Thoracic Trauma

Thoracic trauma includes any damage to the chest, lungs, heart, great vessels, or the esophagus. It can be the result of blunt or penetrating trauma and accounts for 20-25% of all trauma-related deaths.

General Workup

• NEXUS indications for CXR
  • Age >60 years
  • Rapid deceleration mechanism
  • Fall >20 feet
  • Motor vehicle crash >40 mph
  • Chest pain
  • Intoxication
  • Abnormal alertness or mental status
  • Distracting injury
  • Chest wall tenderness
• NEXUS indications for chest CT
  • Abnormal CXR
  • Distracting injury
  • Chest wall tenderness
  • Sternum tenderness
  • Thoracic spine tenderness
  • Scapula tenderness
  • Rapid deceleration injury

Thoracotomy

• Goals
  • Control bleeding
  • Relieve cardiac tamponade
  • Cardiac compression
  • Cross-clamp aorta → improve perfusion to brain/heart
• Indications
  • Isolated penetrating chest wounds
  • Blood loss >1500 mL after chest tube placement or blood loss >200 mL per hour for 4 hours
• Exposure
  • Median sternotomy
    • Heart
    • SVC
    • Pulmonary vessels
    • Pulmonary hilum
  • Left posteriolateral
    • Posterior heart
    • Thoracic structures
    • Thoracic aorta
    • Great vessels
    • Left lung
    • Distal esophagus
    • Distal left mainstem bronchus 
  • Right thoracotomy
    • Right lung
    • Trachea
    • Proximal mainstem bronchi
    • Upper and midesophageal injuries

Rib Fractures

• Presentation
  • Most commonly fractured ribs: 4-10
  • Tenderness to palpation 
  • Flail chest → segmental fractures of ≥3 ribs
    • Paradoxical movement of chest with respirations
    • Chest moves inward with inspiration and outward with exhalation
  • Associated with other injuries due to blunt mechanism
• Scoring Systems
  • RibScore → ≥4 in total may benefit from surgical stabilization
    • ≥6 rib fractures
    • ≥3 bicortical displaced fractures
    • ≥1 fracture in each anatomic area
    • Flail chest
    • Bilateral fractures
    • First rib fracture
  • Rib Fracture Score
  • Chest Wall Injury Score
  • Clinical Rib Score
• Treatment
  • Admission criteria for rib fractures
    • Admission if ≥2 of the following present after PO pain medication
      • Respiratory rate >18
      • Incentive spirometry <75% predicted
      • Numeric pain score ≥6
      • Poor cough
      • Age ≥65
      • ≥3 fractures 
    • If admission criteria met, ICU admission if ≥1 of the following are present
      • Age ≥65
      • ≥6 fractures
      • Incentive spirometry <60% predicted
      • Flail chest
      • >4L oxygen required to maintain SpO₂ >90%
      • Associated injury requiring ICU admission
  • Multimodal pain regimen
    • Oral
    • Paravertebral nerve block
    • Thoracic epidural anesthesia (gold standard for flail chest)
  • Surgery
    • Controversial
    • Indications
      • Crushed chest with chest wall deformity 
      • Flail chest
      • Rib fracture nonunion with chest wall deformity
      • Open rib fracture
      • Intractable pain
      • Persistent paradoxical respiratory movement 
    • If completed, should take place within 72 hours of injury
• Complications
  • Pneumonia (most common)
  • Atelectasis

Sternal Fractures

• Etiology: unrestrained driver striking steering wheel
• Presentation
  • Severe chest pain
  • Decreased respiratory efforts secondary to pain
  • Associated injuries
    • Myocardial contusion
    • Rib fractures
    • Thoracic spine fractures 
• Workup
  • Lateral CXR
  • CT chest
• Treatment
  • Medical management → pain control
  • Surgery → create longitudinal incision overlying the sternum to expose fracture. Reduce overlying fractures by using a periosteal elevator and secure with a sternal plate

Pneumothorax

• Etiology
  • Penetrating trauma
  • Blunt trauma 
• Presentation
  • Decreased breath sounds
  • Hyperresonance to percussion
  • Decreased expansion of affected lung during inspiration
• Imaging
  • CXR: collapsed lung
  • CT: collapsed lung
• Treatment
  • Surgical exploration indications
    • Chest tube output >1500 mL initially
    • Chest tube output >200 mL each hour for 4 hours

Pulmonary Laceration

• Etiology
  • Rib fracture
  • Blunt or penetrating trauma
• Treatment
  • Surgery
    • Indication
      • Initial hemothorax >1500 mL
      • Hemothorax >200 mL/hour for 4 consecutive hours
      • Persistent air leak for several days
    • Approach
      • Incision
        • Posterolaterally through intercostal space 5-6
        • Anterolateral through interspace space 4-5
      • Repair
        • Simple laceration → continuous absorbable suture
        • Through and through penetration → pulmonary tractotomy with linear stapler
        • Marginal injuries → wedge resection with linear stapler
        • Hilar injuries → lobectomy or pneumonectomy
          • Take down inferior pulmonary ligament with sharp dissection
          • Grasp hilar structures between index and ring finger
          • Clamp hilar structures
          • Resect with TA stapler

Cardiac Injury

• Presentation
  • Beck triad
    • Hypotension
    • Jugular vein distention
    • Muffled heart sounds
  • Hemorrhagic shock
• Labs: Troponin
• Workup
  • Ultrasound of pericardial space
  • Subxiphoid pericardial window 
  • EKG
• Treatment → surgery
  • Incision
    • Median sternotomy
    • Left anterolateral thoracotomy
  • Injury and repair
    • Atria
      • Digital pressure or vascular clamp
      • Close with continuous suture
    • Ventricle
      • Digital pressure
      • Place Foley catheter and inflate balloon to 5-10 mL and outward traction
      • Close with interrupted pledgeted horizontal mattress with monofilament nonabsorbable suture (i.e., 3-0 or 4-0 polypropylene)
      • Can attempt closure with skin stapler
  • Evaluate after with TTE
• Relevant Information
  • “Box” boundaries —> cardiac injuries in 20% of patients
    • Clavicles
    • Midclavicular lines
    • Costal margins 
  • Right ventricle is most commonly injuried structure of the heart

Myocardial Contusion

• Etiology
  • Blunt thoracic injury
• Workup
  • EKG
  • Ongoing cardiac monitoring is indicated if EKG is abnormal
  • TTE should be ordered if there is hemodynamic instability or myocardial contusion is suspected

Tracheobronchial Injury

• Etiology: Penetrating or blunt trauma 
• Presentation
  • Most occur within 2 cm of the carina
  • Associated injuries
    • Pneumothorax
    • Pneumomediastinum
    • Hemoptysis
    • Subcutaneous emphysema 
• Workup
  • Flexible bronchoscopy (most accurate)
  • CT chest
• Treatment
  • Injuries <25% circumference
    • Usually heal without stricture
    • Don’t frequently require surgery
    • Minimize inspiratory pressures when ventilated
  • Surgery
    • Approach
      • Injury within 2 cm of carina → usually approached through right posterolateral thoracotomy incision
      • Distal injury → left posterolateral thoracotomy incision
    • Repair
      • Primary repair with interrupted and continuous absorbable suture
      • Tracheal (<4 cm) or mainstem bronchus (<2 cm) → resectional debridement with primary repair after mobilization, cover with vascularized pedicle (intercostal, diaphragm, or omentum

Esophageal Injury

• Etiology
  • Gunshot wound
  • Stab wound
  • Iatrogenic injury 
• Presentation
  • Usually identified during exploration for associated injury
  • Dysphagia
  • Hematemesis
  • Crepitance
  • Odynophagia 
• Workup
  • Endoscopy
  • CT chest: mediastin/pleural air/fluid
• Treatment
  • Surgery
    • Approach
      • Cervical esophagus → incision at anterior border of sternocleidomastoid
      • Upper and middle thoracic esophagus → right posterolateral thoracotomy
      • Distal esophagus → left 6th intercostal space posterolateral thoracotomy
    • Tube thoracotomy is required
    • Definitive treatment should be performed as soon as possible
    • Repair
      • Diagnosis within 24 hours → repair primarily with interrupted 3-0 or 4-0 sutures
      • Delayed diagnosis → simple repair with reinforcement with intercostal muscle, pleural or diaphragmatic flaps, exclusion, diversion via a spit fistula, intraluminal T-tube drainage, endoscopic stenting, resection + drainage with NG tube or tube thoracotomy → contrast esophagram 5-7 days post repair prior to resuming PO intake
  •  Endoscopic stenting gaining popularity slowly 

Retained Hemothorax and Empyema

• See this Surgery Student post for more details
• Treatment
  • VATS is most efficacious
    • Most successful when completed within 3 days of injury as the clots becomes more adhered to the lung and pleura as days progress. It is largely unsuccessful when completed after 7 days.
    • Place in lateral decubitus position
    • Three 1-2 cm operative sites
  • Posterolateral thoracotomy through 5th intercostal space if VATS is unsuccessful

Diaphragm Injuries

• Etiology
  • Penetrating trauma
  • Risk factors: penetring injury between level of nipple and costal margin
• Epidemiology
  • Male predominance
• Presentation
  • Pain, dyspnea, respiratory failure
  • Often enlarge with time
  • Concomitant injuries to stomach, colon, liver are common
  • Bowel and other organs can herniate through these defects, especially when large (>5 cm) and become incarcerated or strangulated
• Diagnosis
  • Direct operative exam is gold standard – laparoscopy can be beneficial
  • Imaging has a high false negative rate, especially for small (~1 cm) diaphragmatic defects
• Treatment
  • Surgery
    • Laparoscopic primary repair if hemodynamically stable
    • 0 or 1-0 monofilament suture, running or interrupted
    • Need for mesh for complex repair is quite rare (only use if clean)
• Relevant Information
  • Blood supply to diaphragm
    • Phrenic arteries
    • Superior epigastric arteries
    • Intercostal arteries
  • Venous outflow: phrenic veins → IVC