Kaur Manpreet
Group 25
Trauma of thoracic cavity
Introduction
Thoracic trauma accounts for up to 35% of
trauma-related deaths in the United States and
encompasses a broad range of injuries that can
cause significant morbidity and mortality.
[1] Prompt evaluation during the primary trauma
survey is key to identifying those injuries that are
immediately life-threatening and require rapid
intervention. Once these conditions are ruled
out, less urgent thoracic injuries are often
readily diagnosed during the secondary trauma
survey and successfully managed by applying
the fundamental principles of advanced trauma
life support (ATLS).
Etiology
Thoracic trauma is broadly categorized by
mechanism into blunt or penetrating trauma.The most common cause of blunt chest trauma
is motor vehicle collisions (MVC) which account
for up to 80% of injuries. Other causes include
falls, vehicles striking pedestrians, acts of
violence, and blast injuries. The majority
of penetrating trauma is due to gunshots and
stabbings, which together account for 20% of
all major trauma in the United States.
Epidemiology
Blunt chest trauma is more common than
penetrating trauma and directly comprises 20 to
25% of trauma deaths. Among patients
presenting after motor vehicle collisions, higher
morbidity and mortality are associated
with high-speed collisions and with a lack of
seat belt use. Poorer outcomes are also seen in
patients with advanced age and higher injury
severity scores (ISS). Despite its higher
incidence, less than 10% of patients suffering
blunt trauma to the thorax require operative
intervention, whereas 15 to 30% of patients
sustaining penetrating chest injuries will need
operative intervention. Penetrating chest trauma
is associated with higher overall mortality.Incidence varies based on geographic location,
predominating in urban areas, those prone to
interpersonal violence, and areas of conflict.
Pathophysiology
Anatomic Considerations and
Pathophysiology
The major components of the chest wall are the
rib cage, costal cartilage, and intercostal
musculature. The blood supply and innervation
to the chest wall are supplied by neurovascular
bundles, comprising an intercostal artery, vein,
and nerve that course at the inferior border of
each rib. Deep to the rib cage, the parietal
pleura makes up the inner lining of the chest
wall. It receives somatic innervation from the
intercostal nerves and therefore contains pain
fibers. A layer of visceral pleura covers the
intrathoracic structures. The potential space
between the visceral and parietal layers
is termed the pleural space and normally
contains a small volume of hypotonic fluid,
approximately 0.3 mL/kg, which undergoes
constant turnover at a rate of 0.15 mL/kg per
hour.[3]. This pleural fluid is produced by the
parietal pleura itself and reabsorbed by pleurallymphatics. When lymphatic reabsorption is
overwhelmed, pleural effusion occurs.
The chest wall serves 2 main purposes. First, it
functions to facilitate respiration. Contraction of
the diaphragm and intercostal muscles during
inspiration increases intrathoracic volume, thus
decreasing intrathoracic pressure, allowing the
passive flow of air into the lungs. The reverse
occurs during expiration. The diaphragm and
intercostals return to their relaxed positions
resulting in an increase in intrathoracic pressure,
which forces air out of the lungs. The chest wall
also protects intrathoracic structures from
external injury. The sternum and clavicles
provide additional structural support to the
anterior thorax. They are dense bones that
serve as points of attachment for the pectoralis
major and minor muscles and therefore require
significant force to fracture. Similarly, the
scapulas which overlie the superior aspect of
the posterior chest wall provide an added
protective barrier to trauma.
The mediastinum comprises the heart, thoracic
aorta, trachea, and esophagus and is
anatomically located in the center of the chest
between the right and left hemithoraces. It is
bordered by the sternum anteriorly, vertebral
column posteriorly, and parietal pleura andlungs bilaterally and extends from the thoracic
inlet superiorly to the diaphragm inferiorly. The
most common isolated mediastinal injury in
blunt trauma is an injury to the aorta, which can
range in severity from an intimal laceration to
complete aortic transection. In penetrating
trauma, all the mediastinal structures are
equally susceptible, and the injury sustained
depends on the anatomic location of the
penetrating wound and its trajectory. Of
particular importance is an injury within the
"cardiac box" whose boundaries are
the midclavicular lines laterally, the clavicles
superiorly, and the xiphoid process inferiorly.
Trauma in this region is associated with an
increased risk of penetrating cardiac injury and
the development of cardiac tamponade, and
rapid clinical decompensation.
Morbidity and mortality associated with thoracic
trauma are due to the disruption of respiration,
circulation, or both. Respiratory compromise can
occur due to direct injury to the airway or lungs,
as is the case with pulmonary contusions, or
from interference in the mechanics of breathing,
as with rib fractures. The common outcome is
the development of ventilation-perfusion
mismatch and decreased pulmonary
compliance. This then results in hypoventilationand hypoxia, which may necessitate intubation.
Circulatory compromise occurs in the setting of
significant blood loss, decreased venous return,
or direct cardiac injury. Intrathoracic bleeding
most commonly manifests as hemothorax in
both blunt and penetrating trauma, and a
massive hemothorax can lead to hypotension
and hemodynamic shock.
History and Physical
The initial evaluation of a trauma patient is
based on the ATLS protocol. This begins with an
assessment of the patient's airway, breathing,
and circulation (ABCs) during the primary
survey, typically in that order. The initial
evaluation of the patient who has sustained
blunt or penetrating thoracic trauma is similar
and geared toward the rapid identification of
immediately life-threatening conditions, namely
tension pneumothorax, cardiac tamponade,
aortic injury, massive hemothorax, and
tracheobronchial disruption. The clinician must
pay careful attention to the patient's
appearance on arrival to the trauma bay. Signs
of respiratory distress, agitation, diaphoresis, orunwillingness to lay flat suggest underlying
cardiopulmonary injuries, such as tension
pneumothorax or cardiac tamponade, in which
case the breathing or circulation portions of the
primary survey would need to be addressed and
intervened upon first, as indicated. Intubating
such patients may exacerbate the
pneumothorax or hypotension and lead to
cardiovascular collapse due to the increased
intrathoracic pressure generated by positive
pressure ventilation. Therefore, if time and
personnel allow, these interventions should be
performed while the patient is prepared for
intubation. However, assessment of the
airway is generally performed first to
establish patency and evaluate the need for
intubation. The assessment of breathing begins
at the trachea, which is inspected and palpated
to ensure that it is midline and not deviated. The
chest wall in then inspected for asymmetry,
auscultated for breath sounds, and palpated for
tenderness, crepitus, and to detect flail
segments. In assessing circulation, hypotension
in the setting of thoracic trauma should raise
suspicion for tension pneumothorax or
tamponade, which need urgent intervention
before further evaluation of the patient can
proceed.Evaluation
Ultrasound
Sonographic evaluation of the abdomen and
thorax using the focused assessment with
sonography in trauma (FAST) exam is important
in the initial phase of the trauma assessment.
Per ATLS guidelines, it is ideally performed
during the circulation portion of the primary
survey to allow for the rapid detection of
pathologic pericardial, intraperitoneal, or
intrathoracic free fluid. Hemothorax can
be identified using the standard flank views
where the most dependent portions of the
pleural spaces can be imaged. The extended
FAST (E-FAST) exam employs additional chest
views to evaluate for pneumothorax. The linear
ultrasound transducer probe (5 to 10 MHz) is
utilized as opposed to the standard curvilinear
probe (2.5 to 5 MHz) as the higher frequency
enhances visualization of the pleural space. The
exam typically begins in the third or fourth
intercostal space in the midclavicular line, and
evaluation is based on the presence or absence
of the parietal and visceral pleura sliding past
each other, termed lung sliding.[4] Absent lung
sliding suggests the presence of a
pneumothorax. Several signs have also
been described to aid in the diagnosis, mostimportantly the lung point sign, where both lung
sliding and the absence of lung sliding are
visualized in the same sonographic window. The
lung point sign has a sensitivity of over 66% and
is 100% specific for pneumothorax.
Chest X-ray
Most thoracic injuries can be evaluated by
physical exam and chest radiograph. A chest x-
ray is fast, easy to obtain, inexpensive, and
often readily accessible. Any patient who
undergoes an intervention in the trauma bay
should have a repeat chest x-ray performed to
ensure the adequacy of the procedure. An initial
chest x-ray is recommended in any patient who
presents after blunt thoracic trauma, but it is not
mandatory if the trauma is minor and the patient
is not manifesting any physical signs to suggest
underlying injury. Based on the NEXUS chest
decision rules, patients younger than 60 years
old who have no chest pain or tenderness, no
distracting injuries or intoxication, and whose
mechanism did not involve rapid deceleration do
not need a routine chest x-ray.[5] All criteria
being met, there is a low likelihood of clinically
significant intrathoracic injury, with a negative
predictive value of 99%. However, if the patient
meets any individual criterion, chest radiography
should be performed. Conversely, physical examalone has not been shown to have adequate
diagnostic sensitivity, particularly for
pneumothorax, in penetrating trauma patients.
Therefore, all patients who suffer penetrating
injuries need evaluation with a chest x-ray since
many, up to 20%, with negative physical
findings will have hemothorax or pneumothorax.
Cross-Sectional Imaging
The use of CT scans in the evaluation of trauma
patients has significantly increased. Compared
to chest x-ray, chest CT has greater sensitivity
for detecting a pneumothorax or hemothorax
and also allows for evaluation of the rib cage,
the mediastinum, the lung parenchyma, and the
aorta. In blunt trauma, the decision
to obtain chest CT should be based on physical
findings, injury mechanism, and clinical
judgment. Patients who are hemodynamically
stable with a normal chest x-ray and no sternal,
thoracic spinal, or scapular tenderness are
unlikely to have a significant intrathoracic injury
to warrant CT, as shown by NEXUS.[6] Scanning
based on mechanism remains controversial.
However, recent studies have also reported a
substantial number of patients, up to 19%, with
significant underlying injury despite having no
clinical symptoms or abnormal findings on chestx-ray.[7] High-risk mechanisms include high-
energy deceleration MVC over 30 mph with
frontal or lateral impact, MVC with ejection, falls
over 7.62 meters (25 feet), and direct chest
impact. Therefore, current recommendations
are to obtain CT imaging in symptomatic
patients and those presenting after high-risk
mechanism regardless of symptomatology
or chest x-ray findings. In penetrating trauma,
there are several indications for CT
scanning other than the clinician's judgment. All
cases in which the penetrating object crosses
the midline need CT scans as there is an
increased risk for mediastinal injury in these
patients. Patients with symptoms concerning for
underlying tracheobronchial, esophageal, or
vascular injury or those with symptoms that
cannot be adequately explained by chest x-
ray require further investigation.
Esophagography, Esophagoscopy, and
Bronchoscopy
An esophageal injury is often difficult to
diagnose because it lacks specific symptoms. It
is rare in blunt trauma and typically occurs in
the setting of severe polytrauma, which further
complicates the diagnosis. When present,patients may have cervical subcutaneous
emphysema, neck hematoma, or bloody
aspirate from a gastric tube, none of which are
specific. A chest x-ray may demonstrate
pneumomediastinum or pleural effusion
prompting CT, but definitive diagnosis requires
esophagram or endoscopy. Water-soluble
esophagram is typically performed first,
followed by barium esophagram if suspicion
remains. Endoscopy is generally less favored in
the acute setting due to fear of exacerbating an
existing injury. A tracheobronchial injury is rare
in blunt trauma, present in less than 1% of
patients, and is seen in the setting of severe
high-risk mechanisms. Injuries usually occur
within 1cm of the carina and are more common
in the right mainstem bronchus as it is less
flexible. In penetrating trauma, an
esophageal injury is often associated with
concomitant tracheal injury due to proximity,
and these patients require workup for
both. Patients with persistent pneumothorax
after tube thoracostomy, a large air leak after,
difficulty ventilating, and those with
transmediastinal penetrating trauma should all
undergo expeditious flexible bronchoscopy.Treatment / Management
Life-threatening injuries diagnosed during the
initial trauma evaluation require prompt
intervention. Still, the most common injuries due
to thoracic trauma are pneumothorax and
hemothorax, which are definitively managed in
80% of cases with tube thoracostomy. The size
of the chest tube used is a clinical decision
based on the pathology seen on a chest x-ray. If
both pneumothorax and hemothorax are
present, a size 28-Fr or 32-Fr chest tube is
usually considered as this will facilitate the
evacuation of both air and blood while
minimizing the chance of the tube obstructing
due to clot. If no effusion is present, small-bore
catheters are appropriate, although many
trauma clinicians will still opt for formal chest
tubes instead. Occult pneumothorax is a
pneumothorax that is seen on CT but not ona
chest x-ray. They are incidentally found in 2 to
10% of trauma patients who undergo chest CT.
Patients can be observed if the pneumothorax is
less than 8 mm.[8] However, occult
pneumothoraces are associated with a 5% to
10% risk of expansion and should, therefore, be
monitored closely. Patients whose
pneumothoraces expand or those who becomesymptomatic warrant tube thoracostomy.
Chest wall injuries are common in blunt thoracic
trauma, and the vast majority are treated non-
operatively. Most of these injuries are seen in
the setting of MVCs, especially when patients
are seat-belted or sustain frontal impact to the
steering wheel. Rib fractures are found in up to
10% of all trauma patients and 30% of patients
presenting with chest trauma. Sternal fractures
and scapula fractures are less common,
accounting for 8% and 3.5%, respectively, of
blunt thoracic trauma patients[9]. Rib fractures
are diagnosed clinically or radiographically,
typically on initial chest x-ray. Patients will
complain of pain and dyspnea and, on
physical exam, may be found to have
tenderness, crepitus, or diminished breath
sounds. The latter signs should raise suspicion
for underlying pneumothorax. Patients with less
than three rib fractures and no associated
injuries are appropriate candidates for
outpatient management with oral analgesics.
However, consideration for outpatient
management should be on a case-by-case
basis. Patients over the age of 65 and those
who are unable to maintain an oxygen
saturation of 92% or have an incentive
spirometer volume of less than 15 mL/kg shouldbe admitted for respiratory monitoring.[10] All
patients with three or more rib fractures or those
with displaced fractures are at increased risk for
pulmonary complications, such as contusions,
pneumonia, and delayed hemothorax, and
therefore require admission. Initial management
involves providing adequate analgesia,
thoracostomy drainage if indicated, and
respiratory care, including incentive spirometry.
Early and effective pain control is the mainstay
of management and is achieved through a
multimodal approach. Pain management begins
with standing acetaminophen and NSAIDs with
opioids administered as needed. Demand-only
patient-controlled analgesia (PCA) with opioids
is effective when pain is more severe, but
patients should be transitioned to oral narcotics
as they clinically improve. In patients with
multiple or displaced rib fractures and those
with pain refractory to pharmacologic
management, regional anesthesia techniques
are employed. These include the placement of
epidural catheters, paravertebral blocks, and
intercostal nerve blocks. The EAST trauma
guidelines advocate for the use of epidural
anesthesia in patients with greater than three
rib fractures or patients with fewer fractures but
who are over 65 years old or have a significanthistory of cardiopulmonary disease.
[11] Compared to other forms of analgesia, a
continuous epidural infusion has not been
shown to reduce the need for mechanical
ventilation, length of intensive care unit (ICU)
stay, or mortality but has been shown to
decrease the duration of mechanical ventilation.
Paravertebral catheters administer a local
anesthetic to the paravertebral space and have
comparable efficacy to epidural catheters but
with a lower rate of causing systemic
hypotension. Surgical rib fixation is reserved for
patients in whom adequate analgesia cannot be
achieved due to fracture severity and those with
impending respiratory failure. It is ideally
performed within 48 to 72 hours of injury.
Flail chest occurs when 3 or more contiguous
ribs are fractured in at least 2 locations. This
leads to the paradoxical movement of the flail
segment during respiration. The injury itself is
usually not the cause of respiratory
compromise. Respiratory failure in these
patients typically results from the underlying
presence of a pulmonary contusion. Pulmonary
contusions themselves usually progress over the
first 12 to 24 hours post-injury, in which
time worsening hypoventilation and hypoxemia
may necessitate intubation. Initial chest x-rayusually underestimates the degree to which
the lung parenchyma is damaged, and patients
with pulmonary contusions should, therefore, be
admitted and serially monitored for signs of
impending decompensation.
Tension pneumothorax is the presumed
diagnosis when patients present with chest
trauma, respiratory distress, and hypotension. A
physical exam will also demonstrate specific
clinical signs, such as tracheal deviation away
from the affected side, decreased or absent
breath sounds on the affected side, and
subcutaneous emphysema on the affected side.
If recognized in the field, immediate
decompression using a 14-gauge needle placed
in the second intercostal space in the
midclavicular line is indicated. It should be noted
that recent data suggests that needle
decompression through the fifth intercostal
space in the anterior axillary line correlates with
a lower chance of failure (16.7%) due to body
habitus compared to the midclavicular line
placement (42.5%).[12] Once in the emergency
department, patients who have undergone
needle decompression in the field must then
undergo immediate tube thoracostomy for
definitive management.
Massive hemothorax is defined as greater than1500 mL of blood in the adult population.
Although the volume of blood in the pleural
space may be estimated on a chest radiograph,
the most reliable means for quantification is by
tube thoracostomy. In blunt trauma, it is most
commonly due to multiple rib fractures with
associated lacerated intercostal arteries.
However, bleeding can also be due to lung
parenchymal lacerations, in which case there is
usually an associated air leak. In the setting of
penetrating injury, great vessel or pulmonary
hilar vessel injury should be suspected.
Regardless of the etiology, massive hemothorax
is an indication for operative intervention, but
the patient's condition should first be stabilized
with tube thoracostomy to facilitate lung re-
expansion.
Cardiac tamponade is most common after
penetrating injury but can also occur due to
blunt myocardial rupture, particularly of the
atrial appendage. Acutely, less than 100 mL of
blood in the pericardial space can cause
tamponade. As the pressure in the pericardium
rises to match that of the injured chamber,
right atrial pressure is overcome, and this leads
to decreased filling and reduced right ventricular
preload. The classic Beck's triad of muffledheart sounds, jugular venous distention, and
hypotension might not be appreciated in the
trauma setting due to the often loud
environment and the presence of hypovolemia.
Patients presenting with hypotension and chest
trauma must, therefore, be approached with a
high level of suspicion. In the hemodynamically
unstable patient, a pericardial drain is placed in
the trauma bay under ultrasound guidance. This
procedure is successful in approximately 80% of
patients and provides sufficient stabilization for
transport to the operating room for sternotomy.
Penetrating trauma causes over 90% of great
vessel injury compared to blunt trauma. The
incidence of blunt aortic injury (BAI) ranges
between 1.5 to 2% of patients involved in high-
energy blunt trauma, particularly rapid
deceleration MVCs, which account for 80% of
blunt aortic injuries.[13] Most patients who
suffer BAI die in the field from aortic transection.
The patients who survive transport to the
hospital are those who have sustained
contained ruptures or dissections. Undiagnosed
injury at the time of presentation significantly
increases the chance of rupture in the first 24
hours. Clinical signs are neither sensitive nor
specific to diagnose BAI in the hemodynamically
stable patient. Therefore, patients who presentafter high-risk mechanism need to be
approached with a high index of suspicion. Initial
evaluation involves a chest x-ray which may
show a widened mediastinum, an indistinct
aortic knob, abnormal aortic contour, pleural
blood above the left lung apex referred to as
"apical capping," or displacement of the left
mainstem bronchus to the right. These findings
are not pathognomonic but indicate the need for
further testing by CT angiography. A
transesophageal echocardiogram (TEE) also
serves as an important imaging modality,
particularly in patients who are too unstable for
transport to CT. TEE has a sensitivity and
specificity comparable to that of CTA, and it has
the added benefit of being able to be
performed on the operating room table. Initial
management of aortic injury consists of strict
blood pressure and heart rate control with an
SBP goal of less than 100 mm Hg and HR less
than 100 per minute with intravenous beta-
blockade while awaiting surgery. Definitive
repair is by either open surgery via left
thoracotomy or endovascular repair.
Endovascular techniques in BAI have become
increasingly popular, and stenting is now the
mainstay of management, with success rates
ranging from 80% to 100%.[14]Thoracotomy in the operating room has several
indications in thoracic trauma. Most commonly,
patients with massive hemothorax over 1500 mL
and those with over 200 mL per hr of chest tube
output over 3 consecutive hours require an
operation. Additionally, those with cardiac
tamponade, great vessel injury, massive air leak
after thoracostomy placement, diagnosed
tracheobronchial injury, and open pneumothorax
need surgical repair. However, minimally
invasive techniques using video-assisted
thoracoscopic surgery (VATS) have been
increasingly utilized in hemodynamically stable
patients after both blunt and penetrating
thoracic trauma. Several series
have demonstrated favorable outcomes using
VATS, with improved postoperative pain
compared to thoracotomy and a shorter
duration of thoracostomy drainage.[15] The
most common indication is retained hemothorax
after thoracostomy, but VATS has also been
employed in the management of persistent
pneumothorax as well as traumatic
diaphragmatic injury.
The utility of resuscitative
emergency department resuscitative
thoracotomy has been a topic of controversy for
many years. Studies have shown thatoutcomes are based on the location of major
injury and whether signs of life are present on
arrival. Overall, the survival rate after
resuscitative thoracotomy in penetrating trauma
is 8.8% versus just 1.4% in blunt trauma. The
most favorable outcomes are seen in patients
with penetrating cardiac injury who present with
signs of life, with an overall survival rate of
19.4%.[16] Conversely, patients who sustain
blunt chest trauma have an overall survival rate
of 4.6% if signs of life are present on arrival
versus 0.7% without. Resuscitative thoracotomy
is therefore warranted in patients who present
with vital signs or have a history of signs of life
in the field.[17][18] General indications are as
follows:
e Witnessed penetrating thoracic trauma
with less than 15 minutes of prehospital
CPR
e Witnessed blunt thoracic trauma with less
than 10 minutes of prehospital CPR
e Witnessed penetrating trauma to the neck
or extremities with less than 5 minutes of
prehospital CPR
e Persistent, severe post-injury hypotension
(systolic blood pressure less than 60 mm
Hg) due to cardiac tamponade or massive
intrathoracic, intraabdominal, extremity, orcervical hemorrhage.
Differential Diagnosis
The spectrum of injury in blunt trauma is diverse
as multiple structures within the thorax may
sustain damage simultaneously. Injury can
result from direct trauma to the thorax, rapid
acceleration or deceleration, crush, or blasts. A
patient's external appearance may be
deceiving. Injuries to chest wall structures,
particularly the ribs, are frequent in blunt trauma
and are readily diagnosed clinically or
radiographically. Life-threatening injuries may
be present with no obvious external signs of
significant trauma, and these patients must be
approached with a high index of suspicion.
High-speed MVCs, lack of a seatbelt, extensive
vehicle damage or steering wheel
deformity, concomitant head, abdominal,
or major bony injuries, and chest wall bruising
are all factors associated with a higher risk of
underlying thoracic injury. Penetrating trauma,
by definition, results in a violation of the chest
wall. The damage sustained to intrathoracic
structures is based on the trajectory of the
penetrating object. Hemodynamic instability
suggests cardiac tamponade, great vessel injurywith massive hemothorax, or tension
pneumothorax. In stable patients, hemothorax
and pneumothorax are common injuries
and should rapidly be diagnosed. Further
workup should be performed in stable patients if
there is suspicion for underlying esophageal or
tracheobronchial injury, particularly when
wounds are present within the anatomic borders
of the "cardiac box."
Prognosis
The prognosis for thoracic trauma can vary
widely, given that thoracic injuries can range
from simple rib fractures to pneumothoraces to
direct penetrating cardiac injuries. Ultimately
the degree and mechanism of injury combined
with the patient's underlying comorbidities
determine the prognosis of a patient who has
suffered thoracic trauma.
Complications
The chances of a major complication can rangefrom minimal for simple rib fractures to very
likely if a major intervention is required or the
degree of injury is significant. Given the number
of vital structures in the chest, complications
can frequently be significant, including damage
to the vagus or phrenic nerves, the thoracic
duct, or critical vascular structures with
concomitant complications arising. The degree
and mechanism of injury and the interventions
taken to address them ultimately determine the
type and severity of complications that may
arise.