|Year : 2016 | Volume
| Issue : 1 | Page : 8-11
The management of thoracic trauma: Principles and practice
Surgical Health Collective, Atlanta, GA 30315, USA
|Date of Web Publication||25-Jul-2016|
Surgical Health Collective, 777 Cleveland Avenue SW, Suite 305, Atlanta, GA 30315
Source of Support: None, Conflict of Interest: None
The principles of airway control, breathing and circulation maintenance provide the starting point of care for patients with thoracic injury. Intravenous access, thoracostomy tube insertion and balanced resuscitation can address most of the issues seen. Endovascular techniques have altered the course of care for patients with blunt aortic injury. Rib plating holds promise regarding enhanced recovery from a flail chest. This article reviews the basic principles and highlights the changing landscape in thoracic trauma.
Keywords: Blunt aortic injury, flail chest, thoracic trauma
|How to cite this article:|
Walker M. The management of thoracic trauma: Principles and practice. Niger J Cardiovasc Thorac Surg 2016;1:8-11
| Introduction|| |
Thoracic trauma is common in the setting of blunt or penetrating injury.  It is estimated that almost 50% of unrestrained drivers will have some type of chest injury when a motor vehicle collision occurs. The chest cavity contains a number of vital organs in close proximity. Life-threatening injuries can evolve quickly if a high index of suspicion is not maintained. This paper will outline a general approach to thoracic trauma based on the advanced trauma life support protocol.  Specific injuries will be highlighted and their management will be reviewed.
All trauma patients should be assessed with a systematic approach predicated on a rapid assessment of airway, breathing, and circulation. The airway must be secured and for the unconscious patient, this will involve orotracheal intubation with cervical spine precautions.  Once the airway is secured, the primary survey will continue. There are four life-threatening injuries that must be addressed; Airway obstruction, tension pneumothorax, cardiac tamponade, and exsanguinating hemorrhage. As noted, the airway is secured first. If stridor is present, a surgical airway may be needed. An emergency tracheostomy should be done if laryngeal injury is suspected.
Tension pneumothorax is a clinical diagnosis that must be considered for patients with airway hunger or shock. It is characterized by decreased to absent breath sounds on the affected side, shift of the trachea to the contralateral side, and hyperresonance to percussion on the side of the tension. Needle decompression should be done at the 2 nd intercostal space midclavicular line with an 18-Gauge needle. A chest tube should be inserted in the 5 th or 6 th intercostal space in the midaxillary. The chest tube is connected to a Pleur-evac system with a water seal chamber. If there is no persistent air leak and the lung is inflated on follow-up chest X-ray (CXR), the acute problem has been solved. If there is a persistent leak, one must look for injury to the major airways or for an extensive lung injury. A second chest tube may be needed if the lung is not fully inflated after the first chest tube is inserted. Bronchoscopy can then be done to anatomically define the injury.
Cardiac tamponade is usually caused by an injury to the heart or the great vessels. The classical findings of muffled heart tones, distended neck veins, and hypotension may not be present in the emergency room setting because of associated blood loss from additional injuries. A rapid ultrasound examination should detect large amounts of blood in the pericardium. Pericardiocentesis can be performed, but a negative study does not exclude tamponade as there may be clotted blood in the pericardial sac. If pericardiocentesis is positive, it may buy the clinician and the patient vital moments to proceed to the operating room for definitive care. Once in the operating room, a median sternotomy is the most straightforward approach to the injured heart. , Opening the pericardium and suturing the injured ventricle or atrium are straightforward. Once the injury has been fixed, and the pericardium partially closed a mediastinal tube should be placed, and the sternotomy wound closed with sternal wires. At times, an abdominal exploration must be done following the thoracic procedure. If so this operation should proceed and a damage control approach strongly considered. Liver injuries can be packed and the diaphragm repaired as needed. A wound VAC can be used to close the abdominal cavity, and the surgeon can come back and fight another day.
Exsanguinating hemorrhage is the last life-threatening injury. Direct pressure is always preferable, but this is often not possible with injuries in the chest cavity (at least not initially). Operative exposure utilizing an appropriate anterolateral thoracotomy will be most expeditious. The surgeon can repair the lung, resect a segment or lobe or perform a pneumonectomy. The latter procedure is associated with a 50% mortality rate in the acute setting.  Often, the bleeding will be coming from an intercostal artery or vein. Suture ligation is appropriate in this instance. It is axiomatic that most thoracic injuries (80%) can be managed with surgical procedures that do not involve formal exploration of the chest.  Knowledge of chest tube insertion, airway stabilization, and volume resuscitation can provide lifesaving care in the emergency department. If a chest tube has been inserted because of hemothorax, a careful tally of the output from the tube is essential. An initial output of up to 1000 ccs of blood should heighten the sense of concern. If the lung is inflated after the initial blood is evacuated and the output tapers quickly, the patient will probably not need a formal exploration. If 200-300 ccs of blood drains from the chest over a 2-3 h period, formal exploration is indicated.
Although quite dramatic, an emergency department thoracotomy is often futile. In the setting of blunt trauma, the likelihood of success is close to zero.  In penetrating trauma, the results are a little better but still foreboding. Based on a recent study, if there is no cardiac activity on the initial trauma ultrasound, the prognosis is grave.  If the patient has signs of life (a pulse, spontaneous respirations, or movement) or electrocardiogram evidence of cardiac activity, the surgeon can open the left chest, cross-clamp the thoracic aorta, open the pericardium centrally to avoid the phrenic nerve, and repair any obvious injuries. The patient is then transported to the operating room for a definitive exploration. 
In general, operative exposure should be based on the underlying anatomy and the principle of proximal and distal control. For innominate artery injuries, a median sternotomy with a right neck extension will achieve proximal and distal control. For a proximal subclavian injury, a third intercostal thoracotomy will aid in obtaining proximal control. For more distal subclavian problems, a trap door incision involving a chest wall flap may be needed. The pulmonary arteries should be repaired. The superior and inferior vena cava should be repaired. The heart is usually repaired with pledgeted Tevdek suture. Stapling lung injuries can achieve quick hemostasis if the location of the injury lends itself to this approach. As noted, above the lung can be resected but the mortality for this procedure is very high.
There are several specific injuries that must be addressed because of advances in care.
| Blunt Aortic Injury|| |
These are patients that present often after acute horizontal deceleration events. Motor vehicle crashes account for 70% of these injuries. The aorta tears at the point of fixation usually just distal to the take-off of the left subclavian artery at the level of the ligamentum arteriosum - the vestige of the patent ductus arteriosus. The tear involves the intima and media, but the adventitia is intact. , The patient may make it to the hospital alive, but if the injury remains undetected, complete rupture may ensue. The first priority is to look for this injury. The CXR may reveal obliteration of the aortic knob or widening of the mediastinum. These are two hard signs consistent with blunt aortic injury. A computed tomography (CT) survey including a contrast study of the chest will define this injury. One can see a pseudoaneurysm, a periaortic hematoma, or other signs that suggest this diagnosis. Once suspected or confirmed, the blood pressure must be controlled. This can be achieved with beta-blockade. The idea is to lower the stress on the aortic wall by decreasing dP/dt. This therapy must be judiciously applied, especially for the multisystem trauma patient in whom lowering the mean arterial pressure too much can produce a low flow state that can compromise other organ systems. Beta-blockade buys time and allows a consultation with vascular surgery or cardiothoracic surgery. An endovascular approach to blunt aortic injury has been a major advance. , The incidence of paraplegia after repair has dropped dramatically. The left subclavian may need to be covered by the graft and postoperative monitoring for left arm ischemia is essential. A carotid-subclavian bypass may be needed if ischemia is documented. Open repair of a blunt aortic injury still occurs, but most centers have adopted the endovascular approach as the mainstay of therapy. These patients must be followed for a long time. Endoleaks do occur, and additional therapy may be needed. 
| Flail Chest|| |
This injury is defined by the presence of rib fractures at two or more levels that creates an intervening segment of the chest wall that is free-floating.  The clinical presentation involves paradoxical breathing. When inspiration occurs the segment collapses and when expiration occurs it expands. There is usually an underlying pulmonary contusion, and this may determine the need for intubation and ventilator support.  There continues to be debate in the literature regarding the best approach for patients with multiple rib fractures and flail segments. New techniques in rib plating are gaining ground. , A formal posterolateral thoracotomy incision is performed, and the ribs are elevated. A plate and screws are inserted while taking precautions to avoid injury to the underlying lung. Ventilator days may be decreased, and the length of hospital stay shortened with this approach.
| Diaphragmatic Injury|| |
This injury is seen in the setting of blunt or penetrating trauma. In penetrating injury, the defect is usually small and easily repaired. In the setting of blunt trauma (often related to a motor vehicle collision with steering wheel compression of chest and upper abdomen), the defect is large. The left hemidiaphragm is more likely to rupture than the right. The usual clinical presentation is a scaphoid abdomen with the stomach bubble in the left chest or the nasogastric tube located in the left chest. Central tendon rupture of the diaphragm may also occur and can present in a delayed fashion.  The operative approach involves abdominal exploration because the herniated viscera can be easily reduced and additional injuries can be addressed effectively. Chronic ruptures are best addressed via a thoracotomy because of adhesions to associated structures. Occasionally, a combined approach will be needed.
| Thoracoabdominal Injury|| |
Any penetrating thoracic injury at the 4 th intercostal space or below must be considered a thoracoabdominal injury until proven otherwise. The reasoning relates to the elevation of the diaphragm to the level of the 4 th intercostal space on expiration. Plain films often are not definitive. To screen for these injuries, CT scanning is helpful.  Diaphragmatic injuries from penetrating or blunt trauma should be repaired with nonabsorbable suture.
| Damage Control Resuscitation|| |
Much of our knowledge regarding resuscitation has come from advances achieved during world conflicts. The most recent conflict in the Middle East has confirmed the importance of approximating whole blood administration during resuscitation.  Using packed red blood cells, fresh-frozen plasma, and platelets in a ratio of 1:1:1 has resulted in patients having less acidosis, a resolved base deficit, and a more normal lactate when they arrive in the Intensive Care Unit, after a major operative intervention for trauma. , This approach has been applied in the civilian setting with excellent results. Ancillary medications such as tranexamic acid can address fibrinolysis that is seen in the setting of shock.  A thromboelastogram can give us vital information regarding the need for additional component therapy during resuscitation. The damage control approach is predicated on several principles: First, limit crystalloid administration. Second, approximate whole blood (1:1:1 resuscitation), and third, permissive hypotension until definitive control of vascular injury has been achieved.
| Conclusion|| |
Thoracic trauma remains a major challenge for surgeons worldwide. The initial approach is based on airway, breathing, and circulation. Advances in endovascular care and rib plating have produced a changing landscape in the management of patients with thoracic injury. Operative exposures based on anatomy and the principle of proximal and distal control remain essential. These principles have stood the test of time and have allowed us to save increasing numbers of patients with severe thoracic injury.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
LoCicero J 3 rd
, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15-9.
Advanced Trauma Life Support (ATLS). Library of Congress Control Number 2012941519. Dr. Michael F. Rotondo's, Chair of Committee on Trauma. Ch. 4. 9th ed., Chicago, Illinois: American College of Surgeons; 2012. p. 94-121.
Mitchell ME, Muakkassa FF, Poole GV, Rhodes RS, Griswold JA. Surgical approach of choice for penetrating cardiac wounds. J Trauma 1993;34:17-20.
Demetriades D. Cardiac wounds. Experience with 70 patients. Ann Surg 1986;203:315-7.
Stewart KC, Urschel JD, Nakai SS, Gelfand ET, Hamilton SM. Pulmonary resection for lung trauma. Ann Thorac Surg 1997;63:1587-8.
Cogbill TH, Moore EE, Millikan JS, Cleveland HC. Rationale for selective application of emergency department thoracotomy in trauma. J Trauma 1983;23:453-60.
Inaba K, Chouliaras K, Zakaluzny S, Swadron S, Mailhot T, Seif D, et al.
FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: A prospective evaluation. Ann Surg 2015;262:512-8.
Kaljusto ML, Skaga NO, Pillgram larse J, Tonnessen T. Survival predictors for penetrating cardiac injury a 10 year consecutive cohort from a Scandinavian trauma center. Scand J Trauma Resusc Emerg Med 2015;23:41.
Demetriades D. Blunt thoracic aortic injuries: Crossing the Rubicon. J Am Coll Surg 2012;214:247-59.
Fox N, Schwartz D, Salazar JH, Haut ER, Dahm P, Black JH, et al.
Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015;78:136-46.
Avery LE, Stahlfeld KR, Corcos AC, Scifres AM, Ziembicki JA, Varcelotti J, et al.
Evolving role of endovascular techniques for traumatic vascular injury: A changing landscape? J Trauma Acute Care Surg 2012;72:41-6.
Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg 1982;196:481-7.
Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: A systematic review and meta-analysis. Ann Surg 2013;258:914-21.
Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T 3 rd
, et al.
Management of pulmonary contusion and flail chest: An Eastern Association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5 Suppl 4):S351-61.
Akpele I, Douglass P, Walker ML. Traumatic central diaphragmatic hernia. Contemp Surg, January 1993.
Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM. Penetrating torso trauma: Triple-contrast helical CT in peritoneal violation and organ injury - A prospective study in 200 patients. Radiology 2004;231:775-84.
Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al.
Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008;248:447-58.
Cotton BA, Reddy N, Hatch QM, LeFebvre E, Wade CE, Kozar RA, et al.
Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011;254:598-605.
Duchesne JC, Kimonis K, Marr AB, Rennie KV, Wahl G, Wells JE, et al.
Damage control resuscitation in combination with damage control laparotomy: A survival advantage. J Trauma 2010;69:46-52.
Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg 2012;147:113-9.