INTRODUCTION

As with all traumatic injury, the management of thoracic trauma is centered on both the rapid diagnosis and the correction of the insult. Particular to injuries to the chest is the possible simultaneous disruption of two of the three life-sustaining physiologic processes (namely, breathing and circulation). Therefore, life-saving treatment and diagnosis often must occur in congruity. Many of the pitfalls that present themselves in the management of thoracic trauma are mistakes of omission and carry the risk of extreme morbidity and mortality. Many of the physiologic principles apply in the management of both blunt and penetrating injuries. As such, specific injuries are addressed in this chapter rather than mechanism.

The steps followed in the care of the traumatically injured patient are well described and outlined by the Advanced Trauma Life Support training put forth by the Committee on Trauma of the American College of Surgeons.¹ Ensuring an airway and confirming effective breathing and circulation are prime goals and permit appropriate diagnosis and guide treatment options.

INDICATIONS

MANAGEMENT OF THORACIC TRAUMA STEPS

On arrival at the trauma bay, once an airway is deemed secure, the lung fields are auscultated with a stethoscope. Absence of breath sounds suggests loss of pulmonary aeration and is likely due to collapse of the pulmonary parenchyma and replacement with air, blood, or abdominal contents owing to diaphragmatic rupture (very rare on the right). Adjunctive physical examination findings may aid in the cause of pulmonary collapse such as tracheal shift from midline, hyperresonance (pneumothorax), or dullness (hemothorax) to percussion. However, in a busy, loud trauma room, these are rarely discernible. Victims of penetrating trauma will have wounds that will aid in identification of potential injury and that must be sealed as a source of pleural air. Accompanying hypotension may suggest tension physiology, which requires immediate decompression either by placement of a large-bore intravenous catheter into the pleural space (via the second intercostal space in the midclavicular line) or by immediate chest tube placement if it is readily available. Chest radiograph as an adjunct to the primary survey is often helpful in identifying hemo- or pneumothorax in the hemodynamically stable patient.

Incomplete Pleural Decompression of a Pneumothorax

• Consequence

Because victims of thoracic trauma are at risk of multiple injuries contributing to the overall picture, accurate diagnosis and treatment are vital. An inadequately performed decompression of a tension pneumothorax not only continues the circulatory embarrassment of the patient but also confuses the picture and may delay vital diagnostic and therapeutic decision making. The thoracic cavity may be entered in the initial attempt at tube placement, thereby relieving the immediate tension pneumothorax. However, if the tube is subsequently left in the subcutaneous space, the tension may reaccumulate owing to ongoing leak from the pulmonary parenchyma.

Grade 4/5 complication

• Repair

Replacement of the intravenous catheter. Replacement of a subcutaneous chest tube.

• Prevention

Intravenous decompression: The apex of the thoracic cavity at the level of the second rib slopes posteriorly, though the chest wall in most patients remains parallel to the floor in the supine patient. To properly position this catheter, it is angled in a caudal direction and passed over the third rib.

Chest tubes: This is often identified at postprocedure chest x-ray. Making the skin directly over the sixth rib at the point at which the tube is intended to enter the thoracic cavity and not trying to tunnel the chest tube helps avoid subcutaneous placement and ensure correct positioning. Obese patients are particularly at risk.

Incomplete Decompression of a Hemothorax

• Consequence

Persistent hypotension after appropriate treatment of tension pneumothorax suggests an alternative ongoing source of shock. Massive hemothorax with ongoing bleeding is a well-recognized indication for operative intervention. Unrecognized persistent hemothorax at minimum hinders respiratory status, but more worrisome is the failure to recognize the source of ongoing hemorrhage and basing decision making on incomplete or faulty data (i.e., unnecessary laparotomy or delayed thoracotomy). This may be due to ongoing thoracic bleeding or improper positioning or kinking of the chest tube.

Grade 3/4 complication

• Repair

A postinsertion chest radiograph confirms positioning of the chest tube. Recognition of a kinked chest tube on x-ray leads the surgeon to reposition it appropriately (Fig. 74-1). Clotted chest tubes can occur; however, this scenario is often associated with massive hemothorax and ongoing blood loss (Fig. 74-2).

Figure 74-1 This patient suffered multiple rib fractures on the left after a motor vehicle collision. Initial chest tube placed for a pneumothorax was kinked at the most distal hole. Persistent pneumothorax is evident at the left apex on the chest x-ray.

Figure 74-2 This patient suffered a gunshot wound to the right chest and presented with a hemopneumothorax. The persistent massive hemothorax can be seen despite the excellent position of two chest tubes.

• Prevention

Insertion of a large-bore chest tube (36, 38, or 40 Fr) allows for maximal drainage of blood in patients with hemothorax. By twirling the chest tube around its longitudinal axis while inserting it through the chest wall, one ensures that it is not kinked. This maneuver should be performed whether the tube is inserted for hemothorax or pneumothorax.

Unrecognized Aortic Tear

In the absence of hemothorax, the approach to the management in this scenario depends upon whether the mechanism of injury is blunt or penetrating.

Patients suffering blunt injury of significant force are at elevated risk for aortic tear, most frequently seen just distal to the left subclavian orifice. Frequently, chest x-ray evidence suggests signs of great vessel injury including widened mediastinum, loss of the aortic knob, and pleural capping.² Other signs that indicate heightened energy transfer include high rib fractures and sternal or scapular fractures.

• Consequence

The ultimate consequences of unrecognized aortic injury include rupture and death. In addition, if the rupture remains contained, subsequent thoracic aortic aneurysm may develop.

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