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Clinical Management of Chest Trauma

Thoracic trauma accounts for one quarter of trauma deaths, and two thirds of these deaths occur after the patient reaches

Mechanism of Injury

Penetrating thoracic injuries (e.g., stab wounds, gunshot wounds, and impalement on a foreign body) primarily injure the peripheral lung, producing both a hemothorax and pneumothorax. More than 80% of all penetrating chest wounds cause a

Blunt trauma can induce injury by three distinct mechanisms: a direct blow to the chest (e.g., rib fracture), deceleration injury (e.g., pulmonary or cardiac contusion and aortic tear), and compression injury (e.g., cardiac and diaphragm rupture). Rib fracture is the


The thorax is responsible for the vital cardiopulmonary physiology of delivering oxygenated blood to metabolically active tissues. Three pathologic consequences of thoracic injury, either alone or in combination, are responsible for inadequate oxygen

Initial Treatment

The initial approach to the patient with thoracic trauma follows the basic tenets of resuscitation of all critically injured patients. The primary goal is to provide oxygen to vital organs. Airway control, adequate ventilation, and shock management are the top priorities. Some specific features of the initial management of thoracic trauma patients bear emphasis. Restlessness, confusion, and anxiety are

Treatment of Specific Injuries


Rib Fractures.

Fracture of the ribs is the most common thoracic injury. With simple fractures, pain on inspiration is the principal symptom. Localized pain, tenderness, and occasionally crepitus confirm the diagnosis. A chest x-ray should be obtained to exclude other intrathoracic injuries and not necessarily to identify a rib fracture. The use of narcotics in small amounts, intercostal nerve blocks, and muscle relaxants are usually adequate treatment. Hospital admission for pain relief, cough assistance, and endotracheal suction may be

Flail Chest.

Unilateral fracture of four or more ribs anteriorly and posteriorly or bilateral anterior or costochondral fracture of four or five ribs produces enough instability that paradoxical respiratory motion results in hypoventilation of an unacceptable degree . Although

Open Pneumothorax.

A defect in the chest wall provides a direct communication of the pleural space with the environment. A wound large enough to exceed the laryngeal cross-sectional area provides an alternative air pathway with less resistance than that of the normal tracheobronchial


Pulmonary Contusion.

As noted earlier, pulmonary contusion occurs in most patients with flail chest but can also appear without any evidence of rib fracture. Critical intrathoracic trauma may be present in the absence of skeletal injury, particularly in children, owing to the marked elasticity


Pneumothorax results from lacerations of the chest wall or lung, or rupture of an alveoli (paper bag effect) and can be caused by either penetrating or blunt trauma. Tension pneumothorax develops when a flap valve leak allows air to enter the pleural space but prevents


Hemorrhage into the pleural space occurs in some quantity in almost every patient with a diagnosable chest injury. Blood loss may vary from slight to extensive. Although an upright chest x-ray examination can diagnose an intrathoracic accumulation of more than

Pulmonary Parenchyma Injury.

Although most pulmonary parenchyma injuries can be effectively managed nonoperatively, about 15% of penetrating lung injuries require thoracotomy for hemorrhage control. Various techniques for hemorrhage control have evolved, ranging from simple oversewing to anatomic resection. Approximately 80% to 90% of pulmonary injuries requiring operation can be managed by

Trachea and Bronchus Injuries.

Blunt tracheal or broncial injuries are often due to compression of the airway between the sternum and the vertebral column in decelerating steering wheel motor vehicle accidents with resultant shearing of the right main stem bronchus from the carina or transverse lacerations of the trachea. Alternatively, a blow-out injury to the membranous trachea may occur during chest wall


Blunt Cardiac Injury.

Blunt cardiac injury represents a spectrum of pathologic changes from a cardiac wall bruise (contusion) to ventricular, septal, or valvular rupture. The right ventricle is most frequently involved, presumably because of its proximity to the sternum. Although most patients with rupture of the atrial or ventricular chambers do not reach a medical facility, survivors have been reported if vital signs can be maintained during transportation. [100] Myocardial contusion is a curious clinical entity whose definition, diagnosis, and


Cardiac tamponade is most frequently caused by penetrating thoracic injuries, but occasionally it is observed in blunt thoracic trauma from myocardial rupture, coronary artery laceration, or ascending dissection of an aortic tear. Accumulation of as little as 150 ml. of


Rupture of the thoracic aorta is the most lethal injury following blunt chest trauma, accounting for up to 40% of fatalities in motor vehicle accidents. The exact mechanism of injury is not fully understood, but the aortic arch at the descending aorta is believed to



Penetrating lacerations of the diaphragm outnumber blunt ruptures at least four to one. Both may result in herniation through the


Blunt injury of the esophagus is rare, and penetrating injuries are rarely isolated. The most common symptom of esophageal