TRAUMA

Chest trauma Learning objectives

Bevan Roodenburg
Owen Roodenburg
Abstract
This article summarises major life-threatening injuries in thoracic trauma.
Timing, clinical features, necessary investigations and interventions are
described within the clinical approach of primary and secondary surveys.
Emphasis is on immediate resuscitation with some discussion on further
management. Injuries included are tension pneumothorax, open pneumo-
thorax, massive haemothorax, pericardial tamponade, aortic injuries, car-
diac injuries, lung contusion, flail chest, diaphragmatic injury, airway
injury and oesophageal rupture.
Keywords Aorta; blunt; flail; haemothorax; penetrating; pneumothorax;
tamponade; thorax; trauma
Royal College of Anaesthetists CPD matrix: MT_BK_01, OA_BS_05,
MT_BK_12, RC_BK_16, CI_BK_20, CT_IK_23, MT_IK_02, 2A02
After reading this article you should be able to:
C list the mechanism of common deadly injuries in chest trauma
C describe why specific injuries require urgent interventions
C describe a systematic approach to assessing and managing
thoracic injuries
preferably team approach to assessment and correction of res-
piratory, cardiovascular and neurological injuries. This involves:
 securing or maintaining a patent airway
 protecting the patient from further spinal cord injury
 optimizing ventilation and oxygenation
 controlling major external haemorrhage
 establishing large-bore intravenous access for necessary
drug and fluid delivery
 blood sampling for cross-match, blood counts, biochem-
istry, blood gas analysis
 assessing neurological deficits
 full exposure of the patient
 immediate access to chest and pelvic X-ray, and focussed
assessment with sonography for trauma (FAST).

Chest injuries Invasive procedures

Chest injuries are commonly responsible for 20e25% of deaths Further invasive procedures are sometimes immediately neces-
due to trauma. These injuries arise from penetrating (usually sary in the resuscitation of patients with chest trauma, as follows.
gunshot or knife) and non-penetrating trauma (deceleration in-  Tube thoracostomy (or finger thoracostomy): an inter-
juries and blunt trauma mechanisms such as motor vehicle ac- costal catheter (ICC) is placed in the mid-axillary line at the
cidents (MVA), falls, crushes, blasts, and burns). fourth or fifth intercostal space.
This article addresses common life-threatening injuries  Emergency department thoracotomy is indicated in blunt and
(Table 1) appearing: penetrating thoracic trauma, where arrest is witnessed or
 immediately within 10 minutes of arrest if suitably skilled staff are pre-
 early (in the primary survey) sent.1 This allows for internal cardiac compressions. Closed
 late (hours to days after hospital presentation). chest compression is rarely successful in the trauma setting.
Injuries may be single organ or more complex depending on the  Needle chest decompression: a large-bore cannula inserted
mechanism and pattern of injury (stabbing vs. motor vehicle through the second intercostal space in the mid-clavicular
crash). Penetrating wounds usually require earlier (sometimes line.
during resuscitation) surgical intervention, with faster recovery.
Blunt injuries more likely require complex imaging after initial Primary survey resuscitation
stabilisation and longer recovery times.
Chest injuries include five immediate life-threatening conditions
Thoracic spine and spinal cord injuries, whilst significant and
which dominate the primary survey (Table 2).
common, are not dealt with in this review, but are addressed
elsewhere.
Tension pneumothorax, in which air accumulates under posi-
The approach to the management of chest trauma contributes
tive pressure in the pleural space, collapsing and shifting
within a more comprehensive approach to resuscitation in the
context of major trauma. The primary survey and correction of
immediate life-threatening injuries includes a systematic, Deadly injury; typical timing
Immediate Early (minutes to hours) Late
(at scene) (hours to days)
Bevan Roodenburg MBBS is an Advanced Trainee in Intensive Care and
Emergency Medicine at the Alfred Hospital in Prahran, Melbourne,
C Aortic rupture C Tension pneumothorax C Flail chest
Australia. Conflicts of interest: none declared.
C Cardiac chamber C Open pneumothorax C Lung
rupture C Massive haemothorax contusion
Owen Roodenburg MBBS (Hons) FRACP FCICM Grad Cert HSM is Deputy Director C Cardiac C Pericardial tamponade C Sepsis
of Intensive Care and Head of Trauma Intensive Care, and is also arrhythmia C Aortic tears then rupture
Supervisor of Intensive Care Training (CICM) at the Alfred Hospital,
Prahran, Melbourne, Australia. Conflicts of interest: none declared. Table 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:9 411 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
 TRAUMA
Classic signs differentiating deadly injuries
RR BP HR O2sats JVP Tracheal deviation
Tension pneumothorax Contralateral
Open pneumothorax /e /e Contralateral or
midline
Massive haemothorax /e /e Contralateral or
midline
Pericardial tamponade /e Midline
Flail chest e /e e Midline
Lung collapse (e.g. after ? e e e Ipsilateral
right main bronchus
intubation
Table 2
mediastinal structures away from the affected side. Death occurs
due to obstruction to venous return causing obstructive shock,
coupled to hypoxia due to lung collapse.
Signs: hypoxia, tachycardia, tachypnoea, hypotension and
contralateral tracheal deviation. Reduced air sounds, hyper-
resonance, hyper-expansion and reduced thoracic wall move-
ments on the affected side. Subcutaneous emphysema is common.
Treatment traditionally included needle decompression, fol-
lowed by ICC insertion. Many now advocate tube thoracostomy
rather than needle decompression due to higher failure rates
of needle thoracostomy.2 In the case of cardiac arrest, bilateral
tube or finger thoracostomy is indicated rather than needle
thoracostomy.
Where cardiorespiratory compromise is present and tension
pneumothorax is suspected clinically, needle decompression
may be performed without awaiting imaging, but must be fol-
lowed by definitive intercostal catheter placement. The catheter
usually need not be under suction. A one-way valve or single
bottle drainage system will usually suffice.
Bilateral pneumothorax is a difficult diagnosis to make clini-
cally. If suspected or confirmed on imaging (ultrasound or
X-ray), bilateral tube thoracostomies are indicated. Simple
pneumothorax may be managed conservatively with surveillance
chest X-ray (CXR) at 4e6 hours if small, but tube thoracostomy
should be placed if intubation is required, or the pneumothorax
is expanding.
Open pneumothorax involves an open wound communicating
with the pleural space, leading eventually to death by tension
pneumothorax.
Signs are the same as simple or tension pneumothorax, but
include a ‘sucking’ wound allowing air to enter the thorax during
inspiration.
Treatment consists of application of an occlusive dressing,
sealed on three out of four sides allowing air to escape from the
pleural space, and preventing entry of air in through the wound.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:9 412
Chest examination/auscultation Other signs
Quieter, hyper-expanded,
hyper-resonant
Quieter, hyper-expanded, Sucking wound
hyper-resonant
Quieter, dull percussion.
Reduced expansion
Muffled heart sounds Pericardial fluid on
FAST scan. Pulses
paradoxus (10%)
Paradoxical chest wall Signs may disappear
movement during spontaneous after intubation
ventilation
Quieter and reduced expansion
over collapse
This is accompanied by ICC insertion at a sight separate from the
wound. Positive pressure ventilation will reverse the ‘sucking’
negative intrapleural pressure during inspiration, but can convert
a simple pneumothorax to a tension pneumothorax. Tube thor-
acostomy should precede airway intubation and positive pres-
sure ventilation.
Massive haemothorax occurs when a large amount of blood
(typically >1.5 litres) accumulates in the pleural cavity. This can
cause lung compression with collapse, and contralateral medi-
astinal shift. Death occurs due to haemorrhagic shock and further
cardiovascular compromise due to obstruction to venous return,
coupled with respiratory compromise.
Signs that distinguish haemothorax from pneumothorax are
dull percussion note rather than hyper-resonance. Investigations
that confirm haemothorax include CXR, CT scan and ultrasound.
Treatment is immediate large-bore intercostal catheter inser-
tion, requiring low pressure suction (<20 cmH2O), fluid resus-
citation and replacing necessary blood and coagulation products.
Surgical thoracotomy should be considered and is indicated if
large rates, typically more than 200 ml/hour, of bleeding
continue.
Pericardial tamponade is caused by bleeding (as little as 50 ml)
into the pericardial space. It is more common in penetrating
wounds but should be considered in blunt trauma where there is
distended neck veins and hypotension out of keeping with blood
loss volume. Death occurs because of cardiovascular compro-
mise, due to reduced venous return because of collapsing right-
sided heart chambers and subsequent failure of delivery of blood
to the left ventricle.
Signs include hypotension, pulsus paradoxus >10 mmHg,
tachycardia, tachypnoea, raised JVP and dull heart sounds. ECG
changes include diminished voltages and electrical alternans.
None of these signs is 100% sensitive. Investigations to confirm
the diagnosis include FAST scan or formal echocardiography.3
Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
 TRAUMA

Intervention is immediately necessary in the crashing patient,

and involves emergency thoracotomy in theatre or the emer-
gency department.4 Pericardiocentesis is not useful in the acute
trauma setting. Stable patients can be referred for surgical
intervention with pericardial window or thoracotomy.

Flail chest should be noted on examination during primary

survey, as positive pressure ventilation will hide the diagnostic
signs. Two or more fractures occur on two or more adjacent ribs,
with paroxysmal movement of the flail segment during sponta-
neous ventilation leading to hypoventilation. Flail chest con-
tributes to mortality because of respiratory failure.
Initial therapy can include continuous positive airway pres-
sure and analgesia, but intubation and positive pressure venti-
lation may be necessary. Recent evidence supports surgical
fixation in some circumstances5 (Figure 1).

Definitive care
Disposition may be surgical intervention in operating theatres
(especially in unstable patients and those with penetrating chest
wounds), further detailed imaging (such as CT, digital subtrac-
tion angiograms, trans-oesophageal echocardiography), or
observation and supportive care in an appropriately monitored
environment.

Other specific life-threatening injuries

Aortic injury is divided into minor and significant injury. Minor
injuries involve small intimal tears with small periaortic hae-
matoma formation. Significant injuries involve the intima and
full thickness of media and have high risk of rupture. Immediate
death follows rupture of the aorta after blunt trauma. Of those
patients with aortic injury who survive to hospital admission,
90% will have a significant injury.
Signs include unequal limb pulses, interscapular murmur,
stroke or nerve plexus palsy, supraclavicular haematoma, and
hypotension.
Investigations: CXR (Figure 2) may show signs of widened
mediastinum, blunted aortic knuckle, pleural cap, pleural fluid
(haemothorax) and deviated trachea and deviated nasogastric
tube within theoesophagus. These findings are highly sensitive
but poorly specific. Chest CT angiography has much better
specificity for diagnosing aortic injury.6 Transoesophageal
Figure 1 Flail segment. (a) CT reconstructed image prior to fixation.
echocardiography (TOE) is useful in the diagnosis of aortic
(b) Plain chest X-ray after fixation.
injury, but distal ascending aortic views are more difficult, as are
lower descending aortic views (below the stomach). TOE has the
benefit that it provides assessment of blunt cardiac injury. More Minor ECG changes and cardiac enzyme rises usually resolve
than one imaging modality is often required (CT angiogram, and require no further intervention if the following have not been
TOE, CXR, MRI) to exclude or confirm the diagnosis when observed within 24 hours.
suspected. Fatal or complicated arrhythmias where hypotension or
Treatment aims at improving chances of arrival in the oper- heart failure necessitate antiarrhythmic therapy or electrical
ating theatre for surgical management; open or endoluminal cardioversion.
repair. Further sheering stress to the vessel wall should be Heart failure may be best investigated with urgent echocar-
reduced by use of anti-hypertensives and heart rate control, diography (transthoracic or TOE). Myocardial contusion can
preferably with titratable IV b-blockers, and as necessary cause pump failure due to poor contractility. Inotropic support
vasodilators. may be required to maintain sufficient cardiac output. If these
fail, intra-aortic balloon pumps have been used. Valve disruption
Cardiac injury may result in specific complications requiring and septal rupture may also be involved in development of heart
treatment as recognised, including the following. failure and surgical repair is required. Free wall rupture and

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:9 413 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.

Figure 2 Early recognition of aortic injury on chest X-ray is paramount.
Widened mediastinum is a common finding.
coronary artery rupture may cause demise due to pericardial
tamponade. Emergency department thoracotomy is reported to
successfully drain pericardial blood and control further cardiac
rupture bleeding until operating theatre transfer and surgical
repair can be completed.
Lung contusion involves blood and oedema accumulating in
alveoli in the injured lung. Further injury follows from inflam-
matory mediators released in the injured parenchyma. Large
contusion can lead to acute respiratory distress syndrome.
Signs include respiratory distress and haemoptysis.
Investigations: CXR may show changes up to 48 hours after
clinical demise occurs. CT is more sensitive at confirming
contusion and better at estimating the volume of lung involved.
Treatment is supportive, with humidified high-flow oxygen,
analgesia allowing effective physiotherapy. Non-invasive posi-
tive pressure ventilation with continuous positive airway pres-
sure reduces the need for intubation. Intubation and lowest
possible pressure ventilation are indicated for hypoxic respira-
tory failure. If unilateral lung injury exists single lung ventilation
can be used to rest the injured lung.
Diaphragmatic rupture may occur from blunt abdominal or
chest trauma. Diagnosis is difficult unless abdominal structures
enter the thoracic cavity, causing respiratory compromise and
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:9
TRAUMA
sometimes bowel sounds in the chest. The diagnosis may be
made on CXR (bowel or nasogastric tube seen above the dia-
phragm). Diaphragmatic paralysis is seen on CXR as an elevated
hemidiaphragm and diagnosis may by delayed due to positive
pressure ventilation. Treatment is surgical repair.
Tracheobronchial rupture may lead to airway compromise.
Signs also include respiratory distress, subcutaneous emphy-
sema and haemoptysis. CXR findings include pneumothorax and
pneumomediastinum. If suspected clinically, diagnosis and
assessment is further aided with bronchoscopy. Surgical repair is
not always necessary.
Oesophageal rupture rarely occurs from blunt trauma. Radio-
graphic signs include pneumomediastinum, hydrothorax, and
widened mediastinum. If unrecognized, septic shock from
mediastinal soiling can occur. Treatment is surgical closure. A
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FURTHER READING
Brohi Karim. Emergency department thoracotomy. Trauma. org June 2001;
6, http://www.trauma.org/archive/thoracic/index.html (accessed 22
Mar 2014).
Reardon R. Ultrasound in trauma e the FAST exam, ultrasound guide for
emergency physicians. 2008, http://www.sonoguide.com/FAST.html
(accessed 22 Mar 2014).
414 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.