TRAUMA REVIEW

The Diagnosis And Treatment Of Non-Cardiac

Thoracic Trauma
JV O’Connor1, J Adamski2
Director of Thoracic and Vascular Trauma, R Adams Cowley Shock Trauma Center, Associate Professor of Surgery, University of
1

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.

transplantation and the widespread use of minimally invasive

History
Thoracic trauma has always been part of the human condition.
The first descriptions date to the earliest written records in
antiquity; the Edwin Smith Papyri, Homer’s accounts of thoracic
wounds in the Iliad, and Hippocrates’ characterization of thoracic
empyema. Since then there have been many milestones in the
development of thoracic surgery. The first was in the late 18th
century with the development of the stethoscope by Laennec;
further advances the following century included a more
sophisticated understanding of infection and antisepsis. A
significant impediment to the development of thoracic surgery was
the difficulty of operating in a cavity which is normally exposed to
pressure which is less than ambient atmospheric pressure. The
problem of maintaining ventilation during operation was first
addressed at the beginning of the 20th Century by Sauerbruch’s
development of a negative pressure operating environment. Major
advances ensued including experience gained in both World Wars.
The First World War saw few advances in the initial treatment of
chest injuries, again limited by intraoperative ventilation, but
improvements in the treatment of subsequent empyema.
Subsequent understanding of the basic science of pulmonary
physiology, shock, volume resuscitation and transfusion, coupled
with the routine use of endotracheal intubation, positive pressure
ventilation, antibiotics and sophisticated post-operative intensive
care lead to stunning advances over the last sixty years. These
include intrathoracic tracheal and oesophageal procedures, lung
Corresponding Author: Dr JV O’Connor MD, 22 South
Green Street, Baltimore, Maryland 21201 USA
Email: jvomd@msn.com
JR Army Med Corps 156(1): 5-14
techniques such as video-assisted thoracic surgery (VATS).
Imaging studies beginning with Roentgen’s introduction of x-ray to
the multi-slice computed tomography with reconstruction, and the
addition of interventional techniques have improved our ability to
both diagnose and treat intrathoracic pathology [1].
Initial Evaluation
The initial evaluation of patients with and without thoracic trauma
is similar, with a few important caveats. The history may be
provided by the patient but often it is given by pre-hospital
personnel. The mechanism of injury, time from injury, vital signs
and neurologic status at the scene and any changes during
transport are critical. With blunt injury the specifics of the event
may be important, for example in motor vehicle collision (MVC)
prolonged extrication, the location and degree of occupant
compartment deformation may provide useful information. With
penetrating trauma the specific details are usually vague and often
unreliable, unless the patient is impaled. The physical examination
is uncomplicated, following the ABC’s (Airway, Breathing,
Circulation) during the primary survey. It is during this initial
examination that potentially life-threatening conditions such as
tension pneumothorax are treated. The presence of chest injury,
especially if severe, may prompt airway control by endotracheal
intubation. A secondary survey is then performed as well as
placement of appropriate intravenous access. While these patients
may require evaluation and imaging for potential neurologic, intra-
abdominal, vascular or extremity trauma, this article focuses on
thoracic injuries, and specifically non-cardiac injuries that have
been covered in this journal previously.
5
Non-Cardiac Thoracic Trauma

Physical exam is often not rewarding but the presence of
distended neck veins, tracheal deviation, subcutaneous
emphysema, chest wall instability, absent breath sounds or muffled
heart sounds may all provide crucial information. Vital signs
should be frequently monitored with careful observation of
respiratory function and arterial saturation. An arterial blood gas
should be sent with the initial laboratory studies, an
electrocardiogram and a portable chest radiograph (CXR) should
be obtained. A portable CXR yields rapid information about the
pleural space including pneumothorax or haemothorax, which
may require tube thoracostomy. A Focused Abdominal
Sonography for Trauma (FAST) of the abdomen and precordium
should be rapidly performed. The need, if any, for additional
imaging and/or procedures is driven by the patient’s
cardiopulmonary stability, physical examination, laboratory and
radiographic findings.
Penetrating thoracic trauma in a haemodynamically unstable
patient warrants operative intervention. The only question is which
incision should be used (see below). This decision may be
problematic especially if there is concomitant abdominal or
extremity arterial injury. Clinical judgment is paramount in this
situation. The haemodynamically stable patient may benefit from
additional imaging especially chest computed tomography which
provides more detailed and organ specific information [2]. If
indicated an echocardiogram will provide detailed information
about cardiac function. Likewise, suspected airway or oesophageal
injury require endoscopic and/or dedicated contrast studies.
thoracostomy tube placement [7]. Although small spontaneous
pneumothoraces may be managed by syringe aspiration, this is not
recommended for traumatic pneumothoraces [8]. In contrast to
non-occult pneumothoraces, a pneumothorax may be
asymptomatic and may not be seen on initial chest x-ray [9].
Occult pneumothoraces are generally diagnosed on CT scan
during trauma evaluation and managed conservatively, with close
observation and follow-up x-ray depending upon the patient’s
accompanying injuries. It is estimated that 10% of occult
pneumothoraces will later require thoracostomy tube placement
[10], and there is a fourfold increase when positive pressure
ventilation is needed [11]. Thus, trauma patients with non-occult
and occult pneumothoraces should prompt thoracostomy tube
placement when mechanical ventilation is needed.
Despite the relative need for chest tube decompression, it is
important that physicians remember thoracostomy tube placement
has a 6-36% complication rate [12,13]. Complications include
empyema, improper tube positioning, parenchymal lung injury,
undrained effusion, haemothorax or pneumothorax [14].
Moreover, these complications appear two to four times more often
when thoracostomy tubes are placed by non-surgeons [12]. The
use of prophylactic antibiotics in patients with chest tubes is
controversial and not advocated by most surgical societies (EAST
Guidelines, 1998). In regards to risks versus benefits of
thoracostomy tube placement, we advocate good judgment,
appropriate diagnostics, careful evaluation of concomitant injuries
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

Haemothorax hospital stays and fewer complications, such as empyema, when

Haemothorax is common with chest trauma, most are venous in compared to thoracotomy or the use of lytics [32-34]. The critical
origin and stop spontaneously. Bleeding from the great vessels, variable in the success of VATS is timing. All the studies have
intercostal or internal mammary arteries tend to be brisk requiring demonstrated a higher success rate with early VATS, within 5 to 7
intervention to prevent a tension effect and/or control bleeding. days of injury, when compared to those performed after one week.
Symptoms may include shortness of breath and chest pain, and With time the haemothorax becomes more organized and fibrotic
with a large haemothorax signs of haemorrhagic shock may be and the need for an open procedure increases.
present. Haemothorax may be suspected by mechanism and
physical findings of decreased breath sounds and unilateral chest
movement. The diagnosis can be confirmed by a portable supine
CXR which can detect 150-200ml of blood [15] (Figure 3).
Although some institutions use bedside ultrasound to detect a
haemothorax, it has not been universally adopted as it provides less
information than CXR [16,17]. Similar to treatment of a
pneumothorax, thoracostomy tube placement is needed to
evacuate the pleural space and re-expand the lung. Complete lung
re-expansion is the goal as it will decrease the risk of complications
and need for additional procedures.
Evacuation of greater than 1000ml of blood is considered a
“massive haemothorax” that may warrant operative intervention.
Although different authors use various thresholds (greater than
1500ml or more than 200ml/hr for 4 hours) as indication for
thoracotomy, the patient’s haemodynamic status, rate of bleeding
and associated injuries should guide the management [18,19]. It
cannot be over emphasized that decreased chest tube output does
not necessarily imply there is no persistent bleeding in the pleural
space. A poorly positioned or clotted chest drain will not evacuate Figure 3. Chest radiography with a large right haemothorax. Endotracheal tube and
tube thoracostomy are seen.
ongoing bleeding and may give the clinician a false sense of
security. Interval CXRs are extremely valuable in assessing the
pleural space for increasing haemothorax which may require
operation. In the stable patient chest CT can confirm the presence
and size of a residual haemothorax, and detect active bleeding if a
contrast blush is present [Figure 4]. Although transcatheter
angioembolization for a persistent haemothorax may be indicated
in the stable patient, the mainstay of treatment is operative
evacuation [20]. In contrast, haemodynamically unstable patients
with identified chest trauma and massive haemothorax require
emergency thoracotomy performed in the operating room [21].
Likewise, emergency room thoracotomy is warranted in patients
with massive haemothorax and imminent cardiac arrest. Clamping
the thoracostomy tube is dangerous and has not been shown to
decrease haemorrhage or promote tamponade [22]. Overall
thoracotomy is required less than 15% of the time and
thoracostomy tube remains the fundamental tool for treatment of
haemothoraces [19]. Autotransfusion of evacuated blood is an
excellent adjunct in resuscitating these patients, particularly those
in haemorrhagic shock.
Delayed haemothoraces after blunt and penetrating chest
trauma, while rare, have been reported occurring as early as 48
hours and as late as four weeks after trauma [23]. Their incidence
is related to the number and severity of rib fractures, and may be
related to intercostal artery pseudoaneurysm [24]. Treatment Figure 4. Chest CT showing a massive right haemothorax. There is significant
compression of the lung parenchyma.
consists of haemothorax evacuation and if present, control of the
pseudoaneurysm by operative or transcatheter methods [20].
Complications related to chest tube placement are the same for Rib Fractures
both pneumothorax and haemothorax. An undrained Rib fractures are the most common chest injury in trauma with an
haemothorax may lead to empyema or fibrothorax [25,26]. incidence varying from 7 – 40% [35] (Figure 5). The presence of
Slightly over 20% of those with chest trauma will have a retained lower rib fractures (9th – 12th) on the left or right should prompt
haemothorax and 15.6% of them developed empyema [27]. an examination for splenic or hepatic injury respectively [36]. Rib
Another study demonstrated one-third of retained haemothoraces fractures are often associated with additional chest injuries such as
develop empyema [28]. Evacuation of the pleural space has been pneumothorax, haemothorax, pulmonary contusion and flail
advocated for many years. Prior to minimally invasive techniques chest. Morbidity, mortality and complications correlate with the
this was accomplished by thoracotomy [29]. While some authors number of fractured ribs [35,37]. This trend is more prevalent in
recommend the use of intrapleural lytics, it has not found wide the elderly who have a more fragile chest wall. This is in contrast to
spread acceptance and is associated with increased length of a child’s chest wall, which is more flexible and severe pulmonary
hospitalization and bleeding complications [30,31]. trauma may occur in the absence of rib fractures [38,39].
Video assisted thoracic surgery (VATS) has brought a minimally Pain from ribs fractures adversely affect pulmonary function and
invasive approach for the evacuation of retained haemothorax. mortality. It is believed that “chest wall splinting” from pain leads
Several studies have shown that early VATS results in shorter to increased atelectasis, inability to clear secretions and
hypoventilation. Pulmonary contusion can further impair gas
JR Army Med Corps 156(1): 5-14 7
Non-Cardiac Thoracic Trauma

exchange resulting in hypoxemia. Aggressive pain control is needed

to improve vital capacity and clearance of secretions. Although
parental narcotics have been the standard for pain control in the
trauma patient, epidural analgesia has been shown to be superior in
improving pulmonary mechanics, and is our preferred modality
[40]. If an epidural is not possible, as with associated spinal trauma
or coagulapathy, patient controlled analgesia (PCA) is advocated
[41]. Regional rib blocks may serve as an important adjunct for
patients with mid to lower rib fractures [42]. With appropriate
analgesia, adjuncts such as early patient mobilization, incentive
spirometry, and chest physiotherapy can be instituted [43]. A
combination of these modalities used in a multidisciplinary
pathway can improve morbidity and mortality associated with rib
fractures

Figure 6. Flail chest as seen on a reconstructed chest CT. Invariably there is an

associated pulmonary contusion.

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.

8 JR Army Med Corps 156(1): 5-14

 Non-Cardiac Thoracic Trauma

extended across the midline or onto the abdomen as a laparotomy

and is preferred over the postero-lateral approach in the shocked
patient. The main disadvantage is exposure of posterior thoracic
structures. We have found bumping the chest wall up
approximately 20° allows the incision to be carried more
posteriorly (Figure 9). The postero-lateral approach (Figure 10)
affords optimal exposure of the posterior thoracic structures and is
the preferred incision for most elective operations. Its lack of
versatility and possible detrimental effect on a hypotensive patient
limit the usefulness of this approach. Sternotomy (Figure 11) is the
preferred access to the heart and great vessels. It is versatile as it can
be extended as a laparotomy, periclavicular or neck incision
[62,63]. Depending on the surgeon’s experience lung resection can
also be accomplished through this access.

Figure 8. Chest CT demonstrating a large left lower lobe pulmonary contusion

resulting from a motor vehicle collision. Lung lacerations are present.

Thoracic Duct Injury

Thoracic duct injury is uncommon in trauma but failure to
recognize and treat it may result in increased morbidity and
mortality. Most injuries occur at the junction of the left subclavian
vein and thoracic duct [57] and may be associated with great vessel
injury or vertebral body fractures. Penetrating trauma results in
direct ductal disruption. The diagnosis is suspected when milky
white chest drainage is noted and confirmed when drain effluent
has triglycerides >110 mg/dl and protein > 3 gm [58]. Non-
operative management consists of a low fat diet (medium chain
fatty acids) and pleural drainage. Occasionally parenteral nutrition
is necessary. Somatostatin has been demonstrated to decrease
chylothorax output [59]. Chylous output less than 1000ml/day
tend to close spontaneously. Persistent ie greater than seven days or
high output chylothorax, require further intervention [60].
Although several techniques have been described, surgical ligation
is the procedure of choice in controlling high output or continuous
thoracic duct leak, and can be accomplished either open or by
VATS [61]. Direct ligation of the duct may not be straight forward
due to the presence of multiple lymphatic tributaries, which if not
controlled will lead to operative failure. The thoracic duct may be Figure 9. Approach for an antero-lateral thoracotomy. Placing a bump under the back
and extending the arm provides improved thoracic exposure.
difficult to identify. Instilling 50ml of heavy cream or olive oil via
a nasogastric tube at the start of the operation will aid in identifying
ductal structures. The authors have found this technique far
superior to using methylene blue, which once it has stained the
tissues, obscures the anatomy. The thoracic duct and its tributaries
should be clipped or suture ligated, and fibrin glue and chemical
pleuredesis may be helpful adjuncts.

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.

JR Army Med Corps 156(1): 5-14 9

Non-Cardiac Thoracic Trauma
Figure 11. The sternotomy affords excellent exposure to all structures except those in
the posterior mediastinum. It is versatile and can be extended as a neck or
periclavicular incision, as well as a laparotomy.
Anaesthetic Management
The role of the anaesthetist is often two fold; airway management
and intra-operative management. The latter may be complicated
by haemorrhagic shock making the choice of anaesthetic agents
problematic. Airway assessment is an essential part of any patient’s
evaluation and especially so in the trauma victim. The presence of
severe facial trauma, or the signs and symptoms of possible tracheal
injury are particularly important as they may dictate the need for
more advanced techniques when securing the airway. In the
absence of these factors routine airway management is indicated
with well described indications for endotracheal intubation.
Although a comprehensive discussion of airway, and intraoperative
anaesthetic management is beyond the scope of this paper a few
salient points need to be made. Those with severe facial trauma or
suspected tracheal injury can be evaluated using a Glidescope
(Verathon Inc; Bothell, WA, USA), or intubating over a fiberoptic
bronchoscope. This technique is particularly useful when a partial
or complete tracheal tear is present. Blind endotracheal intubation
carries the risk of not securing the distal airway or of converting a
partial to a complete airway disruption. For elective thoracic
surgical procedures lung isolation with a double-lumen
endotracheal tube affords the advantage of working on an inert
lung in a quiet operative field. Almost all emergent thoracic
operations, however, are performed with a single lumen tube.
Generally this is not a problem except when operating on the
trachea itself (see below). In that specific instance, to avoid an
airway disaster, there must be constant communication between
the surgeon and the anesthesiologist.
The anaesthetist also has an important role in the intraoperative
management of the individual thoracic trauma, including on-going
volume resuscitation with blood, blood products and crystalloid,
administration of vasoactive medications and anaesthetics. There
must also be diligent attention to the respiratory status including
10
acid-base balance since acidosis from haemorrhagic shock can be
exacerbated by hypoventilation and respiratory acidosis.
Medications and inhalation agents routinely administered during a
chest operation may need to be avoided if they would lead to
cardiac depression or vasodilatation.
Pulmonary Parenchymal Injury
Injuries to the lung from penetrating trauma cover the spectrum
from minimal and self-limiting to devastating and life-threatening.
The indications for operative intervention, include those for
tracheo-oesophageal injuries, great vessel injury, cardiac injury or
tamponade, and haemorrhage. This section will focus on the
discussion of haemorrhage and parenchymal injury, damage
control thoracotomy and traumatic pneumonectomy.
Since the majority of pulmonary blood supply is from the lower
pressure pulmonary circuit and mean airway pressures tend to be
low, except in some pre-existing conditions or acutely with changes
in pulmonary compliance, most parenchymal tears and bleeding
are self limiting. This is the most important reason why over 80%
of penetrating chest injury can be managed with tube
thoracostomy. Therefore those patients requiring operative
intervention tend to have more severe parenchymal damage, more
arterial injuries, and often present in shock with minimal or no
response to volume resuscitation. Generally accepted indications
for immediate surgery are initial chest tube output of 1,500ml,
although some would argue at 1,000ml, ongoing drainage of
200ml per hour for 3 to 4 hours and inability to control a large air
leak [21,64]. One must be careful in evaluating these guidelines.
The initial chest tube output may be less than one litre but chest
imaging may reveal a large retained haemothorax. Also the decrease
in chest tube output may be related to a clotted chest drain and not
a decrease in ongoing bleeding. A CXR can be invaluable in
assessing the pleural space for retained blood. Isolated penetrating
thoracic injury in a patient in shock is an indication for exploration.
Numerous studies have evaluated the outcome of pulmonary
resection for trauma and more specifically lung-sparing techniques
and several principles have emerged. Emergency thoracotomy
performed for patients in shock carries a higher mortality than
when carried out in a haemodynamically stable individual. The
majority of parenchymal injuries can be treated by
pneumonorraphy, tractotomy, or wedge resection. Mortality and
morbidity both increase with the extent of resection and with the
need for concomitant laparotomy [64-67]. Pneumonorraphy is
generally all that is needed to control a superficial lung laceration.
Peripheral parenchymal injuries can easily be controlled with a
surgical stapler. The particular device used is less important than
achieving a haemostatic and air tight staple line. Grasping the
tissue with a lung clamp and firing the staples at the base of the
injured tissue is a very useful technique. Often multiple staple
cartridges are needed. The same principles can be applied to
performing a non-anatomic lung resection. In an emergency it is
often difficult, and possibly ill-advised, to perform a formal
lobectomy. In this situation a non-anatomic resection may be
preferred and performed in a similar manner to a stapled wedge
resection. For through and through parenchymal injuries, stapled
tractotomy is extremely useful. The jaws of the stapler are placed
through the tract and fired. Once the tract is open, large bleeding
vessels and small bronchi are suture ligated. In any of these
techniques if the staple line is not haemostatic or if a significant air
leak is present, the staple line can be oversewn with a running
suture. Fibrin glue applied to the staple line is a useful adjunct.
The reported mortality from a non-anatomic resection is 4%
compared to 77% with anatomic resection [68]. These results are
not necessarily related to the magnitude of the resection itself, but
rather to the severity of the injury which necessitates a complex
resection. Obviously if appropriate, a non-anatomic resection
should be performed. As expected the morbidity is also higher
among those with more extensive procedures. Complications
include pneumonia (87%), respiratory failure (62%) and less
JR Army Med Corps 156(1): 5-14

commonly post-operative haemorrhage, empyema and wound
infection [69].
Pneumonectomy
Traumatic pneumonectomy is seldom required and is only
indicated for severe pulmonary hilar injury. Given the rarity of this
injury there are few published series but the operative mortality
approaches 80%. Massive uncontrollable haemorrhage accounts
for the majority of intra-operative deaths and acute right heart
failure is the usual cause of death of those who survive the initial
operation [70,71]. Prompt pre-hospital transport and a rapid intra-
operative decision for the need for pneumonectomy are mandatory
alongside meticulous post-operative critical care management.
Lung protective strategies, pre-emptive treatment of right
ventricular failure and organ support such as continuous renal
replacement therapy are crucial. Transoesophageal
echocardiography is extremely useful in assessing both right
ventricular dysfunction and volume status, and allows goal directed
therapy. This includes judicious fluid management, the need for
inotropic support and the use of nitric oxide (NO). Vasoactive
medications should primarily be pulmonary vasodilators avoiding
medications which may increase pulmonary hypertension and
exacerbate right ventricular dysfunction. Inhaled NO is a
pulmonary vasodilator, which has little to no systemic effect, and
has demonstrated improved oxygenation [72]. Our experience has
prompted us to institute early veno-venous extra-corporeal
membrane oxygenation (ECMO) without systemic
anticoagulation. This allows maximal pulmonary support therefore
the lung can be “rested” with minimal mean airway pressure.
Patients requiring a pneumonectomy for trauma are both complex
and challenging to care for.
Damage Control
The principles of damage control in trauma have less to do with
rigid rules than with a philosophy of abbreviated operation.
Uncontrolled haemorrhage will rapidly and invariably lead to
death. Fundamentally, damage control abbreviates the surgical
procedure after bleeding is controlled, resuscitation continues in
the intensive care unit and re-exploration is planned after
physiologic normalization. With thoracic trauma haemorrhage
alone is not the only fatal variable; hypoxia and hypercarbia can
also lead to early death [73,74]. The essentials of damage control
remain with an abbreviated operation as the cornerstone. Useful
techniques include tractotomy, packing and temporary chest
closure [75-77]. Of these, tractotomy is the most widely employed.
It can be rapidly performed, achieves haemostasis and results in
little or no air leak. Chest packing is a useful technique but the
packs must not compromise already jeopardized cardio-pulmonary
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
JR Army Med Corps 156(1): 5-14
Non-Cardiac Thoracic Trauma
portion or near the carina; penetrating injuries may occur
anywhere along the trachea’s course. Subcutaneous emphysema,
haemoptysis, change in phonation, and dyspnoea should alert the
physician to the possibility of a tracheal injury. Air escaping from a
cervical wound with respiration is almost always the result of an
adjacent tracheal injury and is an indication for neck exploration.
Securing the airway is of paramount importance and
consideration should be given to using a Glidescope (Verathon Inc;
Bothell, WA, USA) or flexible bronchoscopy to assist the
endotracheal intubation. Injuries to the intrathoracic trachea and
bronchi may be more subtle. The same signs and symptoms as for
cervical injury may be present; however, a persistent pneumothorax
or continuous air leak following tube thoracostomy may be the
only indication of this injury. Chest CT is invaluable in assessing
the mediastinum and defining the trajectory of the weapon (Figure
12). Pneumomediastinum, while possibly from a tracheal or
oesophageal injury, may be the result of pulmonary parenchymal
injury. Bronchoscopy will confirm or exclude the diagnosis. It is
important not only to visualize the injury but to determine the
level of the injury with respect to the cords or carina, as it will guide
the surgical approach (Figure 13). Obviously the oesophagus also
requires evaluation and will be discussed in another section.
A low collar incision provides adequate exposure of the cervical
trachea. Distal tracheal and proximal right bronchial injuries are
best approached through a right postero-lateral thoracotomy.
Division of the azygous vein and widely opening the mediastinal
pleura allows excellent visualization. In general, left bronchial
injuries are approached through the left chest although the aorta
may make the repair somewhat more challenging. The proximal
right mainstem can be approached from the right side. While
tracheal repair itself is straightforward, appropriate airway
management is critical to a successful operation, and
communication between the surgeon and the anesthesiologist is
essential. Any devitalized tissue is debrided and the airway defect
closed without tension using interrupted absorbable sutures. The
authors’ preference is to use a tapered 3-0 PDS (Ethicon;
Somerville, NJ, USA) and place the sutures prior to tying them.
When placing the sutures care must be taken to avoid the
endotracheal balloon (Figure 14). Once the sutures are tied, the
endotracheal tube is manipulated confirming no sutures have been
placed though it. In the absence of a concomitant oesophageal or
vascular injury muscle coverage is generally not necessary. Most
injuries can be treated in this manner [81,82]. A complex injury in
an unstable patient can be temporized with a T-tube [83]. While it
may appear to be counter-intuitive, early extubation is the goal.
The mortality from penetrating injury is quite variable, ranging
from 18% to over 50% and is often related to associated vascular
trauma [82-84]
Figure 12. Chest CT demonstrating posterior wall tracheal disruption.
11
Non-Cardiac Thoracic Trauma
Figure 13. Bronchoscopy of the patient in Figure 12.There is a large posterior tracheal
wall disruption extending to the upper lobe orifice.
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
procedure and the effect of time from perforation to surgical repair.
12
A comprehensive review of this topic is beyond the scope of this
paper but the interested reader is directed to excellent review
articles on the subject [85,86]. There are several principles which
guide therapy. The combination of CT scan, a contrast
oesophagram and oesophagoscopy will diagnose virtually all
oesophageal injuries.
Perforation of the thoracic oesophagus carries a higher mortality
than cervical injury. Primary repair should be performed,
independent of time from perforation, if there is not gross
mediastinal contamination. These same principles can be applied
to penetrating oesophageal trauma. Mediastinal air may have
several aetiologies and it is incumbent on the trauma team to
exclude an oesophageal injury. The combination of
oesophagoscopy and oesophagram are fundamental to the
evaluation, and should be performed without delay.
Oesophagoscopy should be performed first as the contrast for the
oesophagram will obscure the view during endoscopy. If an injury
is found prompt surgical repair is the optimal treatment.
Cervical injuries can be approached via a left standard neck
incision, staying anterior to the pre-vertebral fascia. The injury is
closed in two layers and drains are placed. Generally oral intake can
begin in 2-3 days and the drain output monitored. Injuries to the
thoracic oesophagus are more problematic. The mid-thoracic and
lower oesophagus can be exposed respectively, through right and
left thoracotomy. Devitalized tissue is debrided and a primary two-
layer repair is performed. Buttressing the repair with vascularized
muscle or pleura, and wide mediastinal drainage are then
performed. Nasogastric and distal enteral feeding tubes are placed
and the patient is kept nil by mouth. The authors prefer to assess
the repair by oesophagram approximately one week post-op. If
there is no leak, oral intake is begun and the chest tubes are
removed if there is no drainage with feeding. If there is a
concomitant vascular or tracheal injury they are repaired; muscle
interposition will decrease the chance of a fistula. We prefer to
harvest the closest, non-traumatized intercostal preserving its blood
supply. In extreme circumstances such as damage control or
significant injury to the oesophagogastric junction, a T-tube or
retrograde oesophageal drainage (Figure 15) can be used [87,88].
The combination of rapid evaluation , prompt operation and
adherence to sound surgical principles and techniques will yield
gratifying results.
In a large multi-institutional study of oesophageal injury which
enrolled 405 patients, there was a 19% mortality rate and over half
of the survivors had complications. Independent predictors of
mortality were delay to operation, and resection and diversion
[89].
Figure 15. Retrograde oesophageal drainage as a damage control technique for severe
oesophageal or oesophagogastric trauma.
JR Army Med Corps 156(1): 5-14

Complications
As discussed above, operative mortality increases with the
magnitude of the lung resection [64,65]. This results from at least
two factors; the resection itself and the extent of the traumatic
injury which necessitated the resection. Blunt trauma carries a
higher mortality than penetrating injury and may be secondary to
associated injuries. Complications following pulmonary resection
for trauma are common and can be divided into those directly
related to, and not related to the resection itself. Empyema,
persistent air leak, necrotic lung secondary to impaired blood
supply, and torsion are most often related to the pulmonary
resection. Post-operative empyema is not at all uncommon and,
unlike parapneumonic empyema, will often require operation as
opposed to tube thoracostomy and antibiotics alone. Persistent air
leak, necrosis and torsion can be minimized by inspecting the post-
resected lung while fully inflated. Residual staple line air leak can
be oversewn and re-enforced with a variety of topical fibrin
sealants. Post-operative torsion is rare but may result in a
gangrenous lobe, sepsis and death. The more extensive the
resection and the presence of a complete fissure increase the risk of
torsion. Stapling the remaining lobes together is an excellent
technique for all but eliminating this particular complication.
Given the lung’s robust blood supply both pulmonic and systemic,
necrosis is a rare but dreaded complication. It is more prone to
occur with either an extensive or central resection. One report
suggested examining the inflated lung after pulmonary resection
for signs of ischemia [65]. At re-exploration for either torsion or
necrosis further resection is necessary.
Other common complications that occur following, but are not
necessarily related to, a lung resection are pneumonia, respiratory
failure, wound infections and haemorrhage. Not surprisingly, the
two most common complications are pulmonary related;
pneumonia (87%) and respiratory failure (62%) [69]. Post-
operative detailed intensive care management and the early
implementation of lung protective strategies are essential. Return to
the operating room for post-operative haemorrhage is also not
uncommon (16%). Monitoring hourly chest tube output,
coagulation studies and chest x-ray are crucial. Generally, a chest
tube drainage of 200ml/hr for 2 to 3 hours is an indication for re-
exploration. Frequent coagulation studies are advisable especially in
those with on-going resuscitation. Appropriate administration of
clotting factors, platelets and Factor VIIa can be life-saving. Interval
chest x-rays are invaluable to assess the pleural space for retained
haemothorax. It is important to remember that decreasing chest
tube output does not necessarily imply decreased bleeding. Clotted
or mal-positioned chest drains may fail to evacuate blood which
will be apparent on chest x-ray. It is our practice to obtain a chest
film in the operating theatre at the conclusion of the procedure.
Subsequent films can be compared to evaluate the pleural space.
Since the chest wall musculature has excellent blood supply, post
operative wound infections are infrequent and usually do not
involve the bony thorax. Unless the infection is trivial, it is our
practice to explore these wounds in the operating theatre. They are
often deeper than appreciated on examination. Widely opening the
wound, debridement and antibiotics generally suffice, and many
can subsequently be closed. Another useful technique is the
application of a Vacuum Assisted Closure; our results with this
modality have been excellent [90].
Summary
The thorax is one of the most commonly injured structures
resulting from trauma. The chest wall, lung parenchyma, trachea,
oesophagus and vascular structures may be involved, individually
or in combination. Concomitant injury to the head, abdomen,
pelvis and extremity may also be present. A clear understanding of
the injury mechanism, rapid but through physical examination
coupled with portable chest radiograph and FAST are often all that
is needed to formulate a treatment plan. Haemodynamic
instability precludes further imaging studies and prompts emergent
JR Army Med Corps 156(1): 5-14
Non-Cardiac Thoracic Trauma
operative intervention. Imaging studies especially chest CT are
extremely useful in stable patients.
Over 80% of chest injuries can be managed non-operatively.
Tube thoracostomy, adequate analgesia, supplemental oxygen and
aggressive respiratory therapy often suffice. Those patients
requiring immediate surgery are often haemodynamically
unstable, have persistent bleeding, tracheal or oesophageal injury.
The appropriate incision, surgical exposure and attention to the
anesthetic management are critical. The surgeon should be familiar
with the various techniques to manage lung, tracheal or
oesophageal injuries. Clinical judgment is paramount in deciding
which technique is optimal and if an abbreviated operation and
damage control are appropriate.
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