Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.
Adrales G, Huynh T, Broering Bet al.2002. A thoracostomy tube guideline improves management efficiency in trauma patients. J Trauma52: 210-216.
2.
Ahmed Z, Mohyuddin Z.1995. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg110: 1676-1680.
3.
Ali J, Qi W.1995. Effectiveness of chest tube clamping in massive hemothorax. J Trauma38: 59-62.
4.
American College of Surgeons Committee on Trauma. 1997. Advanced trauma life support student course manual, 6th edition. Chicago: American College of Surgeons.
5.
Anderson ID, Woodford M, DeDombal FTet al.1998. Retrospective study of 1000 deaths from injury in England and Wales. BMJ296: 1305-1308.
6.
Asensio JA, Chahwan S, Forno Wet al.2001. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma50: 289-296.
7.
Asensio JA, Demetriades D, Rodriguez A.2000. Injury to the diaphragm. In: Mattox KL, Feliciano DV, Moore EE eds. Trauma, 4th edition. Stanford: Appleton and Lange, pp. 603-632.
8.
Baker CC, Oppenheimer L, Stephens B, Lewis R, Trunkey DD.1980. Epidemiology of trauma deaths. Am J Surg140: 144-150.
9.
Barton ED, Rhee P, Hutton KC, Rosen P.1997. The pathophysiology of tension pneumothorax in ventilated swine. J Emerg Med15: 147-153.
10.
Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R.2001. Chest tube removal: end-inspiration or end-expiration?J Trauma50: 674-677.
11.
Bertelsen S, Howitz P.1972. Injuries of the trachea and bronchi. Thorax27: 188-194.
12.
Bertinchant JP, Polge A, Mohty Det al.2000. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiactroponinI and T elevation in haemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma48: 924-931.
13.
BifflWL, Moore FA, Moore EE, Savaia A, Read MA, Burch JM.1994. Cardiacenzymes are irrelevantin the patient with suspected myocardial contusion. Am J Surg169: 523-528.
14.
Boffard K. (ed). 2003. Manual of definitive surgical trauma care: International Association for the Surgery of Trauma and Surgical Intensive Care. Arnold.
15.
Bokhari F, Brakenridge S, Nagy Ket al.2002. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma53: 1135-1138.
16.
Boulanger BR, Milzman DP, Rosati C, Rodriguez A.1993. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma35: 255-260.
17.
Bowling WM, Wilson RF, Kalen GD, Buchman TG.2000. Thoracic trauma. In: Tintinalli JE, Kelen GD, Stapczynski JS eds. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, pp. 1675-1698.
18.
Britten S, Palmer SH, Snow TM.1996. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury27: 321-322.
19.
Brooks A, Bowley DMG, Boffard KD.2002. Bullet markers - a simple technique to assist in the evaluation of penetrating trauma. J Royal Army Med Corps148: 259-261.
20.
Cerfolio RJ.2002. Advances in thoracostomy tube management. Surg Clin North Am82: 833-848.
21.
Chen SC, Markmann JF, Kauder DR, Schwab CW.1997. Hemopneumothorax missed by auscultation in penetrating chest injury. J Trauma42: 86-89.
22.
Chirillo F, Totis O, Cavarzerani Aet al.1996. Usefulness of transthoracic and transesophageal echocardiography in recognition and management of cardiovascular injuries after blunt trauma. Heart75: 301-306.
23.
Cogbill TH, Landercasper J.2000. Injuryto the chest wall. In: Mattox KL, Feliciano DV, Moore EE eds. Trauma, 4th edition. Stanford: Appleton and Lange, pp. 507-522.
24.
Collins JN, Cole FJ, Weineter LJ, Riblet JL, Britt LD.2001. The usefulness of serum troponin levels in evaluating cardiac injury. Am Surg67: 821-825.
25.
Croce MA, Fabian TC, Davis KA, Gavin TJ.1999. Early and late acute respiratory distress syndrome: two distinct clinical entities. J Trauma46: 361-368.
26.
Curry JD, Recine CA, Snavely E, Orr M, Fildes JJ.2002. Periaortic haematoma on abdominal computed tomographic scanning as an indicator of thoracic aortic rupture in blunt trauma. J Trauma52: 699-702.
27.
Demetriades D, Kakoyinannis S, Parekh D, Hatzitheofilou C.1988. Penetrating injuries of the diaphragm. Br J Surg75: 824-826.
28.
Deneuville M.2002. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J Cardiothoracic Surg22: 673-678.
29.
Downing SW, Sperling JS, Mirvis SEet al.2001. Experience with spiral computed tomography as the sole diagnostic method for traumatic aortic rupture. Ann Thorac Surg72: 495-501.
30.
Etoch SW, Bar-Natan MF, Miller FB, Richardson JD.1995. Tube thoracostomy: factors related to complications. Arch Surg130: 521-525.
31.
Feczko JD, Lynch L, Pless JE, Clark MA, McClain J, Hawley DA.1992. An autopsy case review of 142 nonpenetrating(blunt)injuries of the aorta. J Trauma33: 846-849.
32.
Feliciano DV, Cruse PA, Mattox KLet al.1988. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma28: 1135-1144.
33.
Feliciano DV, Rozycki GS.1999. Advances in the diagnosis and treatment of thoracic trauma. Surg Clin N Am79: 1417-1429.
34.
Ferjani M, Droc G, Dreus Set al.1997. Circulating cardiac troponin T in myocardial contusion. Chest111: 427-433.
35.
Flowers JL, Graham SM, Ugarte MAet al.1996. Flexible endoscopy for the diagnosis of esophageal trauma. J Trauma40: 261-265.
36.
Freeman RK, Al-Dossari G, Hutcheson KA.2001. Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg72: 342-347.
37.
Galan G, Penalver JC, Paris Fet al.1992. Blunt chest injuries in 1696 patients. Eur J Cardio-thoracic Surg6: 284-287.
38.
Gelman R, Mirvis SE, Gens D.1991. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. Am J Roentgenol156: 51-57.
39.
Gonzalez RP, Falimirski M, Holevar MR, Turk B.2003. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma54: 61-64.
40.
Hoff SJ, Shotts SD, Eddy VAet al.1994. Outcome of isolated pulmonary contusion in blunt trauma patients. Am Surg60: 138-142.
41.
Ivatury R.2000. The injured heart. In: Mattox KL, Feliciano DV, Moore EE eds. Trauma, 4th edition. Stanford: Appleton and Lange, pp. 545-558.
42.
Jackson A, Fields JM, Wong-You-Chong JJ.1991. The costal hook: an indicator of occult flail segment in chest trauma. Eur J Radiol13: 69-71.
43.
Jackimczyk K.1993.Blunt chest trauma. Emerg Med Clin N Am11: 81-96.
44.
Jimenez E, Martin M, Krukenkamp I, Barrett J.1990. Subxiphoid pericardiotomy versus echocardiography: a prospective analysis of the diagnosis of occult penetrating cardiac injury. Surgery108: 676-680.
45.
Jorden RC.1993. Penetrating chest trauma. Emerg Med Clin N Am11: 97-106.
46.
Kamy-Jones R, Jurkovich GJ, Nathens AB.2001. Timing of urgent thoracotomy for hemorrhage after trauma. A multi-centre study. Arch Surg136: 513-518.
47.
Killeen KL, Mirvis SE, Shamuganathan K.1999. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR173: 1611-1616.
48.
Kiser AC, O’Brien SM, Detterbeck FC.2001. Blunt tracheobronchial injuries: treatment and outcomes. Ann Thorac Surg71: 2059-2065.
49.
Knottenbelt JD, James MF, Bloomfield M.1991. Intrapleural bupivicaine analgesia in chest trauma: a randomised double blind controlled trial. Injury22: 114-116.
50.
Kunisch-Hoppe M, Hoppe M, Rauber K, Popella C, Rau WS.2000. Tracheal rupture caused by blunt chest trauma: radiological and clinical features. Eur Radiol10: 480-483.
51.
Kwon CC, Gill IS, Fallon WFet al.2002. Delayed operative intervention in the management of traumatic descending thoracic aortic rupture. Ann Thorac Surg74: S1888-S1891.
52.
LoCicero J, Mattox KL.1989. Epidemiology of chest trauma. Surg Clin North Am69: 15-19.
53.
Luchette FA, Barrie PS, Oswanski MF, Flynn W, Hassett JM.2000. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic haemopneumothorax: the EAST practice management guidelines work group. Eastern Association for Surgery of Trauma. J Trauma48: 758-759.
54.
Luchette FA, Radafshar SM, Kaiser Ret al.1994. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma.J Trauma36: 865-869.
55.
Macho JR, Machison RE, Schecter WP.1993. Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination. J Trauma34: 711-716.
56.
Maenza RL, Seaberg D, D’Amico F.1996. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med14: 237-241.
57.
Mattox KL, Wall MJ Jr, LeMaire SA.2000. Injury to the thoracic great vessels. In: Mattox KL, Feliciano DV, Moore EE eds. Trauma, 4th edition. Stanford: Appleton and Lange, pp. 559-583.
58.
McGhee A, Swinton S, Watt M.1999. Use of autologous transfusion in the management of acute traumatic haemothrax in the accident and emergency department. J Accid Emerg Med68: 629-630.
59.
McGwin G Jr, Reiff DA, Moran SG, Rue LW.2002. Incidence and characteristics of motor-vehicle collision related blunt aortic injury according to age. J Trauma52: 859-865.
60.
Meredith JW, Riley RD.2000. Injury to the oesophagus and trachea. In: Mattox KL, Feliciano DV, Moore EE eds. Trauma, 4th edition. Stanford: Appleton and Lange, pp. 507-522.
61.
Meyer D, Jessen M, Grayburn P.1995. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: a prospective study. J Trauma39: 902-909.
62.
Miller PR, Croce MA, Bee TKet al.2001. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma51: 223-228.
63.
Mitchell RS.2002. Stent grafts for the thoracic aorta: a new paradigm?Ann Thorac Surg74: S1818-S1820
64.
Morales CH, Villegas MI, Angel W, Vasquez JJ.2001. Value of digital exploration for diagnosing injuries to the left side of the diaphragm caused by stab wounds. Arch Surg136: 1131-1135.
65.
Murray JA, Berne JB, Arsenio JA.1998a. Penetrating thoracoabdominal trauma. Emerg Med Clin N Am16: 107-128.
66.
Murray JA, Demetriades D, Asensio JAet al.1998b. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg187: 626-630.
67.
Nagy KK, Krosner SM, Roberts RRet al.2001. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg25: 108-111.
68.
Ochsner MG, Rozycki GS, Lucente F, Wherry DC, Champion HR.1993. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma34: 704-709.
69.
Odell JA.1999. The trauma patient -critical decision making-when to explorethe chest?Trauma1: 125-131.
70.
Pacanowski JP, Waack ML, Daley BJet al.2000. Is routine roentgenography needed after closed tube thoracostomy removal?J Trauma48: 684-688.
71.
Pape HC, Remmers D, Rice J, Ebisch M, Krettek C, Tscherne H.2000. Appraisal of early evaluation of blunt chest trauma: development of a standardised scoring system for initial clinical decision making. J Trauma49: 496-504.
72.
Pikoulis E, Delis S, Scandalakis Pet al.2000.Reliabilityof chest radiographs in the diagnosis of blunt diaphragmatic rupture. Ann Chir Gynaecol890: 10-13.
73.
Pryor JP, Schwab CW, Peitzman AB.2002. Thoracic injury. In: Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC eds. The trauma manual, 2nd edition. Philadelphia: Lippincott, Williams and Wilkins, pp. 203-223.
74.
Ranasinge AM, Hyde JAJ, Graham TR.2001. Management of flail chest. Trauma3: 235-247.
75.
Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Buchler MW.1998. Missed diaphragmatic injuries and their long-term sequelae. J Trauma44: 183-188.
76.
Richardson JD, Spain DA.2000. Injury to the lung and pleura. In: Mattox KL, Feliciano DV, Moore EE eds. Trauma, 4th edition. Stanford: Appleton and Lange, pp. 523-544.
77.
Rizoli SB, Brenneman FD, Boulanger BR, Maggisano R.1994. Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex. Ann Thorac Surg58: 1404-1408.
Rossbach MM, Johnson SB, Gomez MA, Sako EY, Miller OL, Cahoon JH.1998. Management of major tracheobronchial injuries: a 28 year experience. Ann Thorac Surg65: 182-186.
80.
Roszycki GS, Feliciano DV, Oschner MGet al.1999. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicentre study. J Trauma46: 543-552.
81.
Salim A, Demetriades D.2001. Mediastinal trauma. Trauma3: 33-41.
82.
Segers P, Van Schill P, Jorens P, Ven Den Brande F.2001. Thoracic trauma: an analysis of 187 patients. Acta Chir Belg101: 277-282.
83.
Shah R, Sabanathan S, Mearns AJ, Choudhary AK.1995. Traumatic rupture of the diaphragm. Ann Thorac Surg60: 1444-1449.
84.
Short K, Scheeres D, Mlakar J, Dean R.1996. Evaluation of intrapleural analgesia in the management of blunt traumatic chest wall pain: a clinical trial. Am Surg62: 488-493.
85.
Simon BJ, Leslie C.2001. Factors predicting early in-hospital death in blunt thoracic aortic injury. J Trauma51: 906-910.
86.
Sodestrom CA, DuPriest RW, Jr, Cowley RA.1980. Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg Gynaecol Obst151: 513-518.
87.
Stassen NA, Lukan JK, Spain DAet al.2002. Reevaluation of diagnostic procedures for transmediastinal gunshot wounds. J Trauma53: 635-658.
Velmahos GC, Karaiskakis M, Salim Aet al.2003. Normal electrocardiographic and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma54: 45-50.
96.
Vidhani K, Kause J, Parr M.2002. Should we follow ATLS guidelines for the management of traumatic pulmonary contusion: the role of non-invasive ventilatory support. Resuscitation52: 265-268.
97.
von Oppel UO, Bautz P, De Groot M.2000. Penetrating thoracic injuries. What have we learnt? Thoracic Cardiovasc Surg48: 55-61.
98.
White RK, Morris DM.1992. Diagnosis and management of esophageal perforations. Am Surg58: 112-119.
99.
Woodring JH, King JG.1989. Determination of normal transverse mediastinal width and mediastinal-width to chest-width (M=C) ratio in control subjects: implications for subjects with aortic or brachiocephalic arterial injury. J Trauma29: 1268-1272.