Thoracic Trauma


Article Author:
Luke Edgecombe


Article Editor:
Lambros Angus


Editors In Chief:
Ritesh Menezes


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/26/2018 11:55:09 AM

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 which 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 into blunt and penetrating. The most common cause of blunt chest trauma is motor vehicle collisions (MVC) which account for up to 80% 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.[2]

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 multiple 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 need an operation eventually. 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 pleural lymphatics. 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 and lungs 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, usually a tear 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 to 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 hypoventilation and hypoxia which may necessitate intubation. Circulatory compromise occurs in the setting of bleeding as in hemothorax, decreased venous return, or direct cardiac injury. Intrathoracic bleeding most commonly manifests as hemothorax in both blunt and penetrating trauma and can be massive leading 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 also pay careful attention to the patient's appearance on arrival to the trauma bay. Signs of respiratory distress, agitation, diaphoresis, or unwillingness 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 being 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 there is no deviation and that it is midline. 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 pneumothorax. Several signs have also been described to aid in diagnosis, most importantly 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. Initial chest x-ray is recommended in any patient who presents after blunt thoracic trauma but is not mandatory if trauma is minor and the patient is not manifesting any physical signs to suggest underlying injury. Based on NEXUS chest, 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 exam alone 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 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 trauma has significantly increased. Chest CT has the greatest sensitivity for detecting 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 chest x-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, large air leak after, or difficulty ventilating, and those with transmediastinal penetrating trauma should 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 which is seen on CT but not on a 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. Patients whose pneumothoraces expand or those who become symptomatic 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 should be 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 narcotics administered as needed. Demand-only patient-controlled analgesia (PCA) with narcotics 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 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 significant cardiopulmonary disease.[11] Compared to other forms of analgesia, 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 paradoxical movement of the flail segment during respiration. The injury itself is usually not the cause of respiratory compromise. Respiratory failure in these patients results from the development of pulmonary contusions that decrease lung compliance and increase shunt fraction. 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-ray usually 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, though, that studies suggest that needle decompression through the fifth intercostal space in the anterior axillary line correlates with a greater chance of success due to body habitus, 16.7% versus 42.5% failure rate compared to midclavicular line placement.[12] Once in the emergency room, patients must then undergo tube immediate tube thoracostomy for definitive management.

Massive hemothorax is defined as greater than 1500 mL of blood in the adult population. Although the volume of blood in the pleural space may be estimated on 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 muffled heart sounds, jugular venous distention, and hypotension is often appreciated in the trauma setting due to the often loud environment and multifactorial causes 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.

Great vessel injury occurs over 90% of the time due to penetrating trauma as opposed to blunt. The incidence of blunt aortic injury (BAI) ranges between 1.5% to 2% of patients who are involved in high-energy blunt trauma, particularly rapid deceleration MVCs which accounts for 80%.[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 present after high-risk mechanism need to be approached with a high index of suspicion. Initial evaluation involves 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 also serves as an important imaging modality particularly in patients who are too unstable for transport to CT. Its sensitivity and specificity are comparable to that of CTA, and it has the added benefit of being able to be performed on the operating room table. Initial management consists of strict blood pressure and heart rate control to goals of SBP 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 increasing 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 room thoracotomy has been a topic of controversy for many years. Studies have shown that outcomes 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, 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:

  • Witnessed penetrating thoracic trauma with less than 15 minutes of prehospital CPR
  • Witnessed blunt thoracic trauma with less than 10 minutes of prehospital CPR
  • Witnessed penetrating trauma to the neck or extremities with less than 5 minutes of prehospital CPR
  • Persistent, severe post-injury hypotension (systolic blood pressure less than 60 mm Hg) due to cardiac tamponade or massive intrathoracic, intraabdominal, extremity, or cervical 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 injury with massive hemothorax, or tension pneumothorax. In stable patients, hemothorax and pneumothorax are common injuries and are also usually rapidly diagnosed. Further workup should be performed in stable patients if there is suspicion for underlying esophageal or tracheobronchial injury, particularly when wounds are present in the cardiac box.

Enhancing Healthcare Team Outcomes

Thoracic trauma accounts for up to 35% of trauma-related deaths in the US 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 which 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 ATLS.

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.

Evaluation of patients who sustain thoracic trauma begins with ATLS and then employs various imaging techniques based on initial symptomatology. Life-threatening injuries diagnosed during the initial trauma evaluation require prompt intervention. However, the most common findings are injuries to the chest wall with associated hemothorax or pneumothorax, the majority of which can be definitively managed with a chest tube. Certain patients require urgent or emergent operative intervention. As minimally invasive techniques have become more popular, VATS has been increasingly used in the acute trauma setting for the management of a variety of injuries.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Thoracic Trauma - Questions

Take a quiz of the questions on this article.

Take Quiz
With blunt trauma to the chest, the thoracic aorta is often injured with other vessels in what percentage of cases?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following patients needs a thoracotomy after blunt chest trauma?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents to the emergency department after being involved in a motor vehicle collision. He complains of right-sided chest and shoulder pain and has difficulty moving his right upper extremity. Initial chest x-ray shows a fracture of the right 3rd rib. CT is performed and shows additional right 4th and 5th rib fractures and an associated 7mm right pneumothorax. How can this patient be managed?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
With blunt trauma to the chest, the thoracic aorta is in what percentage of cases?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following patients needs a thoracotomy after blunt chest trauma?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 22-year-old male presents to the trauma bay after being involved in an altercation where he sustained a gunshot wound to the right anterior chest within the cardiac box, adjacent to the sternum. He is hemodynamically stable en route but during the primary survey becomes acutely hypotensive and loses vital signs. The patient undergoes resuscitative thoracotomy. Where should incision be made?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 68-year-old female who was the restrained driver is brought in by emergency medical services after a high-speed rollover motor vehicle collision involving multiple vehicles. She is awake and alert and is complaining of right arm, neck, and facial pain. Exam reveals an obvious right upper extremity fracture, multiple facial contusions, and subcutaneous emphysema and swelling at the base of the neck. Chest x-ray shows a nondisplaced left 4th rib fracture and a small pleural effusion but no pneumothorax. In addition to cross-sectional imaging what diagnostic study should be performed?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Thoracic Trauma - References

References

Lichtenstein DA,Mezière G,Lascols N,Biderman P,Courret JP,Gepner A,Goldstein I,Tenoudji-Cohen M, Ultrasound diagnosis of occult pneumothorax. Critical care medicine. 2005 Jun     [PubMed]
Miserocchi G, Physiology and pathophysiology of pleural fluid turnover. The European respiratory journal. 1997 Jan     [PubMed]
Rhee PM,Acosta J,Bridgeman A,Wang D,Jordan M,Rich N, Survival after emergency department thoracotomy: review of published data from the past 25 years. Journal of the American College of Surgeons. 2000 Mar     [PubMed]
Seamon MJ,Haut ER,Van Arendonk K,Barbosa RR,Chiu WC,Dente CJ,Fox N,Jawa RS,Khwaja K,Lee JK,Magnotti LJ,Mayglothling JA,McDonald AA,Rowell S,To KB,Falck-Ytter Y,Rhee P, An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. The journal of trauma and acute care surgery. 2015 Jul     [PubMed]
Rodriguez RM,Anglin D,Langdorf MI,Baumann BM,Hendey GW,Bradley RN,Medak AJ,Raja AS,Juhn P,Fortman J,Mulkerin W,Mower WR, NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA surgery. 2013 Oct     [PubMed]
Rodriguez RM,Langdorf MI,Nishijima D,Baumann BM,Hendey GW,Medak AJ,Raja AS,Allen IE,Mower WR, Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLoS medicine. 2015 Oct     [PubMed]
Inaba K,Ives C,McClure K,Branco BC,Eckstein M,Shatz D,Martin MJ,Reddy S,Demetriades D, Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Archives of surgery (Chicago, Ill. : 1960). 2012 Sep     [PubMed]
Salim A,Sangthong B,Martin M,Brown C,Plurad D,Demetriades D, Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Archives of surgery (Chicago, Ill. : 1960). 2006 May     [PubMed]
Dyer DS,Moore EE,Ilke DN,McIntyre RC,Bernstein SM,Durham JD,Mestek MF,Heinig MJ,Russ PD,Symonds DL,Honigman B,Kumpe DA,Roe EJ,Eule J Jr, Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients. The Journal of trauma. 2000 Apr     [PubMed]
Tang GL,Tehrani HY,Usman A,Katariya K,Otero C,Perez E,Eskandari MK, Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis. Journal of vascular surgery. 2008 Mar     [PubMed]
Moore FO,Goslar PW,Coimbra R,Velmahos G,Brown CV,Coopwood TB Jr,Lottenberg L,Phelan HA,Bruns BR,Sherck JP,Norwood SH,Barnes SL,Matthews MR,Hoff WS,de Moya MA,Bansal V,Hu CK,Karmy-Jones RC,Vinces F,Pembaur K,Notrica DM,Haan JM, Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study. The Journal of trauma. 2011 May     [PubMed]
Sirmali M,Türüt H,Topçu S,Gülhan E,Yazici U,Kaya S,Taştepe I, A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2003 Jul     [PubMed]
Brasel KJ,Moore EE,Albrecht RA,deMoya M,Schreiber M,Karmy-Jones R,Rowell S,Namias N,Cohen M,Shatz DV,Biffl WL, Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. The journal of trauma and acute care surgery. 2017 Jan     [PubMed]
Meredith JW,Hoth JJ, Thoracic trauma: when and how to intervene. The Surgical clinics of North America. 2007 Feb     [PubMed]
Galvagno SM Jr,Smith CE,Varon AJ,Hasenboehler EA,Sultan S,Shaefer G,To KB,Fox AD,Alley DE,Ditillo M,Joseph BA,Robinson BR,Haut ER, Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. The journal of trauma and acute care surgery. 2016 Nov     [PubMed]
Goodman M,Lewis J,Guitron J,Reed M,Pritts T,Starnes S, Video-assisted thoracoscopic surgery for acute thoracic trauma. Journal of emergencies, trauma, and shock. 2013 Apr     [PubMed]
DiGiacomo JC,Angus LDG, Thoracotomy in the emergency department for resuscitation of the mortally injured. Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2017 Jun     [PubMed]
Champion HR,Copes WS,Sacco WJ,Lawnick MM,Keast SL,Bain LW Jr,Flanagan ME,Frey CF, The Major Trauma Outcome Study: establishing national norms for trauma care. The Journal of trauma. 1990 Nov     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pathology-Forensics. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pathology-Forensics, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pathology-Forensics, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pathology-Forensics. When it is time for the Pathology-Forensics board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pathology-Forensics.