Treatment of Blunt Trauma to the Thorax

JAMES V. MALONEY, JR., M.D. AND LLOYD MCDONALD, M.D., Los Angeles, California

From tbe Department of Surger,y, University of California not present an emergency probIem. On the
Medical Center, Los Angeles, Calijornia. Tbis work was other hand, rapid and efficient resuscitative
supported by grants-in-aid jrom tbe United States Public
Healtb Service (H-2812 and HTS-5357), Wasbington,
effort is required for those patients with major
D. C. Dr. Maloney’s work was supported in part hy tbe thoracic trauma who have cardiorespiratory
John and Mary R. Markle Foundation, New York, distress when first seen by the physician. The
New York. rehef of respiratory distress may consist of the
HE PROGRESSIVE increase in the speed of establishment of a cIear airway, the adminis-
T modern transportation has resuIted in a tration of intermittent positive pressure breath-
paraIIe1 increase in the frequency and impor- ing for apnea or flail chest, or the reIief of ten-
tance of blunt trauma to the thorax. The mor- sion pneumothorax. The principa1 probIem in
tality of thoracic injuries has steadily decreased the cardiovascuIar system engendered by blunt
during the past four decades. These improved thoracic trauma is a diminished bIood voIume
cIinica1 resuIts are the outcome, not of new due to intrathoracic bleeding. The re-estabIish-
operative technics, but of the judicious use of ment of effective circulating bIood voIume by
adjuvants such as respirators, antibiotics and administration of bIood or bIood substitutes is
the control of bIood volume. of cardina1 importance.
ReIativeIy few significant contributions have Perforating thoracic injuries are of a much
been made in recent years to the treatment of more urgent nature than are the bIunt injuries
bIunt trauma to the thorax. Many of the meth- under discussion here. Neverthetess, a standard-
ods of therapy which have been used for dec- ized procedure for the rapid evaIuation of a11
ades have never been subjected to critica thoracic injuries in the hospita1 emergency room
anaIysis or controlled observation. As a result, is highly desirabIe. A patient in cardiorespira-
many empiricisms have deveIoped and cur- tory distress from a thoracic injury is given
rentIy serve as guides in cIinica1 treatment. It precedence over other emergency cases. He is
is probabIe that some of these empiricisms are immediateIy Iaid on a huoroscopic tabIe whiIe
valuabIe and result from accurate cIinica1 ob- the surgeon dons semiopaque glasses to become
servation; others cIearIy have no basis in physi- dark adapted. He performs a rapid diagnostic
ologic fact. It is the purpose of this presentation evaIuation of the patient and observes the per-
to examine critically the current methods of cussion note over each hemithorax, the puIse
treatment of bIunt trauma to the thorax. rate and character, the bIood pressure, the Ioud-
ness of the heart tones and the character of the
GENERAL CONSIDERATIONS respiratory sounds on auscuItation. Within two
to three minutes, dark adaptation permits
Most patients with bIunt thoracic trauma are ff uoroscopic examination adequate to detect
suffering from muItipIe injuries. In fact, it is the the presence of a Iife threatening pIeura1 hemor-
associated injuries which frequentIy Iead to the rhage, cardiac tamponade or massive pneumo-
demise of the patient. This point is we11 made thorax. If these conditions are not present, the
by the exceIIent study of Harrison and associ- physician may proceed in an orderly manner to
ates [I] which reviews the clinica resuIts of the take a compIete history, and examine the pa-
treatment of 216 patients suffering from non- tient with meticuIous care. A detailed descrip-
penetrating injuries to the chest. tion of the cIinica1 evaIuation of the patient
The patient suffering from minor degrees of with thoracic injury is presented eIsewhere in
bIunt trauma, such as minor rib fractures, does this symposium by FeIton.
American Journal of Surgery. V&me 109,April 1963 484
 Treatment of Blunt Trauma to Thorax

patient from deveIoping sufficient negative

FRACTURED RIBS
intrapIeura1 pressure to exchange respiratory
The principa1 cIinica1 probIem associated voIumes adequate for metaboIic needs. The re-
with simple rib fracture is severe pain. Only suit is that the patient quickIy becomes anoxic,
infrequently is multiphcity of fractures or dis- hypercapneic and tachypneic. Tachycardia and
pIacement of ribs adequate to produce the more hypotension are frequently present. These
dangerous complications of this condition. The symptoms have in the past been attributed to
more serious compIications of rib fracture in- “pendeIIuft,” the penduIum-like movement of
clude massive hemothorax, pneumothorax, and air from one hemithorax to the other in associ-
respiratory embarrassment due to the deveIop- ation with the “paradoxica1” movement of the
ment of flai1 chest. chest waI1 with each inspiration. A recent study
SimpIe rib fracture calls for simple treatment in this Iaboratory [2] has demonstrated that
which will not compound the patient’s injury pendeIIuft does not in fact occur under these
and discomfort. Since the principal probIem is conditions. The physioIogic deficit consists in
subjective pain, the most effective treatment the patient’s inabiIity to create an adequate
consists of oral anaIgesics and rest to prevent degree of negative intrapleural pressure to ven-
excessive respiratory motion. AIthough injec- tiIate the Iungs (a change in the pressure-voI-
tion of local anesthetic agents into the invoIved ume diagram of the thorax resuIting from the
and adjacent intercosta1 nerves wiI1 give reIief thoracic injury). For many years, surgeons
of pain, the procedure is in itseIf a triai to the directed their attention to attempts at externa1
patient and the benefit is of short duration. and internal fixation with traction on the ster-
Strapping of the affected hemithorax with ad- num and ribs. These procedures were generaIIy
hesive plaster is a time honored, aIthough only unsatisfactory. In 1945, Mrch, Avery and
partiaIIy effective, means of reducing the mo- Benson [3] emphasized the value of controIIed
tion of fractured ribs. Both sides of the chest artificia1 respiration by intermittent positive
are prepared for strapping by shaving and by pressure breathing in the treatment of flai1
the application of compound tincture of ben- chest. The results with intermittent positive
zoin to the skin. With the patient in a sitting pressure breathing are so dramatic that sur-
position, and with the shoulder on the affected geons, once introduced to the method, abandon
side depressed in order to decrease the voIume a11 attempts at interna or externa1 fixation.
of the affected hemithorax, individua1 straps The genera1 steps to be taken in a case of fIai1
of 1 inch adhesive plaster are applied from the chest in which the paradoxing chest waI1 is suf-
anterior axillary Iine on the contraIatera1 side, ficient to embarrass respiratory exchange are
fixed to the skin over the affected ribs during as foIIows: (I) AppIy the intermittent positive
expiration, and continued around the thorax to pressure respirations with either an appropriate
the posterior axiIIary line of the contralateral mechanica device or with an ordinary anes-
side. There are a number of Iimitations of this thesia mask and breathing bag. If the patient is
method. Some surgeons believe that the inci- unconscious, endotracheal intubation wiI1 facili-
dence of puImonary ateIectasis is increased foI- tate the administration of artificial respiration.
Iowing immobilization of one hemithorax. It is (2) Perform a tracheotomy. The infIatabIe
particularly ineffective in women with signifi- cuff may be removed from an ordinary endo-
cant breast deveIopment. The method should trachea1 tube and appIied to a Iarge (No. 6, 7
not be applied where doubIe fractures of single or 8) tracheotomy tube; or, a cuffed endotra-
ribs permit the taping to produce a depression chea1 tube may be inserted directIy into the
of the thoracic wall. It is cIearIy not appIicabIe trachea via the tracheotomy wound. (3) The
in a patient with biIatera1 rib fractures. patient is hyperventirated by empIoying a high
respiratory rate, or by increasing the positive
FLAIL CHEST
inspiratory pressures. The patient uItimateIy
The severeIy injured patient with multipIe wiI1 become apneic and the positive pressure
rib fractures, frequently associated with a frac- respirator wiI1 assume contro1 of the patient’s
tured sternum, has in the past presented one of respiration. Patience and skiI1, as we11 as a good
the most diffIcuIt therapeutic probIems in the mechanica respirator, are essentia1 to achieve
fieId of thoracic trauma. The Ioss of the struc- apnea. The chemoreceptors of the human re-
tura1 integrity of the thoracic cage prevents the spiratory system are so constituted that if the
485
 MaIoney and McDonaId

patient is ventilated adequately to keep arterial clinical problems concerns the handling of the
oxygen saturation above 85 per cent and to residual blood in the pleural space.
reduce arterial pC0~ below 40 mm. Hg, the lZlinimal Hemothorax. Approximately 300
patient will inevitably become apneic. Some ml. of blood must collect in the pleural space
patience on the surgeon’s part may be required, before it is visible on a roentgenogram. A hemo-
since a prolonged period of hyperventilation thorax containing approximately $00 ml. of
may be required to blow off the carbon dioxide blood may be observed without specific treat-
which has accumulated during a prolonged ment. The remarkable absorptive powers of the
period of hypoventilation. A respirator capable pleura will ordinarily restore a chest roentgeno-
of producing high instantaneous flow rates is gram to normal within ten days to two weeks.
essential to the success of the method.* Major Hemothorax. The principal problem
The emergency resuscitators commonly used in the immediate treatment of a major hemo-
by fire departments and life guards have too thorax concerns the question of continued
low an instantaneous flow rate to be satisfac- bleeding. Most authorities have recommended
tory for this application. If a high flow respi- repeated aspiration of the accumulated blood
rator is not available, the tank type of body from the pleural space until continued bleeding
respirator (Drinkeri) will serve equally well. makes the need for operative intervention ap-
It has been previously demonstrated that the parent. If there is concern about the possibility
pressure relationships and the physiology of the of continued bleeding, we believe repeated aspi-
tank respirator employing negative intratank ration to be unwise. Even if repeated aspiration
pressures are the same as those of intermittent and chest roentgenograms should be done as
positive pressure breathing machines [4]. often as every thirty minutes, a bleeding pa-
The rate and depth of respiration should be tient may have sufficient occuIt hemorrhage in
adjusted so that the patient remains apneic, but the pleural space to threaten his life from hypo-
begins spontaneous respiratory effort within fif- volemia. A much wiser procedure is to institute
teen to twenty seconds after the respirator is closed chest drainage through a No. 26 French
turned off. Hyperventilation adequate to pro- drainage tube inserted through a trocar into the
duce prolonged periods of apnea may cause dis- eighth or ninth intercostal space in the poste-
turbances in acid-base balance. Artificial respi- rior axillary line and connected to water seal
ration is ordinarily continued for ten days to drainage. Connecting the chest drainage tube
three weeks, at which time, the thorax shows to approximateIy 20 mm. Hg negative pressure
a remarkable degree of stability. will help ensure that blood does not collect in
the thorax. The advantage of this method is
HEMOTHORAX
that it allows an immediate and accurate assess-
Hemothorax following blunt thoracic trauma ment of the volume of blood loss. Loss can be
is aImost always secondary to the injury of replaced by transfusion and the rate of bleeding
intercostal arteries or the pulmonary paren- precisely determined.
chyma by fractured ribs. After the initial emer- The blood should be removed completely
gency treatment is completed, the principal and immediately from the pleural space, since
there is little to support the contention that
* The Bird Respirator, Bob Wells and Associates aspiration of pIeural bIood will re-initiate
ConsuIting Engineers, Bird Oxygen Breathing Equip- hemorrhage. This fear is not based on sound
ment, BeNlower, CaIifornia, and the Bennett Pressure
physiologic grounds [y]. Although it has been
Breathing Unit, Bennett Respiration Products, Inc.,
Los AngeIes, CaIifornia, are two respirators having such recommended by some that the aspirated blood
high instantaneous flow rates. The piston respirator of be replaced with air, there seems to be little
Mijrch [3] also produces high instantaneous flow rates. clinical or physiologic reasons to support this
Some discussion has occurred regarding the relative advice.
merits of the pressure-flow cycled respirator (that is
Bird, Bennett) and the voIume cycled respirator (that
Late Treatment of Hemothorax. The remark-
is, March). Since respirators of both designs have emer- able absorptive powers of the pIeura make
gency reI;ase valves-set at a specilic pressure, both res- nothing more than watchful waiting necessary
Dirators are in essence pressure cvcled. The choice is, in the majority of patients who have clotted
therefore, one of preference rather than of physiologic
blood remaining in the thorax after blunt in-
merit.
t Drinker-type fuI1 body respirator, J. H. Emerson jury. Operative decortication in hemothorax
Company, Cambridge, Massachusetts. has resulted in disappointing functional results,
486
 Treatment of BIunt Trauma to Thorax

and the use of enzymatic decortication causes of watchfu1 waiting or repeated aspiration. In
significant morbidity due to infection [5]. We the past years, it has been usual to give no spe-
have previously reported a long term folIow-up cific treatment for pneumothorax involving Iess
study of forty cases of traumatic hemothorax than 20 per cent of the pIeura1 space. NormaIIy,
which gave strong evidence in favor of a policy such air absorbs in a period of seven to twenty
of nonoperative treatment. of retained bIood days. Larger pneumothoraxes were treated by
clots in the pIeura1 space [5]. needle aspiration. The first aspiration usually
did not affect the roentgenographic picture
PNEUMOTHORAX
since the leak in the Iung parenchyma was
Pneumothorax is much more common in rareIy seaIed at the time the first aspiration
association with penetrating than with bIunt was carried out after trauma.
thoracic trauma. A simple pneumothorax re- There has been an increasing tendency in
sulting from a leakage of air from the Iung must recent years toward a more aggressive treat-
be differentiated from the more morbid condi- ment. The patient is admitted to the hospital,
tions of bronchia rupture or rupture of the closed water sea1 drainage is established, and
esophagus. Pneumothorax caused by bronchial 20 mm. Hg negative pressure appIied to the
rupture is discussed elsewhere in this sympo- pleural catheter. Re-expansion of the lung with
sium by i!lunneII. The diagnosis of esophageal apposition of the pIeura1 surfaces occurs imme-
rupture is confirmed by thoracentesis after the diateIy. AIthough the treatment requires hospi-
patient has ingested a small amount of coIored talization and incapacitates the patient for sev-
clye. era1 days, it has great economic advantages in
Tension Pneumothorax. AIthough most pa- that it quickly obIiterates the pneumothorax
tients can tolerate (with onIy miId distress) a and permits the patient to return to his normal
complete pneumothorax which causes the Ioss occupation within a few days.
of function of one lung, a tension pneumothorax If the air leak in the lung parenchyma is sig-
is a life-threatening condition. Mediastinal shift nificant, it is essentia1 that suction machines
severeIy impairs the function of the contra- producing a high instantaneous flow rate be
IateraI Iung. In addition to the severe respira- attached to the chest drainage bottle. nlachines
tory distress, there may be a profound hypo- designed for gastrointestinal suction, or those
tension secondary to the depression of venous producing high negative pressures but having
return to the heart caused by the positive intra- Iow instantaneous flow rates will not create a
thoracic pressure. The critica condition of the sufficient differential pressure across the lung
patient may not permit time for ffuoroscopic to produce complete puImonary expansion.
or radiographic examination. The diagnosis PIeuraI infection as a resuIt. of either the aspira-
must be made immediately on the basis of tion or intercostal drainage technic is aTmost
trachea1 displacement away from the affected unknown. Perforating thoracic wounds from
side and a hyper-resonant note with percussion large missiIes associated with parenchymal
on the affected side. Immediate treatment con- damage do have a significant incidence of in-
sists of the insertion of a large bore hypodermic fection. In these patients it is al1 the more essen-
needIe anteriorly into the affected hemithorax. tia1 to obliterate the pIeural space by continu-
Although this procedure wiI1 not expand the ous closed catheter drainage.
affected lung, it wiI1 suffrcient.Iy reIieve the pres-
TRACHEOTOMY IN THORACIC TRAUMA
sure in the pIeura to permit function of the
contraIatera1 lung and to aIIow norma venous In recent years, the performance of a “rou-
return. Thereafter, cIosed thoracotomy drain- tine” or “prophylactic” tracheotomy in pa-
age should be established. (Fig. I .) It is pertinent tients suffering from thoracic trauma has been
that the thoracotomy tube shouId be inserted in vogue. Tracheotomy is recommended be-
anteriorIy in the treatment of pneumothorax in cause it is stated that it reduces respiratory
contrast to a posteroIatera1 insertion for hemo- deadspace, reduces resistance to breathing, and
thorax. Drainage is estabIished in the second or permits the remova of trachea1 secretions.
third intercostal space in the midclavicular line. This rationale is so attractive that trache-
Simple Pneumothorax. For many years sat- otomy has probabIy enjoyed more popuIarity
isfactory results have been obtained in the than is justified. Unfortunately, the rationale
treatment of simpIe pneumothorax by a policy is unsound. Tracheotomy has been stated to
487
 MaIoney and McDonaId

FIG. I. These instruments are useful in performance of closed thoracotomy. Left, standard cIosed thoracotomy trocars
illustrating how the catheter is threaded into the pIeura1 cavity after the obturator is removed. Center, a gallbladder
trocar may be used when a thoracotomy trocar is not available. The Iarge bore needIe is used for the emergency
treatment of the tension pneumothorax unti1 a thoracotomy trocar becomes avaiIabIe. Rigbt, in an emergency situa-
tion it is onIy necessary to incise the skin with a scaIpe1 and force the drainage tube through the intercosta1 muscIes
with the aid of a KeIIy cIamp.

reduce the work of breathing by ehminating tions from the Iower airway for the starch spIit-
the resistance of the upper airways. In fact, our ting enzyme, ptyaIin, indicates that the secre-
measurements of the airway resistance indi- tions aspirated from the Iungs immediately
cates that the usua1 size tracheotomy tubes after tracheotomy are in fact almost pure
(No. 5, 6 and 7) increase many foId the resist- saIiva. Tracheotomy eIiminates the body’s nor-
ance to air flow in the upper part of the respira- ma1 mechanism for preventing saIiva from
tory tract. It is stated that a tracheotomy eIimi- entering the Iarynx. Much of the favorabIe
nates the respiratory deadspace of the upper cIinica1 impression regarding the benefits of
airway. In fact, the major portion of respiratory tracheotomy on puImonary secretion, arises
deadspace is located below the carina. The tra- from the fact that tracheotomy permits the
cheotomy, therefore, has onIy sIight effect on aspiration of saliva from the trachea; however,
deadspace. It has been stated that tracheotomy that wouId not have been there if the trache-
permits the removal of secretions of the Iower otomy had not been performed.
airway which might otherwise produce atelec- There can be no question of the benefit of
tasis and pneumonia. This is certainly the case; tracheotomy in the presence of specific indica-
however, our analysis of the aspirated secre- tions for its performance (that is, upper airway
488
 Treatment of BIunt Trauma to Thorax

obstruction; the presence of secretions in the has been impaired by the existence of a number
lower airway which either the patient himself of empiricisms which do not have a basis in
cannot raise by coughing, or which the physi- physioIogic fact. The best clinical results wiI1
cian cannot aspirate bv means of trachea1 suc- arise from a program of treatment which is de-
tion; or flail chest requiring prolonged artificia1 signed to restore function and relieve pain and
respiration). Flowever, its “routine” or “pro- which is based on sound physioIogic principles.
phylactic” use is open to some question since
REFERENCES
the physiologic rationale upon which it is based
is IargeIy in error. I. HARRISOK, W. H., JR., GRAY, A. R., COUVES, C. hI.
and IIOWARD, J. M. Severe non-penetrating in-
SUMMARY
juries to the chest: clinical results in the manage-
ment of 216 patients. Am. J. Surg., IOO:713, 1960.
In the past forty years there has been a pro- 2. MALONEY, J. V., JR., SCHMUTZER, K. J. and RASCHKE,
gressive improvement in the morbidity and E. Paradoxical respiration and “pendelIuft.” J.
mortality of patients treated for blunt trauma Tboracic Surg., 41: 291, 1961.
3. MARCH, E. T., AVERY, E. E. and BENSON, D. W.
to the thorax. Since the treatment of this con- Hyperventilation in the treatme1.t of crushing in-
dition is generaIIy nonoperative, it is apparent juries of the chest. S. Forum, 6: 270, 1955.
that these improvements have resulted from 4. MALONEY, J. V., JR. and WIIITTENBERGER, J. L.
the application of the adjuvant methods of Clinical. applications of pressure used in the body
respirator: An. J. M. SC., 221: 425, 195 I.
therapy: contro1 of bIood volume, appIication MALONEY. J. V.. JR. The conservative management
of respirators and the use of antibiotics. Prog- of traumatic hemothorax. Am. J. Surg., 93: 533,
ress in the treatment of blunt thoracic trauma 1957.

489