Chest Trauma

General Aspects
Key Points
o Thoracic traumas are one of the leading causes of death,
especially in young people.
o Remember the ABCDE assessment as a primary survey.
o Most blunt chest traumas can be treated conservatively
o Penetrating traumas are often fatal, so proper and immediate
diagnosis is mandatory for those patients who survive.
o When surgery is indicated, the doctor should decide fast.

Introduction
Chest trauma represents a prominent part of injuries, regarding
mortality being second to head trauma as a cause of death in
injured patients and accounting for 25% of all trauma mortality.
Thus, physicians working in trauma centers must be prepared to
make quick decisions to deal with them .

we should be aware that injuries differ regarding causes, the types

of injury, severity, and prognosis.

it is essential to know about the trimodal distribution of death due

to trauma. Almost 50% of deaths occur within seconds to minutes
after injury, usually, due to massive bleeding or severe neurologic
injury. The second peak of death amounts for 20–30% of passing,
occurs within minutes to several hours after the injury and it is due
to progressive neurologic, cardiovascular, or pulmonary
compromise; especially during this period, organised trauma care
could improve the chance of survival of the patient. The final third
peak of death (10–20%) occurs several days to weeks after initial
 injury, usually secondary to infections and multiorgan system
failure.

Primary Survey
The primary survey is essential to rapidly identify life-threatening
conditions to prevent death. Patients are assessed, and their
treatment priorities are established, based on their injuries, vital
signs, and injury mechanisms.

A simple mnemonic (ABCDE) is used to direct the primary survey:

• Airway with cervical spine control.
• Breathing and ventilation.
• Circulation and hemorrhage control.
• Disability and neurologic assessment.
• Exposure/Environmental control.
The main goal of this algorithm is to avoid distractions by obvious
injuries and to identify life-threatening conditions in a prioritized
sequence based on the effects of the injuries on the patient’s
physiology.

Airway with Cervical Spine Control

In the initial evaluation of a trauma patient ,the airway should be
assessed first to ensure patency while protecting the cervical spine
and to identify any causes of airway obstruction (Foreign bodies,
facial, mandibular, or tracheal/ laryngeal fractures etc.).

Initially, the chin-lift or jaw-thrust manoeuvre is recommended to

achieve airway patency.

Conscious patients should be asked to open their mouth, which

should be inspected, and then to talk. Airway control in the
conscious patient can be achieved with an easily inserted
nasopharyngeal trumpet; on the contrary, an oropharyngeal airway
is used in the unconscious patient .
Definitive control of the airway, with eventual ventilation and
oxygenation of the patient, are obtained with endotracheal
intubation via the nasal or oral route.

An airway should be established surgically if intubation is

contraindicated or cannot be accomplished.

Breathing and Ventilation

Airway patency alone does not ensure adequate ventilation. Thus,
once airway patency is established, the patient’s ability to breathe
must be assessed.

A regular function of the lungs, chest wall and diaphragm are

necessary for ventilation and gas exchange to occur. thus, each
component must be rapidly examined and evaluated.

Injuries that severely impair ventilation in the short term include

tension pneumothorax, fail chest with pulmonary contusion,
massive Haemothorax, and open pneumothorax.

These injuries need to be identified during the primary survey and

treated promptly.

Every injured patient should receive supplemental oxygen through

the orotracheal tube if intubated or through a mask-reservoir
device if not. The pulse oximeter should be used to monitor oxygen
hemoglobin saturation

Circulation and Haemorrhage Control

Hypotension in the trauma patient is caused by blood loss until
proven otherwise.
The elements of clinical observation that yield valuable information
in hypovolemic patients within seconds are level of consciousness,
skin color, and pulse.
In the case of significant hemorrhage with hypovolemia, the level
of consciousness is reduced due to low cerebral blood flow; the skin
is ashen and pale, the pulse is rapid and thread. The source of
bleeding should be identified as either external or internal.

External bleeding can usually be defined and controlled by direct

manual pressure, avoiding tourniquets, when possible, because of
the risk of distal ischemia.

The major areas of internal bleeding are the chest, abdomen,

retroperitoneum, pelvis, and long bones. The source of the
bleeding is usually identified by physical examination and imaging.

Management may include chest decompression with a pleural

tube, pelvic binders, and surgical intervention.

Disability and Neurologic Assessment

Rapid neurologic evaluation is performed at the end of the primary
survey. This evaluation establishes the patient’s level of
consciousness (using the Glasgow Coma Scale), pupillary size and
reaction, lateralizing signs, and spinal cord injury level.

An altered level of consciousness may be caused by decreased

cerebral oxygenation and/ or perfusion, or it may be caused by
direct cerebral injury.

Traumatic injuries may cause damage to the central and peripheral

nervous systems. Spinal cord injuries happen most commonly in the
cervical and lumbar regions; the rigidity of the bony thorax protects
the thoracic spine.

A rapid assessment of disability and neurologic function is of

primary importance to prevent further neurologic injury.

Exposure/Environmental Control
The patient should be completely undressed, to examine the entire
body and assess any injuries . Complete exposure, usually by
cutting off his or her garments, allows the identification of entry
and exit wounds, extremity deformities, contusions, or lacerations.
 After the examination ,the patient should be covered with warm
blankets or an external warming device to prevent hypothermia.

Emergency Department Interventions

Thoracic trauma has a high mortality rate.
Many patients with thoracic trauma die right before or just after
reaching the hospital; however, many of these deaths could be
prevented with prompt diagnosis and treatment. In those patients,
once adequate oxygenation and ventilation have been established,
the primary resuscitation effort must rule out other life-threatening
chest injuries such as pneumothorax, Haemothorax and pericardial
tamponade.

Pneumothorax
Pneumothorax is defined as the presence of air in the intrapleural
space, with subsequent lung collapse.
From an etiopathological point of view, a pneumothorax can be
classified as spontaneous and non-spontaneous (Iatrogenic and
Traumatic). Pathophysiologically, it can be classified as open,
closed (simple) and tension.

A simple pneumothorax is created when a tear in the pleura

allows entry of air into the pleural space with resultant loss of
negativity in intrathoracic pressure. It’s usually secondary to blunt
trauma, but it can be caused by penetrating injuries damaging the
lung too.

In the case of pneumothorax, breath sounds are usually decreased

on the affected side, and percussion may demonstrate
hyperresonance. chest X-ray aid in the diagnosis. A small,
asymptomatic pneumothorax may be treated with observation and
rest; otherwise, insertion of a chest tube should be performed.

Neither general anesthesia nor positive-pressure ventilation should

be administered in a patient who has sustained a traumatic
pneumothorax or who is at risk for unexpected intraoperative
tension pneumothorax until a chest tube has been inserted
because the risk for conversion to a tension pneumothorax is high.

Open pneumothorax is characterized by direct communication

between the chest cavity and the environment.
In penetrating chest injuries, if the size of the chest wall injury
reaches two-thirds of the diameter of the trachea, air passes
preferentially through the chest wall defect with each respiratory
effort, impairing effective ventilation and leading to hypoxia and
hypercarbia.
Open pneumothorax will generally require chest wall repair. The
timing of it depends on whether the defect can be controlled, its
size, and the severity of the patient’s other injuries. Therefore,
initial management is accomplished by promptly closing the defect
with a sterile occlusive dressing, immediately followed by
placement of a chest tube.

Tension pneumothorax develops when a “one-way valve” air

leak occurs from the lung or through the chest wall. Air accumulates
into the pleural space, resulting in complete lung collapse,
contralateral displacement of the mediastinum, decreased venous
return impairing the cardiac output and eventually causing cardiac
arrest.
The diagnosis of tension pneumothorax should always be
considered in a patient with penetrating chest trauma. It is less
likely to occur after blunt trauma. However, the most common
cause of tension pneumothorax is mechanical ventilation with
positive-pressure ventilation in patients with a visceral pleural
injury.
Clinical findings in case of tension pneumothorax are hypotension,
and tachycardia, absent breath sounds on the affected side,
tracheal deviation to the opposite side, neck vein distention and
cyanosis.
Tension pneumothorax requires immediate decompression,
initially by the insertion of a large needle into the second intercostal
space in the midclavicular line of the affected hemithorax and
afterwards by the introduction of a chest tube in the 5th mid axillary
line.
Haemothorax
Haemothorax is defined by the presence of fluid in the pleural
cavity with a hematocrit higher than 25–50% of the patient’s blood.
Both blunt and penetrating injuries may be associated with it, but
it is more common after a penetrating injury.

A Haemothorax can be defined as moderate, if there are less than

1500 ml of fluid, or massive if it is more than 1500 ml.

The primary cause of Haemothorax is usually lung laceration or

laceration of an intercostal vessel or internal mammary artery, a
massive hemothorax more often occurs secondary to a penetrating
wound that disrupts the systemic or hilar vessels.

On physical examination, there is the absence of breath sounds

over the injured hemithorax and dullness to percussion; in case of
massive hemothorax, signs of shock and hypoxia may be found.

Management of hemothorax is usually by the insertion of a large-

bore (36 Fr or greater) chest tube and blood volume replacement.

If the first blood removed from the chest is>1,500 mL, or if ongoing
blood loss is 200 mL/hr. for at least 2–4 hours, or if repeated blood
transfusions are needed, the patient should be explored in the
operating room.

Cardiac Tamponade

Cardiac tamponade is a life-threatening condition in which

blood accumulates in the pericardium.
The pericardial sac is a relatively fixed fibrous structure, so a
relatively small amount of blood can interfere with cardiac activity,
reducing venous return to the heart, dropping its filling and cardiac
output, eventually leading to circulatory collapse.

Cardiac tamponade may develop slowly or may occur rapidly,

requiring prompt diagnosis and rapid intervention.

The diagnosis is suggested by Beck’s triad of hypotension, distant

heart sounds, and elevated central venous pressure.
Echocardiogram focused assessment sonography in trauma
(FAST), or pericardial window help with the diagnosis.

Pericardiocentesis with the aspiration of 10–20 ml of blood or

insertion of a flexible catheter can temporarily restore normal
hemodynamics, buying time for everyone to prepare for surgery.
These patients should generally be considered for surgery in the
operating room to diagnose and repair any sources of the bleeding.

Emergency Room Thoracotomy

In the severely injured, hypotensive patient, a physician,
sometimes, needs to ask himself whether to perform thoracotomy
in the emergency department as a life-saving maneuver.
The decision to perform it is a difficult one and requires different
considerations. In the case of penetrating injuries and pulseless
patients but with myocardial electrical activity, there may be an
indication for emergency thoracotomy.
This procedure is rarely indicated in patients without vital signs
(reactive pupils, spontaneous movement, or organized ECG
activity) since the success rate in resuscitating these individuals is
very poor.
Emergency thoracotomy permits evacuation of hemopericardium,
direct control of intrathoracic hemorrhage, open cardiac massage,
cross-clamp of the descending aorta to increase perfusion of brain
and heart during simultaneous blood replacement.
 Despite the value of these maneuvers, the usefulness of emergency
thoracotomy is still under debate, in fact, multiple papers report
survival rates less than 10 percent.

Secondary Survey
The secondary survey begins when the ABCs have been assessed,
and resuscitation has been initiated. It involves a complete physical
examination to identify additional injuries, an upright chest X-ray,
if possible, arterial blood gas analysis (ABGA), and pulse oximetry
as well as ECG monitoring.

The final phase of acute trauma care is instituting definitive

treatment, that may vary from observation of the patient to
complex surgery

Blunt Chest Trauma

Blunt traumas to the chest can injure any of the components of the
chest wall and organs in it.

They usually are caused by direct injuries, but also rapid

deceleration and other mechanisms can cause damage to chest
organs.

Motor vehicle crashes, pedestrians hit by vehicles, falls or violence,

are responsible for most blunt thoracic traumas.

Clinical presentation depends on the mechanism of trauma, the

involved organs and associated extrathoracic injuries.

Tracheobronchial Injuries
Injury to the trachea or a major bronchus is rare but potentially a
fatal condition.
 It is usually associated with simultaneous injuries to adjacent
structures such as the great vessels (especially the descending
thoracic aorta), oesophagus, manubrium etc.

Most tracheobronchial injuries occur within 2.5 cm of the carina,

secondary to sudden deceleration either because of a motor
vehicle accident or a fall, causing the trachea or bronchi to be
completely disrupted.

Most patients do not reach the hospital in time, and those who do
have a high mortality rate and often need surgery.

Signs and symptoms on physical examination depend on the type

of injury; patients typically present with subcutaneous
emphysema, difficulty speaking, respiratory distress,
pneumothorax, or haemoptysis.

Bronchoscopy confirms the diagnosis and the location of the

lesion.

In case of suspected injury to the cervical or mediastinal trachea,

intubation should be obtained beyond the injury, possibly under
direct bronchoscopic guidance.

In patients with unilateral bronchial injury, temporary intubation of

the opposite mainstem bronchus may be required.

Treatment is conservative or operative depending on the nature

and severity of the injury.

Pulmonary Contusion
Pulmonary contusion is the disruption of alveolar-capillary
interfaces and subsequent accumulation of blood and protein in
the interstitium and alveoli.
 It occurs during blunt traumas secondary to transmission of kinetic
energy (with or without overlying rib fractures and subsequent
laceration) to the lung parenchyma.

Patients may be asymptomatic or present with rapidly developing

severe hypoxia and the need for mechanical ventilation, depending
on the extent of the injury and the need for volume replacement
that aggravates the process.

In addition to associated injuries, pre-existing medical conditions

such as chronic obstructive pulmonary disease, heart failure and
renal failure greatly influence the course of patients with
pulmonary contusions, increasing the risk for hypoxia with the need
for intubation and mechanical ventilation.

Initial chest radiographs may be normal or only show small nodular

patchy changes, but severe contusions may present as frank
consolidation involving a significant part of the lung parenchyma.

Chest CT scans can define the degree more accurately and detect
occult changes not seen on chest X-rays .

The treatment is generally supportive: oxygen is often needed,

restricted intravenous fluids to avoid volume overload and diuretics
(in a stable patient), optimal pain control and Intubation is
performed if indicated.
A significant early complication is a pneumonia, and intubation
increases its rate.

Blunt Cardiac Injury

The exact definition of blunt cardiac trauma is difficult because it is
not one single entity but rather includes a spectrum of cardiac
injuries.
 Blunt cardiac trauma can result in myocardial muscle contusion,
cardiac chamber rupture, coronary artery dissection and/or
thrombosis, or valvular disruption.

Any mechanism that transfers kinetic energy to the heart may

cause injury so that it may occur secondary to compression,
deceleration, blast, direct forces applied to the chest (even after
closed cardiopulmonary resuscitation).

Clinical presentation may range from chest discomfort to complete

hemodynamic instability and cardiopulmonary arrest. Similarly,
cardiac rupture typically presents with cardiac tamponade.

Diagnostic modalities include chest X-ray, electrocardiogram (ECG),

measurement of cardiac enzymes, echocardiography.

Early use of FAST can facilitate diagnosis.

The electrocardiographic abnormalities detected by ECG are

variable and may range from sinus tachycardia, atrial flutter and
atrial fibrillation to ventricular tachycardia and ventricular
fibrillation, bundle-branch block (usually right), and ST-segment
changes.

The presence of a normal ECG in a hemodynamically stable patient

warrants no further investigation, on the contrary, unstable
patients or patients with an abnormal ECG should be monitored for
the first 24 hours.

The presence of positive cardiac troponins can be diagnostic of

myocardial infarction, but their use in diagnosing blunt cardiac
injury is inconclusive.

Therapy depends on the nature and the severity of the injury and
the subsequent damage.
Traumatic Aortic Disruption
More than 90% of thoracic great vessel injuries are due to
penetrating trauma.

Blunt traumas could cause lesions but require tremendous energy

to produce them, so they are usually traumas due to falls or high-
speed frontal impacts.

Traumatic aortic rupture is a common cause of sudden death after

those kinds of accidents.
It usually involves disruption of the aorta just distal to the
ligamentum arteriosum.

Patients with aortic rupture who have a chance of survival tend to

have an incomplete laceration of the vessel or a contained
hematoma. This lesion should be suspected in the appropriate
clinical circumstances because specific signs and symptoms are
frequently absent.

History may direct the diagnosis, together with some adjunctive

radiologic signs on chest X-ray: widened mediastinum, loss of aortic
knob contour, nasogastric tube deviation to the right (if present),
deviation of the trachea to the right, first or second rib fracture, or
pleural cap (accumulation of blood above the pleura), left
hemothorax.

Aortography contrast computed tomography (CT), or

transesophageal echocardiogram can be used in diagnosis.
If there is even a slight suspicion of aortic injury, the patient should
be evaluated for surgery in a qualified center.

The treatment is either primary repair or resection of the torn

segment and replacement with an interposition graft. Endovascular
repair is nowadays an acceptable alternative approach.
Rib Fractures and Flail Chest
The ribs are the most injured component of the thoracic cage,
occurring in about 10% of chest traumas and 20% of severe injuries.

They are relatively uncommon in childhood thanks to the flexibility

of the rib cage, and the risk increases with age secondary to
osteoporosis.
Rib fractures can be caused by a direct and focal application of
force, leading to internal displacement of the rib and lesion of the
inner part of the bone (fracture en dedans) or by an anteroposterior
force (crushing trauma), leading to an increase of the external
curvature of the bone and lesion of its outer cortical part (fracture
en dehors).

Clinically, rib fractures may be almost asymptomatic or may

present with manifestations ranging from pain on motion to
pneumonia secondary to splinting and hypoventilation.

On physical examination, point tenderness or a ridge may be

present over the fracture site.

Chest X-ray is usually the first radiological exam done, primarily to

exclude other intrathoracic injuries and not just to identify rib
fractures, which could be missed, especially fractures of the
anterior cartilages or separation of the costochondral junctions.

CT scan may provide better documentation of other associated

injuries, but circumstances indicate it. The management of rib
fractures may vary from bed rest, optimal pain control (oral,
intravenous therapy or epidural catheter) and aggressive
pulmonary toilet to major surgery (fixation with pericostal sutures
around or through the ribs, plates, wires, Judet staple etc.).
Moreover, the therapeutic approach depends on which ribs and
how many of them are injured. Fracture of the upper ribs (1–3)
requires significant force and can be associated with major vascular
or nerve injury (the subclavian vessels and the brachial plexus).
Because of the severity of the associated injuries, mortality may be
as high as 35%.

An arteriogram is mandatory in case of abnormalities in pulse or

the neurologic examination of the upper extremities. Fractures of
the middle ribs (4–9) are the most common ones because of their
exposure and lack of muscular protection; they may be associated
with a lung contusion, extra pleural hematoma (differential
diagnosis with pleural effusion), hemothorax and pneumothorax.
Fractures of the lower rib cage (10–12) are rare because of their
flexibility and are frequently seen in association with liver or splenic
injuries.

Flail chest occurs when at least three ribs are fractured in two
or more points creating a part of the chest wall that moves
independently with respiration.

During paradoxical motion of the chest cavity, when the patient

inhales, the flail segment collapses, following the decreased
intrathoracic pressure. In contrast, on expiration, the flail segment
is pushed out. Thus, fail chest may result in dramatic impairments
of lung function (rebreathing of the airway with following dead-
space abnormality) and is in principle a life-threatening condition.

Flail segments are most common in the anterior and anterolateral

chest and are more common in the mid to lower part of the chest
wall, and the reasons are multiple. First, the percentage of anterior
traumas, second, the exposure of the mid-lower rib cage and third,
the support of the large dorsal muscles.

Although Chest X-rays often show the multiple fractures, fail chest
is first a clinical and not a radiological diagnosis.
 The force of the injury required is high and often causes a significant
lung contusion, which worsens gas exchange. Treatment of pain
with rib blocks may improve ventilation.

Intubation will allow lung expansion for the same reason as for
open pneumothorax.

Current treatment aims at avoiding intubation and mechanical

ventilation unless it is strictly necessary. Management is, once
again, directed to aggressive pain control, even with continuous
epidural analgesia, and pulmonary toilet. surgical fixation may be
required for incompletely disrupted segments of the chest wall.

Sternal Fractures
Sternal fractures usually occur during motor vehicle accidents
secondary to direct impact of the anterior chest against steering
wheels or the dashboard.

In almost 20% of cases, another severe injury to the chest wall is

observed, especially single or multiple costochondral dislocations,
eventually resulting in fail chest.

there is an association with severe intrathoracic injuries such as

myocardial contusion or rupture, aortic or bronchial disruption,
lesions to the vertebral column or with extrathoracic ones,
particularly to the skull.

Isolated sternal injuries are relatively rare, because the high energy
required to break it, usually transfers to other organs nearby.
Sternal fractures are most often transverse and occur at the
junction of the manubrium and the sternal body.

Patients, when alert, complain of pain. On physical examination,

chest wall deformity and ecchymosis or abrasion of the skin
overlying the sternum may be seen.
palpation may reveal point tenderness or a ridge. Sternal fractures
are difficult to detect on anterior or oblique films, so in case of
 suspicion, a lateral chest X-ray is suggested. A CT scan is rarely
needed.

Simple nondisplaced sternal fractures require no treatment.

Complex fractures with overlapping fragments may require surgery
with reduction, debridement, and fixation.

Diaphragmatic Injuries
Diaphragmatic injuries may occur from penetrating or blunt
trauma. Almost 75% of injuries are secondary to blunt traumas and
25% secondary to penetrating ones.

Usually, injuries arising after blunt mechanisms tend to produce

more substantial defects than penetrating traumas. Left-sided
lesions are more commonly seen during clinical practice, probably
because of the shock-absorbing effect of the liver on the right side.

In case of blunt traumas, the general mechanics responsible for

diaphragmatic rupture is a direct anterior blow to the abdomen
that increases the intra-abdominal pressure significantly, causing
the damage. Another possibility is a lateral blow that may detach
the fibers of the diaphragm from the chest wall.

Patients may present with symptoms that are abdominal or

thoracic or both. They may present with chest or abdominal pain,
dyspnea, and orthopnea, nausea, and vomiting.

Moreover, a diaphragmatic injury is often associated with damage

to other organs such as rib fractures, myocardial contusions,
abdominal organ rupture or wounds of the chest and abdomen etc.

Diagnosis is not always easy to make, because history as well as

physical examination lack both, sensitivity, and specificity. Chest X-
ray is the most valuable simple test, but immediately after trauma,
diaphragmatic injuries are frequently missed, especially when the
 chest film shows an elevated diaphragm, acute gastric dilatation or
loculated hemopneumothorax.

If a laceration of the left diaphragm is suspected, a gastric tube

should be inserted to identify it on the chest X-ray. CT scan is a
second level imaging choice and may help recognize small ruptures,
identify any organ herniation, and eventually associated lesions
(Fig. 10). MRI is helpful in equivocal cases but rarely needed.

Treatment depends on the extent of the injury as well as the time

of diagnosis. Nevertheless, all diaphragmatic injuries should be
repaired, either with direct suture or with prosthetic mesh, because
there is a high risk for complications such as incarceration, possible
strangulation, and pulmonary compression. Abdominal approach
(either by laparoscopy or laparotomy) is suggested in cases of acute
herniation secondary to abdominal trauma; on the contrary, a
transthoracic surgery (open or minimally invasive) is recommended
in cases of delayed rupture.

Traumatic Asphyxia
Traumatic asphyxia, or crushing injury to the chest, is a medical
emergency resulting from severe thoracic trauma.
A rare condition occurs when a powerful compressive force is
applied to the thoracic cavity of a patient during Valsalva
manoeuvre.

Exhalation against the closed glottis leads to a sudden increase of

the intrathoracic pressure causing venous backflow from the right
atrium into the valveless veins of the neck and the head. Findings
associated with a crush injury to the chest include oedema,
cyanosis and petechiae of the upper torso, neck, and face
(Morestin’s Mask) and bilateral conjunctival hemorrhage.
Massive swelling and even cerebral oedema may be present.

Diagnosis is usually clinical, and the treatment is primarily

supportive.
 Penetrating Chest Trauma
The knowledge about penetrating trauma comes from the
management of military injuries experienced over the centuries.

Nowadays, the likelihood of penetrating chest traumas is high in

developing countries and in those where the general population
has free access to handguns.

Penetrating injuries are the result of the application of a mechanical

force to a restricted area; thus, the magnitude of damage depends
on the type of weapon, site of entry and direction of the weapon or
bullet.

For stab wounds, the injury depends on the type and length of
the instrument; moreover, rotation of the weapon increases the
severity of the injury.

gunshot wounds usually cause visceral injury and are highly lethal.
Their damage depends on the velocity and biomechanics of the
projectile. Another factor responsible for the damage is the
structure of the bullet, accordingly its shape and deformity (i.e.
jacket bullets, hollowpoint bullets). survival is better in stab
traumas compared to gunshot wounds.

Iatrogenic penetrating traumas that occur after diagnostic or

therapeutic procedures such as thoracentesis, chest tube insertion,
lung biopsies, liver biopsies or pericardiocentesis.

Direct deaths are usually due to massive bleeding. Physical

examination is once again the primary tool. Chest X-ray is the first
radiological exam requested, and it should be obtained in every
patient with a penetrating trauma of the chest. Further
investigations may vary from CT scan to angiography. Treatment
depends on the involved organs.
Chest Wall Injuries
Chest wall injuries account for approximately 10% of all penetrating
chest traumas but rarely need intervention.
In any chest wall penetrating trauma, surgeons should be aware of
associated injuries, especially pneumothorax and Haemothorax.
Physical examination should evaluate all signs and symptoms that
may help identify any associated condition. Chest radiography is
mandatory after a primary survey. Patient’s conditions and
involved organs direct the treatment to clinical observation or
surgery

Lung Injuries
The lungs occupy the entire thoracic cavity, so penetrating traumas
usually injure them., its damage may be minor and localized or
extensive and destructive.

Knife and low-velocity projectiles tend to create perforation and a

small area of contusion. It results in air entry into the pleural space
(pneumothorax) or Haemothorax. Anyhow, pulmonary artery
pressure usually is>25 mmHg, and the levels of tissue
thromboplastin are high. Thus, persistent blood leak is uncommon,
and bleeding often stops without intervention.

In the case of high-velocity projectiles, the damage of the lung itself

is usually less than in other organs, thanks to the elasticity of the
lung, even though it may be extensive in some cases.

A severe complication of penetrating lung injury is systemic air

embolization, caused by direct communication between the airway
and the pulmonary venous system, leading to death if not
recognized.
Tracheobronchial Injuries
Tracheobronchial injuries can be life-threatening. They are usually
more often associated with penetrating wounds than with blunt
trauma. Any part of the central airway may be involved, but cervical
tracheal lacerations usually follow stab injuries.
Bullet wounds generally damage the intrathoracic trachea and
main bronchi. Most of these injuries are lethal before medical
arrival secondary to associated injuries to major vessels.

Clinical presentation depends on the size and the site of injury.

Cervical tracheal damage usually presents with emphysema,
haemoptysis, and dyspnea.

On the other hand, a tension pneumothorax can be the first sign of

an injury of the intrathoracic trachea or one of the main bronchi. If
needed, intubation should be obtained beyond the injury, possibly
under direct bronchoscopic guidance, especially in case of
haemoptysis to protect the lungs.

Isolated and small (<50%) cervical tracheal wounds can be

managed conservatively; otherwise, surgery is mandatory to save
the patient’s life.

Heart and Major Vessels Injuries

Penetrating cardiac injuries are a leading cause of traumatic death.
Their mortality, including pre-hospitalization deaths reach almost
90%.
Those patients arriving alive at the hospital usually have an injury
to a low-pressure chamber of the heart.
Diagnosis is generally easy to make. Immediate intervention is
imperative and based on the patient’s hemodynamic status. This
includes emergency thoracotomy and suture of the cardiac wound.
 Major vascular injuries generally cause death immediately, so
patients rarely reach medical facilities. Death occurs because of
exsanguinating hemorrhage, massive Haemothorax or pericardial
tamponade. Survival injuries usually involve low-pressure systems,
including pulmonary artery, vena cava, innominate or pulmonary
veins. Involved vessels may be deduced from the site of the
penetrating trauma.
Treatment in alive patients includes pericardiocentesis, chest tube
insertion, transfusion of blood, emergency thoracotomy or
sternotomy and closure of the injury.

Oesophageal Injuries
Oesophageal injuries are uncommon (<1% of patients) and most of
these injuries are due to penetrating trauma.

The anatomical position of the oesophagus usually protects it from

damage ;in fact, the most injured part is the cervical oesophagus.
Isolated lesions are rare.

Diagnosis may be difficult due to the rarity of these injuries, the

scarcity of clinical signs, and the associated injuries. The clinical
presentation depends on the site of injury and the time of its
identification.

Dyspnea, cyanosis, pneumomediastinum, subcutaneous

emphysema, sepsis, and shock may be present.

small perforations may heal spontaneously and may sometimes

even go unrecognized. Large lesions can cause mediastinitis and
consequent sepsis.

Early diagnosis is vital for the patient, Chest X-ray and

esophagoscopy direct the clinician. Immediate surgery with
primary repair and adequate tissue buttressing is mandatory.
 Exercises/Self-study
1. Which statement about clinical signs of tension pneumothorax is true?
a. tachycardia
b. cyanosis
c. neck vein distention
d. a b and c

2. Morestin’s mask occurs in:

a. Open pneumothorax
b. multiple rib fractures
c. traumatic asphyxia
d. pulmonary contusion

3. Complications of the diaphragmatic injury are:

a. incarceration
b. strangulation
c. pulmonary compression
d. a b and c

4. Which statement is not true about the indication for surgery in a hemothorax:
a. initial blood removed from the chest>1,500 mL
b. ongoing blood loss 100 mL/hr.
c. repeated blood transfusions are needed
d. persistent anemia

5. Flail chest occurs when:

a. At least three ribs are fractured in two or more points: this condition creates a part
of the chest wall moves independently with respiration.
b. At least two ribs are fractured in one point: no part of the chest cavity moves for its
own.
c. one rib is fractured in two or more points: the involved area is not enough to create
a paradoxical movement of the cavity.
d. All ribs are fractured in one point: no part of the chest cavity moves for its own