARY SURVEY
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
ADJUNCTS
CXR
SECONDARY SURVEY

Severe bilateral pulmonary contusions may present with hypoxia but more usually hypoxia develops as the pulmonary contusions
blossom or as a result of subsequent ARDS.

Chest X-ray
Most significant pulmonary contusions are diagnosed on plain chest
X-ray. However the chest X-ray will often under-estimate the size
of the contusion and tends to lag behind the clinical picture. Often
the true extent of injury is not apparent on plain films until 24-48
hours following injury.

Pulmonary Contusion
Admission CXR

Pulmonary Contusion
24 Hours

L pulmonary contusion
L pneumothorax

lung contusion at
thoracotomy

Computed Tomography
Computed tomography (CT) is very sensitive for identification of
pulmonary contusion, and may allow differentiation from areas of
atelectasis or aspiration. CT also allows for 3-dimensional
assessment and calculation of the size of contusions. However,
most contusions that are visible only on a CT scan are not clinically
relevant, in that they are not large enough to impair gas exchange
and do not worsen outcome. Nevertheless, CT will accurately
reflect the extent of lung injury when pulmonary contusion is
present.

Management
Managment of pulmonary contusion is supportive while the
pulmonary contusion resolves. Most contusions will require no
specific therapy. However large contusions may affect gas
exchange and result in hypoxaemia. As the physiological impact of
the ocntusions tends to develop over 24-48 hours, close
monitoring is required and supplemental oxygen should be
administered.
Many of these patients will also have a significant chest wall injury,
pain from which will affect their ability to ventilate and to clear
secretions. Management of a blunt chest injury therefore includes
adequate and appropriate analgesia. Tracheal intubation and
mechanical ventilation may be necessary if there is difficulty in
oxygenation or ventilation. Usually ventilatory support can be
discontinued once the pulmonary contusion has resolved,
irrespective of the chest wall injury.
The classic management of pulmonary contusion includes fluid
restriction. Much of the data to support this comes from animal
models of isolated pulmonary contusion. However, while relative
fluid excess and pulmonary oedema will augment any respiratory
insufficience, the consequences of the opposite - hypovolaemia are
more severe and long-lasting. Prolonged episode of hypoperfusion
in trauma patients will result in inflammatory activation and acute
lung injury, and may result in ARDS and multiple organ failure.
Hence the goal for management of patients with pulmonary
contusion should be euvolaemia.

Complications
Pulmonary contusions will usually resolve in 3 to 5 days, provided
no secondary insult occurs. The main complications of pulmonary
contusion are ARDS and pneumonia. Approximately 50% of
patients with pulmonary contusion develop ARDS, and 80% of
patients with pulmonary contusions involving over 20% of lung
volume. Direct lung trauma, alveolar hypoxia and blood in the
alveolar spaces are all major activators of the inflammatory
pathways that result in acute lung injury.
Pneumonia is also a common complication of pulmonary contusion,
blood in the alveolar spaces providing an excellent culture medium

R pulmonary contusion
(Chest wall injury)

ARDS after
R pulmonary contusions

for bacteria. Clearance of secretions is decreased with pulmonary

contusion, and this is augmented by any chest wall injury and
mechanical ventilation. Good tracheal toilet and pulmonary care is
essential to minimise the incidence of pneumonia in this
susceptible group.

References
Cohn SM. 'Pulmonary contusion: review of the clinical entity.'
J Trauma 1997; 42:973979
Trinkle JK, Furman RW, Hiushaw MA et al. 'Pulmonary contusion:
pathogenesis and effect of various resuscitative measures.'
Ann Thorac Surg 1973;16:568
Bongard FS, Lewis FR. 'Crystalloid resuscitation of patients
with pulmonary contusion.' Am J Surg 1984;148:145
Miller PR, Croce MA, Kilgo PD et al. 'Acute respiratory distress
syndrome in blunt trauma: identification of independent risk
factors.' Am Surg 2002;68:845-50
Miller PR, Croce MA, Bee TK et al. 'ARDS after pulmonary
contusion: accurate measurement of contusion volume
identifies high-risk patients.' J Traum 2001;51(2):223-8
Tyburski JG, Collinge JD, Wilson RF et al. 'Pulmonary contusions:
quantifying the lesions on chest X-ray films and the factors
affecting prognosis.' J Trauma 1999;46(5):833-8

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Blunt Chest Trauma

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Synonyms and related keywords: motor vehicle accidents, MVAs, car accident, falls, blast
injuries, blast injury, violence, chest wall fracture, dislocation, barotrauma, diaphragmatic injuries,
diaphragmatic injury, pneumothorax, hemothorax, hemopneumothorax, broken rib, cracked rib, rib
fracture, flail chest, clavicular fracture, clavicle fracture, sternoclavicular joint dislocation, sternal
fracture, scapular fractures, scapula fracture, traumatic asphyxia, scapulothoracic dissociation,
pulmonary contusion, parenchymal injuries, parenchymal injury, parenchyma injury, tracheal
injuries, tracheal injury, trachea injury, bronchial injuries, esophageal injuries, esophageal injury,
esophagus injury, myocardial injuries, myocardium injury, myocardial injury, chylothorax, blunt
thoracic injury, chest trauma, thoracic trauma, chest injury, thoracic injury, broken collar bone,
collar bone fracture, flail shoulder

AUTHOR INFORMATION

Section 1 of 11

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Treatment Complications Outcome And Prognosis Future And Controversies Pictures Bibliography

Author Informa
Introduction
Relevant Anato
Workup
Indications And
Contraindicatio
Blunt Thoracic
Injuries And Th
Treatment
Complications
Outcome And
Prognosis
Future And
Controversies
Pictures
Bibliography

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Author: Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of

Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial
Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Coauthor(s): Elizabeth M Sawyer, MD, MAJ, MC, Consulting Surgeon, Chief,
Department of Specialty Care, Reynolds Army Community Hospital, Fort Sill, Oklahoma;
David Jablons, MD, Chief, Section of Thoracic Surgery, Associate Professor, Department
of Surgery, University of California at San Francisco Medical Center; Jasleen Kukreja,
MD, MPH, Staff Physician, Division of Cardiothoracic Surgery, University of California
San Francisco Medical Center
Michael AJ Sawyer, MD, is a member of the following medical societies: American
College of Surgeons, Society for Surgery of the Alimentary Tract, Society of
American Gastrointestinal Endoscopic Surgeons, and Society of
Laparoendoscopic Surgeons
Editor(s): Benson B Roe, MD, Emeritus Chief, Division of Cardiothoracic Surgery,
Emeritus Professor, Department of Surgery, University of California at San
Francisco Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy
Editor, eMedicine; Shreekanth V Karwande, MBBS, Chair, Professor,
Department of Surgery, Division of Cardiothoracic Surgery, University of Utah
School of Medicine and Medical Center; Paolo Zamboni, MD, Professor of
Surgery; Chief, Day Surgery Unit; Director, Vascular Diseases Center, University
of Ferrara, Italy; and Mary C Mancini, MD, PhD, Professor of Surgery, Director of
Cardiothoracic Transplantation, Department of Surgery, Louisiana State University
Health Sciences Center
Disclosure

INTRODUCTION

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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, sternum),
lungs and pleurae, tracheobronchial tree, esophagus, heart, 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

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diagnostic and treatment measures are outlined.

Historical perspective
Records describing chest trauma and its treatment date to antiquity. An ancient Egyptian
treatise (the Edwin Smith Surgical Papyrus [circa 3000-1600 BC]) and Hippocrates' writings
in the 5th century contain a series of trauma case reports, including thoracic injuries.
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 1985 statistics, approximately 94,000 accidental deaths occur
annually in the United States.
Frequency
Trauma is responsible for 100,000 deaths annually in the United States. Estimates of thoracic
trauma frequency indicate that injuries occur in 12 persons per million population per day.
Approximately 33% of these injuries require hospital admission. Overall, blunt thoracic
injuries are directly responsible for 20-25% 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, 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.
Space-occupying lesions, such as pneumothoraces, hemothoraces, and

hemopneumothoraces, interfere with oxygenation and ventilation by compressing otherwise

healthy lung parenchyma. A situation of 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. Following 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 with a 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, the authors divide blunt thoracic injuries into 3 broad
categories as follows: (1) chest wall fractures, dislocations, and barotrauma (including
diaphragmatic injuries); (2) blunt injuries of the pleurae, lungs, and aerodigestive tracts; and
(3) 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

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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 comprise
the brachial plexus also access the upper extremities via the thoracic outlet. The veins that
drain the arm, most importantly 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 3 lobes, and the left lung has 2 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 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 (remnant of ductus arteriosus) exists between the
descending thoracic aorta and pulmonary artery just beyond the take-off 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

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Initial emergency workup of a patient with multiple injuries should begin with the ABCs of
trauma, with appropriate intervention taken for each step. Additional workup includes the
following:

Lab studies
Complete blood cell count
A complete blood cell (CBC) count is a routine laboratory test for most trauma patients. The
CBC count helps gauge blood loss, although 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
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.
Serum chemistry profile
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.
Coagulation profile
The coagulation profile, including prothrombin time/activated partial thromboplastin time,
fibrinogen, fibrin degradation product, and D-dimer analyses, can be helpful in the
management of patients who receive massive transfusions (eg, >10 U packed RBCs).

Patients who manifest hemorrhage that cannot be explained by surgical causes should also
have their profile monitored.
Serum troponin levels
The rate of cardiac injury in patients with blunt chest trauma varies widely depending upon
the diagnostic criteria. Troponin is a protein specific to cardiac cells. While 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. As
such, troponin I level determination does not, by itself, help predict the occurrence of
complications that may require admission to the hospital. Accordingly, their routine use in
this clinical situation is not well supported.
Serum myocardial muscle creatine kinase isoenzyme levels
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 recently been criticized because of poor
sensitivity, specificity, and positive predictive value in relation to clinically significant blunt
myocardial injuries.
Serum lactate levels
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.
Blood type and crossmatch
Type and crossmatch are some of 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.

Imaging studies
Chest radiographs
The chest radiograph (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 should be immediately decompressed before obtaining a chest
radiograph.
Chest CT scan
Due to lack of sensitivity of chest radiography to identify significant injuries, computed
tomography (CT) scan 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 scan. As a result, obtaining a chest CT scan
in a supposedly stable patient with significant mechanism of injury is becoming routine
practice.
Helical CT scanning 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.
Aortogram
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, with the new generation spiral CT
scanners, which have 100% sensitivity and greater than 99% specificity, the role of
aortography in the evaluation of trauma patients is declining. 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.
Thoracic ultrasound
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 ultrasound in
these settings are all more than 90%.
Contrast esophagogram
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 the Sonographic Examination of the 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.

Diagnostic tests and procedures

Twelve-lead electrocardiogram
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.
Transesophageal 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%. Its advantages 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.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
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.
Flexible or rigid 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.
Fiberoptic or rigid 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

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Indications

Operative intervention is rarely necessary in blunt thoracic injuries. In one report, only 8% of cases with blunt
injuries required an operation. Most can be treated with supportive measures and simple interventional proced
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 requiring a
immediate operation and those in which surgery is needed for delayed manifestations or complications of traum
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) blun
diaphragmatic injuries.

Relatively immediate and long-term indications for surgery include (1) delayed recognition of blunt diaphragm
injury and (2) the development of a traumatic diaphragmatic hernia.
Blunt injuries of the 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 inser
continued loss of 250 mL/h for 3 consecutive hours); (3) radiographically or endoscopically confirmed trachea
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 fibroth

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 persisten
thoracic duct fistula/chylothorax.
Blunt injuries of the heart, great arteries, veins, and lymphatics

Indications for immediate surgery include (1) cardiac tamponade, (2) radiographic confirmation of a great vess
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
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
blood loss via chest tube).

A controversial area has been the use of ED thoracotomy in patients with blunt trauma presenting without vita
The results of this approach in this particular patient population have been dismal and have led many authors t
condemn it.
BLUNT THORACIC INJURIES AND THEIR TREATMENT

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Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injurie

Rib fractures

Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients us
report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tende
and crepitus over the site of the fracture. If a pneumothorax is present, breath sounds may be decreased and res
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. Frac
ribs 8-12 should raise the suggestion of associated abdominal injuries. Lee and colleagues reported a 1.4- and
increase in the incidence of splenic and hepatic injury, respectively, in those with rib fractures.

Elderly patients with 3 or more rib fractures have been shown to have a 5-fold increased mortality rate and a 4
increased incidence of pneumonia. Effective pain control is the cornerstone of medical therapy for patients wit
fractures. For most patients, this consists of oral or parenteral analgesic agents. Intercostal nerve blocks may b
feasible for those with severe pain who do not have numerous rib fractures. A local anesthetic with a relatively
duration of action (eg, bupivacaine) can be used. Patients with multiple rib fractures whose pain is difficult to
can be treated with epidural analgesia.

Adjunctive measures in the care of these patients include early mobilization and aggressive pulmonary toilet. R
fractures do not require surgery. Pain relief and the establishment of adequate ventilation are the therapeutic go
this injury. Rarely, a fractured rib lacerates an intercostal artery or other vessel, which requires surgical control
achieve hemostasis acutely. In the chronic phase, nonunion and persistent pain may also require an operation.
Flail chest

A flail chest, by definition, involves 3 or more consecutive rib fractures in 2 or more places, which produces a
floating, unstable segment of chest wall. Separation of the bony ribs from their cartilaginous attachments, term
costochondral separation, can also cause flail chest. Patients report pain at the fracture sites, pain upon inspirat
and, frequently, dyspnea. Physical examination reveals paradoxical motion of the flail segment. The chest wall
inward with inspiration and outward with expiration. Tenderness at the fracture sites is the rule. Dyspnea, tach
and tachycardia may be present. The patient may overtly exhibit labored respiration due to the increased work
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
should be aggressively sought. The clinician should specifically be aware of the high incidence of associated th
injuries such as pulmonary contusions and closed head injuries, which, in combination, significantly increase t
mortality associated with flail chest.

All of the treatment modalities mentioned above for patients with rib fractures are appropriate for those with fl
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 contusio
may necessitate endotracheal intubation and positive pressure mechanical ventilation. Intravenous fluids are
administered judiciously because fluid overloading can precipitate respiratory failure, especially in patients wi
significant pulmonary contusions.

In an attempt to stabilize the chest wall and to avoid endotracheal intubation and mechanical ventilation, vario
operations have been devised for correcting flail chest. These include pericostal sutures, the application of exte
fixation devices, or the placement of plates or pins for internal fixation. With improved understanding of pulm
mechanics and better mechanical ventilatory support, surgical therapy has not been proven superior to the supp
and medical measures discussed. However, most authors would agree that stabilization is warranted if a thorac
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
transfer required to injure these sturdy and well-protected structures. First and second rib fractures are harbing
associated cranial, major vascular, thoracic, and abdominal injuries. The clinician should aggressively seek to
the presence of these other injuries.

Pain control and pulmonary toilet are the specific treatment measures for rib fractures. First and second rib fra
do not require surgical therapy. An exception to this would be the need to excise a greatly displaced bone fragm
Clavicular fractures

Clavicular fractures are one of the most common injuries to the shoulder girdle area. Common mechanisms inc
direct blow to the shaft of the bone, a fall on an outstretched hand, or a direct lateral fall against the shoulder.
Approximately 75-80% of clavicular fractures occur in the middle third of the bone. Patients report tenderness
the fracture site and pain with movement of the ipsilateral shoulder or arm.

Physical findings include anteroinferior positioning of the ipsilateral compared to the contralateral arm. The pr
segment of the clavicle is displaced superiorly because of the action of the sternocleidomastoid muscle.

Nearly all clavicular fractures can be managed without surgery. Primary treatment consists of immobilization w
figure-of-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 displace
fracture.
Sternoclavicular joint dislocations

Strong lateral compressive forces against the shoulder can cause sternoclavicular joint dislocation. Anterior dis
of the joint is more common than posterior dislocation. Patients report pain with arm motion or when a compre
force is applied against the affected shoulder. The ipsilateral arm and shoulder may be anteroinferiorly displac
anterior dislocations, the medial end of the clavicle can become more prominent. In posterior dislocations, a
depression may be discernible adjacent to the sternum. Associated injuries to the trachea, subclavian vessels, o
brachial plexus can occur with posterior dislocations.

Closed or open reduction is generally advised. Treatment strategies depend on whether the patient has an anter
posterior dislocation. For anterior dislocations, local anesthesia and sedative medications are administered, and
traction is applied to the affected arm that is placed in abduction and extension. This maneuver, combined with
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 m
traction to reduce the joint. Proper levels of pain control, up to and including general anesthesia, are provided.
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 affec
transverse fashion. Patients report pain around the injured area. Inspiratory pain or a sense of dyspnea may be
Physical examination reveals local tenderness and swelling. Ecchymosis is noted in the area around the fractur
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 ar
fractures, long bone fractures, and closed head injuries. The association of blunt cardiac injuries with sternal fr
has been a source of great debate. Blunt cardiac injuries are diagnosed in fewer than 20% of patients with stern
fractures. Caution should be used before completely excluding myocardial injury. The workup should begin w
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.

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 su
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 produc
and the attendant high incidence of associated injuries. The rate of associated injuries is 75-100%, most comm
involving the head, chest, or abdomen.

Patients with scapular fractures report pain around the scapula. Tenderness, swelling, ecchymosis, and fracture
crepitus can all be present. The fracture is most frequently located in the body or neck of the scapula. More tha
of scapular fractures are missed during the initial patient evaluation. The discovery of a scapular fracture shoul
prompt a concerted effort to exclude major vascular injuries and injuries of the thorax, abdomen, and neurovas
bundle of the ipsilateral arm.

Shoulder immobilization is the standard initial treatment. This can be accomplished by placing the arm in a sli
shoulder harness. Range-of-motion exercises are started as soon as possible to help prevent loss of shoulder m
Surgery is infrequently indicated. Involvement of the glenoid, acromion, or coracoid may require open reducti
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 ot
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 ed
the shoulder area. Neurologic deficits include loss of sensation and motor function distal to the shoulder. Pulse
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
course of this injury. If the affected limb retains sufficient neurovascular integrity and function, operative fixat
be indicated to restore shoulder stability. Many scapulothoracic dissociations result in a flail limb that is insens
associated with severe pain due to proximal brachial plexus injury. An above-the-elbow amputation may be the
approach for these patients.
Chest wall defects

The management of large, open chest wall defects initially requires irrigation and debridement of devitalized t
avoid progression into a necrotizing wound infection. Once the infection is under control, subsequent treatmen
depends on the severity and level of defect. Reconstructive options range from skin grafting to well vasculariz
to a variety of meshes with or without methylmethacrylate. The choice of reconstruction depends upon the dep
the defect.
Traumatic asphyxia

This curious clinical constellation is the result of thoracic injury due to a strong crushing mechanism, as might
when an individual is pinned under a very heavy object. Some effects of the injury are compounded if the glot
closed during application of the crushing force. Patients present with cyanosis of the head and neck, subconjun
hemorrhage, periorbital ecchymosis, and petechiae of the head and neck. The face frequently appears very ede
or moonlike. Epistaxis and hemotympanum may be present. A history of loss of consciousness, seizures, or bli
may be elicited. Neurologic sequelae are usually transient. Recognition of this syndrome should prompt a sear
associated thoracic and abdominal injuries.

The head of the patient's bed should be elevated to approximately 30 to decrease transmission of pressure to t
Adequate airway and ventilatory status must be assured, and the patient is given supplemental oxygen. Serial
neurological examinations are performed while the patient is monitored in an intensive care setting. No specifi
surgical therapy is indicated for traumatic asphyxia. Associated injuries to the torso and head frequently requir
surgical intervention.
Blunt diaphragmatic injuries

Diaphragmatic injuries are relatively uncommon. Blunt mechanisms, usually a result of high-speed MVAs, cau
approximately 33% of diaphragmatic injuries. Most diaphragmatic injuries recognized clinically involve the le
although autopsy and CT scanbased investigations suggest a roughly equal incidence for both sides. This inju
should be considered in patients who sustain a blow to the abdomen and present with dyspnea or respiratory di
Because of the very high incidence of associated injuries, eg, major splenic or hepatic trauma, it is not unusual
these patients to present with hypovolemic shock.

Most diaphragmatic injuries are diagnosed incidentally at the time of laparotomy or thoracotomy for associate
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, C
is not very accurate, and MRI is not very realistic. Bedside emergency ultrasonography is gaining popularity, a
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 appro
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
is best approached through the chest because the liver obscures the abdominal approach. Most injuries can be r
primarily with a continuous or interrupted braided suture (1-0 or larger). Centrally located injuries are most ea
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.

Blunt injuries of the pleurae, lungs, and aerodigestive tracts

Pneumothorax

Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib penetrates the lung
parenchyma. This is not absolute. Pneumothoraces can result from deceleration or barotrauma to the lung with
associated rib fractures.

Patients report inspiratory pain or dyspnea and pain at the sites of the rib fractures. Physical examination demo
decreased breath sounds and hyperresonance to percussion over the affected hemithorax. In practice, many pat
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
trauma need a tube thoracostomy. The chest tube is connected to a collection system (eg, Pleur-evac) that is en
to suction at a pressure of approximately -20 cm water. The tube continues suctioning until no air leak is detec
tube is then disconnected from suction and placed to water seal. If the lung remains fully expanded, the chest t
be removed and another chest radiograph obtained to ensure continued complete lung expansion.
Hemothorax

The accumulation of blood within the pleural space can be due to bleeding from the chest wall (eg, lacerations
intercostal or internal mammary vessels attributable to fractures of chest wall elements) or to hemorrhage from
lung parenchyma or major thoracic vessels. Patients report pain and dyspnea. Physical examination findings va
the extent of the hemothorax. Most hemothoraces are associated with a decrease in breath sounds and dullness
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 using tube thoracostomy. Multiple chest tubes may be required. Pain control and
aggressive pulmonary toilet are provided. The chest tube output is monitored closely because indications for su
can be based on the initial and cumulative hourly chest tube drainage. This is because massive initial output an
continued high hourly output are frequently associated with thoracic vascular injuries that require surgical
intervention. Guidelines are provided in the Indications section (see Blunt injuries of the pleurae, lungs, and
aerodigestive tracts.

Large, clotted hemothoraces may require an operation for evacuation to allow full expansion of the lung and to
the development of other complications such as fibrothorax and empyema. Thoracoscopic approaches have be
successfully in the management of this problem.
Open pneumothorax

This injury is more commonly caused by penetrating mechanisms but may rarely occur with blunt thoracic trau
Patients are typically in respiratory distress due to collapse of the lung on the affected side. Physical examinati
should reveal a chest wall defect that is larger than the cross-sectional area of the larynx. The affected hemitho
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 leadin
hemodynamic instability.

Treatment for an open pneumothorax consists of placing a 3-way occlusive dressing over the wound to preclud
continued ingress of air into the hemithorax and to allow egress of air from the chest cavity. A tube thoracostom

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 ope
wound debridement and closure. Those with loss of large chest wall segments may need reconstruction and clo
with prosthetic devices such as polytetrafluoroethylene patches. Patch placement can serve as definitive therap
a bridge to formal closure with rotational or free tissue flaps. With low chest wall injuries, some authors descri
detaching the diaphragm, with operative reattachment at a higher intrathoracic level. This converts the open ch
wound into an open abdominal wound, which is easier to manage.

Traumatic pulmonary herniation through the ribs, though uncommon, may occur following chest trauma. Unle
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 pneumothora
However, with a tension pneumothorax, air continues to leak from an underlying pulmonary parenchymal inju
increasing pressure within the affected hemithorax. Patients are typically in respiratory distress. Breath sounds
severely diminished to absent, and the hemithorax is hyperresonant to percussion. The trachea is deviated awa
the side of the injury. The mediastinal contents are shifted away from the affected side. This results in decrease
venous return of blood to the heart. The patient exhibits signs of hemodynamic instability, such as hypotension
can rapidly progress to complete cardiovascular collapse.

Immediate therapy for this life-threatening condition includes decompression of the affected hemithorax by ne
thoracostomy. A large-bore needle (ie, 14- to 16-gauge) 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 pu
contusion, as characterized by development of pulmonary infiltrates with hemorrhage into the lung tissue. Clin
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. Othe
parenchymal injuries (eg, lacerations) can be produced by fractured ribs and, rarely, by deceleration mechanism

Pain control, pulmonary toilet, and supplemental oxygen are the primary therapies for pulmonary contusions a
parenchymal injuries. If the injury involves a large amount of parenchyma, significant pulmonary shunting and
space ventilation may develop, necessitating endotracheal intubation and mechanical ventilation. Laceration o
avulsion injuries that cause massive hemothoraces or prolonged high rates of bloody chest tube output may req
thoracotomy for surgical control of bleeding vessels. If central bleeding is identified during thoracotomy, hilar
is gained first. Once the extent of injury is confirmed, it may become necessary to perform a pneumonectomy,
in mind that trauma pneumonectomy is generally associated with a high mortality rate (>50%).
Blunt tracheal injuries

While incidence of blunt tracheobronchial injuries is rare (1-3%), most patients with these injuries die before r

the hospital. These injuries include fractures, lacerations, and disruptions. Blunt trauma most often produces fr
These injuries are devastating and are frequently caused by severe rapid deceleration or compressive forces ap
directly to the trachea between the sternum and vertebrae. Patients are in respiratory distress. They typically ca
phonate and frequently present with stridor. Other physical signs include an associated pneumothorax and mas
subcutaneous emphysema.

Blunt tracheal injuries are immediately life threatening and require surgical repair. Bronchoscopy is required to
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 pref
route if feasible. This can be facilitated by arming a flexible bronchoscope with an endotracheal tube and perfo
the intubation under direct bronchoscopic guidance. The tube must be placed distal to the site of injury. Alway
prepared to perform an emergent 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 restora
airway continuity with a primary end-to-end anastomosis. Defects of 3 cm or larger frequently require proxima
distal mobilization of the trachea to reduce tension on the anastomosis. The type of incision made for repairing
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 pati
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
are severely diminished to absent, and the hemithorax is hyperresonant to percussion. Subcutaneous emphysem
be present and may be massive. Hemodynamic instability may be present and is caused by tension pneumotho
massive blood loss from associated injuries.

Laceration, tear, or disruption of a major bronchus is life threatening. These injuries require surgical repair. As
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 patien
cannot tolerate this and require jet-insufflation techniques. Operative repair consists of debridement of the inju
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 thi
are rare. Blunt esophageal injuries are usually caused by a sudden increase in esophageal luminal pressure resu
from a forceful blow. Injury occurs predominantly in the cervical region; rarely, intrathoracic and subdiaphrag
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 significa
after the injury may manifest signs and symptoms of systemic sepsis.

General medical supportive measures are appropriate. Fluid resuscitation and broad-spectrum intravenous anti
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 s
choose to reinforce these repairs with autologous tissue. Wide mediastinal drainage is established with multipl
tubes. If more than 24 hours have passed since injury, primary repair buttressed by well-vascularized autologo
is still the best option if technically feasible. Examples of tissues used to reinforce esophageal repairs include p
pleura and intercostal muscle. Very distal esophageal injuries can be covered with a tongue of gastric fundus. T
called a Thal patch.

For patients in poor general condition and those with advanced mediastinitis or severe associated injuries, esop
exclusion and diversion is the most prudent choice. A cervical esophagostomy is made, the distal esophagus is
the stomach is decompressed via gastrostomy, and a feeding jejunostomy tube is placed. Wide mediastinal drai
established with multiple chest tubes.

Blunt injuries of the heart, great arteries, veins, and lymphatics

Blunt pericardial injuries

Isolated blunt pericardial injuries are rare. Blunt mechanisms produce pericardial tears that can result in hernia
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 arrhythm
rupture of the valve mechanisms, interventricular septum, or myocardium (cardiac chamber rupture). Therefor
patients can be asymptomatic or can manifest signs and symptoms ranging from chest pain to cardiac tampona
muffled heart tones, jugular venous distension, hypotension) to complete cardiovascular collapse and shock du
rapid exsanguination.

Many patients with blunt cardiac injuries do not require specific therapy. Those who develop an arrhythmia are
with the appropriate antiarrhythmic drug. Elaboration on these drugs and their administration is beyond the sco
this article.

Patients with severe blunt cardiac injuries who survive to reach the hospital require surgery. Most patients in th
group have cardiac chamber rupture due to a high-speed MVA. The right side involvement is most common, in
the right atrium and right ventricle. They present with signs and symptoms of cardiac tamponade or exsanguin
hemorrhage. A few may be stable initially, resulting in delayed diagnosis. Those with tamponade benefit from
pericardiocentesis or surgical creation of a subxiphoid window. The next step is to repair the cardiac chamber b
cardiorrhaphy. Cardiopulmonary bypass techniques can facilitate this procedure. Unstable patients may benefi
insertion of an intra-aortic counterpulsation balloon pump.

Commotio cordis or sudden cardiac death in an otherwise healthy individual generally results from participatio
sporting event or some form of recreational activity. It is a direct result of blow to the heart just before the T-w
resulting in ventricular fibrillation. Survival is not unheard of, if resuscitation and defibrillation are started wit
minutes. Preventive strategies include chest protective gear during sporting activities.
Blunt injuries of the thoracic aorta and major thoracic arteries

High-speed MVAs are the most common cause of blunt thoracic aortic injuries and blunt injuries of the major
arteries. Falls from heights and MVAs involving a pedestrian are other recognized causes. The mechanisms of
are rapid deceleration, production of shearing forces, and direct luminal compression against points of fixation
(especially at the ligamentum arteriosum). Many of these patients die from vessel rupture and rapid exsanguin
the scene of the injury or before reaching definitive care. Blunt aortic injuries follow closely behind head injur
cause of death after blunt trauma.

Important historical details include the exact mechanism of injury and estimates of the amount of energy trans
the patient (eg, magnitude of deceleration). Other important details include whether the victim was ejected fro
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 fracture
sternal fractures, steering wheel imprint), hypotension, upper extremity blood pressure differential, loss of upp
lower extremity pulses, and thoracic spine fractures. Signs of cardiac tamponade may be present. Decreased br
sounds and dullness to percussion due to massive hemothorax can also be found. Up to 50% of patients with th
devastating, life-threatening injuries have no overt external signs of injury. Therefore, a high index of suspicio
warranted for earlier intervention.

The management of these injuries, especially those of the thoracic aorta, is evolving. Many patients have delay
repair of contained descending thoracic aortic ruptures. This approach is most frequently used when severe ass
injuries are present that require urgent correction.

Temporizing medical therapy includes the administration of short-acting beta-blocking agents (eg, labetalol, es
to control the heart rate and to decrease the mean arterial pressure to approximately 60 mm Hg. Because repair
thoracic aortic injuries using cardiopulmonary bypass is associated with fewer major neurologic complications
authors advocate stabilization of the victim plus beta-blocker administration until transfer is feasible to a facili
where the injury can be repaired using cardiopulmonary bypass or centrifugal pump techniques. These techniq
maintain distal aortic perfusion. Results have been excellent, and postoperative paraplegia rates have been
significantly reduced.

Endovascular stent grafts are being developed to repair thoracic aortic injuries. While several authors have rep
success in treating such injuries with endo stents, the long-term durability of the stents is yet unknown. Furthe
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 o
Many require only lateral arteriorrhaphy. Large injuries of the innominate artery are managed first by placeme
bypass graft from the ascending aorta to the distal innominate artery. The injury is then approached directly an
oversewn or patched.

Proximal pulmonary arterial injuries are relatively easy to repair when in an anterior location. Posterior injurie
frequently require cardiopulmonary bypass. Pulmonary hilar injuries present the possibility of rapid exsanguin
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
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
other major thoracic vascular structures. The clinical history, including mechanisms of injury, and physical
examination are similar to those presented in 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 impossib
injured subclavian or azygous veins can be ligated. Injuries of the thoracic inferior or superior vena cava may
shunt placement or cardiopulmonary bypass to facilitate repair.
Blunt injuries of the thoracic duct

Thoracic ductal injuries due to blunt mechanisms are rare. They are sometimes found in association with thora
vertebral trauma. No signs or symptoms are specific for this injury at presentation. The diagnosis is usually de
and is confirmed when a chest tube is inserted for a pleural effusion and returns chyle. This is termed a chyloth

Conservative management with chest tube drainage is successful in most cases, effecting closure of the ductal
without surgery. Chyle production can be decreased by maintaining the patient on total parenteral nutrition or b
providing enteral nutrition with medium-chain triglycerides as the fat source. If a fistula persists after an attem
nonoperative management, thoracotomy is performed to identify and ligate the fistula. This is usually advisabl
2-3 weeks of persistent drainage or if the total lymphocyte count dwindles. Provision of a meal high in fat con
ice cream) the night before the operation increases the volume of chyle and facilitates identification of the fistu

General preoperative details

Patients with immediately life-threatening injuries that require surgery cannot afford a protracted workup. At
minimum, they must have their airway, breathing, and circulation (ABCs) established. Frequently, resuscitatio
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. Based
mechanism of injury, clinical history, and physical findings, a search is conducted to exclude associated injurie
Diagnostic procedures are completed if time and the patient's condition permit (eg, cervical spine x-ray films,
scan, chest and abdominal CT scan, FAST examination). Blood is drawn and sent for typing, crossmatching, a
tests (eg, CBC count, ABG values).

General intraoperative details

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 seve

injury, preoperative functional status, and anticipated length of the operation. Some injuries may require the us
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 incis
very important. Median sternotomy is used to access the heart, intrapericardial portion of the pulmonary vesse
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 ao
right subclavian artery is exposed via a median sternotomy that is extended into the neck. Proximal control for
subclavian artery is achieved through an anterolateral left thoracotomy in the third intercostal space. Distal con
this vessel is obtained through a supraclavicular incision.

The distal esophagus can be approached via a left posterolateral thoracotomy; more proximal injuries require a
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. In
to the proximal 2 thirds of the trachea are best approached through a collar incision and extension via a T-incis
through the manubrium, which allows exposure to the mid and distal trachea. Injuries of the distal trachea, car
right main stem bronchus are best approached through right fourth intercostals posterolateral thoracotomy. Inju
the left mainstem bronchus are best approached through a left posterolateral thoracotomy.

General postoperative details

Patients are extubated as soon as feasible in the postoperative period. Monitoring devices are kept in place whi
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
can be fed. Patients with severe associated injuries, especially those in a coma, may require prolonged enteral
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 ne
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 expand
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.

General follow-up care

After discharge, patients are monitored to ensure 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 excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center and Procedures Cente
see eMedicine's patient education articles Bruises and Bronchoscopy.
COMPLICATIONS

Section 7 of 11

Author Information Introduction Relevant Anatomy Workup Indications And Contraindications Blunt Thoracic Injuries And Their Treatment Complications Outco
And Prognosis Future And Controversies Pictures Bibliography

Patients with blunt thoracic trauma are subject to myriad complications during the course of their care. This se
outlines most major complications that may occur.
Wound

Wound infection
Wound dehiscence - Particularly problematic in sternal wounds

Cardiac

Myocardial infarction
Arrhythmias
Pericarditis
Ventricular aneurysm formation
Septal defects
Valvular insufficiency

Pulmonary and bronchial

Atelectasis
Pneumonia
Pulmonary abscess
Empyema
Pneumatocele, lung cyst
Clotted hemothorax
Fibrothorax
Bronchial repair disruption
Bronchopleural fistula

Vascular

Graft infection
Pseudoaneurysm
Graft thrombosis
Deep venous thrombosis
Pulmonary embolism

Neurological

Causalgia - Injuries that involve the brachial plexus

Paraplegia - Spinal cord at risk during repair of ruptured thoracic aorta
Stroke

Esophageal

Leakage of repair
Mediastinitis
Esophageal fistula
Esophageal stricture - Late

Bony skeleton

Skeletal deformity
Chronic pain
Impaired pulmonary mechanics

OUTCOME AND PROGNOSIS

Section 8 of 11

Author Information Introduction Relevant Anatomy Workup Indications And Contraindications Blunt Thoracic Injuries And Their Treatment Complications Outco
And Prognosis Future And Controversies Pictures Bibliography

The outcome and prognosis for the great majority of patients with blunt chest trauma are excellent. Most (>80%
require either no invasive therapy or, at most, a tube thoracostomy to effect resolution of their injuries. The mo
important determinant of outcome is the presence or absence of significant associated injuries of the central ne
system, abdomen, and pelvis.

Some injuries, such as cardiac chamber rupture, thoracic aortic rupture, injuries of the intrathoracic inferior an
superior vena cava, and delayed recognition of esophageal rupture, are associated with high morbidity and mo
rates.
FUTURE AND CONTROVERSIES

Section 9 of 11

Author Information Introduction Relevant Anatomy Workup Indications And Contraindications Blunt Thoracic Injuries And Their Treatment Complications Outco
And Prognosis Future And Controversies Pictures Bibliography

Future directions for improving the diagnosis and management of blunt thoracic trauma involve diagnostic tes
endovascular techniques, and patient selection.

The use of thoracoscopy for the diagnosis and management of thoracic injuries will increase. Also, ultrasound
the diagnosis of conditions such as hemothorax and cardiac tamponade will become more widespread. Finally,
CT scanning techniques will be used more frequently for definitive diagnosis of major vascular lesions (eg, inj
the thoracic aorta and its branches).

Endovascular techniques for the repair of great vessel injuries will be developed further and applied more freq
Also, patient selection and nonsurgical therapies for delayed operative management of thoracic aortic rupture w
refined.
PICTURES

Section 10 of 11

Author Information Introduction Relevant Anatomy Workup Indications And Contraindications Blunt Thoracic Injuries And Their Treatment Complications Outco
And Prognosis Future And Controversies Pictures Bibliography

Caption: Picture 1. Left pulmonary contusion following a motor vehicle accident

involving a pedestrian.
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Picture Type: X-RAY
BIBLIOGRAPHY

Section 11 of 11

Author Information Introduction Relevant Anatomy Workup Indications And Contraindications Blunt Thoracic Injuries And Their Treatment Complications Outco
And Prognosis Future And Controversies Pictures Bibliography

Adams JE 3rd, Davila-Roman VG, Bessey PQ, et al: Improved detection of cardiac contusion
cardiac troponin I. Am Heart J 1996 Feb; 131(2): 308-12[Medline].
Ahrar K, Smith DC, Bansal RC, et al: Angiography in blunt thoracic aortic injury. J Trauma 199
42(4): 665-9[Medline].
Ansari MZ, Chaudhry MA, Singal A, Joshi R: Unusual cardiac injury following blunt chest traum
J Emerg Med 2001 Sep; 8(3): 229-31[Medline].

Ben-Menachem Y: Assessment
http://www.emedicine.com/med/topic3658.htm

Pulmonary Contusion
Bruising of the lung results from passage of a shock wave through the tissue.
Microscopic disruption occurs at any air-tissue interface of which the lungs have
plenty. Injuries involving high velocity rather than slow crushing are more likely to cause
pulmonary contusion.
Clinical Findings: Rales will often be heard. The chest x-ray shows opacity in the
peripheral lung near to the injured chest wall. The chest x-ray may lag 12-24 hours
behind the clinical extent of the contusion. Blood gases will tend to worsen for two or
three days as edema increases in the lung. Stiffness of the lung causes dyspnea and
elevated respiratory rate.
Diagnosis: The diagnosis is made when parenchymal infiltrate is seen adjacent to

injured chest wall. Pulmonary contusion may exist, however, despite a normal x-ray.
Treatment: Treat milder cases with oxygen and observation. If respiratory distress is
present, intubation and mechanical ventilation are beneficial while the lung recovers. Be
aggressive in treating patients who have pulmonary contusion combined with severe
abdominal injuries or COPD.
] http://www.madsci.com/manu/trau_che.htm#50
chest_trauma (p.point) http://www.iformix.com/spu/chest_trauma.ppt