Thoracic trauma is the second most common cause of death in India following trauma (the most common cause is the head injury).

• Blunt trauma chest is the more common than penetrating trauma
• Ribs fracture is the most common type of chest trauma.
• Severe thoracic trauma dies during transport or after reaching the hospital, these deaths can be prevented by prompt diagnosis and intervention.
• Most chest trauma patients can be managed by Non-operative treatment.
• Only 10% of blunt trauma chest & 15-30% of penetrating chest trauma required Surgery.
• Physiological Triad of Thoracic Trauma – 1. Hypoxia, 2. Hypercarbia & 3. Acidosis.
• Most life-threatening thoracic trauma patients can be treated with – securing airway and chest decompression (Needle/ Finger or tube).
• Always remember – securing the airway is more important before chest decompression.

Thoracic Trauma – pattern

Life-Threatening Thoracic Injury	Potentially Life-Threatening Thoracic Injury
(Diagnose in Primary survey)	(Suspect in Primary Survey & diagnose in the secondary survey)
Tracheobronchial Tree Injury	Simple Pneumothorax
Tension Pneumothorax	Flail Chest
Open Pneumothorax	Hemothorax
Massive Hemothorax	Pulmonary contusion
Cardiac Tamponade	Blunt cardiac Injury
Circulatory cardiac Arrest	Traumatic Aortic disruption
	Traumatic Diaphragmatic injury
	Blunt Esophageal Rupture

Tracheobronchial Tree injury

• Case-A chest trauma patient with falling SpO2 – you intubated but  SpO2 is not improving or even worsen (may be associated with Subcutaneous emphysema)- most probably you are dealing with TBT injury.
• Potential fatal injury and most difficult to diagnose – required expert to suspect injury & Prompt intervention to salvage the patient.
• Most common site – 1 inch (2.54cm) from the carina.
• Intubation can worsen the condition and kill faster.
• A high index of suspicion and prompt thoracotomy or fibreoptic intubation may save the patient.

Tension Pneumothorax

• Case – A chest trauma patient presented in your ED with breathlessness with Low O2 saturation, and hypotensive. Affected side absent breath sounds & no respiratory movement noted on that side – most probably you are dealing with Tension Pneumothorax, Now you have few seconds to save the patient.
• Pathophysiology – One-sided valve air leak
• Continuous expanding air shift mediastinum to the opposite side and leads to obstructive shock.
• Remember – Open pneumothorax can be converted into tension pneumothorax if the wound is sealed completely.

• Intervention – Immediate Needle/finger decompression followed by chest tube placement.
• Site – 5th Intercostal space at just anterior to the midaxillary line (According to 10th edition of ATLS). Few still prefer at 2nd ICS at the midclavicular line.
• Misinterpreting diagnosis with tension pneumothorax is cardiac tamponade.
• Attempting Needle decompression is not harmful as not attempting. (may kill your patient)

Open Pneumothorax

• Penetrating chest trauma
• Immediate 3 sided dressing followed by chest tube placement and closure of the wound.
• Never close the wound without putting a chest tube – that will kill your patient faster than not doing anything.

Massive Hemothorax

• 1500 ml of fresh blood comes immediately or 200 ml/ hr for 3-4 hours – leading to the patient being hemodynamically unstable.
• Immediately treated with ICD placement.
• Need urgent blood transfusion and thoracotomy to secure bleeding.

Cardiac Tamponade

• Most commonly associated with penetrating chest trauma
• Can be caused by Blunt trauma chest – usually after blunt cardiac rupture of the heart.
• Cardiac tamponade mimics – tension pneumothorax.
• In Tension Pneumothorax – air entry will be absent and in cardiac tamponade, air entry will be present.
• Beck’s Triad – 1. Hypotension, 2. Distended neck veins and 3. Distant (muffled) heart sounds.
• Intervention – Cardiocentesis follow by Thoracotomy
• CECT thorax is recommended in stable patients only.
• All Penetrating thoracic trauma cases leading to cardiac tamponade – Thoracotomy is mandatory.

Traumatic cardiac arrest

Approach a patient with cardiac arrest patient following trauma – completely different from a non-trauma patient.

Simple Hemothorax or Pneumothorax

• Chest trauma is most commonly associated with multiple ribs fracture
• Simple pneumo or hemothorax is most commonly associated with Multiple ribs fracture.
• Diagnosed radiologically with chest x-rays or USG or CT

References

1. Henry S. ATLS 10th edition offers new insights into managing trauma patients. Bulletin of the American College of Surgeons. 2018 Jun 1.
2. Henry S. Earn CME.