Management of chest trauma can be divided into three distinct levels of care; pre-hospital

trauma life support, in-hospital or emergency room trauma life support and surgical trauma
life support. At each level of care, recognition of thoracic injury is crucial for the later
outcome. Initial resuscitation and management of chest trauma patient based upon protocols
from the Advanced Trauma Life Support (ATLS) (1). After a primary survey immediately,
life-threatening injuries should be excluding or treat such as:
(I) Airway obstruction;
(II) Tension pneumothorax;
(III) Open pneumothorax;
(IV) Massive haemothorax;
(V) Flail chest;
(VI) Cardiac tamponade
Secondary survey will provide information on potentially life-threatening injuries:
(I) Pulmonary contusion
(II) Myocardial contusion
(III) Aortic disruption
(IV) Traumatic diaphragmatic rupture
(V) Tracheobronchial disruption
(VI) Oesophageal disruption
Assessment of breathing and clinical examination of the thorax (respiratory movements and
quality of respiration) are necessary to recognize major thoracic injuries such as tension
pneumothorax, open pneumothorax, fail chest, pulmonary contusion and massive
haemothorax. Inspection, palpation, percussion and especially auscultation [sensitivity 90%,
specificity 98% (5)] will provide information as to whether a tension pneumothorax is
present. Clinical diagnosis of pneumothorax, may require immediate intervention, by initial
needle decompression of the pleura space (6). Should this not be successful or there is
evidence of pneumothorax, chest tube drainage is necessary. In the absence of
hypoventilation on auscultation, or thoracic pain in a stable patient a major tension
pneumothorax can be ruled out. Repeated examination is mandatory to avoid omission of
progression of a pneumothorax. As tension pneumothorax is the most frequent reversible
cause of death in trauma patients with cardiac arrest (7-9).
Initial Actions and Primary Survey

Life-threatening injuries associated with thoracic injuries are often identified in the primary
survey by carefully assessing the patient’s ABCDEs.
The injuries to be identify and treated in the thoracic region during the primary survey are:
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Flail chest and pulmonary contusion
5. Massive hemothorax
6. Cardiac tamponade
Secondary Survey: Potentially Life-threatening Chest Injuries
1. Tracheobronchial tree injury
2. Simple pneumothorax
3. Pulmonary contusion
4. Hemothorax
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Blunt esophageal rupture
8. Traumatic diaphragmatic injury
These injuries usually require immediate interventions such as intubation, needle
decompression, tubethoracostomy, or pericardiocentesis. These life-threatening injuries and
related problems are resolved as they are discovered. Chest trauma patients can present to the
ED via Emergency Medical Services (EMS), often placed on a backboard and in a cervical
collar. Prehospital treatment of penetrating thoracic trauma patients can include needle
decompression, 3-sided occlusive dressing, and IV resuscitation. Patients can also walk into
the ED, in which case it is prudent to immediately apply a C-Spine collar and proceed with
Advanced Trauma Life Support Assessment.
All trauma patients must be managed in accordance with ATLS algorithms1:
A (Airway with c-spine protection): Is the patient speaking in full sentences?
B (Breathing and Ventilation): Is the breathing labored? Are symmetrical, breath sounds
present bilaterally?
C (Circulation with haemorrhage control): Are pulses present and symmetric? How does the
patient’s skin appear? (cold clammy, warm well-perfused)
D (Disability): What is their GCS scale? Are they moving all extremities?
E (Exposure/Environmental Control): Completely expose the patient. Is rectal tone present?
Is there any gross blood per rectum?
Initial Interventions:
IV – 2 large-bore (minimum 18 Gauge) Antecubital IV
O2 – Nasal cannula, Face Mask
Monitor: Place the patient on a cardiac monitor
It is important to note that if there is any deficiency noted during the primary survey, the
problem must be addressed immediately, without proceeding until the patient has been
stabilized. If the patient’s primary survey is intact, the adjuncts to the primary survey and
resuscitation begins. The adjuncts to the primary survey include any of the following as
necessary: EKG, ABG, chest X-ray, pelvis x-ray, urinary catheter, eFAST exam and/or DPL.
Next, a secondary survey must be performed. The secondary survey is the complete history
and physical examination. This is completed after the primary survey and after any
intervention performed as part of an abnormal primary survey.
Start by taking an “AMPLE” history:
 Allergies
 Medications
 Past Medical History
 Last Meal
 Events regarding the trauma
Chest exam should detail entry and exit wounds, the total number of wounds, ecchymosis and
deformities, paradoxical movement, or crepitus. Bedside sonography should be used to
perform an eFAST exam, which has assesses for the presence of pneumothorax, hemothorax,
cardiac tamponade and intraperitoneal blood. Details of the trauma mechanism are crucial.
For motor vehicle accidents (MVAs) speed of collision, position of colliding cars to each
other, position of patient in the car, seatbelt use, extent of car damage (intrusion, windshield
damage, difficulty of extrication, air bag deployment) are important elements to elicit. With
respect to falls, the height of fall is important to know. When treating patients with gunshot
wounds, the type of gun, distance from the shooter, and number of shots heard are all
relevant. For stab wounds, it is prudent to obtain information on the kind of weapon used.

Management
Immediate chest trauma treatment can be conservative (with invasive or non-invasive
mechanical ventilation, aggressive respiratory and pain therapy, lung toilet) or operative
(surgical internal fixation or open reduction of flail chest) (1,4-6). Conservative treatment is
usually the treatment of choice; it consists of tracheal intubation (with or without subsequent
tracheostomy) and invasive mechanical ventilation for more injured patients, or non-invasive
mechanical ventilation in patients who are less injured. Both invasive and non-invasive
mechanical ventilation can be challenging in blunt chest trauma patients and require ICU
admission. Often, the presence of pneumothorax and/or hemothorax pose the need for chest
drainage and complicates the ventilatory approach, with challenge in end expiratory, mean
airway and peak pressure level selection, also making ventilation and recruitment of
atelectatic and contused part of the lung complicated. Lung toilet, aggressive respiratory
therapy and early mobilization are key to success in patient recovery. Nonetheless, in selected
patients, operative fixation may lead to better outcomes, even though nowadays only less
than 1% of patients undergo surgical stabilization after blunt chest trauma. Literature is not
clear about surgical fixation indication and techniques; case-reports and randomized
controlled trials compare a wide variety of different pathologies (from unicortical non-
displaced fracture in stable patients to severely displaced fractures in flail chest) and
approaches (percutaneous thoracoscopic with muscle sparing versus open thoracotomy).
Generally, ribs 1–2, 11–12 are not considered for surgical stabilization because of their
minimal contribution to chest wall integrity; ribs 3–10 should, on the other hand, be
considered for stabilization in patients with flail chest. Further research is needed to clearly
define the category of patients who will benefit most from surgical stabilization and to
identify the ideal timing for surgical intervention (1,4,6).
Analgesia (Table 1)
Epidural analgesia (EA)
EA is extremely effective in acute pain treatment; it ameliorates pulmonary function test
(FRC, lung compliance, vital capacity, airway resistance reduction and respiratory exchange
amelioration) and patient participation to physiotherapy with an increase number of deep
breathing and a more effective cough. EA is of level I recommendations in blunt chest trauma
patients, either with lumbar or thoracic approach depending on lesion localization; in patients
with bilateral rib fractures EA is the technique of choice. Usually, local anesthetic (LA) with
or without adjuvants (opioids, clonidine) are administered in boluses or as continuous
infusion (2,8,13). Pain relief with EA is dramatic, immediate and superior to either
intravenous (IV) and intra-pleural block; a reduction in patient’s inflammatory response, with
a decrease in interleukin-8 secretion, has also been demonstrated (1,3). In patients older than
60 years old, EA decreases mortality and incidence of pulmonary complication; in all
patients, it shortened ICU and hospital LOS (1,3,4). EA is contra-indicated in coagulopathic
patients or in patients with elevated clotting time, vertebral fractures, acute spinal cord
injuries and sepsis; it can be difficult and technically demanding, especially in distressed
patients. EA can mask abdominal injuries and enhance hypotension in polytraumatized
hypovolemic patients for its sympatholytic action; rare complications are epidural infections
and dural puncture (2,3,6,8,13-16) (Figure 4).

Intrapleural analgesia
Intrapleural analgesia has been proposed, via a transcutaneous catheter placement, to obtain
unilateral ICNB through LA diffusion in the pleural space. The patient needs to be supine for
LA diffusion and multiple unilateral dermatomes block, which is not optimal in a patient with
compromised respiratory mechanics; moreover, with this approach, there is a possibility of
diaphragmatic function compromise with respiratory function worsening. Possible side
effects are intraparenchymal or extrapleural catheter placement, pneumothorax and chest wall
misplacement; moreover, high plasma concentration via pleural absorption has been
demonstrated, with a high potential for possible LA systemic toxicity (1,3,8,13). Horner’s
Syndrome, pleural infections and catheter rupture have also been described (19). Its use is
limited and not strongly supported in literature; patients always reported lower pain
thresholds and less analgesic use with EA or IV analgesia when compared to intrapleural
analgesia (1,8,13).
IV analgesia
In patients not eligible for neuraxial or regional techniques, usually because of coagulation
pathology (either intrinsic or iatrogenic), IV analgesia with opioids (with or without patient
controlled analgesia) supported by non-steroidal anti-inflammatory drugs (NSAIDs) and
acetaminophen is a widespread choice (8,13). Clearly, this is not the first choice for older
patients, patients with an altered mental status (either because of dementia, Alzheimer,
delirium or brain trauma), patients with renal insufficiency and in need for strict neurologic
monitoring (1,3,15,18). Moreover, systemic side effects associated with prolonged and/or
high dosage use of opioids should be kept in mind by the clinician: excessive sedation and
respiratory depression may have a significant impact on patient’s recovery, ICU and hospital
LOS (21). When necessary and possible, IV analgesia can be associated by intra-muscular,
trans-dermal or oral routes (1).