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Maryland School of Medicine Baltimore, Maryland, USA; 2Assistant Professor of Surgery, R Adams Cowley Shock Trauma
Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
Abstract
Penetrating and blunt force mechanisms frequently result in thoracic trauma. Thoracic injuries cover the spectrum from trivial
to lethal, and more than half are associated with head, abdomen or extremity trauma. Fortunately over eighty percent of
injuries can be managed non-operatively utilizing tube thoracostomy, appropriate analgesia and aggressive respiratory therapy.
Patients requiring emergency thoracotomy are either in shock or have life threatening injuries and, as expected, have significant
mortality and morbidity. Injury to the thorax directly accounts for approximately 25% of trauma related mortality and is a
contributing factor in another 25%. Early mortality results from haemorrhage, catastrophic injury or associated head or
abdominal trauma. Not unexpectedly, late deaths are related to sepsis and organ failure.
Blunt injury to the thorax most commonly results from motor vehicle collisions, with motorcycle accidents, pedestrians
struck and falls next in frequency. Stab wound and gunshot wounds comprise the vast majority of penetrating injuries. In
general the mortality from penetrating injury is higher and related to vascular injury and shock. Mortality from blunt trauma
often results from abdominal and, especially, head injury.
Rapid assessment and interventions, such as tube thoracostomy and airway control, can be life saving. The patient’s
haemodynamic status drives early treatment, often necessitating emergency surgery. Detailed imaging studies are reserved for
haemodynamically stable patients. The evaluation and treatment of specific thoracic injuries will be discussed, as well as some
general principles in treating thoracic trauma.
Physical exam is often not rewarding but the presence of thoracostomy tube placement [7]. Although small spontaneous
distended neck veins, tracheal deviation, subcutaneous pneumothoraces may be managed by syringe aspiration, this is not
emphysema, chest wall instability, absent breath sounds or muffled recommended for traumatic pneumothoraces [8]. In contrast to
heart sounds may all provide crucial information. Vital signs non-occult pneumothoraces, a pneumothorax may be
should be frequently monitored with careful observation of asymptomatic and may not be seen on initial chest x-ray [9].
respiratory function and arterial saturation. An arterial blood gas Occult pneumothoraces are generally diagnosed on CT scan
should be sent with the initial laboratory studies, an during trauma evaluation and managed conservatively, with close
electrocardiogram and a portable chest radiograph (CXR) should observation and follow-up x-ray depending upon the patient’s
be obtained. A portable CXR yields rapid information about the accompanying injuries. It is estimated that 10% of occult
pleural space including pneumothorax or haemothorax, which pneumothoraces will later require thoracostomy tube placement
may require tube thoracostomy. A Focused Abdominal [10], and there is a fourfold increase when positive pressure
Sonography for Trauma (FAST) of the abdomen and precordium ventilation is needed [11]. Thus, trauma patients with non-occult
should be rapidly performed. The need, if any, for additional and occult pneumothoraces should prompt thoracostomy tube
imaging and/or procedures is driven by the patient’s placement when mechanical ventilation is needed.
cardiopulmonary stability, physical examination, laboratory and Despite the relative need for chest tube decompression, it is
radiographic findings. important that physicians remember thoracostomy tube placement
Penetrating thoracic trauma in a haemodynamically unstable has a 6-36% complication rate [12,13]. Complications include
patient warrants operative intervention. The only question is which empyema, improper tube positioning, parenchymal lung injury,
incision should be used (see below). This decision may be undrained effusion, haemothorax or pneumothorax [14].
problematic especially if there is concomitant abdominal or Moreover, these complications appear two to four times more often
extremity arterial injury. Clinical judgment is paramount in this when thoracostomy tubes are placed by non-surgeons [12]. The
situation. The haemodynamically stable patient may benefit from use of prophylactic antibiotics in patients with chest tubes is
additional imaging especially chest computed tomography which controversial and not advocated by most surgical societies (EAST
provides more detailed and organ specific information [2]. If Guidelines, 1998). In regards to risks versus benefits of
indicated an echocardiogram will provide detailed information thoracostomy tube placement, we advocate good judgment,
about cardiac function. Likewise, suspected airway or oesophageal appropriate diagnostics, careful evaluation of concomitant injuries
injury require endoscopic and/or dedicated contrast studies. and chest tube placement by well trained individuals.
Pathology
Pneumothorax
Pneumothorax is a common injury resulting from both penetrating
and blunt chest trauma. The incidence of pneumothorax after
major trauma is estimated at 20% with the predominate
mechanism being MVCs [3]. Air can collect in the pleural space
from the outside atmosphere through a penetrating wound or from
within the thorax due to airway or alveoli disruption. The
spectrum of symptoms varies from cardiovascular collapse with a
tension pneumothorax through to no symptoms at all with small
occult pneumothoraces. Diagnosis is generally made by physical
examination in conjunction with imaging such as CXR, CT scan
and bedside ultrasound [4]. Nevertheless, any pneumothorax has
the potential to cause respiratory compromise and possibly result in
a tension pneumothorax. This is especially true if positive pressure
ventilation is required. Therefore diagnostic decision making and
proper treatment is important (Figures 1 & 2).
Figure 1. Portable chest radiograph demonstrating a large right pneumothorax.
Development of a tension pneumothorax is potentially lethal,
and a medical emergency requiring immediate intervention. It is a
clinical diagnosis and should not wait for confirmation on CXR.
Shock, distended neck veins and unilateral absent breath sounds
are the hallmarks of a tension. Needle decompression can be life
saving and can be performed in the pre-hospital setting by placing
a large bore needle in the second intercostal space in the mid-
clavicular line. This will convert a tension pneumothorax to a
simple pneumothorax which warrants definitive treatment with a
tube thoracostomy. Rather than using standard needles and
angiocatheters which may not penetrate the chest wall of larger
muscular patients, new catheters (> 5cm in length) increases the
chance of decompression [5].
Pneumothoraces from penetrating trauma almost always require
thoracostomy tube placement. Similarly, a large pneumothorax or
a symptomatic blunt trauma patient will always require a
thoracostomy tube. Standard thoracostomy tube placement is
accomplished in the fifth or sixth intercostal space in the anterior
midaxillary line. Twenty percent of pneumothoraces have an
associated haemothorax and a relatively large bore chest tube (32-
40Fr) is recommended [6]. Although numerous studies advocate
conservative management of small (< 1.5cm on CXR) or anterior
Figure 2. Right tension pneumothorax. The mediastinum is shift to the left, away
pneumothoraces, close observation is time consuming, institution
from the side of the pneumothorax.
dependent and still results in 10% of patients requiring late
6 JR Army Med Corps 156(1): 5-14
Non-Cardiac Thoracic Trauma
Pulmonary Contusion
Pulmonary contusions can result from either blunt or penetrating
trauma. The former is the more common mechanism, especially
from MVCs [52,53]. Although present on CXR or CT scan,
pulmonary contusions range from clinically silent to those resulting
in respiratory compromise requiring mechanical ventilation
(Figures 7 & 8). Energy transmitted to the lung tissue occurs from
Figure 5. Portable chest film with non-displaced left rib fractures. rapid deceleration, compression, shear and inertial forces [54].
Haemorrhage and oedema result, with significant changes in the
Flail Chest alveolar architecture [54,55]. Decreased compliance, increased
More than one rib fracture in three or more adjacent ribs can work of breathing, and an increased intra-pulmonary shunt may
produce chest wall instability as a flail segment (Figure 6). lead to hypoxemia and respiratory distress. While several variables
Traditionally, it was believed that paradoxical movement of the flail have been studied to predict respiratory distress, the most useful
segment during inspiration created abnormal gas exchange one is the degree of hypoxia on admission. Treatment consists of
secondary to inefficient ventilation and increased work of analgesia for associated rib fractures, early mobilization, chest
breathing. It is now known that respiratory failure is secondary to physiotherapy and judicious fluid administration. Close
the underlying pulmonary contusion [44,45]. Inefficient monitoring of oxygen saturation and the work of breathing are
ventilation and clearance of secretions, due to associated fracture mandatory. Intubation and mechanical ventilation may be needed
pain, leads to increased shunting, hypoxemia and atelectasis. In in severe cases. Mortality is most often the result of associated
comparison to multiple rib fractures, flail chest is associated with injuries [56].
higher morbidity and mortality. Patients with flail segments have
longer hospital stays, more often require mechanical ventilation
and develop more respiratory complications when compared to
those with multiple rib fractures [46]. Flail chest is an independent
marker for poor outcome and should alert physicians to potential
pulmonary decompensation. Treatment of a flail chest is similar to
that for rib fractures; analgesia including an epidural, pulmonary
toilet and selective mechanical intubation are all important to
improved outcome. Avoiding mechanical ventilation in patients
who do not require it has resulted in improved outcomes [47], and
non-invasive positive pressure ventilation has also been shown to be
a useful modality [48].
Operative chest wall stabilization with absorbable and non-
absorbable plates have been advocated to provide early mechanical
stabilization [49,50]. While chest wall stabilization improves
pulmonary function tests at two months, there remain questions
concerning patient selection [51]. Operative chest wall stabilization
remains controversial and surgical solutions need to be
individualized. Figure 7. Large right upper lobe pulmonary contusion from a gunshot wound.
Ballistic fragments, endotracheal tube and tube thoracostomy are present.
Surgical Technique
Surgical Exposure
The thoracic cavity can be approached via multiple incisions, each
with its own advantages and disadvantages, and several variables
influence the choice of incision. Haemodynamically unstable
patients may not tolerate lateral positioning, as it may exacerbate
pre-existing hypotension. Also, in unstable patients the only
imaging is the portable chest radiograph thereby limiting the
clinician’s knowledge of possible mediastinal involvement, the
projectile’s path and additional cavitary involvement. The choice of
incision in the stable patient is simplified since more detailed
information can be obtained from CT scans. With penetrating
thoracic trauma there is the possibility of injury in other body
regions such as the abdomen and neck and so a thoracic incision
must be versatile. Lastly, the surgeon’s experience and comfort with
the various incisions needs to be considered.
The most commonly employed incisions are antero-lateral,
postero-lateral, bilateral anterior thoracotomies (“clamshell”) and
Figure 10. Standard postero-lateral thoracotomy. While this approach provides
median sternotomy. The antero-lateral approach is rapid, can be excellent exposure its utility in emergent thoracic surgery is limited.
commonly post-operative haemorrhage, empyema and wound portion or near the carina; penetrating injuries may occur
infection [69]. anywhere along the trachea’s course. Subcutaneous emphysema,
haemoptysis, change in phonation, and dyspnoea should alert the
Pneumonectomy physician to the possibility of a tracheal injury. Air escaping from a
Traumatic pneumonectomy is seldom required and is only cervical wound with respiration is almost always the result of an
indicated for severe pulmonary hilar injury. Given the rarity of this adjacent tracheal injury and is an indication for neck exploration.
injury there are few published series but the operative mortality Securing the airway is of paramount importance and
approaches 80%. Massive uncontrollable haemorrhage accounts consideration should be given to using a Glidescope (Verathon Inc;
for the majority of intra-operative deaths and acute right heart Bothell, WA, USA) or flexible bronchoscopy to assist the
failure is the usual cause of death of those who survive the initial endotracheal intubation. Injuries to the intrathoracic trachea and
operation [70,71]. Prompt pre-hospital transport and a rapid intra- bronchi may be more subtle. The same signs and symptoms as for
operative decision for the need for pneumonectomy are mandatory cervical injury may be present; however, a persistent pneumothorax
alongside meticulous post-operative critical care management. or continuous air leak following tube thoracostomy may be the
Lung protective strategies, pre-emptive treatment of right only indication of this injury. Chest CT is invaluable in assessing
ventricular failure and organ support such as continuous renal the mediastinum and defining the trajectory of the weapon (Figure
replacement therapy are crucial. Transoesophageal 12). Pneumomediastinum, while possibly from a tracheal or
echocardiography is extremely useful in assessing both right oesophageal injury, may be the result of pulmonary parenchymal
ventricular dysfunction and volume status, and allows goal directed injury. Bronchoscopy will confirm or exclude the diagnosis. It is
therapy. This includes judicious fluid management, the need for important not only to visualize the injury but to determine the
inotropic support and the use of nitric oxide (NO). Vasoactive level of the injury with respect to the cords or carina, as it will guide
medications should primarily be pulmonary vasodilators avoiding the surgical approach (Figure 13). Obviously the oesophagus also
medications which may increase pulmonary hypertension and requires evaluation and will be discussed in another section.
exacerbate right ventricular dysfunction. Inhaled NO is a A low collar incision provides adequate exposure of the cervical
pulmonary vasodilator, which has little to no systemic effect, and trachea. Distal tracheal and proximal right bronchial injuries are
has demonstrated improved oxygenation [72]. Our experience has best approached through a right postero-lateral thoracotomy.
prompted us to institute early veno-venous extra-corporeal Division of the azygous vein and widely opening the mediastinal
membrane oxygenation (ECMO) without systemic pleura allows excellent visualization. In general, left bronchial
anticoagulation. This allows maximal pulmonary support therefore injuries are approached through the left chest although the aorta
the lung can be “rested” with minimal mean airway pressure. may make the repair somewhat more challenging. The proximal
Patients requiring a pneumonectomy for trauma are both complex right mainstem can be approached from the right side. While
and challenging to care for. tracheal repair itself is straightforward, appropriate airway
management is critical to a successful operation, and
Damage Control communication between the surgeon and the anesthesiologist is
The principles of damage control in trauma have less to do with essential. Any devitalized tissue is debrided and the airway defect
rigid rules than with a philosophy of abbreviated operation. closed without tension using interrupted absorbable sutures. The
Uncontrolled haemorrhage will rapidly and invariably lead to authors’ preference is to use a tapered 3-0 PDS (Ethicon;
death. Fundamentally, damage control abbreviates the surgical Somerville, NJ, USA) and place the sutures prior to tying them.
procedure after bleeding is controlled, resuscitation continues in When placing the sutures care must be taken to avoid the
the intensive care unit and re-exploration is planned after endotracheal balloon (Figure 14). Once the sutures are tied, the
physiologic normalization. With thoracic trauma haemorrhage endotracheal tube is manipulated confirming no sutures have been
alone is not the only fatal variable; hypoxia and hypercarbia can placed though it. In the absence of a concomitant oesophageal or
also lead to early death [73,74]. The essentials of damage control vascular injury muscle coverage is generally not necessary. Most
remain with an abbreviated operation as the cornerstone. Useful injuries can be treated in this manner [81,82]. A complex injury in
techniques include tractotomy, packing and temporary chest an unstable patient can be temporized with a T-tube [83]. While it
closure [75-77]. Of these, tractotomy is the most widely employed. may appear to be counter-intuitive, early extubation is the goal.
It can be rapidly performed, achieves haemostasis and results in The mortality from penetrating injury is quite variable, ranging
little or no air leak. Chest packing is a useful technique but the from 18% to over 50% and is often related to associated vascular
packs must not compromise already jeopardized cardio-pulmonary trauma [82-84]
function, and can be mitigated by temporary chest closure. Post-
operative resuscitation is essential to achieve a normalized
physiologic status prior to planned re-exploration and definitive
surgery.
Although the use of human recombinant factor VIIa for the
treatment of haemophilia was described in 1990, it was several
years later before it was adopted for traumatic haemorrhage. In the
United States, for trauma it is used “off-label” for massive, non-
compressible haemorrhage and reversal of coagulapathy [78]. It has
also been reported to reverse life-threatening haemoptysis following
blunt thoracic trauma [79]. While this modality is clearly not the
first line therapy for haemorrhage and is not without possible
thrombotic complications, it remains an extremely valuable and
potentially life-saving option in those with severe coagulapathy.
Tracheal Injury
Penetrating tracheal injures, while infrequent, may present a
technical challenge to repair. It has been reported that tracheal
injury occurs in less than 1% of trauma patients [80]. Following
blunt trauma the trachea is most often injured either in the cervical
Figure 12. Chest CT demonstrating posterior wall tracheal disruption.
Figure 14. Intra-operative photograph of a distal tracheal repair. The mediastinal pleura
had been widely opened and tacked with stay sutures. Note the endotracheal tube in the
operative field.
Oesophageal Injury
Although penetrating oesophageal injury is rare, it can be highly
lethal if diagnosis is delayed. Because of the proximity of the
oesophagus to other important structures, such as the trachea,
blood vessels and spinal cord, these must be evaluated if an
oesophageal injury is identified. Many of the principles regarding
the diagnosis and treatment of oesophageal trauma were developed
for oesophageal perforation. There has been debate among
surgeons over the appropriate treatment, extent of the surgical Figure 15. Retrograde oesophageal drainage as a damage control technique for severe
procedure and the effect of time from perforation to surgical repair. oesophageal or oesophagogastric trauma.
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